As we entered our 40s, we were prescribed chronic disease medications, and tuned into how our mily members wrestled with daily adherence. We also discovered the incredibly high cost of the problem to society.
How long did it take to develop the GlowCap?Its had a long developmental period. Weve been working on the product for about three years. This is the fourth-generation product were launching now. The fourth-generation product connects over an AT&T cellular network. You dont need a computer, you dont need broadband, and you dont need WiFi. You just need to be able to plug the nightlight in, and it creates connections to the AT&T network. Previous versions relied on a home phone line or a broadband connection. The new version is easier to install, and its just magical. It just connects to the Internet on its own.
My Philips wakeup light masterfully coaxes my out of sleep every morning with a sunrise-like experience. I set the alarm for 6:30, and between 6am and 6:30 it slowly becomes brighter and brighter to awaken me calmly. If Im not up by 6:30 it plays quiet then louder birds chirping which my wife mistakes for actual robins outside the apartment. It serves the function of being an alarm without being alarming. Other product designers should aim for the same subtly.
To prove the system workswe conducted a randomized research trial with Partner&8217;s Center for Connected Healthand discovered we could durably change peoples behavior, improving adherence by over 35%. With our product, that we dubbed GlowCaps, most people take their medications over 95% of the time! These results spurredmajor customers like Novartis and Express Scriptsto adopt the product. Andour partnership with AT&Tcreated a magically- setup experience.
Forgiveness empowers change. Catholics are forgiven whenever they confess. Protestants receive absolution weekly with command to go forth and sin no more. Jews have to wait until Yom Kippur.
Potential INVESTORS want to see as much progress as possible with your other bridges. If you arent getting termsheets, try to get a commitment for a termsheet when you reach specific milestones. Ideally a near-future, high-probability milestone. At least you can add very thin boards by letting investors take you to breakst and lunch to nurture the relationships and conceptually stress-test your bridges.
Back when I was CEO ofAmbient Devices, we discovered that peripheral displays like the Ambient Orb were remarkably effective at encouraging energy conservation because it didnt require active engagement. When color is mapped to energy price, its hard to avoid glancing across the room and noticing it.The Vitality nightlight (with AT&T connectivity)leverages this same glanceability. Its usually steady blue, or pulses orange if any of your GlowCaps need your attention. Its unavoidable.
Sorry health apps, you need a way to become ambient to be effective.
With any luck you can get past the paywall and read the feature on the Chameleon Project,Putting Care In Patients&8217; Hands, by The Boston Globe.
1) Mutual dependency
President
Philips direct-life, an aRoseology? cheerleading poster ideasctivity tracking key fob and web service, does this well. Each activity program is ten-weeks long. Its short enough period to believe that you can stick with it. After all its just a couple of months. But in reality these programs are daisy-changed together. As soon as you complete one, you are offered to change your goal and sign up for another 10 weeks. Consider the demotivating alternative: Are you willing to walk 10,000 steps each day for the next 10 years? A series of bite-sized 10-week sprints is better.
Philips Wakeup light (image not of the author)
When driving in the fog, obstacles emerge quickly. The timing of important business milestones like profitability, awards, key contracts, or an acquisition are often hard to predict. Most days the best you can do is to keep hammering away despite the poor visibility. With perseverance youll see the finish line of your labors the moment before it happens.
David Rose
What about texting you ask? I know my colleagueBJ Fogg at Stanford, and many others, believe that push-messaging will provide an effective coaching tool for behavior change.Maybegiven hyper-personalized messages, and an understanding of context, such a system wont feel too annoying. For now, I turn off push messages for almost all apps because the cacophony is unbearable (especially you, FourSquare.) Would you adopt a coaching program that texted you a few times a day with meal and exercise suggestions and medication reminders? I think youd hate it after about three days.
There are two types of social nudges that weve designed into the product. One is where you select one or more people in your social network, like a mily member, in order to see the data about how youre taking your medication on a weekly basis. And so it gives you a little calendar of which days you did or did not take your medication and how youre tracking against a goal. And the second type is really a product forsharing your data with a physician. There are certain personality typespeople who respect their doctors and have a high respect for authoritythat really respond [to this approach.]
If you are resource constrained, prototype some aspect of your PRODUCT to build this bridge. Make a video scenario that illustrates your vision. Work on the service design or detailed specification if you cant hire the electrical engineering talent or start tooling. This bridge will require constant adjustments as you get feedback each of the other bridges, especially customers.
With Dr. Soon-Shiong&8217;s acquisition, we are expanding market reach and product depth. We are developing new products which inspire positive behavior related to diet, exercise, and stress to support a healthier future-you.
