Introduction Crowdsourcing Feedback Connectivity Enables Competition Placing Bets, Fundraising, Real World Rewards Building Virtual Worlds,

Characters Metrics for the Already Motivated? Health Outcomes as Motivators Regulations Holding Back Feedback Loops?

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odays health and fitness devices are connected. Whether they are Bluetooth-enabled, WiFi-ready, full-on cellular, or easily plugged into a mobile, these devices are collecting data that is much more meaningful and impactful because it is not locked within the device itself. This mobility of health and fitness data is a key enabling factor for the many health behavior change experiments currently being led by consumer health startups. At the heart of these experiments these new devices and companion apps the search is for effective, positive health feedback loops. At its most basic level, the kind of feedback loop often leveraged in these experiments follows these three steps: 1. Device collects data. 2. Data moves to application. 3. Application provides device user with personalized feedback. Granted the three steps outlined above often occur right from the same device. Smartphones equipped with motionsensing accelerometers, location-aware GPS chips, and increasingly better cameras, have helped make the smartphone a standalone health and fitness data collection hub. With their current suite of sensors, however, smartphones are not able to collect data related to all of the major biometrics. In recent years blood pressure monitor makers, weight scale manufacturers, blood glucose meter developers, pulse oximetry device makers and more have added connectivity. As a result these device makers have had the opportunity to transform themselves or at least augment their current status from hardware companies to software companies with companion applications or even service plans attached to their device offerings.

Of course, not everyone has fully embraced that opportunity. In early 2011 iHealth Lab, a Mountain View, California-based subsidiary of China-based medical device company Andon Health, became the first company to have an FDA-cleared medical device sold at Apple Stores. As the name implies iHealths Blood Pressure Dock connects directly to an iOS device just like a charging dock or speaker dock accessory. The blood pressure device is actually controlled by its companion app, which the user downloads to the iOS device from iTunes AppStore. The iHealth BPM apps feedback is sparse and streamlined by design. Apart from the big, centered button that the user pushes on their iOS device to make the cuff inflate and take the blood pressure measurement, the app offers a simple graph that shows where the BP reading falls on a scale of dark green, green, yellow, orange, dark orange and red. It also offers a historical table of past readings and a comparative color-coded chart for past BP readings. Like almost every other company that offers connected health devices, iHealth keeps feedback to qualitative colors to avoid moving into the more regulated territory of diagnosis. Are we looking to be everything to everyone? iHealths Senior Vice President and General Manager Adam Lin asked. No. Forget whether or not we could do it, no one has ever done both hardware and software incredibly well. Apple may be the exception. Our focus is still on the hardware, first and foremost. We are focused on enabling connectivity and

ensuring the data is truly mobile, secure, and not restricted. There are a number of [third party] apps out there that do [software] really well. Considering iHealths success with its Apple partnership, Lins comments are understandable. While many others working in connected health agree that opening APIs and enabling third party apps to use data collected by dedicated devices is an important trend, most companies building hardware also see companion apps and services as a big opportunity. Some even believe the service and software side of the digital health opportunity is the bigger one. This report aims to highlight and illustrate some of the ways digital health companies are using feedback loops in an attempt to encourage healthy behaviors. While this is not a comprehensive document, it will provide a broad overview of the most common types of feedback loops and mechanisms used by consumer health applications today. It is also worth noting that many of the digital health services mentioned here offer a number of different kinds of behavior change mechanisms beyond the ones highlighted in this report.

iHealths Blood Pressure Dock and BPM iPad App

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// Crowdsourcing Feedback
When Silicon Valley-based consumer health startup Massive Health launched in 2011, its founder Aza Raskin, who formerly served as the creative lead at Mozilla Firefox, wrote that health care needs to have its design Renaissance, where products and services are redesigned to be responsive to human needs and considerate of human frailties. Apart from evangelizing the need for a design Renaissance in healthcare, Massive Health became the leading proponents for better healthrelated feedback loops. The feedback loop became core to the startups original pitch. The human brain famously doesnt deal well with delayed gratification, Raskin wrote. The reason why weight is hard is because the feedback loop is too loose: The cake I eat today doesnt materially change my body for the rest of today or tomorrow. Its the incremental amount of cake I eat or dont [eat] over weeks and months that makes me fit or fat. Our brains pleasure circuits lead us to optimize short-term happiness (cake!) over longterm healthiness (obesity, coronary heart disease, diabetes). Massive Health used the dashboard that Toyota included on its hybrid Prius cars as an example of how feedback loops can change longstanding behavior. Think about it like driving a car, Raskin wrote. While you know it is bad for the environment to drive, that knowledge doesnt really change your behavior. When the Prius introduced a large screen with instant and average MPG with a pretty graph, Toyota created a small breed of hyper-milers and a much larger populace that changed routes and driving behavior to optimize that number. Toyota had tightened the feedback loop and pushed people to drive more green on a daily basis.
The Eatery iPhone App by Massive Health

