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This ebook provides the global health industry with a simple and flexible method for justifying investments in digital health content. Proving digital health is worth it economically is essential. This is the only way the health industry will move from digital laggard to leader.
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Beyond ROI: Measuring Digital Health Content's Full Economic Benefits
1. Ju$tifying th€
Digita£ Health
Content Investment
Why It Matters | How to Do It
2. Use Statement and Acknowledgment
Use Statement
Enspektos, LLC is licensing this content under the Creative Commons License, Attribution-ShareAlike 3.0
(http://creativecommons.org/licenses/by-sa/3.0). Please feel free to use material in this ebook in blogs,
podcasts, presentations, and other content. You may also e-mail it to your colleagues and others
you think will benefit from it.
Acknowledgment
We would like to thank Jane Sarasohn-Kahn of THINK-Health for her invaluable assistance in helping us to refine our
work on quantifying the economic benefits of behaviors activated or sustained by digital health content. Information
about THINK-Health is below.
About THINK-Health
THINK-Health is a strategic health consultancy founded in 1992. Focusing at the nexus of health care and
technology, the firm's toolkit includes environmental analysis, scenario, strategic and business planning, forecasting,
and health policy analysis.
THINK-Health assists every segment of the health care industry, including technology and medical device companies,
educational institutions, pharmaceutical manufacturers and distributors, health care providers, payers and plans,
consumer products companies, non-profits and financial services firms.
Learn more about THINK-Health at www.healthpopuli.com.
Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
Page 2
3. Just What Is Digital Health Content?
In this ebook, we'll spend a lot of time talking about digital health content so here's a
brief definition.
Digital Health Content: Information about health, medicine or wellness distributed and
consumed via digital technologies, such as the Internet and social and mobile media.
This includes sites like WebMD, Facebook, Twitter, mobile apps and more.
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4. The Bottom Line: Health Marketers and Communicators
Must Justify Investments in Digital Health Content
In 2005, Harris Interactive found that 58% of online
What Are the Economic Benefits of Digital Health Content?
adults reported going online "sometimes or often" to
find health or medical information. (1) By 2011, 73%
of online adults were frequently turning to Dr. Web for
advice, content and support. (Part of this increase may
be attributable to cost-shifting from payers to
consumers as they seek to reduce medical costs.)
As the Internet has increased in importance for
patients, medical providers, caregivers and others, the
health industry has taken notice — and action. For
example, government agencies like the U.S. Food and
Drug Administration (FDA) and the U.S. Department of
Health and Human Services are increasingly leveraging
online and social media technologies. Government has
Moreover, many are not tying social media activities to
been joined by hospitals, pharmaceutical companies and
standard measures of return on investment (ROI), such as
others in the private sector.
increased sales, revenues and profits.
However, many health organizations have hesitated to
The public sector's enthusiasm has also been tempered
aggressively use these technologies. One reason is
because of uncertainty about whether and how digital
regulatory uncertainty. Pharmaceutical companies have
content activates changes in health behavior.
not received clear guidance from the FDA on how to
employ social media in a compliant fashion. Hospitals
For digital health evangelists, this caution has been
and managed care organizations have concerns about
frustrating. Many fear the industry will fall further behind
violating HIPAA regulations.
as patients and other stakeholders embrace these
technologies.
Another contributing factor is a lack of clarity about
whether investing in digital health content is worth the
Convincing the industry to act will require demonstrating
effort. The health industry is not alone in this regard.
digital health content investments are economically
For example, according to a January 2012 survey
justifiable. Assertions that the health industry must get
produced by Wildfire, most marketers lack a standard
involved because "everyone's doing it" are unpersuasive.
metric for social media success. (2)
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5. The Bottom Line: Health Marketers and Communicators
Must Justify Investments in Digital Health Content
Here's the bottom line: The health industry won't move Our approach to justifying investments in
forward unless we prove producing, curating and
digital health content is behavior-centric.
distributing digital health content is worth the effort.
This is equally true for the public and private sectors.
Health marketing communications initiatives
are not just about increasing revenue.
Our Goal Encouraging people to begin or sustain
behaviors that lead to long, active lives is
We developed this ebook to provide marketers and vital.
communicators with a simple and flexible method for
justifying digital health content investments. This is not just a "feel good" perspective.
Activating behavior change has many
Our suggested approach is behavior-centric. Unlike
other industries, health-related marketing and economic benefits for health organizations
communications activities are not solely designed to and society.
drive revenue and profits. Instead, a major objective is
to change or sustain positive health behaviors so people Health is different. Existing metrics
can live long, active lives. This is not just about doing undervalue digital health content. Because of
the right thing. Activating behavior change can have this, we've developed a new one.
significant economic benefits.
