Customer Perceptions

Health care is a personal issue that has become wholly public--as the national debate over reforming our system makes painfully clear. But what's often lost in the gun-toting Town Hall debates about the issue is a clear vision about how medicine could work in the future. In this feature article, frog design uses its people-centered design discipline to show how elegant health and life science technology solutions will one day become a natural part of our behavior and lifestyle. What you see here is the result of frog's ongoing collaboration with health-care providers, insurers, employers, consumers, governments, and technology companies. You can join the conversation too: this Thursday October 8 at noon eastern, frog will hold a discussion about the future of health care on Twitter (follow the hash tag #futureofhealthcare). You can also download a .pdf version of this article from the last page. - Noah Robischon, editor.

Susan's life is full. That's a nice way of saying that she is frenetically, overwhelmingly busy--too busy, she sometimes jokes, to be healthy. She has a husband and two small children, a full-time job, and aging parents who rely on her for support. She also has two younger brothers and a community of friends both near and far that she keeps in touch with mostly online.

At 39, Susan finds herself at the center of managing the health and wellness of her young family, her parents, and herself. While numerous tools on the market can help Susan do this, few are connected, the information they provide is confusing, and they're often so difficult to use that they cost her time--time she doesn't have.

Susan is not alone. Too many of us are too busy to be healthy--not because we lack awareness. We know what we need to do. It's finding the time to do it that's the problem. In an age of 24/7 connectivity that requires our near-constant vigilance, time feels more pressed than ever. Yet, it may be that the very technology allowing us this around-the-clock connection can transform how we manage our health.

Fortunately, we are at an inflection point in history both from a policy and technological perspective. Advances in wirelessly connected devices and social networking platforms will make the job of a "family health manager" much easier, more meaningful, and more effective.

In this outlook, we illustrate trends in networked devices and social networking platforms to project a future where Susan can tend to her family's varying health needs while still having time for herself.

Using networked devices and tapping into net works of people, Susan manages her own health and the health of her family. Her health-care team is comprised of her friends, her husband, her parents, her siblings, her pharmacists, her traditional health-care providers, along with online "friends" from around the world. This broad team, coupled with more personalized data collected from mobile phones, wireless health devices, and ongoing information exchanges, will lead to better health for her and her family. Susan no longer has to rely upon the infrequent office visit to yield health information; instead, she can draw from a steady stream of useful and personally relevant data, some of which may trigger the need for an office visit.

Wireless monitoring and communication devices are becoming a part of our everyday lives. Integrated into our daily activities, these devices unobtrusively collect information for us. For example, instead of doing an annual health checkup (i.e. cardiac risk assessment), near real-time health data access can be used to provide rolling assessments and alert patients of changes to their health risk based on biometrics assessment and monitoring (blood pressure, weight, sleep etc). With predictive health analytics, health information intelligence, and data visualization, major risks or abnormalities can be detected and sent to the doctor, possibly preempting complications such as stroke, heart attack, or kidney disease. Wireless scales and activity monitors gather information about our health and behaviors and feed seamlessly into desktop software, Web applications, and social networks.

While much work remains to be done to connect these devices and the data they generate in universal and interchangeable ways, there are standards evolving to ensure that the data will speak the same language, that the algorithms, analytics, and data output are validated, and that the collective potential of these devices will paint a truly holistic picture. Similarly, increasing adoption of open identification and authentication standards are early indicators of a truly portable and accessible social interchange upon which a secured personal health-care network can emerge. Users like Susan will depend on governed levels of access to protect their privacy while leveraging the support and power of many to manage their family's health.

Susan's father is forgetting things, the kind of forgetting that Susan can no longer chalk up to "just being dad." Susan's parents still live in the house where she grew up, but many of their friends have moved away. Susan herself has moved a few hours away, so it's hard for her to visit her parents often. She learned that initial memory loss can be slowed through mental stimulation, so she began scheduling a weekly "virtual Scrabble" date with her dad to help keep his mind challenged and acute. She bought her dad a physical Scrabble set with wireless sensors and low-power e-ink displays, and they use the same connected TV that enables video calls. It's almost as if they are playing in the same room. The games make her dad laugh, and he can see her kids as they jump around and say hello. After the game, Susan catches up with him and her mom about how they are feeling and what they are doing. Sometimes, she learns more from what she sees in their appearance or expressions than from what they say.

