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Patients, We Are Counting on You


Remote Patient Monitoring of dataThe primary focus of the remote monitoring industry is on the collection of data from patients.  By placing a device on or near someone’s body, we can get a continuous stream of information about how a person is breathing, beating, sweating, digesting and even thinking.  Sensors are growing more powerful, smaller and easier to attach to a needy patient.  At the same time, as the “Internet of things” are connecting machines together, the Internet of medical devices is turning each of us into an addressable URL.   The promise of George Orwell’s book “Nineteen Eighty-Four” with its dystopian society and big brother interventions maybe arriving through the doors of a medical clinic.

But extracting information from the human body is only half of the equation.  Unlike the patient who comes into a hospital or clinic where paid professionals ensure that the patient is connected to the appropriate telemetric devices, remote monitoring ultimately depends on patients to make care happen.  Sending the hospital home with the patient requires a different set of behaviors from the patient, not just the technology.  Patients must move from passive receivers of care to active participants in their care plan delivery.

This past week I spoke at a conference called “Shaping the Future of MEMS (Micro-electro-mechanical sensors) and Sensors.”  We are probably most familiar with MEMS because this type of device allows us to adjust how we are holding our cell phone and have it automatically rotate the content to match the new orientation.  This same type of technology can measure blood flow through a capillary or determine the orientation of a human body at a given point of time.  Increasingly, these types of devices will allow us to understand what is happening with a patient or customer at any point in time.

The lunch keynote was given by Bnedetto Vigna, the EVP of MEMS and Sensors at STMicroelectronics.  (STMicroelectronics is a strategic business partner of ours.)  A major focus of his keynote was on the evolving nature of how people interact with machines.  From the beginning of time (or at least the 1950s) until the invention of the mouse in the 1990s, people communicated with machines with some type of keyboard.  Everything that we wanted a machine to do to had to be translated into some type of character sequence and communicated through a cumbersome process.

In the past decade, our ability to interact with machines has changed dramatically.  Apple introduced us to Siri who now listens to our questions and finds us restaurants and then gives us spoken turn-by-turn directions.  Microsoft Kinnect introduced us to a world where hand gestures can be used to play games and communicate without having to have a mouse or a keyboard serve as an intermediary.  And this spring, Samsung introduced us to the Samsung Galaxy IV where the device itself can be tilted or twisted to take instructions.  Users can twist and tilt the device to instruct it to go to the next page or next picture.

Over the next decade, body worn sensors will evolve to the point where their size, battery life, and sensitivity will become commoditized.  Competition will force the creation of sensors that are lightweight, comfortable, low cost, and highly effective at measuring human vital signs of all types.

Increasingly, success in this marketplace will require a complete loop of communication between the mind of the patient and the “ears” of the devices that we put in place to listen.  We will then be able to capture both hard measurements such as ECG and blood sugar as well as the experience of the patient who can report on what they feel is happening to them. 

The Fashion Dimension


BodyGuardianThis past week I attended and spoke at the Wearable Technology Conference in San Francisco.  While most of the events that Preventice attends are medical in nature, this conference included the larger the wearable sensor marketplace.  Day 1 featured speaker topics ranging from battery technologies to Bluetooth standards to chip miniaturization.  If someone had told me two years ago that I would be absorbed by a compelling presentation on emerging battery technologies I would never have believed them!  But, extended battery life is a critical component of wearable devices and thus is an ongoing area of focus, investigation and improvement.   The wide-range of components that make up a remote monitoring solution are truly amazing.

Several speakers talked about the importance of “fashion” as an aspect of the wearable sensor product category.  We humans naturally come to think of clothing and jewelry as extensions of ourselves and of our personality.  While these talks focused more on consumer devices, where vendors compete for consumer attention at a retail point of sale, I realized that the appearance of the device is critical in medical applications as well.

A great example of this can be found in another area of technology development.  I recently read the biography of Steve Jobs.  While Mr. Jobs can rightly be viewed as the inventor of the personal computer and the executioner of the music CD (or maybe record stores), he can also be given credit for revolutionizing personal electronics with style. Steve Jobs understood the incredible power of individual identification with things beyond our clothes, jewelry and hairstyles.

