It’s a common refrain in healthcare, heard among established companies and entrepreneurs alike, and among patients, providers, and payers: Despite massive investment, no one has figured out how to change human behavior.

Most illness is caused by what we do, or — to be more precise — what we fail to do. According to statistics issued by the CDC in 2014, up to 40% of annual deaths from each of five leading U.S. causes are due to “modifiable risk factors.”

Indeed, nudging people into healthy habits has proved difficult. That’s despite decades of research done by and for behavior-change professionals, ranging from Lester Wunderman’s direct-marketing theories in the 1960s to the insights into human psychology developed by B. J. Fogg of the Stanford Persuasive Technology Lab.

See also: Effective communication requires rethinking the patient experience

Study of how to change behavior has crossed from academia over to pop-sci with books like FreakonomicsNudge, and Hooked. And it’s even started to filter into agencyland, with healthcare communications shops adopting such principles in the early 2000s. The ideas have infiltrated pharma, too.

Why is behavior change so nettlesome? One reason is that what motivates people to change varies from person to person, so solutions need to be customized. By and large this is lacking, says Dr. Maulik Majmudar, a cardiologist and associate director of the Healthcare Transformation Lab at Massachusetts General Hospital.

Clinicians have a limited understanding of what makes people’s lives tick. “Most physicians only see patients maybe once or twice a year if they’re stable — maybe four times a year if they’re unstable,” adds Dr. Majmudar, who’s also a board member of the MIT Hacking Medicine Institute. “So it’s very hard for us to have a meaningful impact on a consistent and continual basis.”

That’s where technological solutions, like assistive tech or smartphone apps, can play a big role in monitoring and communicating with the healthcare team more frequently, he says.

See also: New mobile app seeks to address medication adherence

Of course, cautionary tales abound for newcomers: about 160,000 of them. That’s the approximate number of health apps aimed at things like adherence that are available in the Apple and Android stores. According to a Compuware study in 2013, though, anywhere from 80% to 90% of all downloaded apps are used once and then eventually deleted by the users.

“From lifestyle changes to medication adherence, getting people to do what you want is still a big black box,” notes Sara Holoubek, CEO of Luminary Labs, a consultancy that works with healthcare innovation groups from big pharma to government agencies and nonprofits.

Whether medication compliance, kicking a bad habit, or some other form of behavior modification, change remains elusive, yet it’s obviously extremely vital. Read on to see four trends that hold the promise of nudging healthier behavior along the patient journey.

Left to right: Guidemark Health’s Fred Petito, behavioral psychologist Richad Payne, and Vishal Lala, marketing professor at Pace University, discuss patient behavior at the MM&M Transforming Healthcare conference in May. Photo credit: Erica Berger

1. STAGE: EXPERIENCING SYMPTOMS | TREND: Marketers get serious about behavior change

“Behavior change has been in place in a lot of ways in marketing for decades and decades,” says Johanna ­Skilling, EVP, director of planning, U.S., at Ogilvy CommonHealth Worldwide. “Every time you ‘click here’ or ‘call here’ or download something, that’s behavior change. We just didn’t call it that. So we’ve been doing it, we just didn’t necessarily mean it.”

Nowadays, healthcare communications agencies are talking the talk and walking the walk, underpinning behavior change approaches with serious academic rigor. Skilling herself has worked on numerous support programs, from the Get Quit program prescribed along with Pfizer’s smoking-cessation pill Chantix to newer partnerships with patient-centric bodies.

These are built on behavioral modeling and take aim at getting people to think and act like nonsmokers, as in the case of Chantix, and leveraging other psychological tenets to uproot other entrenched behaviors.

See also: Guidemark Health’s Fascetti on Ads that Change Behavior

She walked MM&M through a typical illustration of the agency’s approach. Change agents must “get people to think differently before they do something differently,” says Skilling. “We [can’t] shortcut that.”

Fostering a healthy habit requires prodding them along what’s known as Prochaska’s stages of change, which range from precontemplative to contemplative and preparation and then to action and maintenance.