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In November 2011, nearly a year after the companys founding, Massive Health launched its first experiment, a free iPhone app called The Eatery that helped people get feedback on how healthy their food choices were. The apps core feature enabled users to snap photos of the food they were about to eat, label it if they wanted to, rank it on a spectrum of fit to fat and then share it with other users of The Eatery app. Within a few minutes the community of users would give the snapshot of food their own numerical ranking on the fit to fat scale, and the users food submission had a crowdsourced health review. While the company admitted crowdsourcing the reviews is not as precise as using a team of dieticians, the startup said research shows that collectively people are good at rating the healthfulness of food. Good was good enough for the purposes of the experimental app. Seven months later Massive Health amassed nearly 8 million crowdsourced food ratings from people in more than 50 countries. The person about to eat the food photographed rated the food as healthier than the rest of the community about 72 percent of the time. The company also found that people eat about 1.7 times less healthy with each passing hour of the day. In an early interview shortly after The Eatery app launched, Massive Healths head of business development Andrew Rosenthal noted that part of what makes an app engaging is speed. When The Eatery first launched, it only took about 2.8 seconds to snap a photo of food and have it appear in The Eatery, which is the same amount of time it takes to take a photo and have it appear in the iPhones native camera app, according to Rosenthal. When Apple saw that we could match their native camera time, they were impressed, he said.

Withings iPhone App and Twitter Integration

While Massive Health stands out as the biggest evangelist of feedback loops in digital health, many other companies have leveraged crowdsourcing and social media channels in an effort to create meaningful feedback loops. Soon after it first launched its WiFi-enabled weight scale in the United States, Francebased Withings integrated its web app with Twitter so that users could share their current weight, weight goal, and how many pounds they have to go, in real-time, daily, weekly, or monthly via their Twitter account. While the integration was something of an open-ended feedback loop, the intent was clearly to enable friends or Twitter acquaintances to encourage or at least comment on the users latest numbers. The new feature was met with considerable skepticism from tech blogs. Engadget

called the integration a way to ensure that your followers will start dropping faster than even you could imagine and that Withings had given Twitters iconic fail whale a new meaning. Despite Engadgets negative review for Withings Twitter feedback loop attempt, in mid-2011 a newspaper in the United Kingdom called The Daily Mirror published an article about a 40-year-old man who claimed posting his weight on Twitter for all his friends, family, and work colleagues to see was the motivating factor that got him to make better decisions about his diet. He ended up shedding about a quarter of his body weight, according to the newspaper, without attempting any special diet: The prospect of going into work and having to face people knowing you had put weight on wasnt a great one, he explained. \\

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// Connectivity Enables Competition

Crowdsourced judgment and the prospect of embarrassment arent the only social network-enabled feedback loops that digital health companies employ. Connected health devices also make a wide variety of competitions possible. Boston-based Partners Health Care spinoff Healthrageous has developed a consumerized version of disease management that incorporates some elements of workplace wellness initiatives. Healthrageous integrates connected devices from various medical device makers, including, activity monitors, weight scales, blood glucose meters, blood pressure cuffs and more to continually collect and track a users various biometrics. With this data, Healthrageous creates personalized action plans for each of its participants, with specific, incentivized behavioral goals in mind. The Healthrageous platform also captures Healthcare Effectiveness Data and Information Set (HEDIS) measures for the payer to benchmark progress. Once the platform begins to notice unhealthy patterns, the automated system can ask the participant questions to help pinpoint which behaviors need to be changed. Once Healthrageous has established a particular health goal, it begins to leverage its social features: For example, it invites family and friends to provide encouragement to the participant or it can use the specific behavior change goal as part of a corporate-wide competition. Workplace competitions see one group of employees teaming up to compete against others where individual participants get points for making progress on their individual goals. Work colleagues are not necessarily privy to the specifics of each others goals or health problems, but they might know when they are making progress or slipping based on how many points that team member contributes. Healthrageous CEO Rick Lee describes the end result of the platform as a virtuous cycle with a biofeedback loop. While Healthrageous may be one of the few companies on the leading edge of consumerizing chronic disease management through competitions, many fitness applications have included competitive elements in their mobile apps. RunKeeper announced a major upgrade for its popular running app in October 2012: The addition of a personal leaderboard that shows how active users are in comparison to their friends. RunKeepers app uses the GPS chip in a users smartphone to track runs, walks, bike rides, hikes, and other activities. RunKeeper now shows which of your friends have been active most recently and how many activities they have done in the recent past. Those friends who have not been active recently are given a rank that displays an image of a couch. The app also now enables friends to nudge each other if they think they should be trying to be more active. Once a friend is selected, the app gives users the option to tell their friend to go for a run, go for a walk, or go for a bike ride. Many running apps also make it easy to run virtual races with others who have run a similar distance or the same route at a different time. These same features can enable runners to race against themselves to beat past running times.