Once, a sharp business school student asked me if a better startup metaphor would be digging four tunnels to meet below a mountain. She may be right. Many days company-building feels dingy, mucky, oxygen-deprived, and the only way forward is with explosives.
Just as a follow-on to the ease-of-use point, one of the advantages in embedding technology in everyday objects like a pill [bottle] cap is it doesnt look like technology. Its not a computer program or a Web site or an iPhone app. Its a dedicated, very inexpensive microprocessor just for that one app. As the cost of wireless and computation lls, I think youll be seeing this more and more. You can afford to create a $5 pill cap that people use every day. And that people can throw out.
In this interview with MX, Rose discusses the social dynamics of behavioral change, encouraging clinical study results, the slow rate of innovation adoption within the healthcare bureaucracy, and the therapeutic value of lifting ones voice in song.
The term juicy feedback comes from game design when a small action produces a surprisingly large reaction. Here are six design ideas relevant to products intended to change people&8217;s behavior.
Roseology? cheerleading poster ideas,I mean, seriously: in what other industry can health leaders respond to &8220;This is hard to use&8221; and &8220;I dont like doing this&8221; by saying &8220;Youre just not good enough for our wonderful inventions?&8221;
Most technology needs to go to finishing school. Beeps, buzzes and startup sounds are usually so exaggerated that we come to resent them after about three days. My TIVO, Samsung TV, Microwave, toaster oven, phone, and Mac all have terribly overstated sound effects. The panera food-ready buzzer is especially panic-inducing. Like doctors in the ICU, we get alert tigue and simply turn the sound off (or throw the offending object out).
Mayo Transform ConferencefromVitality GlowCaponVimeo.
Furthermore, because Chameleon is web-enabled, the child is alerted if there are environmental triggers like high pollen count that day in their zipcode. The mily can see which areas have triggered asthma attacks in other children like them. A location-based app marks these automatically. Likewise, when the child has a cold or has the classic asthma symptoms like tightness in the chest, nighttime coughing, or shortness of breath, the parents can monitor the severity of these symptoms via built-in spirometer. We also connected the device and app to an online medical record for the doctor. MIT is developing on an opensource platform started at Childrens Hospital in Boston calledIndivo. The power of this connection allows the doctor to see the childs symptoms,triggers, spirometry data, and use of the daily or emergency inhaler then adjust medication and asthma plan accordingly to avoid that expensive and scary visit to the emergency room.
So r, smartphone apps dont provide this type of persistent, unavoidable display because apps require launching and focal attention.The Vitality dynamic wall concept (image below) summarizes how healthy you are. Each pedal of the flower maps to a different aspect of vitality: sleep, activity, diet, meds and stress.
4) Be Subtle
There is a great debate about which incentives are more effective for which customer segments. Is it better to use social OR financial incentives? Extrinsic OR intrinsic rewards? Should people select their reward program OR be automatically segmented by a motivational profiling algorithm? All are interesting questions, but I believe the most important work is around how to mix and blend rewards to gain the largest multiplier effect. The challenge with blended rewards is to design programs that remain enough to explain and remember, while still hitting multiple keys as a chord that will resonate in peoples minds.
When I speak at business school classes (on either side of the Charles river) about entrepreneurship I use this metaphor:
Okay, but has it been difficult then to find investors for the device in this economic environment?No, the problem of medication adherence is such a well-understood one that lots of people have been interested in coming and funding it. Especially if you have a product that breaks new ground in terms of simplicity, and also if you get the sort of blue-chip research evidence weve gotten.
Behavior has tremendous effects on health &8212; for many, it is much more important than genetics &8212; but effective tools are lacking. We believe GlowCaps are like seat belts: Once an option, today a standard. Our mission is to make connected packaging ubiquitous and develop other innovative tools which inspire healthy behavior.
We set out to build a business that offered well-designed, personalized feedback loops to remake the daily pill-taking chore into a delightful, affirming moment.
Like heart disease and diabetes,asthmadoesnt necessary present its symptoms everyday. This makes taking a daily inhaler especially difficult for the child. And parents obviously dont want to over-medicate their kids. Thats where the mobile application comes in. By linking the childs daily adherence to the Chameleon game on their mobile device, we reward the child for taking medication as prescribed even when theyre symptomless. This positive feedback loop happens without the prompting of parents or the explicit nudging of a professional caregiver.
On my Apple iThings, I download and try to use health apps likeLoseIt(where you choose from a large database of foods to count calories) andMealSnap(where you take a picture and it estimates calories in each meal). Both seem like a great idea, but I cant seem to do it consistently three of four times a day.