In many cases, the external fashion element will be missing.  Devices such as our BodyGuardianTM are designed to-be-worn under clothing with little or no exposure to the outside world.  For the user, a device that is potentially less visible is a key design benefit vs. a device with visible wires, sensors and indicator lights that communicate, “I’m sick.”   In other cases, devices may need to be worn around the arm or like a fully visible shirt.  Being bold and visible may be seen as positive indicator and wearing the device is a badge that tells the world, “I’m healthy!” or a fitness buff.  In either case, as product designers and manufacturers we should always assume that the appearance of the device matters to the person wearing it.  Anything worn for more than a few hours actually becomes a part of the individual’s persona—so the design and fashion do matter.

One of the outcomes of our early trials with the BodyGuardian Remote Monitoring System is the strong sense of connection that patients have with their device.  They come to see it as “cool,” “a friend” and “a protector” that keeps them safe.   Keeping an eye to fashion can only serve to enhance the bond that our patients have with the technology that promises to improve their quality of life.

Who knows, maybe the first “Steve Jobs” of the wearable sensor industry will be known for technological advance and outstanding design.

Send the Hospital Home


By Michael Emerson, Senior Vice President of Marketing, Preventice
June 27, 2013

Everyone knows that to truly contain healthcare costs that we will have to reduce the number of days that patients spend inside the four walls of traditional healthcare centers.  The government of Denmark, which manages one of the most successful and well-respected healthcare systems in the world, is presently embarked on a massive rebuilding to effort to modernize its nationwide hospital system.  One strategy?  Reduce the number of patient beds by 20%.  Twenty-five years ago, an effort like this would have added more beds, now beds are being removed.

The only way to make this work is to transition part of the care outside of the hospital and let patients receive a higher portion of their treatments while residing at home or intermediate care facility.  (Assuming of course that demand will remain steady over this period of time.)  As a result, the healthcare industry is now turning to remote monitoring, which allows some part of the care cycle to be sent home with patients, thus negating the need for them to be cared for under the inpatient model.

Unfortunately, much of the early research for this approach has been somewhat disappointing.  Challenges relating to human factors, user adoption, and technological capabilities have all contributed to results that have shown promise, but not results.  These early studies have caused some to ask the question if promise has gotten ahead of reality.  Maybe the promise of remote monitoring is not much more than promise?

The good news is that this tide appears to be turning.

A recent study out of England, offers promise to the types of changes and results that can be obtained with the use of telemedicine types of technologies.  On a rather large sample of more than 3,000 patients with COPD, CHF, and diabetes, they showed that compared to the control group, 7% less of the patients who were covered by remote monitoring technologies were admitted to the hospital.

So, what are some of the conclusions that we can draw from this study and others?

  1. The need to treat patients outside of the hospital setting is enormous and will only grow over the next few years as the demand for cheaper care solutions grows.
  2. Remote monitoring and telemedicine approach can really impact healthcare costs in a numerically meaningful way. 
  3. Much more study is required to understand the true “magic sauce” to reach the types of numbers aspired to by healthcare payers worldwide.

My company, Preventice, is presently involved in more than a dozen clinical trials that are looking how to quantify the medical and financial benefits of remote patient care.  We clearly have seen clear examples of individuals who have had their care transformed by new types of life-saving and life-enhancing technologies.  Some early learnings about this exciting new world.

  1. Technologies must be combined and integrated to deliver a comprehensive care to the patient.  In the same way that a hospital stay is more than just about the food, remote care is more than just a body sensor.
  2. Remote monitoring must be connected to the legacy EMR system.  We have to adopt a technology that is blind to where the patient is at a point in time.  Patients must transition from hospital to home to work and not lose any connection or coverage.
  3. New care plans must evolve.  Care plans have been used by payers to ensure that patients receive consistent and high-value care for a particular clinical indication.  These plans now must include ambulatory as well as in-patient components.

We can’t always send the hospital home with the patient.  However, we can find many instances where we can do just that.  We can shorten stays after surgery by a day or even two.  We can bypass the hospitals for indications, like a-fib, that can be monitored from a distance.  With a lot of new product development and insight from clinical trials, a cut of 20% of hospital days may become a reality over the next decade.

