The Internet of Healthy Things Redux: Chapter 4, The Hardest Sell*

*Thanks to Tara Menon and Gina Cella for their help in editing this piece

This year, I have been blogging about the 10th anniversary of my first book, The Internet of Healthy Things (IoHT). While taking a trip down memory lane, it has been fun to: 

• Assess how well my coauthors and I did in predicting the future.

• Wonder what people we interviewed are doing now. 

• Recall the companies we highlighted and ponder where they are today.

This motivated me to commit to posting about a different chapter regularly throughout the year and to ask you, my valued readers, to grade us.

If you haven’t had a chance to read the first three installments, you may do so here (but go ahead and finish this one first!).

This month, I tackle Chapter 4, The Hardest Sell. This chapter discusses the challenges of engaging patients in proactive health management, particularly regarding remote monitoring for chronic conditions like hypertension. 

Just before the Fitbit (ca. 2009) launch, we began experimenting with smart pedometers at the Center for Connected Health, an early telehealth innovation center at Partners HealthCare (now Mass General Brigham). It turns out that I a) am motivated to adopt healthy behaviors, and b) appreciate having things measured so I can use the data as a guide to track progress. I didn’t realize that these two characteristics placed me in the minority. 

We conducted several trials of tracking devices, providing patients with feedback loops of personal data they could use to guide their behaviors, and our success was modest at best. I thought if we gave everyone these data-driven feedback loops, we could solve the nation’s march toward obesity, diabetes, hypertension, and other chronic illnesses. Well, I wasn’t quite that naïve, but I was pretty excited.  But we learned an important lesson: One of the many reasons people develop chronic illnesses is their difficulty in forming and maintaining healthy habits.  

This insight led to several years of effort to utilize technology to motivate people to adopt healthy habits. Similarly, while I naively believed that simple feedback loops would encourage individuals in their health, we also thought we could apply strategies that mobile developers successfully used to engage consumers in all manner of commerce, from online shopping, rideshare apps, and even banking. As noted in the book, we were aiming to create a consumer health experience that was compelling, sticky, and, yes, as “addictive” as a smartphone (more on this when I dissect Chapter 8).

Some of the things we learned are detailed in this chapter.

1. Many would prefer not to know they are falling short of their health goals. This “out of sight, out of mind” mentality is common in the chronic illness community. Devices like continuous glucose monitors, blood pressure cuffs, and weight scales remind users that they are unwell or not managing their health. And who wants to be reminded that they are sick? One of mobile engagement’s first principles is notifications, which can be very tricky to implement in this context.

2. A second point we made is that the consequences of an extra piece of cake today are felt somewhere down the line, and the human brain is not wired to make those associations or to be motivated by an abstract future state. We called this section “deep in denial” to emphasize the complexity of the psychology, illustrating the downstream consequences of behavior.

3. A third challenge we identified is that many chronic illnesses we need to tackle don’t present symptoms until they are very advanced. Hence, the phrase “silent killer” is often used to describe high blood pressure. I speculated that if high blood pressure were like a broken arm, we wouldn’t need monitoring devices at all. Monitoring tools give us a sixth sense about how our bodies are functioning. 

The use of monitoring tools and wearables such as smartwatches and rings is quite common now, but was just starting to gain traction in 2015. Since then, we’ve managed to identify the population of people who are motivated by numbers (my tribe!) and provide them with all manner of ways to track themselves. We used to call them quantified selfers; now they are just regular folks who are self-aware. How many people do you know who strive to “close the circles” daily on their Apple Watch?

4. Also mentioned in this chapter is the phenomenon that we, healthcare providers, still believe education is the answer. Informing patients that they will face an early death if they don’t adopt healthier behaviors is a failed strategy. Somewhere between the world of annoying notifications and being lectured by your doctor lies a motivational zone for each of us. For some, it involves gamification; for others, it involves goal-setting, and so on. When we wrote the book a decade ago, there were various workplace programs implementing strategies such as donating to a charity you dislike if you don’t reach your goals, forming teams to lose weight together, or paying people to achieve healthier goals. I don’t hear about many of these trendy programs anymore; I suspect this is because they were each effective for a small slice of the population. However, when applied to the entire cohort, they ultimately failed, as each resonates with some but falls flat for most.

   

Of course, I’d be remiss if I didn’t acknowledge the pandemic’s role in creating a surge in remote monitoring and the growing interest—and need—to empower individuals to better manage their health and wellness in various populations. Yet, we are still grappling with strategies to permanently change adherence behaviors for many.

So, using my retrospectoscope as I have in assessing the success of The Internet of Healthy Things in predicting the future, once again, I feel that we’ve underachieved. As noted, the industry has created a tracking economy for motivated individuals but has yet to crack the code for the majority of patients. The nagging question is whether this smaller cohort would be healthy anyway due to their motivation, and how much tracking truly helps. 

We still face relentless growth in all chronic illnesses. Some companies have managed to scale behavior change platforms (Omada Health comes to mind as one example), but it is clearly not easy and is indeed still a ‘very hard sell’ for the broader population.

What do you think? Am I too pessimistic? Share some success with us.