RunKeepers run tracking app with new Leaderboard feature

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Sleep coaching company Zeo does not offer an explicit competition feature as a part of its sleep monitoring platform, but because the company has found ways to quantify how well its users are sleeping, it has enabled competitive sleeping. Zeo Sleep Manager Mobile is a sleep phase monitoring headband that connects to a users iOS or Android device and continuously transmits data about the wearers sleep health as he or she sleeps. The Zeo app on the users phone tracks how much time the sleeper spends in each of the four sleep phases, how long it takes them to fall asleep, how many times they wake during the night, and other metrics to determine a composite sleep score, called the Z Score. Upon waking the user can review how much time they spent in the REM phase of sleep, for example, along with the other metrics, but the Z Score is the easiest one to use as a reference point. Its also an easy way to compare how much better of a sleeper the user is compared to their spouse, sibling, parent, or friend. \\

// Placing Bets, Fundraising, Real World Rewards

Sometimes friendly competition is not enough of a motivator for sustained behavior change. GymPact, which launched in early 2012, helps users stay committed to their workout regimens by promising to pay a certain amount of money if they fail to go to the gym. GymPact users make a pact at the beginning of the week by setting a dollar amount of their choosing that they have to pay if they dont meet their goals. A user might put $50 on the line if they dont make it to the gym three times this week for a minimum of one hour. If the user fails to meet or exceed its goal, GymPact keeps its $50, but those who successfully make it to the gym as promised, also share a portion of the money paid to GymPact by the non-adherent members. The service uses both positive and negative feedback loops to keep users engaged. GymPact leverages the GPS chip in the participants phones to help confirm whether or not that person actually went to the gym. Of course, rewarding people with money or other gifts for good behavior is not a novel concept. Determining whether a person is actually active is the trickier part of the equation. Another startup, EveryMove, is developing a platform that offers rewards to users who can demonstrate an active lifestyle. EveryMove users earn points for everything from biking to mowing the lawn. Everyday activities that are self-reported, like mowing the lawn, count for less points than those actions that are more easily confirmed or quantifiably tracked through a GPS-enabled app like RunKeeper. Friends can cheer EveryMove users on too and that also adds a few points to the total. EveryMove points can be redeemed for rewards that will come from brands, employers, or health insurance providers. EveryMove has a number of partnerships with fitness applications, but it also recently inked a deal with a major fitness equipment maker, Precor. When an EveryMove user logs into their account from a piece of Precor exercise equipment, the activity gives them more EveryMove points. The success of EveryMoves feedback loop, of course, will partially depend on the quality of its rewards, which are largely still in the works. In May 2012 the company received $2.6 million in funding led by Sandbox Industries, which manages the venture capital fund of BlueCross BlueShield, so its prospects for landing health plans as customers has brightened. At least one activity monitoring device company offers a less self-serving monetary incentive to its users: Striiv, the makers of a simple smart pedometer device specifically designed for middle-aged women, enables users to earn points that can be redeemed for dollars that get donated to various charitable causes.

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Mobile devices are making a huge impact on the health care industry. As consumers are snapping up connected devices, the medical device industry is following suit; creating systems to provide clinicians with real-time access to their patients data around specific therapies. The key to any therapy is compliance, and mobile health is no exception. Unless mobile health applications are responsive and reliable, patients and physicians will lose patience, and the promise of mobile health will go unfulfilled.

