The “Modify” Factor: designing engagement

If you have ever taken a yoga class, you know some poses are harder than others. Some poses you can do, some poses you can’t do, and some you can kind of, sort of, do. What determines whether or not a pose is “hard” for someone ranges from experience to motivation to social norms to knowledge to mood to physical capacity to energy.

When a pose is “too hard” any good yoga teacher will encourage a student to “modify” the pose. To modify a pose means to physically adjust your body so the pose is easier, and/or less painful, and/or, more enjoyable, and/or feels better. The lesson in modify is to discover a slightly new and different way to move your body so it works best for you. Typically the decision to modify happens in real time, in that moment of the practice.

Modifying is vital for a quality yoga experience for many reasons, including but not limited to:

  • decreasing pain
  • increasing positive feelings and fun
  • increasing ability and self-efficacy

and overall, empowering the student to practice ways to stay engaged in the class.

Otherwise a student might have a negative experience, feel like they are “not good enough”, end up in pain, and/or never do yoga again.

What digital health products are not doing well yet is designing for the user’s need to modify. At some point, we all need to modify. Whether we are beginner or advanced, calm or stressed, motivated or lazy; sometimes we just need to modify. Being able to modify – because our teacher tells us to or because we decide we need to – in real time is a critical factor in sustained engagement.

So how can digital health products better design for the “modify” factor?

Designing around real human interaction or customer service is key for a healthcare engagement experience.

Some start-up digital healthcare companies  – like Sessions, PokitDok, Sherpaa, Omada Health, Better, Hula (originally and Atelion Health, Inc (originally CollaborRhythm) – seem to be trying. Sessions, for instance, provides exercise health coaches with whom users can interact via text, e-mail, and phone when needed throughout a 12-week program. When a Sessions user first signs up, s/he links with a health coach, who calls to conduct an in-depth starter session. During this initial phone experience, the coach asks a basic set of critical questions to assess where the user is at. Once the program is underway, the coach regularly interacts with the user and vice versa. Sessions Founder Nick Crocker wrote, “people are adding a human layer on top of these [technology] applications, putting the power not just in the hands of the consumer, but in the hands of their network. This provides an incredible resource to doctors, trainers, and others who help people achieve their health goals.” I would argue that the technology is the layer on top of the human interaction, shifting some of the resource burden from the health provider to the user. Which is a good thing.


The main value of designing your technology around a human “authority”(a coach or some sort of figure who the user trusts) is that your solution will “meet the user where s/he is at” when they need to modify.

Sherpaa is a group of NYC based doctors and specialty providers who answer your most pressing healthcare questions via phone or app.  When a user enlists with Sherpaa, they are able to navigate the healthcare system with the guidance of an expert when they need it. Informed decisions made in real time. As you need to modify. As it says on their website, “That’s what we’re here for.”

Philip’s DirectLife uses human coaches to assess which messages get a particular user to eat more healthfully and exercise more consistently. What we are learning is that it is not the same to hear an automated coach saying “You’re doing a great job! I know you like positive feedback so that’s why I’m giving it to you.” The messages must be contextually relevant and personally meaningful in real time. Part of “meaningful” is a belief that the message is coming from a place of perceived authority. offers patients “navigation services to provide the support you need as you face your cancer journey.” That happens through individual mentors who have deep experience with various aspects of cancer treatment. Like one Livestrong user told me “When I found out I had cancer, I went to Livestrong and immediately logged in, and gave them all my details via an online health questionnaire. An oncology nurse called me 24-hours later…and depending on how many boxes I checked, I could be linked to as many “helpers” as I wanted e.g. a Financial, Mentor, Clinical Trials expert, etc. I got a call from someone responsible for matching me to a clinical trial. He gave me info for all the clinical trials around the U.S. relevant to my cancer. I didn’t use clinical trial guy b/c I didn’t want to lose my control over my treatment decisions. I wanted to choose my chemo drug and augment my services as needed as I went. But the oncology nurse was invaluable – she was half shrink/ half nurse. She provided the list of questions to ask my doctor. She knew….She helped me flush out questions and prioritize.”

Social Trust

If you cannot integrate a human authority into your solution, consider building in a social network. A social network solves for the human need because by design, it is person to person. You know there are other real people on the other end of the interaction.  If I knew that when I posted to Facebook, the other people reading were my trusted, valued healthcare providers, I’d engage to share health information because I would believe responses to my post would help me figure out how to modify my health.  This is one reason why patient portals – or Online Health Communities (OHCs) – help users make more empowered decisions and stay engaged in health. Because people who use OHCs trust the other members as authorities and have the chance to practice modifications.

