How to Differentiate between mHealth technologies: The Four Elements of mHealth Technologies that Predict User Engagement

What keeps us engaged in mhealth technologies?

I had the pleasure of attending the Partners Connected Health Care Symposium in Boston, MA, on October 24-25, 2013 where forward-thinking health and technology professionals shared ideas in connected health care including innovators in the mhealth software industry such as, Philip Chen, Sam Patel, Eric Gombrich, Peter Costello,  John Moore, Ben Haywood, Peter Catford, and amazing academics, entrepreneurs, doctors and thought-leaders such as Dr. Joseph Kvedar, Amy Cueva, George Kassabgi, Peggy Johnson, and Dr. Joseph Cafazzo, just to name a very few!

My big take-away from the conference how to sort out which mobile health apps and software work and which don't and why.

It can be hard to how to differentiate between them.  But if we are going to use them, we need to know how to pick and choose.

Why mobile health matters.

But first let's review why mobile health matters so much.  With 90% of the world's population having access to a smartphone, 40,000 health apps currently available on the market and software companies creating new telehealth software every day, mobile is truly the world's largest technology platform and the world's largest health delivery opportunity.

David O'Reilly, CPO of Proteus Digital Health, hit the nail on the head when he said, during a panel discussion:

"The most powerful health care tool we have ever had is in everyone's pocket."

Mobile health matters because it is everywhere.  Smartphones are our favorite technology.  But it also matters because it works, providing improved patient outcomes at reduced cost.

But if you are a health or hospital administrator looking to invest in an mhealth technology, what should you look for?  How do you tell what is good and what is not so good?

George Kassabgi, entrepreneur and co-creator of Catch-Health spoke about what determines patient engagement in a mhealth product on Thursday afternoon.

"Dumb Ways to Die" Red Button

What doesn't work!

First I learned about what doesn't work.

Patients with a chronic health condition were given a telehealth device to use at home to help manage their condition.  If they pressed a button, the machine would automatically send critical health infomation to their doctor.  Simple, no?

Well these patients failed to comply with this device at an astonishingly high rate!

"What!" you are saying,  "What is easier than pressing a button?"  Why won't those patients, just press the button (echoes of Dumb Ways to Die in my head... hmm hmm hmm)!

But, as tempting as the button is to the morphoid on Dumb Ways to Die (for those of you without tweenish children, this was just recently a youtube hit sensation), a button doesn't really engage us humans, especially not after we learn what happens after pressing it the first time.  It's not warm, pretty, or exciting, and more than anything else, it does not engage us.  We tend to forget about it, and we definitely won't press it more than once.

What Works!

In essence, technology works if it is designed around the human brain, around what motivates us and makes us feel good.  George Kassagbi outlines the four features that predict user engagement in mhealth technologies. 

Tip #1:  George lays it out for us. First he says, the technology has to get us to work on a "team." We are, he pointed out, inherently social creatures, and are motivated to act when we know other people can see us, when we have an opportunity to mimic other people's behaviors, and when we know others are counting on us to be there.  Guess, what humans like being on teams!  I knew that!

So, let's say I am a woman recovering from depression and I log on to a service in which I can interact with a limited number of my peers, also struggling through recovery.  We all rely on each other for support and I am motivated to log on because I know we are working together as a team to be successful in recovery.  I want to see what they are doing, I want them to know what I have learned.  I interact because it is social and it draws me in with the opportunity to connect. 

Tip #2:  Secondly, he says, the technology has to help us form "tiny habits."  Instead of insisting on big changes or insisting on big behavior changes, the technology interface helps us learn new habits in small steps, reinforced by the social context.

Today, I see that my friend posts his favorite dark greens salad recipe and then lets me know that getting my daily intake of antioxidants is actually going to help my mood.  Because he suggests it and because I like salad anyway, I might just try his salad!  This is a small step for me, but combined with many other small health improvements, I am on the path to recovery from depression.   

Layers

Tip #3:  The third element he shared with us is the concept of, "unfolding layers,"  This really isn't as mysterious as it sounds.  Simply put, its about incentivizing and rewarding users for engagement.  Basically, he says, if a service provides ways for users to advance in levels, gain points, open new quests, earn badges, or even to compete with other users, it will be used repeatedly, providing greater benefit to the user.

We all want to achieve, in fact we are suckers for achievement!   I will gladly log on to record my daily self-care activities and medication compliance if I have the opportunity to earn points for doing so.  These points will move me into "Double Power Level," and I really want to be the first one on my team to get there!

Tip #4:  Lastly, George tells us, we need to make the technology platform positive and fun!  For me, this goes right along with the three he has already mentioned, but for George it's important enough to be mentioned separately!  I like it!

When my health coach posts an inspirational quote each day, I seek it out because it's positive and uplifting.  I engage with the service because I want something that makes me feel better.  I like her encouragement and her warmth, and I know I need it when I am feeling down.  And engaging more means that I get better over time.