Susan and her parents are socially engaged in ways that researchers may not have even imagined a decade ago. Research has shown that greater social engagement helps people live longer, healthier lives. More studies are needed to determine the health benefits of "virtual" social engagement, but based on myriad studies pointing to improved health outcomes for people with larger social communities, it is plausible that social engagement of any kind--even the virtual kind--is better than isolation. With the advent of social networking and video conferencing, we can now stay in touch with more people, including strangers who share a common interest or illness. As we age, these connections are increasingly important to our mental, emotional, and physical well being.

This social engagement and active monitoring provides Susan some peace of mind and helps her and her parents remain independent for longer. Products such as GE's Quiet Care and Intel's Health Guide monitor and connect people and provide a way to remotely manage their care. They also provide a way to save time and money by reducing office visits and avoiding costly emergencies.

Even when we do our best to stay healthy, we still get sick. Coping with sickness in our already hectic lives can be challenging. In addition to looking out for her parents, Susan manages the health of her two kids, her husband, and herself, and she looks for ways to save time and money while still getting the care that they need. Recently, for example, Susan's son woke up with a sore throat and a fever. She used an at-home strep test to rub a swab of her son's throat culture onto a card. Within minutes, the test results confirmed her son had strep. Through an embedded RFID sensor within the card, the test results were wirelessly transmitted to her computer's reader. On her computer, she was prompted to connect the incoming test results to her son's personal health record. Next, she used her personal health network to book the earliest visit for her son within a 10-mile vicinity. Susan elected to electronically send her son's strep results in advance of her appointment, allowing the receiving retail clinic to accelerate her visit by pre-issuing an e-prescription. Before leaving her computer, Susan selected her son's classroom network, comprised of his teacher and the parents of other students, and sent out a message that her son had strep throat and would be home for the next several days.

After Susan and her son visited the clinic she picked up her son's prescription. While she was there, Susan purchased a quick knee scan guided by the on-site nurse, because her knee has been bothering her. She opted to authenticate and connect the results automatically to her personal health record.

In another scenario, using similar technology such as geographic positioning, ratings, and calendar availability, Susan could have scheduled an appointment with of a local family doctor who makes house calls. The doctor would have been able to electronically respond to Susan's inquiries about her child's health, and the communication thread would have been stored in her child's health-care record. A reminder for a needed immunization would have been received through her general message inbox, the appointment scheduled based on her availability and the event added to her record.

The technological advancements in networked devices and personal health networks are enlarging health-care teams and changing way health care is delivered. Research and clinical studies by companies like Qualcomm and West Wireless Health, GE, and Intel, to name a few, are yielding new medical technologies in the areas of screening, monitoring, and RFID among others. These developments require substantial innovation, validation, and adoption of a standardized, security backbone that providers can trust with their patient's data and that patients can trust to allow them consistent access to their medical histories.

With self-diagnostics, automated schedulers, and e-prescriptions, health care will become more efficient for common maladies and will not entail hours of waiting and frustration. Retail clinics will offer flexible, cost effective, and immediate options when the family doctor is unavailable. Patient results and data will stream into a consolidated health-care record that patients and health-care providers can access and view from any location. And for people like Susan, this offers more efficient access to the information and services she needs as well as potential cost savings.

When Susan's doctor first told her that she was at risk for developing melanoma, she was so frightened that she forgot everything he said as soon as she walked out of his office. When she got home, her personal health-care record was updated from the doctor's visit with the melanoma risk information and a list of suggested resources. Susan learned about tools to help monitor her health including a Smart Mirror. Connected to the family network through fingerprint identification, the Smart Mirror syncs to that family member's personal health record.

Every morning, Susan puts her hand on the mirror, which captures her vital signs. Connected to her personal health record, the mirror also reminds her of the medications she needs to take every day. Bi-weekly, she also uses the mirror to scan her skin, and any moles and other marks found are tracked for abnormal growth or color changes. The data is pushed to her protected record, from which it can be accessed and reviewed during visits with her primary care doctor and dermatologist. Trending analysis can be performed against her data, which can alert Susan and her health-care team to concerns.