Speaking of that, whats your latest research news?We worked with Massachusetts General Hospital, which is part of Harvard Medical School, and we did a study over the last year specifically for hypertension, which is one of the hardest things for people to solve. With hypertension you dont feel sick and you dont feel the medication working, so its very easy to not take the medication.
At Vitality we aim for subtlety. We try to reach people in the zone between conscious and unconscious, so people remember to take their medications but dont resent (or even credit) their GlowCap. We start with light, escalate to iconic sounds (cute arpeggios), then after a few hours of prompting send a text message or an automated call.
Each bridge depends on parallel progress with ALL of the other bridges. It becomes easier to recruit a great teammate when funding is committed. Of course you need a strong team to build a killer product. Paying customers beget salivating investors, etc. Conversely, its very hard to make progress on any bridge without building all bridges.
This is a much better result than anybody else who has been working on this problem has gotten. A 30% lift [represents] about 100 days a year. The current best-of-breed on the market is [an increase of] about 10 days per year. With the current best-of-breed you send somebody a letter, and you call them if they havent picked up their script. Those services buy you about 10 more pills taken per year, so weve really done the classic type of innovation by improving the state of the art by a ctor of 10.
Vitality uses to the same multiceted approach to great effect. We combine polite reminders, social incentives, the sentinel effect (your doctor sees your data), automatic refills, and in some cases pharmacy coupons. One of the most popular (and ridiculous slides) that is often shown at medication adherence conferences is a pie chart showing the reasons why people dont take their medication: forgetfulness, dont believe they need the medication, cost, side effects, etc. Its market-research reductionist drivel. Its like asking people to pick the ONE reason they stay in their marriage. For most of us (I hope) a spouse comes with multiple attractive features. Mine does.
We dont understand why, but we seems we are much more likely to act when multiple reasons conspire. A potential date looks especially attractive if she is good looking, brilliant, wittyandrich.George Loewenstein, a behavioral psychologist at CMU, found that offering acombinationof a high-probability small rewards, with a low-probability large rewards satisfied both the skeptical and optimistic sides of your braicheerleading poster ideasn. You get frequent intermittent reinforcement coupled with the lottery-like chance for big winnings.
Fitbit Benchmarking
Again, you must build the four bridges concurrently, not sequentially, to meet in the middle. There is no order of importance. They are all equally important.
The last isINVESTORS.
Half of the population used the GlowCap with all its services turned on, which were reminders, social support, doctor accountability, and refill coordination. And we gave the other half GlowCaps that just collected data. And then we looked at the difference between those two populations every day for about nine months now. The difference in the peoples medication-taking behavior is about 30% between those groups. Meaning that 70% [were not taking their medication in the second group] and 98% were in the first. The group [adherence] where we had the GlowCaps turned on, where they were doing all the things they do to take medication, was much higher than we expected.
Other behavioral change tools need the adhere to the same big idea:Be Ambient.
1) Forgive Regularly
As any coach or sales manager knows, to get top performance you balance hunger with belief. The team needs to be hungry enough to run after the carrot, combined with a belief that they can succeed. Carrots need to be bright orange, juicy and tasty enough to run after, yet close enough to appear attainable.
In each bridge, aspire to lay down a new board every day. Some days the boards are narrow, some days you put down multiple wider boards.
As one of the Vitality customers said I have to open the GlowCap to get at my medication out anyway. Our product would have iled if we had asked people to go to a web site or app to log their data. In ct, the FaceBook app we built a few years ago to track daily adherence and share that data with friends did il. The social sharing instinct may have been right, but the extra step to log this daily behavior (even if it was just one click) provided too much friction.
We filmed a couple of videos last week of customers talking about their experience using GlowCaps over the last six months.
Josh Wachman
At the core of our healthcare crisis is a crippling lack of patient engagement,Ive talked about this before. Historically, this has been viewed as a compliance problem, but at theMIT Media Lab, this is viewed as a ilure in healthcare infrastructure and attitude. Specifically, tools need to automatically connect patients, caregivers, and providers. And these tools need to be , consumer-friendly, and engaging. Dave Debronkart, better known as@ePatientDave, gets fired up about this. He writes on his site,e-patients.net,
Vitality monthly adherence report
2) Offer Multiple Incentives to Strike a Chord
Did you have any manucturing or design challenges, say with overseas production, for instance?Well, my previous company, Ambient, has been manucturing in China for about eight years. I think the hardest part is designing a product that is polite enough that people want to live with it every day. You cant make it [sound] like a smoke detector, because people would toss it out the window.
