A Guide to User-Centered Healthcare Software Design and Development

How to Create Apps That Change Behavior

In an effort to reduce costs and improve patient clinical outcomes, the Affordable Care Act (ACA) has been instrumental in driving widespread changes in the healthcare delivery system. These changes have caused a cultural shift in the way in which clinicians and patients interact and share personal information with hospitals and insurance exchanges nationwide.

ACA calls upon healthcare consumers to take an active role in both clinical decision-making and choice of healthcare providers and insurers. As a result, patients are required to share an ever- increasing amount of personal information which is giving rise to concerns around privacy and security. While security and privacy rank high, patient engagement is arguably the primary challenge facing healthcare software vendors, health insurers, and Accountable Care Organizations (ACO). As such, moving towards this new vision of healthcare requires technology innovation that will stimulate behavioral change to achieve the end objective of improved delivery of care.

B. J. Fogg, renowned user experience design thought leader and director of the Persuasive Technology Lab at Stanford University, has developed a model of behavioral change. Fogg advocates that technology alone cannot “magically change behavior”. Companies developing software which aim to elicit a response from users must understand how human behavior works.

Fogg’s Behavior Model

According to Fogg’s Behavior model there are three components that simultaneously affect behavior:

Motivation

The degree of willingness to do a behavior: For example, motivations may include pleasure, pain, hope, fear, social acceptance, and social rejection.

Ability

The capability to perform the behavior: Ability, however, can be impacted by training in addition to the degree to which the behavior is perceived as being easy to perform.

Trigger

The call to action: Some triggers are natural and some need to be sparked depending on the level of ability or motivation the person has with the target behavior in mind.

Example:
If someone ignores their goal (motivation) of taking their blood pressure reading every morning (given their ability – i.e. they have a blood pressure machine at home) a mobile application might to remind them to do so (trigger).

Three Steps to Affect Behavior Change

To assist in the design of technologies that look to affect behavioral changes, Fogg developed the following systematic three-step process:

Step 1: Be Specific

Identify and establish the specific target outcomes and goals.

Step 2: Make it Easy

Simplicity changes behavior. How can the behavior be set up so that it is easy to accomplish?

Step 3: Trigger behavior

No behavior happens without a trigger. What will prompt the desired behavior?

Common Trigger Approaches

A major tenet of B. J. Fogg’s methodology is to understand the trigger, or triggers, that will prompt the right response from users at the right time. This is the area that is most open for creativity. Assuming all other obstacles – trust, specificity, simplicity, etc. – have been addressed, what triggers an individual to adopt an application as part of their lifestyle and positively change their behavior?

Common approaches to triggering currently in use

Direct Appeal
White Arrows
This approach focuses on the risks associated with not changing one’s behavior; and is most likely to work when patients have a serious condition with immediate negative consequences.
Social Triggers and Support
Social Support
A wide variety of companies are exploring how to make use of a patient’s online social activity as a motivator for short and long-term goals. PatientsLikeMe is a prime success story of social forums in which individuals with similar conditions can learn from and support one another. However, health conditions remain a topic that many consider private, as a result the jury is still out on how to incorporate social features into health software that users find valuable and unobtrusive.
Gamification
Pushing Buttons
Gaming elements being used include things like level-ups, competition, and high scores. Nike+ was an early pioneer in this space, but even large insurers like UnitedHealth and Cigna are tapping into gamification techniques in their software products to engage customers.
Reward
Gift reward
Incentives are external triggers that can be used to convert behavior. For example, auto insurers who provide consumers with rewards (discounts) based on telematics devices connected to a driver’s automobile diagnostics port to track annual mileage, braking, and quick acceleration.
Data Visualization
Line Graph
Information analytics, in particular the use of interactive information representations to shape and control an analytic reasoning process, has been particularly effective in clinical decision support, and is now a common “feature” within patient software. The ability to scan interactive information representations that change in response to user input or query, allowing users to discover new and emerging patterns in the data, is a potential trigger for some.
Multimodal Design
Multimodal Design
Engaging individuals across multiple interfaces and devices — wearable device, smartphone, email, web, tablet, kiosk — and multiple contexts of use.

 

Remember: No matter what the approach, the important word here is context. For example, in one context, gamification high scores and competition can make sense, but in another context it may be confusing and even insensitive.

Seven Strategies to Influence Behavior

According to Fogg, persuasive technology uses seven strategies to influence behavior:

  • Reduction – Simplification of the task the user is trying to do.
  • Tunneling – A step-by-step sequence of activities that guides the user through the behavior.
  • Tailoring – Provision of feedback to the user based on their actions.
  • Suggestion – Provision of suggestions to the user at the right moment and in the right context
  • Self-monitoring – Enables the user to track his own behavior to change his behavior to achieve a predetermined outcome
  • Surveillance – Observes the user overtly in order to increase a target behavior.
  • Conditioning – Relies on providing reinforcement (or punishments) to the user in order to increase a target behavior.
EXAMPLE: Influencing Behavior

Fogg’s behavior model predicts that if users find something too difficult, they will abandon it. At Macadamian, we have found that this theory bears out. One of our customers, Elsevier, had developed a web application called Mosby’s Nursing Consult. The purpose of the site was to help nurses find answers to pressing clinical questions and bring evidence-based best practices to the point of care. In practice, many nurses found the user interface too cumbersome, as an easier alternative, they turned to performing Google searches to answer the pressing questions they had about their patients’ care.

The need was clear — the website had to provide the same
ease of use as Google if nurses were to use it. After an extensive redesign process with Macadamian that revolved around the user experience, Mosby’s re-launched the website with improved search capabilities and a cleaner and more intuitive UI. The result was increased motivation by the target audience to use the software and, ultimately, improved patient care.

How can product managers determine what will motivate and trigger a desired behavior, and provide users with a desired level of control? In our experience, the best way to ensure a product meets user needs is to team up a product manager, a user experience researcher, and an interaction designer; all of whom are well versed in design patterns that effectively persuade and influence users.

Continuing with the Mosby’s Nursing Consult example; the design approach involved working with Elsevier’s product managers to identify the essential business values that would make the website a success. The team mined existing internal data, such as marketing information, customer feedback, and
the product manager’s own insight. We conducted interviews with users of the existing website to develop personas that represented the most typical users. Next, the prototype website was tested with various users from across the country to address any unforeseen usability problems. In the end, the product struck the right balance between usability, functionality, and simplicity, increasing regular usage substantially.


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