healthy feedback loops

7/29/2019 Healthy Feedback Loops

http://slidepdf.com/reader/full/healthy-feedback-loops 1/11



Healthy Feedback Loops Devices, Apps, and Portals | 2© Copyright October 2012 Chester Street Publishing, Inc. All Rights Reserved.

Introduction

Crowdsourcing Feedback

Connectivity Enables Competition

Placing Bets, Fundraising, Real World Rewards

Building Virtual Worlds, Characters

Metrics or the Already Motivated?

Health Outcomes as Motivators

Regulations Holding Back Feedback Loops?

3

4

6

7

8

9

10

11




T

oday’s health and tness devicesare connected. Whether they areBluetooth-enabled, WiFi-ready,ull-on cellular, or easily plugged

into a mobile, these devices are collectingdata that is much more meaningul andimpactul because it is not locked withinthe device itsel. This mobility o health andtness data is a key enabling actor or themany health behavior change experimentscurrently being led by consumer health

startups. At the heart o these experiments– these new devices and companion apps– the search is or eective, positive healtheedback loops.

At its most basic level, the kind o eedbackloop oten leveraged in these experimentsollows these three steps:

Granted the three steps outlined above

oten occur right rom the same device.Smartphones equipped with motion-sensing accelerometers, location-awareGPS chips, and increasingly better cameras,have helped make the smartphonea standalone health and tness datacollection hub. With their current suite o sensors, however, smartphones are notable to collect data related to all o themajor biometrics.

In recent years blood pressure monitormakers, weight scale manuacturers,blood glucose meter developers, pulseoximetry device makers and more haveadded connectivity. As a result these

device makers have had the opportunity totransorm themselves – or at least augment

their current status – rom hardwarecompanies to sotware companies withcompanion applications or even serviceplans attached to their device oerings.

Device collects data.

Data moves to application.

Application provides device user

with personalized eedback.

1.

2.

3.

O course, not everyone has ully embracedthat opportunity.

In early 2011 iHealth Lab, a Mountain View,

Caliornia-based subsidiary o China-basedmedical device company Andon Health,became the rst company to have anFDA-cleared medical device sold at AppleStores. As the name implies iHealth’s BloodPressure Dock connects directly to an iOSdevice just like a charging dock or speaker

dock accessory. The blood pressure deviceis actually controlled by its companionapp, which the user downloads to the iOSdevice rom iTunes AppStore.

The iHealth BPM app’s eedback is sparseand streamlined by design. Apart rom thebig, centered button that the user pusheson their iOS device to make the cu infateand take the blood pressure measurement,the app oers a simple graph that showswhere the BP reading alls on a scale o dark green, green, yellow, orange, darkorange and red. It also oers a historicaltable o past readings and a comparativecolor-coded chart or past BP readings.

Like almost every other company thatoers connected health devices, iHealthkeeps eedback to qualitative colors toavoid moving into the more regulatedterritory o diagnosis.

“Are we looking to be everything toeveryone?” iHealth’s Senior Vice Presidentand General Manager Adam Lin asked.“No. Forget whether or not we could doit, no one has ever done both hardwareand sotware incredibly well. Apple maybe the exception. Our ocus is still onthe hardware, rst and oremost. We areocused on enabling connectivity and

ensuring the data is truly mobile, secureand not restricted. There are a numbeo [third party] apps out there that do[sotware] really well.”

Considering iHealth’s success with itsApple partnership, Lin’s comments areunderstandable. While many others workingin connected health agree that openingAPIs and enabling third party apps to usedata collected by dedicated devices is an

important trend, most companies buildinghardware also see companion apps andservices as a big opportunity. Some evenbelieve the service and sotware side othe digital health opportunity is the biggeone.

This report aims to highlight and illustratesome o the ways digital health companiesare using eedback loops in an attempto encourage healthy behaviors. Whilethis is not a comprehensive document, iwill provide a broad overview o the mostcommon types o eedback loops andmechanisms used by consumer healthapplications today. It is also worth noting

that many o the digital health servicesmentioned here oer a number o dierenkinds o behavior change mechanismsbeyond the ones highlighted in this report

iHealth’s Blood Pressure Dock and BPM iPad App




When Silicon Valley-based consumer healthstartup Massive Health launched in 2011, its

ounder Aza Raskin, who ormerly servedas the creative lead at Mozilla Fireox,wrote that “health care needs to have itsdesign Renaissance, where products andservices are redesigned to be responsive

to human needs and considerate o human railties.” Apart rom evangelizingthe need or a “design Renaissance” inhealthcare, Massive Health became theleading proponents or better health-related eedback loops. The eedback loopbecame core to the startup’s original pitch.