In this ebook, we will do the following:
We believe quantifying the economic impact of digital
health content investments on behavior can help in
• Illustrate why focusing on behavior change in digital
these ways:
health is important
• Address whether digital health content can change
• Ensure marketing communications efforts are
behavior
evaluated based on their overall economic benefits
• Discuss the important but misunderstood art of ROI
— not just on organizational profitability
measurement
• Encourage communications and marketing
• Outline why calculating ROI is not enough in health
professionals to think more strategically about
• Introduce a new method for quantifying the
their digital health content initiatives
economic impact of digital health content on
• Drive widespread adoption of digital technologies
behavior
within the health industry
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8. Can Digital Health Content Change Behavior?
Convincing people to stop long-held unhealthy Evidence suggests digital health content
behaviors such as smoking, poor eating and inactivity is
can activate behavior change.
incredibly difficult. Given this, it makes sense to ask
whether content encountered online or in social media
can truly get people to change. According to the 2011 Edelman Health
Barometer study, respondents said they would
Over the past few years, the public relations firm be motivated to change negative health
Edelman has been exploring this question via its global behaviors because of the following:
Health Barometer. (5) In the 2011 edition of the study,
Edelman conducted an analysis of data it collected
• Reading or hearing about benefits [of
among people reporting they engage in negative health
activities (such as eating poorly). When asked which
behavior change] in the news
factors would motivate them to change behaviors, • Using tools and technologies
respondents highly ranked the following: • Joining a support network
• Knowing their long-term health would improve BJ Fogg, director of Stanford University's Persuasive Tech
• Changes in physical appearance Lab, is perhaps the world's foremost expert on how
• Reading or hearing about benefits in the news machines such as computers and mobile devices influence
• Joining support networks human behavior.
• Using supportive tools and technologies
In 2003, Fogg's book, Persuasive Technology: Using
The results of this study suggest a combination of Computers to Change What We Think and Do, was
factors can motivate people to change behavior. Social published. In the book, Fogg described a new concept he
influences such as support groups clearly play a role. coined in 1996 called "captology." He defined captology as
However, delivering health information digitally via the a focus "on the design, research, and analysis of
news or informational articles may also have an interactive computing products created for the purpose of
influence on behavior. changing people's attitudes or behaviors. [Captology]
describes the area where technology and persuasion
Knowing digital health content has the potential to overlap." (6)
change behavior is only the first step. Understanding
how is the next. Since the book's publication, Fogg has continued to refine
the captology concept in a range of ways.
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9. Can Digital Health Content Change Behavior?
In 2009, Fogg introduced the Fogg Behavior Model in What are the types of behavior digital health content can
order to further describe how persuasive technologies influence? We answer this question below.
change behavior (Figure 3). In the model, Fogg
suggests behavior is a "product of three factors: Figure 3.
motivation, ability, and triggers." (7) In order for The Fogg Behavior Model
behavior change to happen (or be sustained), all three
factors must be present.
In brief:
• Motivation refers to willingness to engage in the
behavior; motivation can be manipulated
• Ability is whether someone can actually perform
the behavior; perceived ability can be changed
• Triggers are reminders or cues to engage in the
behavior, such as text messages or on-screen
alerts
Digital health content can support behavior change by
delivering information triggers that motivate and
increase perceived ability at the right time (Figure 4).
Fogg has suggested the following best ways to activate
behavior change:
• Place "hot triggers" in the path of motivated
people, i.e., starting with those who want to
change first (8)
• Reduce perceived difficulty level by making a task
easier to complete or suggesting ways behavior
change can be simple to achieve (8)
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11. Can Digital Health Content Change Behavior?
On the next page, we outline a framework called the They can use the Matrix to determine how difficult
Health Behavior Levels Matrix (Figure 5). It is designed behavior change will be to achieve. (Higher level
to outline the types of behavior those producing digital behaviors are harder to activate.) They can also use it to
health content can activate or sustain. Behaviors plan how best to evaluate digital health content initiatives.
indirectly and directly related to health are included in
the matrix because they are activated in the context of In the next section of this ebook, we outline a method for
this topic. The Matrix describes four levels of behavior: justifying digital health content investments. As we will
discover, in the field of health, using ROI as the sole
• Level I: Engagement or activity behaviors method of evaluation is often inappropriate.
commonly associated with consumption of online
health content. These can include watching The Health Behavior Levels Matrix is designed
videos or sharing a Twitter post.
to help those developing digital health
• Level II: Purchase or donation behaviors initiatives to:
activated by online health content, including
decisions to seek or prescribe medication or • Understand the types of behavior they
donate to a cause. seek to influence
• Use the appropriate levels of
• Level III: Short-term health behaviors which do measurement for their activities
not require a long-term commitment such as
• Determine how difficult it will be to
getting screened for heart disease or being
vaccinated.
activate or sustain behavior change
• Level IV: Long-term health behaviors which
require a significant commitment such as taking
medication for life or maintaining an exercise
program.
