health behavior change

Intro Resources to Contemporary Healthcare Behavior Design

I regularly receive e-mails from folks interested in the intersection of healthcare, behavior design, and technology. They write to ask about my career path and how they might learn more about this professional sweet spot.

Below are my top recommendations for learning more about digital healthcare behavior design:

Stanford’s Persuasive Technology Lab

Product Psychology – this explains everything

Dr. Jay Parkinson

Stanford University School of Medicine Engage & Empower Me

Prescribe Design


Hooked- how to build habit forming products

Texting for Health

The Power of Habit

Influence – the power of persuasion

Designing for Behavior Change

Change by Design

Creative Confidence

This does not include academic publications nor the many countless articles that I believe are super useful; mostly because this list is intended for newcomers to familiarize themselves with the contemporary dialogue.


Digital Health Coaching: how to create success stories

Author’s Note: A shortened version of this post was published on the Rock Health blog this week. Thank you to my co-author, Glennis Coursey for working on this article. 

Meet Mary. She recently decided she wants to get healthy and lose some weight.

So she signs up to work with a personal trainer. Mary likes the sessions but the high cost make them difficult to maintain. She decides to get some workout DVDs and be active on her own. Her sessions quickly start to taper off. She orders a dieting book but never gets past the first few chapters. Her kids give her a Fitbit. She buys a yoga mat.

Mary has almost everything she needs to be healthy. But none of the social support, encouragement, or accountability to actually be healthy.

Then, Mary signs up for digital health coaching.

What the heck is digital health coaching?

It’s no secret that working with a health coach can be a wildly effective behavior change strategy. Research consistently shows that health coaching increases medication adherence, decreases health care costs, enhances perceived happiness, and maximizes overall health related goal achievement (,,,). But the price and logistics aren’t always an option for many people.

Enter digital health coaches.

These are real human coaches who are able to scale their services to large groups of people all over the world using digital tools. When coaching services are combined with data from wearables and apps, coaches can provide almost instant feedback on people’s health choices. This feedback is superior to the feedback a user might get from an app alone because a digital health coach is trained to translate the data on both a social and emotional level. Presenting people with large amounts of data about their behavior isn’t always enough. But presenting data in a personally meaningful context can help trigger actionable change.

Several companies are exploring new and innovative ways to scale digital health coaching including MyFitnessPal, Kurbo Health, Omada Health, ThriveOn and Retrofit.

Efficacy data on digital health coaching is in the early stages, but here are some important lessons from two veteran digital health coaches on how to successfully hook people in creating long term change.

1 – Break cycles of failure.

Let’s go back to Mary. She’s just started working with her digital health coach.

Every time Mary hasn’t succeeded at getting healthy in the past, instead of blaming her diet book or Fitbit or health app, she’s blamed herself. Mary doesn’t think, “These products have failed me”. She thinks, “I have failed.”

Mary’s coach can work to understand her unique history and patterns of failure to support in her in breaking through failure.  How?

2 – Create a success story. Fast.

Almost immediately, Mary’s coach need to help her set a goal she can achieve. Common goals we hear from people starting a new digital health coaching program are:

  • I want a 6-pack.
  • I want to go to the gym five mornings each week.

Coaches can support these as long-term goals, but should quickly help people shift focus to habits and behaviors that have a high likelihood of success. Goals like:

  • I will decrease my waist size by one inch.
  • I will walk my dog around the block three times this week before dinner.

Immediate goal achievement is critical for self-efficacy. Self-efficacy, or a person’s belief in his/her ability to do something, builds over time with successful practice and directly determines a behavior change outcome.

Keeping people focused on the present and near future also increases likelihood of success. Rather than setting out to do 1000 sit-ups for the next year, set the goal to do 10 minutes of core exercises on Monday mornings for the next two weeks. If a person can do sit-ups for two weeks, they are more likely to do sit-ups for a month and so on. BJ Fogg’s Tiny Habits program teaches this concept of baby steps well. When she first started, Mary’s goal was to go to the gym five mornings each week. Instead, her coach worked with her to walk the dog around the neighborhood after dinner three times this week.  Keeping Mary focused on completing something “smaller” in the present and near future increases her likelihood of success.

3 – Provide an enjoyable reason to believe this time will be different.

Most people, like Mary, have been slowly gaining weight pound by pound for years. They often believe – and the diet and fitness industry often tells them – that change can happen fast. But building new habits takes time. Habits are socially, emotionally, and neuroscientifically very difficult to break because they are hard-wired into the habit default center of the brain. It is easier to create a new habit than break an old habit. And to create a new habit well we must find the joy in it.

One of Mary’s new goals is to follow the Mediterranean diet.

She’s been trying the diet long before she started digital health coaching. She’ll stick with the diet for a while, but then her old habits kick in and she’ll head to the bakery for an afternoon pastry.

Instead of focusing on breaking Mary’s established pastry habit, Mary’s coach encourages her to buy some hummus and carrots for her office so she can practice eating those during her afternoon snack break. The hummus she buys is at a market she loves to visit. She soon finds that eating the hummus and carrots make her more energized and notices she’s less tempted to head to the bakery. Her coach validates and celebrates her decision every time she chooses the hummus.

Mary starts to believe that working with a digital health coach is what she needs to learn how to create habits she can maintain. This time will be different. This period of coach-led, data-driven, dynamic experimentation is critical for putting users on a path to success.

4 – Personalize for long-term engagement.

Only after coaches have established social trust do they have the opportunity to really get to know the unique lives and challenges of the people they work with. Now that Mary’s had a taste of success, she’s beginning to trust that her coach can guide her in making better decisions.