“The human brain amously doesn’t deal

well with delayed gratication,” Raskinwrote. “The reason why weight is hard isbecause the eedback loop is too loose:The cake I eat today doesn’t materiallychange my body or the rest o today ortomorrow. It’s the incremental amounto cake I eat or don’t [eat] over weeks

and months that makes me t or at. Our

brain’s pleasure circuits lead us to optimizeshort-term happiness (cake!) over long-

term healthiness (obesity, coronary heartdisease, diabetes).”

Massive Health used the dashboard thatToyota included on its hybrid Prius cars asan example o how eedback loops canchange longstanding behavior.

“Think about it like driving a car,” Raskinwrote. “While you know it is bad or theenvironment to drive, that knowledge

doesn’t really change your behavior. Whenthe Prius introduced a large screen withinstant and average MPG with a pretty

graph, Toyota created a small breed o hyper-milers and a much larger populacethat changed routes and driving behaviorto optimize that number. Toyota hadtightened the eedback loop and pushedpeople to ‘drive more green’ on a dailybasis.”

S P ONS ORE D A DV E RTIS E ME NT B E LOW

The Eatery iPhone App by Massive Health

// Crowdsourcing Feedback

http://www.akamai.com/html/solutions/aquaion.html




In November 2011, nearly a year aterthe company’s ounding, Massive Healthlaunched its rst “experiment”, a reeiPhone app called The Eatery that helpedpeople get eedback on how healthy theirood choices were. The app’s core eatureenabled users to snap photos o the oodthey were about to eat, label it i they wantedto, rank it on a spectrum o “t” to “at” andthen share it with other users o The Eatery

app. Within a ew minutes the communityo users would give the snapshot o ood

their own numerical ranking on the “t” to“at” scale, and the user’s ood submissionhad a crowdsourced health review.

While the company admitted crowdsourcingthe reviews is not as precise as using ateam o dieticians, the startup said researchshows that collectively people are good atrating the healthulness o ood. “Good”was good enough or the purposes o theexperimental app. Seven months laterMassive Health amassed nearly 8 millioncrowdsourced ood ratings rom peoplein more than 50 countries. The person

about to eat the ood photographed ratedthe ood as healthier than the rest o thecommunity about 72 percent o the time.The company also ound that people eatabout 1.7 times less healthy with eachpassing hour o the day.

In an early interview shortly ater The Eateryapp launched, Massive Health’s head o business development Andrew Rosenthalnoted that part o what makes an appengaging is speed. When The Eatery rstlaunched, it only took about 2.8 secondsto snap a photo o ood and have it appear

in The Eatery, which is the same amounto time it takes to take a photo and have it

appear in the iPhone’s native camera app,according to Rosenthal. “When Apple sawthat we could match their native cameratime, they were impressed,” he said.

While Massive Health stands out as thebiggest evangelist o eedback loops indigital health, many other companies haveleveraged crowdsourcing and social mediachannels in an eort to create meaninguleedback loops.

Soon ater it rst launched its WiFi-enabledweight scale in the United States, France-based Withings integrated its web appwith Twitter so that users could share theircurrent weight, weight goal, and how manypounds they have to go, in real-time, daily,weekly, or monthly via their Twitter account.

While the integration was something o an open-ended eedback loop, the intentwas clearly to enable riends or Twitteracquaintances to encourage or at leastcomment on the user’s latest numbers. Thenew eature was met with considerableskepticism rom tech blogs. Engadget

called the integration a way to ensure tha“your ollowers will start dropping astethan even you could imagine” and thaWithings had given Twitter’s iconic “aiwhale” a new meaning.