Even when patients know the end result of not changing is likely to be serious, they might still be mired in precontemplation due to certain kinds of thinking (“my dad smoked and he was fine,” or “I smoke, but only when I drink”). These notions can take months to address.

If the patient is not ready to change, even the most innovative intervention could be useless. “Most of our interventions seem to be focused on the action phase, and there are maybe 20% of patients in healthcare [who] are actually in an action stage,” noted Dr. Richard Payne, a behavioral psychologist and consultant, at the 2016 MM&M Transforming Healthcare conference.

Next, when helping people commit to behavior that’s better for them, it’s important to get the communication right. That means not lecturing, which in and of itself is an ingrained healthcare marketing tactic.

“For healthcare, traditionally, [approaches to changing behavior] have been about providing mostly scientific content — ‘here’s the PI, here’s the label change, and for physicians here’s something you should know’ — and it’s very functional,” says Skilling.

See also: Mobile’s role in healthcare is still experimental

What pharma companies “need to come to terms with is, it’s not just sending out a campaign to do something,” she explains. “We need to get deep into people’s behaviors, biology, and beliefs.”

The point seems to be seeping into industry’s collective consciousness. What’s the upshot for marketers? It’s not to provide a silver bullet for influencing people’s decision-making, said Guidemark Health’s Fred Petito at MM&M Transforming Heathcare, but to achieve a slightly more nuanced understanding of decision-making so that marketers can engage a bit better.

“Human decision-making is complicated,” acknowledged Petito, who is the agency’s chief behavioral and engagement officer. “If we could be a little less wrong about our target audience, that’s not a bad thing.”

Moreover, support and CRM/loyalty programs are getting the data needed to prove their worth in areas like compliance and persistence, which in a disease like diabetes is really key to improving outcomes.

Novo Nordisk’s Cornerstones4Care is a prime example. This program added co-pay support, email reinforcement, and personal coaching from a certified diabetes nurse educator.

Read the story: Loyalty programs: Beyond the co-pay card

The company has already found that enrollees fill 1.4 more prescriptions than those not in the program, according to the article. It’s not clear if Cornerstones4Care also improves outcomes, but Novo is researching a possible A1C-lowering connection.

With such a linkage in hand, and in the context of the ongoing shift from a fee-for-service to an outcomes-based model, it’s easy to envision support programs evolving beyond just a “wrapper to the pill,” but into approaches built on sound psychological principles that figure ever more prominently in industry’s behavior-change armamentarium.

Kognito’s virtual human simulations address antibiotic prescribing and train pediatricians (above). 

2. STAGE: DIAGNOSIS AND DECISION | TREND: Virtual humans make their presence felt

Being a primary care physician is harder than I had imagined. My first patient, “Laura,” a 32-year-old retail manager, had been home from work for the better part of a week nursing a nasty cough. She was pushing hard for antibiotics.

An empathetic person by nature, I do my best to show concern. “You really want to get back to your routine, and this cough won’t quit,” I say.

“Yeah, it’s terrible. I have bills piling up,” she replies.

Encouraged at that, I decide to go back to the empathy well again. “At least it’s Friday, and you can rest on the weekend!”

“No, I work in retail. I’m paid by the hour,” Laura chides, frustration apparent in her voice. “And if I call in sick again this weekend, I’ll miss two more days of work.”

Ouch. Laura may have only been a virtual patient, and I merely role-playing the physician, but the interactive experience taught a lesson: If you want to show empathy, don’t start out with “at least.”

See also: Is virtual reality the ultimate emotive storytelling tool?

The online simulation was designed by the firm Kognito, at the behest of the Robert Wood Johnson Foundation, to address appropriate prescribing of antibiotics in primary care and to empower patients (I could have played the patient role, too).

It’s one of many virtual human (VH) simulations designed by the firm to help clinicians, caregivers, and patients to become more effective at healthcare-related conversations. Kognito’s in-depth simulations are based on principles of behavior, like motivational interviewing, to try to lead people to take meaningful change.

There are effective and ineffective pathways, and they’re designed with game mechanics so I can see if I’m improving the patient relationship (not so much, as it turns out, but a “do-over” function allows me to correct my mistakes).