One thing we hear over and over again is “I want to know that my coach or my program knows me.”  Social trust and personalization is needed for a successful coaching relationship, because

  •       Frustration results when people really want to do something but cannot;
  •       Annoyance results when something is really easy to do and people do not want to do it;
  •       Fear of failure is almost constantly present.

An example of the level of personalization digital coaches should strive for with the people they work with might be:

  •       Rather than: Have you walked for 30 minutes today?
  •       Instead: Hi Mary. Are you and Rover going walking along the river this afternoon?
  •       Rather than: What’s for dinner tonight?
  •       Instead: Hey Mary! What are you thinking about making for dinner tonight? I’m guessing your avocados are just about ripe by now…

Going Forward In Digital Health Coaching

This year we’ve seen a surge of business announcements related to digital health coaching: In February, MyFitnessPal announced it’s acquisition of Sessions. In April, Omada Health completed a Series B funding round of 23 million dollars. In May, Weight Watchers acquired online fitness startup Wello. In July, Kurbo Health announced that it raised $5.8 million to “use digital health coaches to help fight childhood obesity.”

Each of these companies leverage the power of technology to strengthen and scale human-to-human coaching relationships to make big impacts on people’s journey towards better health.

It’s not all about the technology, though. It’s about leveraging the power of technology to strengthen and scale the human-to-human relationships that can hook people better than an app ever could. Digital health coaches are the human force behind people’s journey to better, sustainable health.


A rise in E.R. visits explained by brain & behavior

The Wall Street Journal recently published a story that ER visits are on the rise despite rollout of the Affordable Care Act. 

Lawmakers wanted “to give the uninsured better access to primary-care doctors who could treat routine ailments and prevent chronic disease, with the intent of keeping patients out of the ER and lowering the cost of care”….but “Instead, the ER doctor group’s research and several other recent studies suggest that people who gain private and government insurance are more likely to seek emergency care.”

Of course we can point to a lack of sufficient primary care providers – we do not have enough here in the U.S. to handle all the newly insured. However, here’s a different perspective on why people are still seeking care in the ER:

Most uninsured people go to the ER when they need medical care. This is their habit. Because for years in this country, without health insurance, you could still seek medical attention in the ER. A habit is very difficult to break. In fact, an established habit is harder to break than forming a new habit is to make.

When you do a new behavior – let’s say, cook a meal you have never cooked before – your brain works hard to think about how to do it…how to follow the recipe, what temperate to set the stove at, etc. All that thinking takes place in the front of your brain, the prefrontal cortex. Keep in mind, the human brain is 1 – 1.5% of a human body weight, but takes up to 25% of the energy a human body produces to work. So any time you do something new, the brain function related to that new behavior consumes a lot of energy in the prefrontal cortex.

Once that behavior becomes familiar – meaning, you can cook that meal so easily you don’t need to think about the details – that thinking moves into the habit center of the brain, the striatum. Cooking that meal then becomes your habit. Habits, or defaults behaviors, are strongly wired in the brain and require little energy to maintain. This is why eating behaviors are so hard to change.

As we are learning, giving health insurance to people who are in the habit of seeking care in the ER will not be enough to break their habit. Going to the ER is their default behavior. I would bet that instead, they figure they can continue going to the ER and be covered. Their habit will now be paid for. These folks will not learn a new habit of going elsewhere until we design obvious and easy pathways for them to develop a new habit around seeking care.

Learning to go to a primary care provider is a new behavior for the uninsured who are now insured. Which means as health care designers, we need to figure out how to effectively tap into the prefrontal cortex of millions of people. I’d say we have important work to do!



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.

Reference Based Pricing

Below is a raw chronology of how health insurance companies have arrived at reference-based pricing (RBP) or “maximum allowable amount” or “max price.” RBP is the new “in-network.” Just one of several trends emerging in this new age of healthcare consumerism in America. It will impact our out of pocket (OOP) costs.

  • 15 years ago when the Clinton administration introduced HMO models, independent/private practice doctors negotiated a price-per-patient [“capitation”] deal with health insurance companies. Which means the insurance companies went to docs to say “we have 1 million patients in our network, we will send them all to you for $X/per patient” and the docs said “okay” and so “in-network” was born. A patient was allowed to go only to that provider that the insurance co. had negotiated with. It was an exclusive deal. And doctors who were good at negotiating/business, made a lot of money.
  • Over time, doctors got angry, because most doctors are not good at negotiating, so insurance companies were making loads of money, and doctors were losing; plus, these contracts were fixed prices over 5/10/15 years, so they did not account for rise in operating/living costs. So private practice/independent doctors banded together to argue against insurance companies. In response, health insurance companies sued the doctors under anti-trust laws. And the insurance companies won, because doctors collaborated with each other even though they were not in the same company – they colluded to negotiate with the insurance companies – which is considered price-fixing. However, when doctors are a part of the same company (like Mayo Clinic), then it’s not price fixing. So doctors formed a new entity in medicine, known as multi-specialty groups. The only examples of multi-specialty groups at the time included for instance, Mayo Clinic and Kaiser Permanente. (more…)

Healthcare towards 2014

As we continue to digest the U.S. Supreme Court rulings last week, here is a snapshot of how I am digesting it all.

Mandate: Every US citizen must have health insurance and if not, we get penalized in the form of a tax. It’s not an enforceable tax (nor is it very much money) so unfortunately, many people will opt not to purchase insurance – this is a weakness in the economic model. (more…)