Along the way, we patented a &8220;push to refill&8221; button under each cap, designed escalating light and audio reminders which gently nudge, and a pattern recognition system that learns about you and recommends the best motivational techniques to get you to do what your doctor prescribed.
Technically, of course, we have the ability to store exercise, diet or medication adherence data for eternity. But, especially for under-performers, its more motivating to periodically get a clean slate. Weight watchers gets this too by refreshing your point allotment each week. You cant bank extra exercise or food points week to week. It&8217;s a clean slate weekly.
My recent TEDx talk about how magic anticipates ubiquitous computing, now with captions on each slide to improve understandability. I&8217;m interested in your comments!
Problem:Asthma is the most common childhood disease, resulting in 18 million trips to the Emergency Room every year. 75% of these hospitable visits are preventable with better asthma management. To properly self-manage asthma, a child needs to carry and know how to use a dizzying array of medications, an inhaler spacer, a peak flowmeter, and a asthma journal and an asthma treatment plan. Its overwhelming.
Imagine yourself at the edge of a large foggy lake. Your job is to build four bridges concurrently that meet in the middle. Each bridge mustbelieve the other bridges are being built to meet them in the middle of the fog. You are responsible for building, recruiting others, cheerleading, cajoling, providing the wood and nails and knowing how to make it happen. Your most critical role may be sustaining and communicating the belief that it can, and will, be done.
I met today with a bright young doctor from theHarvard School of Public Healthwho was working withBlue Cross Blue Shieldon a study of health monitoring tools. As she put it,Vitality GlowCapwere her poster-child for an elegantly designed behavioral change tool, and she wanted to learn more about the design philosophy behind the product. She was especially interested in our use of AT&Ts cellular network to reduce the complexity bluetooth and other short-range wireless options.Chronic diseases make up about 75 percent of our healthcare systems $2.3 trillion costs, so the need for more and better tools is acute.
You add boards to your TEAM bridge by recruiting and motivating. If you dont have the resources to hire someone you can at least interview and attract people. Get a commitment from a potential teammate to join if you can close funding or sign up a customer.
I imagine thats a plus for elderly people who may not be technologically savvythat ease of use, wouldnt you say? Yes, absolutely.
6) Keep finish lines in view
2) Incremental progress
David talks about why smart medication packaging should be like seatbelts&8211;free and standard.
We shared optimism that embedded technology &8212; objects that do not look or feel like technology &8212; can improve quality of life. We fixated on the ubiquitous prescription bottle to transform it from a package into a multiceted service, offering feedback to individuals, loved ones, and their doctors and pharmacists.
After some experiments at Vitality we decided to calculate medication adherence monthly, then start from scratch when each new month turns over. While a three or six month rolling average may be more helpful for a physician, we wanted to keep it for customers to explain and understand.
Finally, here are some photos I snapped during Health Week. Enjoy!
Here is a concrete example in an activity program that mispositioned their carrots. Fitbits premium service made the mistake of putting the carrotbehindme. To my surprise, I was already beating the average activity of 40-year-old males in Boston&8211;why change?
MITsNew Media Medicineproject believes that people &8211; ordinary people &8211; have been undervalued in the healthcare system. What started as aproblem of information asymmetry (doctors know all, patients understand little) has become a problem of information inequality (doctors have access, patients do not). The solution is : By embracing (and building) new technologies that enable seamless collaboration between doctors, patients, and communities, we can increase the chances of patient success throughpositive feedback loops. This philosophy drove this yearsHealth and Wellness Innovation Week: to build technology that empowers patients to take control of their health.
So are GlowCaps enchanted objects, too?I do think the GlowCap represents an enchanted object, because its taking an ordinary, everyday object and adding a little bit of computation and a little bit of wireless connectivity and it a lot more useful. Its the same wayand this is a geeky examplethat Frodos sword in The Lord of the Rings showed him whether he needed to use it when Orcs were nearby. Its almost the same thing, showing that [your medication] needs to be used so you dont forget about it.
3)Get off the Web
Importantly, the entrepreneurs job is to frequently broadcast the progress that each bridge is to the other bridges. Each advance builds confidence in the others. Social media makes this easy and affordable. This momentum is critical and contagious.
Her first question was miliar. Wasnt I excited about smart phone apps for helping people track their blood pressure, diet, weight and other indicators? As I told her, Im skeptical that people willusethese apps every day, even the well designed ones. Its true that more people have cellphones than computers, and many of these phones will support vast appstores in the coming years. But that doesn&8217;t mean people will have the discipline or interest tousethese apps, especially for logging what they eat, or if they have taken their medications..especially if they havent.Brian Dolan from Mobihealth newsorSusannah Fox from Pew Researchshould do a study onactualhealth app usage over time (all of the current numbers are based on downloads only).