“What we do is harness the power of conversations, because they’re so powerful to do a lot of different things, from engaging to educating, empowering, activating, motivating,” says Ron Goldman, Kognito CEO.

The firm also applies its VH technology to create healthcare assessments, which is a wise use of the technology as VH interviews were shown in a 2014 USC study to be able to glean more honest information than a questionnaire administered by a flesh-and-blood HCP. Providing more open and honest responses in medical interviews, in turn, “can help patients to receive better care and avoid serious consequences,” researchers noted.

The firm has amassed a number of success stories in which VH conversations were used to motivate behavior change, such as training pediatricians to have more efficient and productive discussions about childhood obesity with young people and their parents (in collaboration with the American Academy of Pediatrics).

See also: Smart devices will improve pharma sales: survey

The latter simulation, called Change Talk, is freely available on the Apple and Android app stores. Like the antibiotics simulation, users play the role of the pediatrician speaking to a mother and her son. Out of 307 physicians who took it for CME, 88% said that they made a change as a result.

Kognito has also been used to prepare caregivers to deescalate emotionally charged talks with veterans exhib­iting signs of PTSD (for the VA) and to enable educators to talk to kids at risk of suicide and substance abuse (for the Substance Abuse and Mental Health ­Services Administration).

Conversations are an extremely powerful tool to drive changes in behavior. More than a dozen published studies show Kognito’s VH simulations result in statistically significant and sustained increases in motivation and skills to engage in conversations, according to the firm.

To Goldman, it’s interesting that all roads lead back to conversations — especially when you look at how some of the other technology-based behavior-change platforms are incorporating phone calls.

“At the end of the day, after all these technologies,” he says, “where did they end up? ‘Let’s hire a bunch of people and have them make phone calls to people, so they can talk to [patients] about actually doing what everything else we tried to push at them didn’t [do].’ It still goes back to this basic concept of talking to people over the phone, Skype, or face to face.”

3. STAGE: TREATMENT | TREND: Health tech goes granular

Behavior change in healthcare is perhaps most associated with chronic disease, but diabetes and heart disease tend to attract the most attention. A number of new companies are now tackling other chronic health problems such as depression.

One of these is Iodine, whose Start app (pictured) aims to help people make an informed decision, after six weeks, as to whether an antidepressant is working for them or not by tracking doses and monitoring side effects. It can also be used to share progress reports with doctors.

It was one of six CareKit apps available, as of this writing, following Apple’s March 2016 launch of CareKit to give developers a framework for building apps that manage daily well-being. It followed Apple’s March 2015 launch of ResearchKit, which seeks to help researchers gather data for clinical studies, and HealthKit, the platform launched in fall 2014 that lets app developers ­integrate tracking of health metrics.

See also: Cancer center and tech co. test Apple Watch in breast-cancer patients

“In depression not every medicine works for everyone, but you must adhere to determine what works,” says Holoubek, who invests in Iodine, “and the nature of depression is that adherence is very low. That’s in contrast to diabetes, where you’re basically trying to get patients to adhere to one insulin rather than six different ones.”

MIT’s 2016 Grand Hack, which took place the first weekend in May, also featured teams focused on depression as well as on heroin addiction.

“A lot of research has gone into demonstrating these are drivers of healthcare costs and of unhealthy behavior and yet they’re really tough problems for the fragmented healthcare institutions to tackle,” says Zen Chu, cofounder of MIT’s Hacking Medicine Institute.

The hackathon groups proposed using artificial intelligence, chatbots, and automated SMS communication with the different populations, reports Chu, as well as automated reminding and geofencing.

See also: Are Wearables a Pharma Field Day?

“They bring loved ones and caregivers and friends together and nudge them, so that these folks — whatever they’re suffering from — don’t drop through the cracks,” says Chu. “The gaps are not cracks, they’re yawning chasms because we have tectonic shifts in how healthcare is paid for and incentived now.”

Indeed, connected health and remote care tech stand to give providers, payers, and industry a much more granular understanding of the patient journey, as these technologies close the loop and reveal what’s going on between doctor appointments. The real test will be whether the healthcare team gets on board.