Despite Engadget’s negative review oWithings’ Twitter eedback loop attemptin mid-2011 a newspaper in the UnitedKingdom called The Daily Mirror publishedan article about a 40-year-old man whoclaimed posting his weight on Twitter or alhis riends, amily, and work colleagues tosee was the motivating actor that got him

to make better decisions about his diet. Heended up shedding about a quarter o hisbody weight, according to the newspaperwithout attempting any special diet: “Theprospect o going into work and having toace people knowing you had put weighon wasn’t a great one,” he explained.

Withings iPhone App and Twitter Integration

\\




Crowdsourced judgment and the prospect

o embarrassment aren’t the onlysocial network-enabled eedback loopsthat digital health companies employ.Connected health devices also make awide variety o competitions possible.

Boston-based Partners Health Carespino Healthrageous has developeda consumerized version o disease

management that incorporates someelements o workplace wellness initiatives.Healthrageous integrates connecteddevices rom various medical devicemakers, including, activity monitors, weight

scales, blood glucose meters, bloodpressure cus and more to continuallycollect and track a user’s various biometrics.

With this data, Healthrageous creates

personalized action plans or each o itsparticipants, with specic, incentivizedbehavioral goals in mind. TheHealthrageous platorm also capturesHealthcare Eectiveness Data andInormation Set (HEDIS) measures orthe payer to benchmark progress. Oncethe platorm begins to notice unhealthypatterns, the automated system can ask

the participant questions to help pinpointwhich behaviors need to be changed.

Once Healthrageous has establisheda particular health goal, it begins to

leverage its social eatures: For example,it invites amily and riends to provideencouragement to the participant or itcan use the specic behavior change goalas part o a corporate-wide competition.

RunKeeper’s run tracking app with new Leaderboard eature

// Connectivity Enables Competition

Workplace competitions see one group o

employees teaming up to compete againsothers where individual participantsget points or making progress on theiindividual goals. Work colleagues are nonecessarily privy to the specics o eachother’s goals or health problems, buthey might know when they are makingprogress or slipping based on how manypoints that team member contributes.

Healthrageous CEO Rick Lee describesthe end result o the platorm as a “virtuouscycle with a bioeedback loop.”

While Healthrageous may be one o theew companies on the leading edgeo “consumerizing” chronic diseasemanagement through competitionsmany tness applications have includedcompetitive elements in their mobile apps.

RunKeeper announced a major upgradeor its popular running app in October 2012The addition o a personal leaderboard thashows how active users are in comparison

to their riends. RunKeeper’s app uses theGPS chip in a user’s smartphone to trackruns, walks, bike rides, hikes, and othe

activities.

RunKeeper now shows which o youriends have been active most recently andhow many activities they have done in therecent past. Those riends who have notbeen active recently are given a rank thadisplays an image o a couch.

The app also now enables riends to“nudge” each other i they think theyshould be trying to be more active. Once ariend is selected, the app gives users the

option to tell their riend to go or a run, goor a walk, or go or a bike ride.

Many running apps also make it easy torun virtual races with others who have runa similar distance or the same route at adierent time. These same eatures canenable runners to race against themselvesto beat past running times.




Sleep coaching company Zeo does notoer an explicit competition eature as a

part o its sleep monitoring platorm, butbecause the company has ound ways toquantiy how well its users are sleeping,it has enabled competitive sleeping. ZeoSleep Manager Mobile is a sleep phasemonitoring headband that connectsto a user’s iOS or Android device andcontinuously transmits data about thewearer’s sleep health as he or she sleeps.The Zeo app on the user’s phone trackshow much time the sleeper spends in eacho the our sleep phases, how long it takesthem to all asleep, how many times they

wake during the night, and other metrics to

determine a composite sleep score, calledthe Z Score. Upon waking the user canreview how much time they spent in theREM phase o sleep, or example, alongwith the other metrics, but the Z Score isthe easiest one to use as a reerence point.It’s also an easy way to compare how muchbetter o a sleeper the user is compared totheir spouse, sibling, parent, or riend.