The largest patient portal in the world is PatientsLikeMe (PLM). Approximately 230,000 patients engage with PLM. According to co-founder Jamie Heywood, over 2,000 health conditions are mentioned; 4,000 posts; and 16 million data points are logged per year.[1]

I listened to Ben Heywood, also co-founder of PatientsLikeMe, at the recent Connected Health Symposium in Boston, and he said one big trend they are seeing is users better adhering to their treatments and better remaining engaged in their care. PLM published research in the Journal of Epilepsy that shows how PLM engagement increased adherence tied to outcomes by 19% among patients with epilepsy. “Prior to using the site, a third of respondents did not know anyone else with epilepsy with whom they could talk; of these, 63% now had at least one other patient with whom they could connect. Perceived benefits include: finding another patient experiencing the same symptoms, gaining a better understanding of seizures, and learning more about symptoms and treatments[2] .”  Users of PLM trust other users.

SmartPatients, a start-up patient portal specifically for the cancer community, is also seeing an increase in adherence to treatments. SmartPatients co-founder Dr. Roni Zeiger, during Health 2.0 Demo Day, said “this portal is increasing adherence to treatments due to social support. People are showing up to treatments even though they don’t want to because of their portal peer advice and encouragement.” Point: a patient who intended not to go to treatment modified that decision and instead went.

According to a recent U.S. Healthcare IT report, the U.S. patient portal market is expected to reach $898.4 million by 2017, up from $279.8 million last year — a 221% increase. Nearly 50% of hospitals and 40% of ambulatory practices currently possess patient portal technology. How well those portals are designed for engagement is yet to be seen.

Like one patient recently told me, “I get on message boards to type in questions and it directs me to where people write about the answers. Some of it pertains to me, most of it doesn’t. It’s just some people talking, though I am not sure who these people are. I find out when I read responses on those discussion boards, I have to sift through so much riff raff. Then I wonder what to trust. In the end, I called ahead to the radiology department at the hospital where I am going for my procedure and he explained for me every step of the experience I am going to have. I had an expert tell me what I wanted to know. That helped.”

What this is all about – and what is needed when you want to modify – is trust. Trust that your modification will make it better. So if you are going to build a social network into your product, make sure it allows for trustworthy interactions:             

According to this study, The strongest finding was that “maintaining a highly cohesive network is necessary for building trusting relationships in OHCs” and that portal designers should design so “members easily recognize and reach others whom they can trust…..such as designing and installing member mutual rating systems (for members’ contribution, caring for other members, and integrity)” 

Even better, though, enable a meaningful 1-1 interactions. Build digital health technology that is an extension of what is already working in real life.  I recently interviewed a cancer patient who was first diagnosed in 2007 and then again in 2012, and he said “The conversation where I received the most support during my treatment was right before my first stem cell transplant – I got a call from a friend who had been through it, and she told me what to expect. She talked me through the process and made herself available to me when I had questions. It helped with my decisions. It was so comforting.” He might have been able to have a similar experience with Better – because Better enables users to tap into the massive database of the Mayo Clinic for immediate health care information. It’s not just reliable information, though, it’s on demand assistance. Users can call Mayo Clinic nurses to talk about the information and any discuss questions or concerns they may have. On the spot.

To clarify, designing for the modify factor is not about getting users to your product or program for the first time – it is not about persuading a first time yoga student to enter the yoga studio. The modify factor is about designing the engagement experience once the students is there. Keeping your user engaged once they have arrived.

What you can do:

Conduct user research so you are clear about your target customer’s needs and values. This will not only allow you to empathize and capture user behaviors, but also allow you to know what is needed to build trust. Health is social; we want other people to validate our decisions.

Prototype often so you can test how well your solution is meeting the needs of your users. Too few healthcare companies do this. Health happens in real time – we need what we need when we need it. An ongoing prototyping plans enables you to build agility into your solution.

Define clearly what engagement means to your business and integrate a way to measure that engagement over time so you can regularly pinpoint “the modify factor.”

 *Thanks to @Nir Eyal for pre-reading this post.

One comment

  1. I’m a big fan of taxonomies AND practical tips, so thank you for providing both in this essay.

    Separating “authority” from “social trust” is a really interesting approach. I appreciate that you placed peer coaches in the same category as clinicians because that resonates with what I’ve observed in fieldwork: expert patients and caregivers take on a mantle of authority in their communities that equals a clinician’s authority. I almost wrote “rivals” instead of “equals” but didn’t because I don’t see that adversarial tinge to it.

    Your “what you can do” section is golden. I need to do more of that in my own writing, to close the loop for readers. I had to stretch myself to do it when I led a class on participatory research — a new role for me. Usually I’m cast in the role of dispassionate observer, just pointing things out, observing, but I think it’s part of our responsibility to draw maps, not just point out to people that they’re entering new territory.

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