While it’s very early days in terms of their use, 15% of online U.S. adults already say they want their care team to monitor their health remotely but their doctor doesn’t provide those services yet, according to Decision Resources Group. “It’s the holy grail of patient centricity,” quips DRG principal analyst Matthew Arnold.

In addition, he adds, there’s substantial consumer demand for decision-support tools, but the marketplace is so cluttered and poorly aggregated that 30% of those going online to make health decisions say they find it difficult to sort through all the online info (which is, in part, a search problem).

“I love how health tech is tackling this,” Holoubek notes, “[but behavior change] is absolutely the hardest nut to crack. It’s not going to happen overnight.”

John Brownstein, pediatrics and biomedical informatics professor at Harvard Medical School, discusses the evolution of digital health tools and his collaboration with Uber at a Klick Muse event.

4. STAGE: CONDITION MANAGEMENT | TREND: Uber fuels on-demand ride revolution

Many parts of the healthcare system are plagued by outdated software. The system that hospital transportation coordinators use is no different. Some 3.6 million patients miss their appointments annually due to lack of transportation access.

What if someone could soften the issue of patients getting to their lifesaving appointments? “For the disabled low-income populations that rely on nonemergency medical transport, this is a real issue,” reports John Brownstein, the PhD epidemiologist behind digital health tools like the MedWatcher mobile app and He has partnered with Uber on a new effort called Circulation to eliminate bottlenecks at this leg of the patient journey.

Circulation is a HIPAA-compliant cloud-based software tool designed to help triage the right ride for the right patient. It was launched March 31 at MUSE, the Klick Health event.

See also: Developers should consider products that serve the underserved, report finds

While there’s an ecosystem of startups trying to facilitate on-demand virtual doctor visits using everything from video to house calls to stand-alone kiosks in big box retailers, “What we’re saying here is, Why can’t Uber be part of the equation when it comes to getting patients to their appointments, getting patients out of the hospital?” queries Brownstein, who is a professor of pediatrics and biomedical informatics at Harvard Medical School and chief innovation officer of Boston Children’s Hospital.

“Why not reduce the length of stay of an individual at the hospital? Why have to wait hours at the hospital before a ride can show up? Why not create seamless ways of getting patients to their scheduled appointments, to getting them to their clinical trials?”

It’s not the first time he’s partnered with the upstart ride company. In 2014 Brownstein mashed the Uber mobile app with the HealthMap Vaccine Finder, a website that connects the public to local vaccine providers through a searchable online map.

The combo spawned UberHealth. For one day that year, users in four cities could order delivery of flu vaccine to their home or office with a nurse to administer doses. More than 2,000 people took advantage of the free vaccination service.

“It was an incredible success,” he recalled at MUSE. “We were oversubscribed for the entire duration. We did not have enough supply of nurses to meet the demand.”

See also: How to seize your omnichannel moment

More than 40% of those who received vaccination had not had it in the previous year, and many of them had never had a vaccination against influenza, he noted. “More important, over 90% valued the concept of on-demand as a service in healthcare.”

So last year the program was rolled out to about 40 cities, garnering the same level of enthusiasm. Circulation aims to extend the low-cost on-demand concept farther into healthcare. Patients will be able to get to a doctor for an acute-care appointment as well as use the service post-discharge, maybe even to have a physician or nurse visit them after they’ve left the hospital.

Brownstein is now in the process of signing up pilot partners — hospitals and health plans — to roll it out nationally. He’s also planning to integrate the tool into cloud-based and proprietary EHR systems.

“There are huge opportunities for on-demand,” he says. Some $5 billion is spent on getting patients to healthcare appointments and even more is lost to lack of adherence. “Moving patients around is the first step. But why not combine getting patients to their appointment and also fulfilling their prescription?” he asks.

With access to Uber’s massive logistical scale, the entrepreneur and public health advocate has aspirations for leveraging Circulation to deliver interventions during a pandemic: “Why not deliver lifesaving vaccinations or antivirals in a way that can be done on-demand, not making people congregate or search for that antiviral across town?” Brownstein wonders.