Sometimes riendly competition is notenough o a motivator or sustainedbehavior change. GymPact, which launchedin early 2012, helps users stay committed totheir workout regimens by promising to paya certain amount o money i they ail to goto the gym. GymPact users make a “pact”at the beginning o the week by setting adollar amount o their choosing that theyhave to pay i they don’t meet their goals.A user might put $50 on the line i theydon’t make it to the gym three times this

week or a minimum o one hour. I the userails to meet or exceed its goal, GymPactkeeps its $50, but those who successullymake it to the gym as promised, also sharea portion o the money paid to GymPact bythe non-adherent members. The serviceuses both positive and negative eedbackloops to keep users engaged. GymPactleverages the GPS chip in the participants’

// Placing Bets, Fundraising, Real World Rewards

\\

phones to help conrm whether or not thaperson actually went to the gym.

O course, rewarding people with money oother gits or good behavior is not a noveconcept. Determining whether a personis actually active is the trickier part o theequation. Another startup, EveryMove, isdeveloping a platorm that oers rewardsto users who can demonstrate an activeliestyle. EveryMove users earn points oeverything rom biking to mowing the lawn

Everyday activities that are sel-reportedlike mowing the lawn, count or less pointsthan those actions that are more easilyconrmed or quantiably tracked through aGPS-enabled app like RunKeeper. Friendscan cheer EveryMove users on too and thaalso adds a ew points to the total.

EveryMove points can be redeemedor rewards that will come rom brandsemployers, or health insurance providersEveryMove has a number o partnershipswith tness applications, but it also recentlyinked a deal with a major tness equipmen

maker, Precor. When an EveryMove uselogs into their account rom a piece oPrecor exercise equipment, the activity

gives them more EveryMove points. Thesuccess o EveryMove’s eedback loop, ocourse, will partially depend on the qualityo its rewards, which are largely still in theworks. In May 2012 the company received$2.6 million in unding led by SandboxIndustries, which manages the venturecapital und o BlueCross BlueShield, soits prospects or landing health plans ascustomers has brightened.

At least one activity monitoring devicecompany oers a less sel-serving monetaryincentive to its users: Striiv, the makers o asimple smart pedometer device specicallydesigned or middle-aged women, enablesusers to earn points that can be redeemed

or dollars that get donated to variouscharitable causes.

http://www.akamai.com/dl/whitepapers/Akamai_Whitepaper_Strong_Medicine_for_Healthcare_Online.pdf?campaign_id=F-MC-16828




Mobile devices are making a huge impact on the health care

industry. As consumers are snapping up connected devices, the

medical device industry is following suit; creating systems to

provide clinicians with real-time access to their patients’ data

around speciic therapies.

The key to any therapy is compliance, and mobile health is no

exception. Unless mobile health applications are responsive and

reliable, patients and physicians will lose patience, and the promise

of mobile health will go unfulilled.

One of the most frustrating experiences for Internet users isslow response time from unreliable connections. And when web

applications don’t perform consistently, users may wind up avoiding

the applications altogether. It’s a common problem: as the physical

distance between users and applications increases, performance

typically deteriorates rapidly. In fact, Web applica¬tion wait times

for users located on the opposite coast of North America can be ive

times longer than those based locally.

Performance issues like these create unique problems for healthcare.

If an Internet-based solution is behaving poorly, a physician could

have dificulty accessing the infor¬mation needed to make the right

treatment decisions. For example, a physician who only sees part of

an X-ray series over the Internet may be unable to make a correct

diagnosis, or worse, make an incorrect one.

In short, physical distance, ineficient protocols, Internet

congestion, and poor routing conspire to add critical seconds to

each transaction. And in the medical profession, this can quickly

become a life and death matter.

Akamai addresses shortcomings in the fundamental design of core

Internet protocols - creating a delivery system designed to improve

the performance and availability of health¬care applications. Its

globally distributed computing platform (The Akamai Intelligent

Platform) eliminates web performance bottlenecks. And within

this massive footprint, 90% of the world’s Internet users are within

one network hop of an Akamai server. This effectively translates

to localized response times delivered to global users. With its

intelligent and dynamic mapping technology, Akamai tackles

Internet trafic jams - dynamically determining the best available,

highest-performing route between an application and the end user.

» sponsored content

The Striiv device is a $99 standalone pedometer (nomobile phone required) that can hang on a keychainor attach to a belt. Its sensors are able to dierentiatebetween walking, running, climbing stairs, and hiking

according to the company. Using points earned romactivity, users can donate clean water to children inSouth America or polio vaccines to children in India

thanks to Striiv’s partnership with GlobalGiving.