The Health Behavior Levels Matrix can be useful for
health marketing and communications professionals
working on online initiatives.
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13. ROI: Important, but Often Misunderstood and
Misapplied
The debate over return on investment (ROI) has been Return on Investment is purely a financial
one of the most heated in the digital world. One major
metric. It measures whether an investment
reason for the argument is that ROI is misunderstood.
According to a 2012 survey of corporate marketing
(such as using financial and human resources
decision makers produced by the Columbia School of to produce social media content) results in a
Business Center on Global Brand Leadership: (9) return (profits or donations) to an
organization.
• 82% of respondents did not realize "ROI consists
of both financial return and spending" Many people substitute measures such as
• 37% did not define ROI as a measure of financial increased awareness (visits, advertising
outcomes
equivalency value) or engagement (Web
• 31% believe determining ROI begins and ends
with measuring audience reach traffic, Facebook Likes, retweets) for ROI.
This is not appropriate.
It is important to understand that ROI is purely a
financial metric. It is used to determine if an These non-financial metrics can be useful.
investment (such as a social media campaign) results in However, quantifying the impact of awareness
returns (profits or donations). As Columbia University and engagement on profits (or donations) is
found, many people substitute easier-to-calculate
required to calculate ROI.
metrics such as online awareness (clicks) and
engagement (Facebook Likes, retweets) for ROI. These
metrics are useful, but unless they are linked to However, the decision about whether ROI is an appropriate
financial return, they are not relevant to the ROI metric also depends on the investment's time horizon.
conversation. To clear up confusion about ROI, we have Some activities must yield a return immediately. Others,
provided a guide below on how to calculate the metric such as building relationships online or experimentation,
(Figure 7). can boost or protect profits in the future. In these cases, it
will take longer to demonstrate positive ROI.
Another part of the debate centers on whether it is
appropriate to evaluate digital and social media using Having a clear understanding of the investment's time
ROI. Revenues or donations are the lifeblood of an horizon is important. This can prevent efforts to use ROI
organization. Given this, they have no choice but to analysis to inappropriately and prematurely cancel
determine if these tools yield positive financial returns. worthwhile projects.
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20. Measuring Digital Health Content's Behavioral Impact
You may agree it is important to link digital health
content to health behavior change. You could also
Figure 12. Few Studies Illustrate
accept the argument that ROhB is a more appropriate Digital Health Content's Impact on Behavior
metric for evaluating health online and social media
initiatives. The question is how?
The first place some turn to for answers is in academic
literature. In 2010, Peel Public Health in Canada
commissioned a literature review examining the
effectiveness of social media on health. (12) The
concern was that public health organizations and others
were embracing these technologies with little proof they
work.
The authors found there were few peer-reviewed
studies demonstrating social media was effective at
increasing issue-related awareness and prompting
adoption of desired behaviors (Figure 12).
In other words, there's little evidence social media
drives health behavior change. However, the Peel Public
Health paper has done little to dampen enthusiasm for
social media in the health industry. People are using
these technologies, so health organizations feel they
must follow suit.
If we've hit a dead end with the academic literature,
then what to do? This is another area where the Health
Behavior Levels Matrix can be helpful (Figure 6). The
Matrix stratifies digital-influenced behaviors by type.
Measuring these behaviors requires different techniques
and technologies, as outlined below.
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21. Measuring Digital Health Content's Behavioral Impact
Use Web and Social Analytics to Measure Level I In the case of surveys, asking people how they heard
Behaviors about an event or why they redeemed a coupon can
reveal a lot about what is driving purchase behavior.
The first goal of any digital health content initiative is to
drive awareness and engagement. Level I of the Matrix Customer relationship marketing (CRM) programs can be
accounts for these behaviors. These can be measured leveraged to provide a range of data on the following:
using a range of technology, as described below.