The Good Ones Keep Us Coming Back

George tells us how to distinguish the good apples in mhealth from the not so good ones.  The good ones engage clients with intelligent design, so we keep coming back.  These technologies create a team for users, help to encourage small steps in health improvement, help to incentivize use through rewards and unfolding layers, and create a positive feeling for their users.

The bad ones offer utility without intelligent design.  They may offer a simple platform with information or one simple function, not tied to other people or allowing us opportunities to achieve.

Mental health app creators take heed, for these are the elements that distinguish the not-so-great mhealth tools from the stellar.

And for the rest of us, consumers, advocates, mental health clinicians, and administrators knowing what we now know helps us figure out which one to use.

Whether you are investing $2.99 for a mental health app for your own personal use, or whether you are investing $29,900 for a new telemental health platform, first ask yourself if these four elements are present, and whether you as a user would want to keep engaging with it.

If the technology will engage the client so they keep coming back again and again, the investment may be very much worth it.

Pics
Engaged:  http://www.flickr.com/photos/expressmonorail/2994523467/
Dumb Ways to Die Button  www.survivingcollege.com
Layers http://www.baptistmilestone.com

Text-Messaging: Real Service for Real People

October 11, 2010 was a day a therapist hopes she never will have.

For a therapist in San Francisco, this day started with the discovery of distressed text messages on her phone sent by one of her young clients, a teenager named Alex. He was desperate and thinking of ending his life.  He wanted to connect with her and needed her support.  But she didn't provide overnight text-messaging services.  The help he needed didn't reach him in time and he chose to end his life by suicide.

You can find more about this heartbreaking story at the website his family created, The Alex Project. 

Thankfully, San Francisco-based crisis text services have been created as a result of this tragedy to prevent further teen suicides.

In fact, text messaging services are popping up all over the country in response to our growing recognition as parents, advocates, mental health professionals, systems planners and funders, that in-person and phone-based services don't work for the majority of youth in crisis. 

In Minnesota, Nevada, and San Francisco, text services have been created and are doing phenomenal work to serve as a lifeline for youth who prefer to communicate via text messaging.  For a complete list of text-messaging services in the USA and abroad (luckily there are many) visit the unsuicide wiki, maintained by Canadian mental health advocate Sandra Kiume.   

A national service has also been formed.  Mental Health Advocate Nancy Lublin of DoSomething.org has worked tirelessly to create a new national service, the Crisis Text Line, which just launched in August 2013 and eventually will reach all youth in crisis in any part of the country.  This is a life-saving service that will be relied on by hundreds of thousands of young people every year.    

But, as Alex's situation poignantly illustrates, these anonymous texting services are not enough.  People want to connect with people they know and trust when they are in crisis.  Alex wanted to text his therapist but she did not provide mental health support via text-messaging.

In fact, many clients want to communicate with their therapists via text messaging and email.  Texting communications can be used for support as well as other general communications such as scheduling appointments. 

Clients want to text their therapists because its just how we communicate.  With 72% of adults and 95% of teens using their phones for text messaging every day, according to a Pew Internet study, it is becoming as ubiquitous as the telephone. 

And for many people, especially teens, who find verbal communication uncomfortable, texting offers a sense of safety, creating an environment that facilitates communication about sensitive subjects and difficult emotions. Thinking about how to reach teens by text-messaging to prevent suicide seems paramount.

The mental health profession is scrambling to catch up.  The majority of therapists and mental health centers do not offer text-messaging services.

But now is the time to move and adopt this service.  There are many software solutions already available and tried and tested to fill this gap.

Applications such as Hipaa Chat allow for two way text-messaging and video conferencing from an iPhone, with capacities for an Android system coming soon.  This application immediately destroys all information transmitted on it, so that no personal health information is stored on the phone where it can be harvested by applications and stored outside of a secure clinical record. 

But this is not the only software solution available.  Mosio, Educational Messaging Services, and iCarol also provide industry-standard encryption to provide secure text-messaging.  Each platform offers slightly different features.  Mosio combines email, chat and text messaging options together, EMS's Prevention Pays platform provides robust outgoing messaging as well as one-on-one texting, and iCarol offers chat and texting on one platform with substantial reporting capacities. 

And models for keeping these services sustainable and staffed also need to be explored.  A partnership with a local crisis center is the most cost effective and secure way to ensure your clients have 24/7 access to someone who can respond immediately and then communicate with the therapist if needed in an emergency.

Therapists can help their clients feel comfortable contacting the crisis center, explaining that they work together and the center can contact the anytime therapist if there truly is an emergency.  In this way the crisis center works effectively as an extension of the therapist-client relationship to facilitate help-seeking in a time of crisis. 

I encourage mental health professionals to start exploring these options actively and now!  People in crisis are trying to reach out for help every day via text messaging and we currently are unable to respond.

 

We are behind the curve, not meeting people where they are and this has resulted in lives lost.  Let's create real, responsive and accessible mental health services for all people. 

I know that text-messaging services can be a big part of that solution.

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