The availability and interpretation of the data over time will empower us to self-manage our wellness or chronic conditions by putting the information and tools at our fingertips. Large amounts of data can be overwhelming, but when that data is interpreted, personalized, and fit into evolving trends such as nutritional habits, sleep patterns, or blood pressure measurement, or when these are compared with family or friends, it can be immensely informative. When coupled with clinical algorithms to process the data, these devices reveal insights about patterns, cause and effect, and the impact of health and lifestyle choices that we make. Visualizing and manipulating this kind of information creates "aha!" moments that may otherwise have gone undetected. We have a daily view into our health and the choices we make as part of a larger context. It also encourages an ongoing dialogue with our friends and our larger health-care "team."

Swapping health-care stories among family and friends is common. This used to be done in small, local communities, and with only a few people. People with rare conditions struggled to find information about their ailments and others with the same condition. Now Susan can interact with family and friends and thousands of people across the globe, finding similarities and differences among a huge group of people. This can pose risks, but community health sites and shared personal health records offer a new frontier of medical discovery and patient support, allowing data collection and data sharing across the population. This can provide opportunities for opt-in research and trending benefits for disease prevention, monitoring, and treatments. It can also yield human-centered responses to sharing, collaborating, and finding meaning and strength in numbers.

PatientsLikeMe, an online patient community network, has a typical privacy policy, but it also has an "openness philosophy" that states, "When patients share real-world data, collaboration on a global scale becomes possible. New treatments become possible. Most importantly, change becomes possible." This community and its openness embody the philosophy of health care in the future: We have much to gain from information and from each other.

Beyond the emotional support Susan gets from sharing parts of her health record with a community of people, she is also learning about her health statistics and her habits by comparing them to those of other people. For example, because she is at risk for diabetes, she has recently started tracking her meals by taking photographs from her mobile phone and uploading them to a service that helps her measure caloric counts and nutritional values. As she evaluates her food choices and other health indicators, she compares them to those of other people of her age with similar lifestyles. She is surprised to learn that her portion sizes are much larger than those of her peers and that she eats more prepared foods than most people.

With the help of her health concierge, an online personal coach that she accesses through her health plan, and others in her network, she creates a meal plan with recipes and portions to help her stay on track with her diet.

The service also provides a "shopping assistant" that helps Susan make healthy choices at the point of purchase. Using her phone, Susan quickly scans products to see if they fit her meal plan, and a simple "red light" or "green light" guides her selections.

Beyond the value and efficiencies Susan gains from this assistance, she can also opt to have specific types of data such as her nutrition, weight, and blood pressure anonymously shared with the medical research community for research and trending analysis. The extrapolation of multiple data points across large groups of people can hasten the pace of medical discoveries and knowledge, and can also foster dialogue between scientists and patients to discern and validate emerging insights. Facilitated by technology, this exchange of information can provide relevant and personalized guidance for Susan and her family. Instead of browsing health magazines and researching online for credible and relevant information, Susan and her family can have a vast pool of information tailored to their own health conditions and coordinated with their own unique trending patterns. This saves Susan time while allowing her to be proactive and informed.

After learning of her health risks from her doctor, Susan vows to pay more attention to what she eats and to get more exercise. She has set these goals for herself before as New Year's resolutions, but she hasn't been successful. This time, it's different. She has easy-to-use tools that help her track, share, and compare her progress with a wide community of people.

Although she never imagined it could happen, Susan has become addicted to morning jogs. It's her time to relax, to listen to music, and to recharge. She especially enjoys jogging with her friend twice a week and catching up. Though her friend lives out of state, the two use their mobile devices and sensors to keep real-time pace with each other, listen to the same songs, and even chat when they're not out of breath. After her jog, Susan's mobile device guides her to do appropriate stretches based on her personal profile, including the knee-scan results recently sent from the clinic.