Thanks for your support and advocacy over the years with Vitality!
Poor medication adherence has confounded doctors, pharmacists, and other entrepreneurs for decades.
5) Design your carrots carefully
The third isCUSTOMERS.
The second bridge is yourPRODUCT.
This multiple-bridges metaphor is useful for at leastthreereasons:
But, Id rather be bridge-building over a misty lake.Wouldnt you?
Whats the genesis of the concept?Most of my mily has suffered from heart disease. My grandther died of it, and my ther is struggling with it. I realized for many of us its something we ce and that we will struggle with every day for, hopefully, decades. And so, more than just being a reminder device, it was seen more as a helping hand or a coach, where if the data about my hopefully good behavior is shared with someone in my life that cares about me, Im much more likely to do the right thing. It does remind me, but I think more importantly it offers a little visibility into my social network and allows others to celebrate my success or my interest in keeping up with my medication regime.
Im an avid self-experimenter. I try to adopt early and often to form grounded opinions about any new shiny thing, especially those that innovate on the human-computer intece like Nintendos Wii Fit, Sony PS3 Move, and Microsofts Kinect; or connected health devices like the WiThings scale, FitBit, Philips DirectLife, Nike+, Garmins bike GPS, etc.
There are already thousands of studies that have documented the financial ramifications of low adherence versus high adherence, and we show we have a product that increases adherence more than any product we know of. And we have a price-point of less than $20 per month for a Blue Cross, a Blue Shield, a Hu
The availability of great literature, for free, on an iPad doesnt mean we&8217;re all reading Jane Eyre.
Over the course of ten days I worked with an amazing team on the problem of childhood asthma:
Any effective behavioral change program must log data automatically and reflect it throughout the course of their day without a web site, app, or annoying SMS text. See my previous post Why Im down on Apps for more. If you are building daily self tracking tools into some web portal or PHR&8230;go home, you are wasting your time.
Recently publishedhere:
As we looked at the literature, we learned almost every successful example of behavioral change uses social dynamics. Whether its smoking cessation programs or Alcoholics Anonymous or weight-loss programs, the recipe for success is all about opening windows of connectivity between you and the people that care about you so that they can support you and try to help you change your behavior. And behavior change is incredibly hard. It doesnt happen without that social nudge.
To advance the CUSTOMER bridge, share the specs or a prototype of your product with potential buyers or distributors for their feedback. Try to get a letter of intent or a conditional purchase order that you can share with your investors.
Solution:Make ONE device that combines the inhaler spacer with the spirometer, wirelessly connect it to the internet, quantify the data, design a game that motivates the child and parent, and share data with the pediatrician. Ultimately, increase awareness, understanding, and medication adherence to keep the child on the ball-field and out of the hospital.
3) Foggy finish lines
A personal note from Josh and me on thebig day!
Whats surprising is just the pace of adopting even innovations that have overwhelming evidence that shows they work. Its still quite slow. Everybody wanted to dotheir own little studies. Here we have evidence for a device that has been shown in a clinically controlled and randomized trial to change peoples behavior by an incredible amount. And other people have already written studies. There are 30,000 studies about medication adherence and the problems and the cost of medication non-adherence. People have already documented what happens with people not taking medication: getting put right into the hospital or a rise in nursing home admissions due to non-adherence or the cost of increased ER visits for diabetics who are non-adherents.
The first bridge is yourTEAM.
We call itChameleon.Why? Because lizards are cute, non-medicalized, and chameleons especially have a magical ability to adapt to their environment to protect themselves. Note: at the beginning of the project I wanted to make the device curved like an elephants trunk or Jewish Shoffur. Wouldnt it be fun if it made a big trumpeting noise? Or the annoying noise of a kazoo? Or the whirlygig sound of a party toy? I know something about the joy of a LOT of noise: I played cello as a child until my sister picked up the french horn, after which I switched to trombone so I could outblow her. To a sixth-grader, decibels trump.
CEO
Your previous position involved selling consumer products. Did you ce new regulatory concerns in designing a product for the healthcare market? We passed all the standard regulatory issues. There are at least six tests we had to pass. We had to use food-safe plastic, the device had to pass the light-and-tight test, which means that no moisture can penetrate the bottle that can change the absorption rate of the drug. We had to pass childproof testing, and we independently had to pass AT&T FCC wireless certification.