The Striiv device is a $99 standalone pedometer (no mobile phone required) that can hang on a keychain or attach to a belt. Its sensors are able to differentiate between walking, running, climbing stairs, and hiking, according to the company. Using points earned from activity, users can donate clean water to children in South America or polio vaccines to children in India thanks to Striivs partnership with GlobalGiving. \\

// Building Virtual Worlds, Characters

Striiv offers the charitable donations reward as just one way to encourage its users to stay active. The company helps users visualize their progress through a game called MyLand, where movement translates to new wildlife and plants on an enchanted island. Striivs MyLand game takes its cues from the wildly popular Facebook-based game FarmVille, which made Zynga a household name. While FarmVille sees users spending virtual currency to build their virtual world, MyLand runs on activity. A step walked detected by Striiv equates to an energy point in MyLand. Running earns five points per step. Climbing a stair equates to 10 points. The world automatically grows and thrives based on the users activity, and inactivity leads to the opposite. Mindbloom is another wellness company that aims to help users visualize their progress. Mindbloom users plant a virtual tree and give it leaves that represent different aspects of their life that they would like to focus or improve upon. These leaves might represent health, career, relationships, finances, spirituality, and more. The application then encourages users to make small but meaningful changes to their lives given the time constraints they face to improve the quality of their lives. Not every virtual structure used by health behavior change companies needs to be as complex as Mindblooms Life Tree or Striivs MyLand. When Fitbit first launched its activity tracking device in late 2009, it debuted with a slender blue flower that glowed on the outside of the device. The flowers height grows based on how much activity the user has logged during the day. The flower could grow to have about twelve leaves running down its stem for very active users. B.J. Fogg, director of the Persuasive Technology Lab at Stanford University, discussed the Fitbits virtual flower with The New York Times when the Fitbit first launched: The little flower growing represents anticipation and hope that something good will happen, which is the

One of the most frustrating experiences for Internet users is slow response time from unreliable connections. And when web applications dont perform consistently, users may wind up avoiding the applications altogether. Its a common problem: as the physical distance between users and applications increases, performance typically deteriorates rapidly. In fact, Web application wait times for users located on the opposite coast of North America can be five times longer than those based locally. Performance issues like these create unique problems for healthcare. If an Internet-based solution is behaving poorly, a physician could have difficulty accessing the information needed to make the right treatment decisions. For example, a physician who only sees part of an X-ray series over the Internet may be unable to make a correct diagnosis, or worse, make an incorrect one.

In short, physical distance, inefficient protocols, Internet congestion, and poor routing conspire to add critical seconds to each transaction. And in the medical profession, this can quickly become a life and death matter.

Akamai addresses shortcomings in the fundamental design of core Internet protocols - creating a delivery system designed to improve the performance and availability of healthcare applications. Its globally distributed computing platform (The Akamai Intelligent Platform) eliminates web performance bottlenecks. And within this massive footprint, 90% of the worlds Internet users are within one network hop of an Akamai server. This effectively translates to localized response times delivered to global users. With its intelligent and dynamic mapping technology, Akamai tackles Internet traffic jams - dynamically determining the best available, highest-performing route between an application and the end user.

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Improve Salesperson Impact iPad Support As the tablet computer is revolutionizing the workplace, it is also transforming healthcare by providing physicians with portable information access. Device manufacturers see the tablet as a much better personal medium for detailing physicians - as well as a vehicle for supporting the on-the-go field sales force. One medical device company wanted to provide salespeople with a local copy of rich detailing material rolled up into the kind of experience theyd come to expect as consumers. It partnered with Akamai to deliver great, consistent performance when delivering large files to its entire salesforce on product launch days and real time stock and pricing information. With Akamai, the company improved download performance by 400% domestically and 600% globally. Monitor Patients Vital Signs Accelerating Performance for Wireless Medical Devices Internet availability can be a matter of life and death for patients who rely on these devices. Wireless medical devices, such as cardiac monitors, can provide physicians and other healthcare providers with invaluable and virtually instant information about a patients condition. Todays pacemakers can wirelessly track and transmit patient data to a device to a bedside monitor, which in turn uses the Internet to provide physicians with access to efficiently track patient status. As one of the leading makers of cardiac implants has discovered, Akamai ensures consistently good performance for wireless medical devices, particularly in far flung regions, without the need for additional infrastructure. Widespread use of health monitoring technology like this is improving care and reducing costs. And Akamai is proud to be a crucial component in keeping connected performance fast, reliable and global.

flower growing, Fogg told the Times. When you push that button and see the change, its instant feedback, a reward. Even though the device seems simple, its tapping into a complex psychology that changes peoples behavior, he said. It hits the right button. Most humans are naturally wired to nurture things and be rewarded for doing so, he said. \\

// Metrics for the Already Motivated?