Knowing that she is running with a friend, even virtually, helps Susan get out the door to do it. And knowing that she is tracking her progress, pace, and distance without any effort on her part, Susan feels motivated to stay with her routine and try harder. She loves the encouragement she gets from her friends and from observing their progress as they work towards their goals.

The tools and technology may be new, but the natural instinct to respond more strongly when you are being observed is not. Studies have long shown that people change their behavior simply because they are being observed. This is based on both a desire for reward as well as fear of punishment. We have seen evidence of this in the huge success of Nike+, with its sensors and online community of runners. Another example is FitBit, which tracks activity and sleep and offers the ability to share collaborative fitness goals with friends, family, and co-workers. Connecting these monitoring devices to communities of people offers social support, peer pressure, and competition to encourage people to change their behavior.

As the "family health manager" for her parents, children, husband, and herself, Susan plays a central role in managing the health choices, budgets, and care of her family. Today, this involves a considerable amount of time and expense in dealing with disparate systems, various health plans, different geographic locations, and incomplete information.

In the future, Susan will be able to manage much of this from her home and mobile phone--a convenience that not only saves her time and money, but also gives her peace of mind. With the wireless monitoring devices and community networks, she will have access to more tailored and complete information to assist her in making the best health and financial choices. Ongoing management and awareness also helps prevent costly, time consuming, and perhaps life-threatening emergencies for her and her family.

Continuous versus episodic monitoring of health can lead to better health outcomes. Periodic visits to the doctor, which are often rushed and focused only on an immediate, pressing issue, may not be enough. Technology allows us to keep watch more closely, leading to more timely and holistically informed health decisions. The devices and the online communities act as a vigilant safety net, making us feel less alone, more empowered, and safer as we navigate the complex world of health. The trajectories in networked health devices and social networking will help people like Susan lead more independent, healthier lives. They are converging to create a new frontier in health care. Collecting health data from mobile applications, embedded sensors, or other devices offers convenient and personalized information to help people manage their health over time. With clinically based algorithms, data visualization, and community sharing, we will receive not just more information, but more meaningful and timely information that is channeled better to improve our health.

Written by:

Jennifer Kilian Creative Director, frog design Barbara Pantuso Director of Health Care Innovation, frog design

Download the Future of Health Care Is Social PDF

I recently published a research report called Consumers’ Likelihood To Recommend 133 Firms that examines how loyal consumers are to 133 firms across 14 industries (the same firms that are in the 2010 Customer Experience Index). Based on surveying more than 4,600 US consumers, I created a metric called Net Recommendations*.

Here are the top 10 firms and their Net Recommendations rates:

• Barnes & Noble (86%)
• Amazon (81%)
• eBay (81%)
• Vanguard (79%)
• Kohl’s (79%)
• USAA (78%)
• Apple (77%)
• BJs Wholesale Club (76%)
• Marriott Hotels & Resorts (75%)
• Costco (75%)

To get a more complete picture of which firms are generating loyal customers, I compared the Net Recommendations score for each company to its industry average. The top five on the list are credit unions, Sun Trust Bank, JetBlue, Vanguard, and Kaiser.  Here are the 25 firms that were 10 points or more above their peers:

*Net Recommendations: We asked consumers how likely they were to recommend firms to a friend or colleague on a 5-point scale from (1) not at all likely to (5) very likely. To create the Net Recommendations score, we took the percentage of consumers who gave the company a “4″ or “5″ and subtracted the percentage of consumers that gave the company a “1″ or “2.”

The bottom line: Does your business generate enough recommendations?

Kevin Maney has a book out in September about the trade off between delivering extraordinary experiences (which he calls fidelity) and doing it in a way that's cheap and easy (convenience). The book takes this simple idea and supports it with dozens of examples.

The simplest example is movies. You pay to go to a theatre when you want the fidelity of the big screen and the crowd and the speakers. You stay home when you want the convenience of Netflix and the pause button. Vinyl records and live concerts offer fidelity, MP3 on your iPod is convenient.

In the words of Bill Gross, in order to win with a new product, you need to be on one axis or another, and ten times better than what you're aiming to replace. Which means ten times more high impact or ten times cheaper and easier.

