Designing for Digital Health Engagement: The ‘Modify’ Factor

Post Written By Guest Blogger, Steph Habif

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. Some you can kind of, sort of, do. Whether or not a pose is “hard” for someone ranges from experience to motivation to social pressure to knowledge to mood to physical capacity to energy.

Any good yoga teacher will encourage a student to modify when a pose is “too hard." To modify a pose means to physically adjust your body so the pose is easier, and/or less painful, and/or, more enjoyable. 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.

A great challenge in digital health is to figure out how best to design for the user's 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.

How digital health products can 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 SherpaaOmada HealthHealthvanaKurbo Health - are. Kurbo Health, for instance, provides health coaches with whom teenage users can interact via text, e-mail, video and phone when needed throughout a one, three, or six month program. Sherpaa enables their healthcare providers to use the combination of phone, messaging, photos and digital activity streams to stay on top of the multitude of updates a patient can face when managing a health issue. As Sherpaa founder Jay Parkinson wrote, "Health issues are stories that evolve over time and there is simply no better way to keep up to date and arrange care than this kind of communication." Until A.I. designers can match the expertise, empathy, and emotion of a real, human-to-human interaction (if ever), arming people with the latest and greatest technologies will continue to enhance engagement.


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.

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.”

MyFitnessPal (acquired by Under Armour for $475 million) 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. 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). By 2015, approximately 230,000 patients were engaging with PLM. The latest statistics on the PLM website are impressive: 380,000 users, 2,500+ conditions, 70+ published research studies, and 31 million data points about disease.

I listened to Ben Heywood, also co-founder of PatientsLikeMe, at the 2014 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" said Heywood. 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 2015 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 2013 U.S. Healthcare IT report, the U.S. patient portal market is expected to reach $898.4 million by 2017 -- a 221% increase in just a few years. 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.”

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 student is there. Keeping your user engaged once they have arrived.

Remember: the point of modifying is to make the experience easier for your user.

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.