[Updated, 12:05 pm ET] There’s a parable about the elephant and the rider that’s been used by Chip and Dan Heath, and that originated with Jonathan Haidt, to describe how humans make decisions. A person’s mind can be thought of as consisting of a rider, representing the rational part of human thinking, and the elephant she’s riding, representing emotion. Both of these play a role in how a person decides things, and many of us believe the rider–the rational part–is in charge. The rider taps the elephant with her guide stick, and the elephant obediently moves in that general direction or does a specific task, like carrying lumber from place to place. [Editor’s note: This paragraph has been updated to attribute Jonathan Haidt with originating the elephant/rider metaphor]
Except that’s not how a lot of decisions actually get made. Instead, the elephant sees a bunch of bananas, or a herd of other elephants, or a nice cool river to bathe in, and goes that way instead. And the rider…well, the rider can’t do much about it except, after the fact, rationalize how she always wanted to go in that direction to begin with. Yeah, it was time for a bath, sure
This framing has stuck in my mind for years and it’s a really helpful way of looking at many of the odd things that people do or say, ranging from climate change denial, to believing genetically modified organisms are inherently evil, to smoking despite everything we know about the harms that result, to even saying that Paul Blart, Mall Cop II is really, you know, not that bad–really. And it also speaks to one of the more vexing problems we have in human health. Why do people keep doing things they really probably shouldn’t, and know they shouldn’t, if they want to stay healthy?
I’ve touched before on how the power of digital tools can help make it easier for us to make good decisions. OPower is doing this for power consumption and conservation, and with the advent of tools like Apple’s Healthkit and the proliferation of activity trackers, the time is right to do this for health.
That’s where the open standard for a specific type of application programming interface (API) comes in. Such a standard will help provide the right rewards, immediately. People need to get quick positive (or negative) reinforcement for the decisions they make. In the absence of that kind of rapid response, I don’t think trackers, in and of themselves, will encourage healthy behavior.
Before I go further, a few quick definitions: APIs are simply the protocols that allow outside programs to interact with a given piece of software. It’s how programs talk to each other and trade data and instructions. An open standard is a general agreement that each piece of software will have APIs that will be made public to allow other programmers to work with and connect to that specific software tool.
Now, with respect to current health and activity trackers, the data are still coming in on how effectively devices help people change their behavior by themselves. Some research, however, suggests the people most likely to benefit are already inclined to use self-tracking data to change their behavior and improve their health. You might say they represent the cases where the rider and the elephant already have similar goals. What about everyone else? Quick feedback and reinforcement could help them carry out and repeat behaviors that are important for their health, because behavioral economics suggests long-term gratification and goals just won’t do.
It’s true that many of the different apps and trackers already have elements that encourage people to change behavior, providing rapid feedback and rewards. These range from gamification and incorporating social media into activities and goals, to providing quick feedback when milestones are reached—like when a Fitbit buzzes once you reach 10,000 steps. But I don’t think that’s enough. I propose we need to broaden the possibilities for feedback by creating an agreed-upon open standard for app development that makes it easier to tap into rewards of all sorts. Basically, ask everyone creating any kind of app that includes user feedback and rewards (that is, pretty much every app) to agree to include an API allowing that app’s reward to be called when a healthy behavior occurs.
Amazon Web Services basically works under what I think of as the LEGO idea—lots of parts that can snap together in different ways. And Amazon can do that because APIs for interoperability are mandated. Are fitness trackers built this way? Not so much. But they could be. Many of the kinds of programs and apps that could be used to generate rewards are also closed now, but that doesn’t mean they couldn’t be opened up as well in this specific way.
Once the applications are opened up through an agreed-upon open standard, suddenly the possibility for personalized rewards and positive reinforcement for achieving goals is much greater. Because you know, everyone is a snowflake, and everyone responds differently to different kinds of incentives. This is where precision medicine comes in.
Imagine that your primary care physician would like you to walk every day for 30 minutes. You’re not into Facebook posting, and don’t have enough of a rivalry going with your friends or family to make a competition that motivating. But you do really enjoy playing Plants vs. Zombies. And you’ve been having trouble beating some of the higher levels. And you could really use a bunch of jewels to power up your plants. Your Doctor takes your phone, keys in a link between your Apple watch and the Plants vs. Zombies app, and now every time you meet your daily walking goal you get a reward of 50 jewels. Immediately.
Maybe in a few months your interest in Plants vs. Zombies wanes. But you’ve started listening to the collected works of Leonard Cohen. You could buy the albums easily, but instead your doctor suggests linking single-song iTunes downloads to your activity for a while and you agree. Now, every day you listen to your new music while walking, you earn the next song. Save a little money, get a little exercise, get the positive feedback that helps you keep doing something you know you should but really would rather not.
Of course there are a lot of hurdles to clear to achieve all of this, not least of which is convincing various corporations to make some part of their product free to be used for these purposes. I can think of a few arguments, while freely admitting I don’t know if any of them would hold water with the Tim Cooks and Jeff Bezos’ of the world.
First, research: What products, features and rewards does a company have that are so sticky, so useful, so desirable that they can actually get people to change their behavior? Second, advertising and reputation: Are computer games being blamed for childhood obesity and inactivity? Fine, turn that around. Third, this is a logical step in the progression of the internet of things (IoT). Creating a system of interacting apps, tools, and devices that will work together seamlessly is already ongoing. I’m proposing a specific application of that concept, but the IoT will happen. Better to be on top of that trend than left behind.
And, of course, who’s to say profit wouldn’t be the eventual result? If linking specific app rewards can be shown to positively influence individual health, there’s a path to getting reimbursement via payers or maybe even individuals.
There are other problems with this kind of API-driven approach to behavior modification, including privacy, FDA oversight, the technical challenges of minimizing reward exploitation, and figuring out the best ways to motivate individuals. I just saw a great talk by Dr. Bonnie Spring showing that mobile health tools have a lot of nuances and surprises. Still, I think it’s an idea worth exploring and a natural extension of what’s already going on in digital health. The goal of precision medicine is that people be treated in ways specific to their genetics and medical history–their specific biology–to reach their optimum state of health. To that framework I would add understanding and using each person’s unique personality and culture. Medicine–and health–would only be the better for it.
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