A refrigerator is ten times more convenient than an icebox. A cell phone is ten times more convenient than a pay phone. A private jet is ten times more joyful/fidelity than first class for the executive that can afford it. A backstage pass at a Cat Power concert is ten times higher fidelity than a ripped MP3.

There are interesting ways to define 'fidelity'. Wikipedia is certainly more convenient, and the presence of a million articles that aren't even in the Brittanica makes it higher fidelity as well. At the start, though, they were neither. It took a (relatively) tiny group of passionate people to create enough content and enough quality that they could be high enough fidelity to be considered an alternative to the printed encyclopedia. It's interesting to watch Luddite teachers refuse to accept it as a source, claiming that convenience shouldn't trump their definition of fidelity...

The mistake that's so easy to make is to be a little bit higher fidelity and a little bit more convenient. Incumbents fall into this trap all the time, assuming that you'll stick with what you've got because they're sorta both. And insurgents almost always fail because as geeky insiders they think that twice the convenience is enough to persuade anyone who cares. Not going to work.

Saw this today in a presentation given by Google. It comes from "The Social Data Revolution." Can anyone confirm if this is true? Regardless, it's food for thought. Your attention (even seconds of it) is the most valuable currency anyone could ever wish for given this massive deluge.

Social Media has evolved beyond a series of platforms that enable content publishing, sharing, and discovery into a genuine, peer-to-peer looking glass into the real world conversations that affect the perception, engagement, and overall direction of the brands we represent.

Socialized media didn’t invent “conversations,” it simply organized and amplified them and established an opportunity for learning and collaboration.

Twitter and Twitter Search have ushered in a new genre of not only communications and associated search technology, but also dedicated ecosystems that transform and support how we as consumers share and discover relevant information in real-time.

Online discussions, rants, and observations are either alarming (and motivating) brand managers or fooling them into unforeseen enthrallment. But the reality is that real-time dialogue is fueling connections and perceptions in the statusphere, blogopsphere, online communities, and the social web in general. It’s this swelling tsunami of chatter that will only intensify and heighten as it forces a new genre of Social Customer Relationship Management (sCRM). Social CRM is no longer an option. It necessitates brand involvement to proactively share answers, solve problems, establish authority, and build relationships and loyalty, one tweet, blog post, update, and “like,” at a time.

In the world of business, social media, led by Twitter, is forcing companies to augment the offshoring of reactive customer service with the nearshoring of proactive customer engagement. The conversations that power social media are sparking a sense of urgency to identify influential voices and talk to customers in a place and time of their choosing (generally, in public and online).

For example, on Friday at during a panel at the CrunchUp on Real Time Business, Porter Gale, vice president of marketing for Virgin America, made it clear that Virgin America understands the promise, prospect, and value of listening and responding to the social stream.

Erick Schonfeld, who was moderating, asked Porter how her team mines Twitter for the perception of the brand and also for determining how they contact customers.

Porter revealed that the Virgin America team is small and applies roughly the equivalent of 1.5 people to monitoring and engaging on Twitter and other social networks. To her and the team, social media is representative of not only a listening system, but also a complete engagement channel. The word “marketing” doesn’t even enter the mix.

With more than 20,000 followers on Twitter, Virgin America is galvanizing a vibrant and active community of people who will respond in “Twitter time,” thus alleviating the modest team from having to engage in every discussion, whether it’s positive or negative.

The most common example Porter shared was a response to the question, “Should I fly Virgin?”

“The community closes the sale,” exclaimed Porter.

She also shared a story of how Virgin America invests in the good will of customers, simply by publicly acknowledging and supporting them in the same channels where they’re communicating.

During one flight, a woman who just graduated medical school to become a doctor, had tweeted her excitement about graduating and also flying @virginamerica. Instead of simply responding with a congratulatory Tweet, Porter and her team retweeted and asked someone on the flight to buy her a drink (the benefits of offering inflight wifi).

To her surprise, Porter triggered an immediate response, “Row 11 is going to buy her a drink.” And, to her further astonishment, the person who sent that Tweet was live in the audience at the Real-Time stream event.

Alexia Tsotsis, tech writer at the LA Weekly, shouted from the first row, “That was me!”