Striiv oers the charitable donations reward as just oneway to encourage its users to stay active. The companyhelps users visualize their progress through a gamecalled MyLand, where movement translates to newwildlie and plants on an “enchanted island.” Striiv’s

MyLand game takes its cues rom the wildly populaFacebook-based game FarmVille, which made Zynga ahousehold name. While FarmVille sees users spendingvirtual currency to build their virtual world, MyLand runs

on activity. A step walked detected by Striiv equates toan energy point in MyLand. Running earns ve pointsper step. Climbing a stair equates to 10 points. Theworld automatically grows and thrives based on theuser’s activity, and inactivity leads to the opposite.

Mindbloom is another wellness company that aims tohelp users visualize their progress. Mindbloom usersplant a virtual tree and give it leaves that represendierent aspects o their lie that they would like to

ocus or improve upon. These leaves might representhealth, career, relationships, nances, spirituality, andmore. The application then encourages users to makesmall but meaningul changes to their lives given thetime constraints they ace to improve the quality o theilives.

Not every virtual structure used by health behaviochange companies needs to be as complex asMindbloom’s Lie Tree or Striiv’s MyLand. When Fitbirst launched its activity tracking device in late 2009, idebuted with a slender blue fower that glowed on theoutside o the device. The fower’s height grows basedon how much activity the user has logged during the

day. The fower could grow to have about twelve leavesrunning down its stem or very active users.

B.J. Fogg, director o the Persuasive Technology Lab aStanord University, discussed the Fitbit’s virtual fowewith The New York Times when the Fitbit rst launched“The little fower growing represents anticipation andhope that something good will happen, which is the

\\

// Building Virtual Worlds, Characters




Improve Salesperson Impact – iPad Support

As the tablet computer is revolutionizing the workplace, it is also

transforming healthcare by providing physicians with portable

information access. Device manufacturers see the tablet as a much

better personal medium for detailing physicians - as well as a

vehicle for supporting the on-the-go ield sales force. One medical

device company wanted to provide salespeople with a local copy

of rich detailing material – rolled up into the kind of experience

they’d come to expect as consumers. It partnered with Akamai todeliver great, consistent performance when delivering large iles to

its entire salesforce on product launch days – and real time stock

and pricing information. With Akamai, the company improved

download performance by 400% domestically and 600% globally.

Monitor Patients’ Vital Signs – Accelerating Performance for

Wireless Medical Devices

Internet availability can be a matter of life and death for patients

who rely on these devices. Wireless medical devices, such as cardiac

monitors, can provide physicians and other healthcare providers

with invaluable and virtually instant information about a patient’s

condition. Today’s pacemakers can wirelessly track and transmit

patient data to a device to a bedside monitor, which in turn usesthe Internet to provide physicians with access to eficiently track

patient status. As one of the leading makers of cardiac implants

has discovered, Akamai ensures consistently good performance for

wireless medical devices, particularly in far lung regions, without

the need for additional infrastructure.

Widespread use of health monitoring technology like this is

improving care and reducing costs. And Akamai is proud to be a

crucial component in keeping connected performance fast, reliable

and global.

» sponsored content continued...

fower growing,” Fogg told the Times. “When you pushthat button and see the change, it’s instant eedbacka reward. Even though the device seems simple, it’stapping into a complex psychology that changespeople’s behavior,” he said. “It hits the right buttonMost humans are naturally wired to nurture things andbe rewarded or doing so,” he said. \\

The starting point or many devices and apps thathelp users track a particular metric or set o metrics isa chart or a table. Many o the early tracking oeringsonly provided spreadsheets and graphs as eedback

loops or users, which has led to a rallying cry amongthe newest crop o device companies to proclaim thatheir product is not (just) or “Quantied Sel” types buis easy enough to use and accessible enough or theaverage user.

Wrist-worn tracking device maker Lark is the latescompany to make the case that its device is moreaccessible than previous ones because it is less ocused

on the numbers. Lark’s latest device, Larklie, is a $149device that works with a companion app to track activitysleep, and diet. Instead o just providing numbers thamight help users draw their own conclusions, Larklieprompts its users with suggestions or how to improve

their health habits based on the metrics it tracks. Oncethe device gets a sense or the user’s circadian rhythmit can push notications to users to point out that theyhave been sitting or a long time and it might be anoptimal time or a quick walk. It might also notice a usedid not get enough quality sleep the night beore andsuggest they go to bed earlier.

