Relationships are fuel for motivation and behavior change (both positive and negative). Motivations, triggers, and ease of action are keys to enabling behavior change.

Whether it is the new hot topic of patient engagement, consumer-driven healthcare, outcomes-based or value-based payments, or new clinician workflows, the core of all these efforts is successful behavior change.

Startups tout their ability to drive behavior change with expert behavioral scientists. Provider organizations proudly unveil new patient experiences and technologies to improve workflows. Payers introduce pricing tools “as convenient and easy-to-use as Amazon” so consumers can make better and more informed medical choices.

All these new and different capabilities come to market with the promise of revolutionizing healthcare. Yet few deliver on that promise, and many find themselves eating crow and running, not walking, back from their bold claims. Too many of these well-meaning efforts end up creating eyebrow-raising skepticism about whether behavior change can really happen.
Why do so many of these efforts fail? Why do some work? To answer these questions, I will describe some of our experiences and the seven key resulting insights we have found around driving behavior change to illustrate what has worked.

1. The first important important step is to think about what framework will you use to drive the desired behavior change. There are many frameworks to choose from so this is a non-trivial task. When chosen appropriately a framework considers who, where, and how they are when the desired behavior change is attempted. Then motivations, triggers, and ease of actions can be effectively addressed.

In my organization, we use games to motivate and help patients manage chronic health conditions. A subtle but important distinction, especially for driving sustained behavior change, is the difference between gamification and games. Gamification is the concept of applying gaming mechanics such as badges, points, leaderboards, in a non-gaming scenario. Gamification doesn’t necessarily have an objective. A game, however, is a complete end-to-end experience. A game has a set of rules, a beginning, middle, and end, and an objective to meet. Consider gamification as a set of tools to build a house versus the game which is the whole house itself.

Gamification will drive behavior change to a certain extent. A game, when executed properly, can create behavior change like never seen before. A common and well understood example of this effect was the Pokémon Go phenomenon. There were numerous reports of people who started moving around – people who were previously sedentary. Players self-reported improvement in physical well-being and reduction in their depression. Some case managers we work with reported that Pokémon Go inspired some of their most difficult-to-reach patients to start exercising. With Pokémon Go, the objective of the game is to collect all the Pokémon. Foursquare, a local search-and-discovery service mobile app which provides search results for its user, is an early example of a gamified experience. It offers badges and progress towards being a “mayor” of a region but there isn’t a final objective. Gamification of the Foursquare experience drove engagement and there was a stickiness. Pokémon Go’s gaming experience drove engagement that eclipsed Foursquare’s.

2. One of our key findings is that a product or experience must be empathetic to the user if it is to drive behavior change. Failed efforts don’t consider the mindset, emotional state, and cognitive ability of the end user. So, as we build our games, we consider the motivations a patient may have. For example, many times people play games to disconnect from their reality. If we believe one reason a person may be playing our game is to get some relief, we’d consider bringing up health topics or encouraging activities without directly bringing it up. Or raising these topics in a respectful way that encourages and honors a patient’s agency and gives them back control in what can seem an uncontrollable time.

Patient Story: “I am with the fox.” An example of driving sustained substantive behavior change and understanding patient motivation. One of our Medicaid patients was given our mental health game to help her with impulse control issues which would usually result in anger outbursts. In our game Socks the Fox is the protagonist. The patient had one of these outbursts in the clinic that was so disruptive that supervisory staff was required to come out to the waiting area to subdue her. When they came out, they found her sitting in a chair, gripping her phone and breathing. When asked what she was doing, she said,”I am with the fox.” This illustrates that experience was approachable and non-threatening enough that she was willing to try it once. Before this incident it looked like she had used previously used the game multiple times during similar times of crisis. This created self-awareness and gave her agency so the next time she found herself in a similar situation, she had tools and knowledge to know what to do. And she trusted our game to do so.

We talk about putting the “humanity back into healthcare.” We do this with art, language, pacing, and color scheme. This also requires a great deal of empathy for the end user . When we first implemented the beta test of our first game, several users complained that the language our team had used was very off-putting. We went back and edited the language to align with their expectations as they began their journey. As a result, we’ve had traditionally difficult to-reach populations, such as Medicaid patients, call us and tell us they were, “ready for the next level” in the journey of improving their mental health.

3. Relationships are also key to driving behavior change. I believe that it will ultimately be an effective collaboration of technology and clinicians that will truly drive health outcomes – it will not be one or the other. A key attribute of successful games is to design in a place for the different relationships that are important in a patient’s health journey. One critical consideration is the relationship with their clinician. Too often, patient-facing solutions omit this key part of the equation. Clinicians can send messages, assessments, or provide in-game incentives and directly impact the game play.

Patient Story. “I was excited to receive state-of-the-art care... My doctor went above and beyond.” That was the reaction a 21-year old biracial transgender individual reacted when her physician recommended our game. This patient didn’t like to talk to people or about their feelings. However they did enjoy working through their problems by texting with Socks the Fox. And they found it an effective tool for them and it strengthened their relationship with their clinician.

We also have included a way for patients to include their support networks as part of the gaming experience – another critical series of relationships important to their healing. In our case, we enable players and their support network to work together and practice daily gratitude.

4. Meet your customers where they are. For clinicians, it is important to create tools to help them strengthen the bonds with patients while improving their efficiency. Systems should fit into a variety of workflows instead of imposing a methodology. And we’ve discovered that clinicians are now using these tools in ways they didn’t even know they could, changing their workflows themselves. To cite just one example, because players can sign into any device to play our games, we find case managers handing their own phones to patients so the managers can observe play even for patients who don’t have a phone with them in their session.

5. It is very important to deeply understand what is one key utility, function, or pain point you want to solve for your end user(s). Focus your solution on solving that well first. Too many companies try to be all things to all people and end up with an undirected solution that does not do any one thing nearly well enough. Get that one thing right, and you earn the right to grow from there. Many digital health companies now have moved beyond just providing a technology/solution to providing supporting services that help with deployment or other aspects of patient care including such as appointment scheduling or patient transportation.

6. Effective behavior change is about easily incorporated, small, repeatable, incremental steps. This is particularly true if someone is overworked, tired, anxious, fatigued, or distracted. Make sure not to design more than your end users can absorb. This requires listening not just with an open mind but an open heart.

7. Finally, drive implementation with compassion. And you’ll achieve engaged patients driving their own outcomes.