Everyone in the audience was a witness to a vivid demonstration of how interaction online extends into real world experiences.

More impressive is Virgin America’s use of the social Web for real-time customer service. They’re actively monitoring issues, frustrations, and recommendations to solve challenges as they arise. In several such instances, Virgin America has used Twitter as a real-time guest service recovery system in flight to address concerns and problems by contacting service staff in the air to alert them to issues – again, the perils and associated benefits of offering inflight WiFi.

Earlier in the day, Peoplebrowsr (disclosure: I am an advisor) showed a demo in which airlines were ranked by the sentiment expressed about each brand on Twitter, and Virgin America was on top. Peoplebrowsr highlighted the ability to analyze conversational sentiment by industry through the alignment of positive, neutral, and negative conversations and perception by brand.

Ross Mayfield, CEO and founder of Socialtext, discussed the nature of the social dialogue enterprises are being pulled into and how conversations require more than one person or department to engage. SocialText offers a dashboard for enterprises that wish to collaborate internally with coworkers and externally with customers and stakeholders.

Ross referenced the engagement iceberg, where he observes only a small portion of customer conversations and engagement as truly visible, with most occurring beneath the water line and thus, out of view.

He’ s right. In my research and experience, we’ve identified that every online conversation worthy of response directly matched specific divisions within an organization and usually rank in this order:

1. Support
2. PR
3. Marketing
4. Sales

It highlights the reality that every department eventually needs to socialize.

Ross then asked his fellow panel members as well as the audience, “Who’s going to own Social Media and the process of responding?”

My answer: No one.

Social Media is, for the time being, tuning-in new channels of influence to incorporate into the brand and marketing mix.  While it takes a station manager time to receive the signals and in turn, coordinate outward broadcasts, it is the divisions within each organization that will need to shift from an introspective support mode to an extrospective group of proactive collaborators.

But as Ross cautioned businesses and eager social media teams, “Before they collaborate with the community, they have to collaborate with themselves.”

If responsibilities and workflow isn’t established and most importantly, if guidelines aren’t drafted and disseminated company-wide, the intention of helping influential customers and advocates can quickly transcend into social, and very public, chaos.

We need rules of engagement.

As Erick pointed out in the discussion, “It used to be unhappy customers who would call into customer service lines to express frustration. Now if businesses don’t immediately respond with a resolution and nip these issues in the bud, they have the potential of spreading and getting out of control. At the same time, companies need to identify and amplify praise as it happens.”

Virgin America’s Porter Gale is trying to rally her team as well as the other departments that are affected by real-time conversations and the issues they raise. She hosts brownbag lunches, where PR, customer service, and other teammates discuss what’s happening with Twitter and other social networks. They also share and review strategies and tactics to teach and learn from each other based on their experiences.

There are social networks, and there are tools with which to identify conversations and facilitate interaction, but everyone agreed, that in the world of new service and marketing, we need to improve the literacy and education among the teams who occupy the front lines.

The “now” web is powerful. It’s building new bridges, networks, and channels. It’s absolutely changing the way people communicate, research, and ultimately make decisions.

Yes, the real-time Web is powered by conversations. But, what’s important to remember, is that conversations are personal and therefore sacred.
Broadcasting messages, or even worse, sponsored messages as a form of resolution or participation is foolhardy.

Companies such as Pizza Hut that relegate Twitter interaction to a summer “Twintern” will indubitably get what they pay for. We’ve already witnessed the public backlash when a twintern abuses Twitter on behalf of an unsuspecting brand. #habitat

The point is that it’s not whether or not an intern or junior staffer on the marketing and communications team is competent or incompetent. The reality is that businesses should view the role of engaging with customers, prospects and influencers as a strategic competitive advantage as well as an earned privilege.

As panelist Maynard Webb of LiveOps pointed out, “A brand can get damaged faster than ever nowadays.”

The true shift represented by the social and real-time Web is not simply the ability to surface relevant conversations as they happen, it represents the opportunity to learn from public sentiment and create a more aware and adaptive organization that leads communities through action.

Monitoring the conversation is not enough.  Brands need to jump in, but in a professional way.