There Is No Place Like Home


Facebook CEO, Mark Zuckerberg, introduced a new Facebook version of an Android phone this past week.  The theme of his introduction—the first phone to be organized around people, not apps.

Mark Zuckerberg, Facebook phone

While I am not going to be the first to run out and endorse this new product with any of my hard cash, I do think he got something right. Our tolerance for “app count” has probably reached its limit. As the number of apps for either Android phones or iPhones now reaches into the hundreds of thousands, I am sure that our ability to assimilate more than a half dozen apps into our daily stream of life has already been reached. 

However, I am confident that the whole notion of a phone experience that is organized around “you” certainly has some “legs.”  It also has some direct relevance for those of us who are designing applications for patients and customers in the social media era. Putting the individual at the center of the experience is the right place to start if our aim is to have patients engage with their care plans and prioritize the actions that we ask of them. 

So where do we start, assuming we don’t have the multi-million dollar marketing budget that Mr. Zuckerberg has at his disposal.  First, we need to remember that the patient world is largely centered around the doctor and the healthcare provider that works on his/her behalf.  All of our applications must incorporate information from the EMR systems that record doctor plans and prescriptions for care.  Health applications that do not integrate with available information won’t cut it with our customers who will quickly understand that your information is irrelevant.

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Incorporating information from remote monitoring solutions is another big step.  The current generation of listening devices put the patient at the center of the care process in a very literal way.  Monitoring collects information in a near real-time basis and uses it to communicate to a health care organization which can use the information for better care.  It also lets patients know that their body is communicating directly to a system that is putting that data to use on their behalf.

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The Facebook Home concept also challenges those of us in the mHealth space to remember the social nature of the individuals who use our engagement solutions.  Facebook users spend an average of over 6 hours a month tapped into the world’s most popular social network.  While patient’s will never engage in our applications with the same fervor, we certainly can use the incredible drive of individuals to be social on our own behalf.  Encouraging individuals to connect with their family and other connections to reinforce the regularity of care can be a major force on our behalf.

Heart Disease-- From Ancient of Days


The just completed ACC (American College of Cardiology) conference in San Francisco provided insight into many new and exciting treatments for a wide variety of cardiac diseases.  Because of our interest at Preventice in diseases relating to heart rhythm, several studies on drugs that treat this disease (or at least the symptoms of the disease) were particularly interesting. 

ACC, Michael, Trade Show, Preventice

Representatives from Boeringer-Ingelheim discussed results of a major study that showed that Pradaxa was significantly better at reducing the risk of ischemic stroke while avoiding any meaningful increase in hemorrhagic stroke when compared to warfarin.  Pradaxa has been on the market for several years and it continues toestablish itself as a market leader.  Another new drug for Afib, Eliqus, was just released to market by Bristol Meyer Squibb.  Eliqus promises to reduce symptoms and actual occurrence of heart arrhythmias.  

American College of Cardiology

But one other study caught my attention—and not because it talked about something new, but because of what it had to say about something quite old—heart disease in ancient Egyptians.  A study by xyz used a CT scan to examine 137 mummies that were believed to have dated back to about 5,000 years before the present time.  They found that individuals, whether they came from privilege or from common folk, contained extensive evidence of cardiovascular disease.

Drew Palin, mHealth, Solutions


So the ultimate question is whether or not new drugs, devices, and emerging technologies such as remote monitoring can begin to cure diseases that have plagued the human race prior to the onset of civilization.  In some way, we struggle simply to keep up with the negative consequences of technology and affluence. New treatments must overcome the impact of modern society on our heart and health in general.

But I remain optimistic that we are winning the race and that patients will benefit from the emerging technologies that were in fulldisplay at ACC

The Human Side of Mobility


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The Mobile World Congress is purportedly the second largest technology conference in the world. It certainly appears to be the most bullish about the future of a connected human race.

It’s a blur of technologies and acronyms. Trying to sort out the relevance of LTE, NFC, IP Backhaul and a handful of other new standards is a challenge to industry veterans. One thing is certain- the mobile industry is prepared to move data more places, faster and with a higher level of security than it did last year.

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But a couple of human statistics really stood out. First, 400 million more people have access to a mobile phone than they do to electricity. Second, we expect to connect another billion humans to the mobile cloud in the next 3 years. I am sure that the gap between access to electricity and the phone network will only widen. 