Still, certain types o users do benet rom reviewinga quantitative analysis o their activity, sleep, caloricintake and more. A new set o tools has emerged in

recent months to help the quantitatively minded makemore sense o their numbers.

Notch.me is building an app that helps people whotrack healthy activity to create beautiul inographics inan eort to help them better understand and engagein their own health. Notch can take user’s data romFitbit, RunKeeper and similar apps and devices tocreate a more visually stimulating representationo their numbers. Notch stylizes itsel as more o anongoing experiment or project and may not become a

// Metrics for the Already Motivated?





A orthcoming app rom San Francisco-based startup 100Plus, which will likely goby the same name, aims to help people

recognize and take advantage o healthopportunities or “hops” like walking hillswith views in their neighborhood and“healthiying” their commute by takingstairs instead o the escalator. 100Plusbelieves these small activities havebecome undervalued and people havebeen trained to think that the only way tobe healthy is to go or a run or head to thegym.

The eedback loop that 100Plus intendsto use is perhaps its most interestingconcept: These small activities aect the

user’s Liescore. That metric gives users asense o how their small actions will likelychange their longterm health by addingsmall increments o additional time to theirlie expectancy. Each user’s Liescore startsat 78.1 years since that is the general lieexpectancy.

“As we learn about you the Liescorechanges,” 100Plus Co-Founder Chris Hoggsaid. “Because I’m a man, my score actually

automatically goes down because womenlive longer than men on average… becauseI live in San Francisco it goes up becausepeople here live longer on average.”

Age, height, and weight can aect theLiescore based on a comparison betweena user and the average BMI o people likethem. Hogg said the data is all based onCDC data sets available rom the edera

government as well as structured clinicadata rom its partner PracticeFusion.

The app also shares a hop that one use

creates with others and 100Plus users cansee how their hops have inspired othersto lead healthier lives. Currently each hoprequires the user to snap a photo o theactivity, which — given the requisite imageand crowd sourcing strategy is reminisceno Massive Health’s The Eatery app(discussed above).

// Health Outcomes as Motivatorsull-fedged company in its own right. Still,it may be providing alternative eedbackloops in the orm o inographics that userso existing health apps benet rom.

Another – much more quantitative tool –

that can help sel trackers better visualizetheir numbers is Daytum, which describesitsel “as an elegant and intuitive tool orcounting and communicating personalstatistics.” Ryan Case and Nicholas Felton

developed Daytum based on Felton’sexperience o producing yearly annualreports based on his sel-tracking, which hehas done since 2005. Felton is somethingo a celebrity in the world o sel-tracking,and Daytum helps his ans and others tocreate similar visual representations o their own tracking metrics. \\

\\

http://www.akamai.com/dl/whitepapers/Akamai_Whitepaper_Strong_Medicine_for_Healthcare_Online.pdf?campaign_id=F-MC-16828




As the soon-to-launch 100Plus appindicates, eedback loops or health apps

and devices are set to become much moresophisticated as analysis o existing bigdata sets (and the ones these tracking toolsare building) yields more insights about thelong term and short term eects o healthdecisions.

Many o the startups working in digitalhealth today are uneasy about theregulatory environment or health-related applications. In mid-2011 the FDA

published a drat guidance document orhow it believes existing medical deviceregulations apply to mobile medicalapplications. The document providedsome clarity but did not go so ar as to

establish a clear line between mobilemedical apps that perorm a diagnosticunction and those that oer some ormo health coaching that lies outside o theFDA’s regulatory purview. As a result manyo the companies working in digital health

purposeully simpliy the kind o eedbackthey provide users o their devices and

apps.

The FDA’s nal guidance or the regulationo mobile medical apps is expected by theend o 2012 or in early 2013.

// Regulations Holding Back Feedback Loops?

\\

Screen shot rom 100Plus’s marketing video (above)

Screen shots rom two dierent 100Plus iPhone apps (right)

healthy feedback loops

Documents