Ayogo and the growing market for digital therapeutics
Interview with Michael Fergusson, CEO of Ayogo
What are digital therapeutics?
Engaging patients to take care of their own health is one of the biggest, most difficult problems to solve in healthcare. Our health is an aggregate of many daily habits — how we eat, exercise and whether we smoke, for example. Behavior interventions that help people change their daily habits typically require extensive 1:1 counseling with trained professionals and a lot of hand holding. Can technology help to make behavioral interventions less expensive, more effective, and an order of magnitude easier to scale? That is precisely what “digital therapeutics” set out to do.
Digital therapeutics are mobile and web apps that help patients shift health behaviors. They address a wide variety of conditions such diabetes, heart disease, obesity, cancer, depression, and asthma. According to a report by Grandview Research, the global market for digital therapeutics could reach $9.3bn by 2025. As millennials grow older, the demand for digital therapeutics will only continue to grow.
Ayogo’s approach to digital therapeutics
A design firm in Vancouver, British Columbia called Ayogo is one player in this market doing outstanding work. They build mobile apps that keep patients engaged in taking care of their health for a wide variety of clients in healthcare organizations, pharma, and medical device manufacturers. Ayogo’s Empower platform can customize a modular set of features to create a “digital wrapper” around any therapeutic program, such as weight loss or medication adherence.
The feature set includes, for example, social networking, cognitive behavioral therapy, educational stories, notifications, and behavior trackers. They are designed to keep patients engaged and wanting more. Some stories and features might be kept “locked” until patients complete certain actions. They draw on a wide variety of disciplines including behavioral science, psychology, neurobiology, and even video game design.
Interview with Michael Fergusson
In this interview with Michael Fergusson, the CEO and Co-Founder of Ayogo, we delve into his motivation for starting the company, the psychology of behavior change, and the future of digital therapeutics.
(If you just want to read my conclusions and reflections on the interview, scroll down to the end!)
Why did you decide to focus on healthcare?
“Why healthcare? We thought we had some real insights into the psychology of engagement that was better than what we had otherwise seen in the world. There is no bigger problem in the world, other than ending war!
We are trying to solve the problem of human behavior as it relates to disease.
The WHO [World Health Organization] in 2001 put out a statement on what they saw as important. One really interesting piece that we took out of the report was that more benefit would be gained in terms of finance and healthcare outcomes, by increasing adherence to existing therapies than development of new therapies.
We have a lot of power to cure, to significantly improve the quality of life, but we are not seeing those outcomes. And, the reason is a lack of engagement, persistence, and adherence on the part of patients.
One has to ask the question — why that is? You could spend your time doing anything — one of those things is saving your own life.”
If environment is so hard to resist, why bother trying?
“I agree. We should all give up! Why resist? Why do anything? Why bother voting at all? Maybe we all have a better idea now of the implications of not voting.
I think the idea that individual people are helpless in the face of entrenched interests is the kind of defeatism that I’m just not willing to submit to.
I think we do have power as individuals, but even more importantly as a group. If we wanted to make sugary drinks very difficult to acquire, in the same way we make cigarettes hard to acquire, we could just do that as a society. We have decided not to, so we have to work with the context that we have. Part of it is taking personal responsibility. I think people want to have tools to help them do that.”
Have you done any outcome studies?
“We have. We are not clinicians here, our customers and partners are and they evaluate everything we produce.
We have shown that we can, by applying our model, as expressed in software: we can improve weight loss in medically-supervised weight loss programs. [We can] increase prescription fill rates. We can increase persistence to programs for people that are engaged in behavior change programs for particular conditions.
We have seen some very exciting results in our product and it’s really just the beginning.
One of the important things to note, software is not like a drug or medical device. You don’t just make it and deploy it. Software is a process and needs to be continually refreshed, optimized, and updated. The thing you produce on day one is never good enough and never right.
The question is not in what way is our design wrong. The question is how bad is our design and how wrong are we. You have to know that. You have to have good ways to identify how you are wrong. So much of software can’t be effectively falsified. You are trying to do too many things at one time and you can’t see what individual pieces are contributing.
We do things as individual subsystems to see what can be tuned. We do outcome studies on programs as a whole.
We are not focused on digital therapeutics, but creating digital wrappers on existing therapies so we can be increasingly efficient at getting to the outcome that it was intended to produce. We are not creating new therapies. Our job is to look for the behavior that is necessary to make that therapy work.”
Are you using predictive analytics in your software?
“Yes we are! We are very interested in using machine learning algorithms to tune our systems on an individual basis. We have a lot of data inside our systems. We have the type of data that other people don’t have. We are aggregating together data from activity trackers and glucose monitors. Aggregating that data and engagement data from the application, as well as data about the patient’s emotional state and what it is they care about, separate from their care plan.
The approach we take is to help the patient construct a narrative where they are the protagonist and not the disease.
We can aggregate their goals and values together with their data and produce an interesting and much more holistic view of the patient. We can use that data set to drive machine learning algorithms to tune to patients on an individual basis.
We are sequencing the psychome! [We are] trying to understand the individual components of the person’s psychology.”
How do you deal with the deep psychological issues that are barriers to behavior change?
“That is a very important issue. Our lead product designer is a passionate advocate on that perspective on healthcare. Here’s the thing — let’s talk about weight loss. Weight loss is not really about food and exercise at all. It’s about your relationship to food and your relationship to exercise. And so you can educate somebody as much as you want on how to eat and what they should eat and calories, but you haven’t at all touched on individual psychology.
The reason one person is not adherent to their medication is almost certainly related to the reason they can’t hold down a job, or maintain a romantic relationship for more than a few months, or can’t sit down at the dinner table at Thanksgiving. It’s not just related to biology.