• Acquisition: How potential customers are acquired
Web Analytics: Web analytics platforms can provide a (via newsletters, Web content or other means)
wealth of information about how people arrive at and • Conversion: Which touchpoints (such as e-mail,
consume health content on a website. This data can events, white papers, in-person detailing, etc.)
also be used to examine the types of content that move people from consideration to purchase
improve awareness and sales. • Social Media Impact: Social media being used by
customers and prospects, and which content drives
Social Analytics: There are many technologies that online purchase behavior (clicks, likes, additional
reveal how people engage with (Likes, tweets, retweets) sales)
and may perceive (sentiment) online content.
Measuring Level III and IV Behaviors:
Measure Level II Behaviors with Digital Analytics, A New Frontier
Surveys and CRM Platforms
Existing techniques and technologies do a good job of
Ignoring sales, revenue and profits is perilous, providing data on Level I and II behaviors. However,
especially for private sector organizations like teasing out how digital content influences Level III and IV
pharmaceutical companies and hospitals. actions is more difficult.
Digital analytics and surveys can reveal how online The authors of Peel's literature review of health and social
health content is driving hospital visits and coupon media tackled this question. (12) They wrote: "When
redemptions. It can also help organizations properly controlled research included an evaluative component,
attribute social media to increased revenues and profits. the results were often confounded by a failure to isolate
the [social media] intervention from other communication
strategies."
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22. Measuring Digital Health Content's Behavioral Impact
Requirements for successfully quantifying the
Clearly, measuring the behavioral impact of digital impact of earned digital content on health
health content is a difficult task. However, as discussed behavior:
above, doing so is critical.
Isolating Digital Inputs: Analyzing digital
Many existing platforms fall down when it comes to inputs separately allows for direct
measuring Level III and IV behaviors. Content activity, comparison. For example, health content
sentiment and engagement data don't provide
received via Facebook may perform differently
information about health behavior.
than information posted to a blog.
In the paid content arena, technology is more
advanced. For example, in 2011, Westat partnered with Accounting for Offline Effects: Behavior is
Lotame to examine how online advertising impacted influenced by many factors. What is the
health behavior. Amelia Burke, Senior Director of relative role of online content versus offline
Digital Media for Westat, reported: influencers?
"[D]ata were analyzed from audience engagement
with . . . banner advertisements and surveys . . . [and]
Controlling for Motivation and Ability: How
metrics such as increase in awareness, intent, and does content perform among individuals with
likelihood to recommend to a friend [were examined]. high versus low motivation and ability?
Across recent public health campaigns, specific . . .
results included increases in intent of upwards of 24% Understanding the Full Digital Environment:
and increases in likelihood to recommend to a friend/ People do not consume digital health content
family member of upwards of 16%." (13) in isolation. What else are they seeing online?
Does this information contain positive or
However, much of the health content people consume
online is earned, or non-advertising. How can we negative messages? How is this content
measure its performance? This is the next frontier in influencing behavior?
health behavior measurement. To the right are some
key requirements for projects or technologies developed Right-Time Data: Digital media is ever-
to tackle this problem. moving. Is data provided at the right time?
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23. Measuring Digital Health Content's Behavioral Impact
Mobile, Big Data and Health Behavior Change Much of the promising work in this area is being
conducted to understand patients' real-world clinical
In the mobile arena, a range of companies and outcomes. For example, data can be mined from social
organizations are tackling the health behavior change media channels to understand the following:
problem firsthand.
• What medication-related decisions consumers are
For example, in March 2012, Johns Hopkins University making
launched an effort to rigorously evaluate mobile health • Why patients made these choices — e.g., because
(mHealth) apps. These applications are being tested to of medication side effects or other factors
determine if they help people begin or sustain behaviors
such as exercising, quitting smoking and improving Two companies, Prism Ideas and dMetrics, launched a
eating habits. (14) partnership in 2012 to analyze "social media to
determine patient actions and insights, profiling patient
In addition, a few companies are leveraging mobile to needs, symptoms and response to treatment."
determine how multiple influencers, including content
received via SMS and e-mail, reflect or predict health Despite these advances, more work is required. First,
behavior. One firm is Ginger.io, which has developed a many consumers in various health stages (pre-
mobile behavioral analytics platform. The company diagnosed, recently diagnosed, considering treatment,
"taps into the continuous sensor data from . . . mobile etc.) are not actively discussing their conditions online.
phone[s] and other devices to predict individual Second, the Web is changing constantly. We need a
behavior changes and identify aggregate trends." (15) better understanding of how ever-evolving digital
While not designed to activate behavior change, information triggers influence the vast majority of
Ginger.io's technology can help us better understand the people consuming rather than creating digital content.
factors influencing a range of health choices.