The starting point for many devices and apps that help users track a particular metric or set of metrics is a chart or a table. Many of the early tracking offerings only provided spreadsheets and graphs as feedback loops for users, which has led to a rallying cry among the newest crop of device companies to proclaim that their product is not ( just) for Quantified Self types but is easy enough to use and accessible enough for the average user. Wrist-worn tracking device maker Lark is the latest company to make the case that its device is more accessible than previous ones because it is less focused on the numbers. Larks latest device, Larklife, is a $149 device that works with a companion app to track activity, sleep, and diet. Instead of just providing numbers that might help users draw their own conclusions, Larklife prompts its users with suggestions for how to improve their health habits based on the metrics it tracks. Once the device gets a sense for the users circadian rhythm, it can push notifications to users to point out that they have been sitting for a long time and it might be an optimal time for a quick walk. It might also notice a user did not get enough quality sleep the night before and suggest they go to bed earlier. Still, certain types of users do benefit from reviewing a quantitative analysis of their activity, sleep, caloric intake and more. A new set of tools has emerged in recent months to help the quantitatively minded make more sense of their numbers. Notch.me is building an app that helps people who track healthy activity to create beautiful infographics in an effort to help them better understand and engage in their own health. Notch can take users data from Fitbit, RunKeeper and similar apps and devices to create a more visually stimulating representation of their numbers. Notch stylizes itself as more of an ongoing experiment or project and may not become a

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full-fledged company in its own right. Still, it may be providing alternative feedback loops in the form of infographics that users of existing health apps benefit from. Another much more quantitative tool that can help self trackers better visualize their numbers is Daytum, which describes itself as an elegant and intuitive tool for counting and communicating personal statistics. Ryan Case and Nicholas Felton developed Daytum based on Feltons experience of producing yearly annual reports based on his self-tracking, which he has done since 2005. Felton is something of a celebrity in the world of self-tracking, and Daytum helps his fans and others to create similar visual representations of their own tracking metrics. \\

// Health Outcomes as Motivators

A forthcoming app from San Franciscobased startup 100Plus, which will likely go by the same name, aims to help people recognize and take advantage of health opportunities or hops like walking hills with views in their neighborhood and healthifying their commute by taking stairs instead of the escalator. 100Plus believes these small activities have become undervalued and people have been trained to think that the only way to be healthy is to go for a run or head to the gym. The feedback loop that 100Plus intends to use is perhaps its most interesting concept: These small activities affect the users Lifescore. That metric gives users a sense of how their small actions will likely change their longterm health by adding small increments of additional time to their life expectancy. Each users Lifescore starts at 78.1 years since that is the general life expectancy. As we learn about you the Lifescore changes, 100Plus Co-Founder Chris Hogg said. Because Im a man, my score actually automatically goes down because women live longer than men on average because I live in San Francisco it goes up because people here live longer on average. Age, height, and weight can affect the Lifescore based on a comparison between a user and the average BMI of people like them. Hogg said the data is all based on CDC data sets available from the federal government as well as structured clinical data from its partner PracticeFusion. The app also shares a hop that one user creates with others and 100Plus users can see how their hops have inspired others to lead healthier lives. Currently each hop requires the user to snap a photo of the activity, which given the requisite image and crowd sourcing strategy is reminiscent of Massive Healths The Eatery app (discussed above). \\

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// Regulations Holding Back Feedback Loops?

As the soon-to-launch 100Plus app indicates, feedback loops for health apps and devices are set to become much more sophisticated as analysis of existing big data sets (and the ones these tracking tools are building) yields more insights about the long term and short term effects of health decisions. Many of the startups working in digital health today are uneasy about the regulatory environment for healthrelated applications. In mid-2011 the FDA published a draft guidance document for how it believes existing medical device regulations apply to mobile medical applications. The document provided some clarity but did not go so far as to establish a clear line between mobile medical apps that perform a diagnostic function and those that offer some form of health coaching that lies outside of the FDAs regulatory purview. As a result many of the companies working in digital health purposefully simplify the kind of feedback they provide users of their devices and apps. The FDAs final guidance for the regulation of mobile medical apps is expected by the end of 2012 or in early 2013. \\

Screen shot from 100Pluss marketing video (above) Screen shots from two different 100Plus iPhone apps (right)

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