If you don’t understand who that person is and what they care about, how could you possibly help them change their life? You can alter behavior for a while, but you can’t make significant impact on them without understanding their motivation.
If you go to a doctor who is treating patient with type 2 diabetes and ask what are your goals — they will say “get A1C under 7.” Ask the patient their health goals and they may not say anything about their A1C. They may say “my health goal is to play with my grandkids and not be exhausted” or “to ensure that if I am traveling I don’t fall into a diabetic coma in a foreign country.”
The healthcare system strives to be a highly-controlled environment full of highly qualified people speaking very dispassionately about big picture issues. This is the opposite of real life. No one really lives in that environment or feels comfortable. We live lives that are chaotic and full of people using the wrong words, and reasoning emotionally about totally trivial things. I call it the 10,000 cups of coffee problem — that’s a super bad amount to drink. But, the one coffee is in my current context.”
What if the patient couldn’t lose weight, for example, due to deep trauma associated with sexual violence or other types of abuse. How could an app address that?
“I do not believe in engineering psychologists, coaches, doctors out. Those people are the high value artifacts of the healthcare system. They are very expensive and very effective. The point of a well-designed system, isn’t to obviate the healthcare system. The job of a digital system is to make it more efficient.
This digital tool can help us translate between these two worlds. We are currently collaborating to help young people that are struggling with opiate addictions, where addiction is rooted in trauma. This helps them stay connected outside of the therapy session. It helps them remain conscious and aware and stay connected with peer support — connecting in between times. Digital tech can be very helpful there.”
What is your core innovation?
“I would say that we have a distinct place to be played in an ecosystem. If you are an organization that requires behavior change to be successful. Ayogo creates a digital wrapper for your program, as opposed to software intended to be therapeutic on its own.
We are a tech company — we have a collection of technologies. Tech and know how.
Our model has some important and unique elements to it. I would say gamification is just one element of our model. We have a love/hate relationship with that word, as it is used so terribly. We take an evolutionary psychology approach and that differentiates us from people who think it’s about making things more entertaining and more fun.
Games work because they are survival mechanisms. Children play hide and seek because [we evolved] literally hiding from predators. What differentiates the game hide and seek from running away from a hyena is that you are probably not going to die. Gamification takes away the danger and allows you to fail successively. That’s what makes it work. That’s what allows us to practice.”
What’s next for you guys?
“We are spending a lot of time looking at machine learning and those pieces. That’s an important part of what’s going on inside our company at the moment. Our business is going to double this year over last year. Things are moving quite fast for us. We are doing a lot of new things, bringing new people into the company, bring new perspectives and capabilities. We always try to leave space for that. Bringing in pharmacists, psychologists, and other people with clinical backgrounds. We are looking for innovation in different places and looking for opportunities.”
Reflections
- Digital Therapeutics differ from health apps in that they have a clinically-evaluated significant impact on health outcomes. But, are they making behavior change interventions cheaper, more effective and scalable? Ayogo’s results indicate yes. However, there are many conflicting studies.
- Designing a digital therapeutic requires a wide range of expertise. Too often I see health behavior apps being designed by a software engineer and a couple of domain experts, such as a dietician or a physical therapist. However, to design a digital intervention that will actually result in behavior change requires a wide variety of disciplines — psychology, behavior change science, UX design, education, data science, and more. Apps are often a simplistic mix of track your actions, earn some leaderboard points, and receive encouragement and tips. This can work for some people that are already motivated and very goal-oriented. However, many people simply get bored and discouraged with such a simplistic interface. What I appreciate about this company and other firms doing similar work (such as Mad*Pow) is that they take a truly interdisciplinary approach to health behavior change design, use evidence-based behavior change techniques, and focus in on keeping the user engaged and feeling empowered.
- Behavior change in the absence of environmental change is hard, but we have to try. The cost savings could be staggering. When I was completing my degree in nutrition, I often heard researchers say “people can’t change.” This always infuriated me. I changed. I know lots of people who changed their health habits and their lives. How can we just give up on people? It is true that the number of people willing to make deep and lasting change to their health habits is well under 50%. But, we owe it to those that have that latent desire for change to give them the tools and support they need to make a go of it. Let’s do a thought exercise: if 10% of the patient population could slow down, prevent or reverse their chronic disease, what savings would accrue to the healthcare system? If 10% of the approximately 30mm people in the US with diabetes managed to get off their medications and normalize their blood sugar, this would result in 3mm people who are no longer heading towards diabetic complications. The average cost to treat a diabetic over a lifetime is on average $85,000. If you multiply 3mm people by $85,000, this results in savings of a staggering $510bn dollars over a lifetime. I think it’s worth the money to try.
- Behavior change interventions must start with respect for the individual. I’ve also observed that many people without a background in health coaching assume that they can manipulate an individual to behave a certain way. This is certainly a recipe for failure. An individual’s choice and “stage of change” must be respected. The purpose of a behavior change intervention, whether it’s through a digital therapeutic or 1:1 counseling with a professional, should first be to empower an individual to make a conscious choice. Once they’ve made the decision to engage, then the challenge is to give them the tools and confidence to stick with the program. Ayogo characterizes this as increasing “adherence and persistence,” which I think is an excellent way to frame the solution.
About me! (The author)
I want inspire a revolution that puts lifestyle interventions at the center of how we approach care so that we change the paradigm in mainstream medicine and empower people to take control of their health. Through this blog, I am on a learning mission to find the best ideas for preventing and reversing chronic disease, to improve outcomes and reduce costs.
To learn more about me (the author), check out: my LinkedIn and Twitter accounts.
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