This information can be used to help people:
There is much excitement about the potential of Big
Data to revolutionize our understanding of a range of • Understand how individual pieces of digital
subjects, including health. Big Data refers to the ability content influence health behavior
to automatically process and analyze large amounts of • Provide the appropriate level of evidence required
information using sophisticated algorithms. A major to accurately calculate ROhB
source of data currently being analyzed comes from the
Web and social media.
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24. Demonstrating ROhB: A Competitive Advantage
Digital technologies will only grow in importance as
patients, health providers and other stakeholders
Health organizations that measure ROhB will
embrace them. Because of this, health organizations have a significant competitive advantage.
will continue to invest in these tools. They will become hubs for innovation and
understand how to produce digital health
But the private and public sectors will not be well served content initiatives that deliver maximum
by simply focusing on the low-hanging fruit of digital economic benefit.
measurement: revenues and content engagement.
We predict organizations that invest in demonstrating
positive ROhB will be at a significant competitive
advantage. They will be more likely to innovate. These
organizations will also reap the economic rewards
associated with consistently delivering effective and
engaging digital health content.
We hope this ebook serves as a roadmap for those
organizations ready, willing and able to understand the
full value of their digital health content investments.
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25. End Notes
1. The Growing Influence and Use Of Health Care 8. BJ Fogg’s 5 Secrets of Behavior Change, Sachin
Information Obtained Online, Harris Interactive, Rekhi's Blog, May 13, 2011, http://bit.ly/jLzkca,
September 15, 2011, http://bit.ly/qNNCzZ, Accessed March 3, 2012
Accessed March 22, 2012
9. Marketing ROI in the Era of Big Data, Columbia
2. Measuring the Business Impact of Social Media, Business School, Center on Global Brand Leadership,
Wildfire, January 19, 2012, http://bit.ly/yal8XS, March 2012
Accessed March 22, 2012
10. Why marketers aren’t giving social the credit it
3. Social Media: Preparedness 101: Zombie deserves, Adobe Digital Index Report, Adobe, March
Apocalypse, Public Health Matters Blog, May 16, 2012
2011, http://www.bt.cdc.gov/socialmedia/
zombies_blog.asp, Accessed March 1, 2012 11. Appropriate Attribution: Addressing the Dramatic
Inaccuracies Associated with Last-Based Campaign
4. Revisiting CDC’s Zombie Apocalypse: It Sparked a Attribution in Digital Analytics, IBM Coremetrics, Web
Global Conversation, But Did it Change Behavior?, Analytics Demystified, 2011
Walking the Path Blog, March 16, 2012, http://
bit.ly/yyfdnY, Accessed March 17, 2012 12. R. Schein, K. Wilson, J. Keelen, Literature review on
effectiveness of the use of social media, Peel Public
5. Edelman Health Barometer 2011: Global Findings, Health, 2010
Edelman Public Relations, October 2011, http://
bit.ly/p63MuJ, Accessed March 25, 2012 13. Finally! Identifying and Setting Social Media
Benchmarks for Public Health Campaigns, Walking
6. B.J. Fogg, Persuasive Technology: Using the Path Blog, September 7, 2011, http://bit.ly/
Computers to Change What We Think and Do, mYwvbK, Accessed March 26, 2012
2003
14. Hopkins researchers aim to uncover which mobile
7. B.J. Fogg, A Behavior Model for Persuasive Design, health applications work, Baltimore Sun, March 14,
2009 2012, http://bit.ly/xoZhuS, Accessed March 27, 2012
15. The Science, Ginger.io Website, 2012, http://
ginger.io/the-science/, Accessed March 27, 2012
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26. End Notes
16. Prism Ideas and dMetrics Launch Pioneering
Service Analysing Patient–Reported Action, Get More Insight
Behaviours and Outcomes with Social Media,
Prism Ideas/dMetrics Press Release, January 25, In September 2012, Enspektos, LLC launched
2012 digihealth pulse. This is the world's first
ongoing tracking study investigating the
impact of online and social media health
content on the perceptions and behaviors of
active digital health consumers (or e-
patients).
Visit www.digihealthpulse.info for more
information about the study.
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27. About Enspektos
Founded in 2005, Enspektos, LLC is a digital health marketing communications innovation consultancy. We work with a
range of health organizations, including pharmaceutical companies, payers, non-profits and government agencies.
We exist to help our clients (and the broad health industry) use digital technologies to inspire patients, caregivers and
others to take action around health and wellness. We achieve this goal by developing and deploying a range of products
and services, including enmoebius, a patent pending digital surveillance and behavioral measurement engine that
reveals the link between digital health content and behavior change.
Learn more about Enspektos at www.enspektos.com.
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