The human side of mobile health is equally apparent here as well. Much of our focus at Preventice is on the industrialized world where people can already afford a high level of health care. Remote monitoring solutions will further increase their quality of life and provide peace of mind that, should something happen; a doctor will know that immediate action is required.

Mobile health has the potential to bring high levels of care to billions of people that previously had no access to care. Visionary individuals talked to us about plans to use mobile technology to deliver care to tens of thousands of villages across central Africa and rural India. Rather than providing individuals with a smartphone, the plan is to provide the village with a phone that can in turn connect an entire community to high levels of care. In this model, one trained medical technician can serve a large community. When extra expertise is required, information can be sent to a doctor that might reside elsewhere in the country or somewhere else in the world.

Previous waves of technology dating back to the printing press and railroad added to the range of life experiences that were available to each individual. Mobility has begun to realize its potential as the first wave of technology that fundamentally transforms how the human race lives and works with each other. Ultimately, health care will transform itself as well.

Extend Versus Replace: Is Patient Engagement Technology the Key?


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Spending on construction for health care peaked in 2009 at just over $48 billion dollars. That number fell dramatically in 2010 to about $40 billion dollars and has remained relatively constant over the past two years. Of course this drop was largely driven by the Great Recession, which hammered capital improvements of all types. Our country has largely paused in its march to build any type of infrastructure and healthcare building is just part of the avalanche caused by decreased demand.

However, demand for all types of health care services continue to increase as people grow older and their dependence on the medical delivery system marches inexorably northward. One can only assume that at some point we will need to build more hospitals and clinics as people grow older and inevitably, more dependent on the services of the health care industry.

However, building more hospitals and clinics is not the only answer. One way that we can support increased demand for health care services is to simply convert in person care to distributed care. Clinics are showing up at Walgreens, Target, and Walmart. This type of substitution will continue to enable a shift in how and where individuals receive care.

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Another option is to replace medical care with automated systems like the IBM Watson technology to reach patients with less direct medical involvement. Watson, most well known for winning a Jeopardy match against an all-star team of ex champions, has now been programmed to move into the medical sphere. Eventually, whether at a remote clinic or even over the Internet, Watson will offer highly accurate diagnostic services that may ultimately rival and perhaps even exceed the acumen of many general practitioners who likely lack deep expertise on every symptom known to mankind. 

While replacing the medical professional is one way to reduce the number of hospital and clinics that have to be built, another strategy is to extend the ability of doctors to reach many more patients. In this way, technology serves as a multiplier, not a replacement for the care and expertise of a doctor. Patient engagement technology extends the ability of doctors to reach many more individuals without actually requiring one to one in person encounters.

 Using patient engagement technology, doctors can create rules that align treatment to data that is gathered from the individual and processed through rules that the doctor has carefully created for a large group of patients that are under common care. In this fashion, a one to many relationship is far superior to a one to one interaction that requires far more medical personnel than we have available today.

Ultimately, this one-to-many paradigm may become the most effective way to deliver care. While it will not preclude the need for more buildings and care facilities, it may continue to “bend the curve” downward and allow many more patients to receive a higher quality of care than can be achieved with simply replacing medical professionals with stand alone technology.

Cyberchondria and Facebook Envy


This past week, I have seen a couple of research pieces on the emerging threats to our mental health brought about by our ever increasing engagement with the online world. First, a study documented the prevalence of Facebook envy amongst on-line users. While this is something I joke about with friends whenever I return from some international travel, I never thought about just how serious it can be. Apparently looking at photos of other people’s smiling kids can cause some serious mental health damage to a large part of the populace.

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 But researchers have now begun to understand that Facebook envy can really impact people’s lives. The investigaors looked at 600 individuals who were actively engaged with Facebook and sure enough, many of them reported that life satisfaction was significantly impacted by their social networking experience.  (Maybe they own stock in Facebook as well!)  Their conclusion—Facebook is an inherently stressful environment.  Apparently, arguing about religion, politics, and work is not the best way to calm your nerves (either at work or at home). For anyone interested, you can read more here.

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 A few days later, research came out that documented the phenomenon now referred to as cyberchondria. A recent study by the Pew Research Center revealed that 59% of adults have reported going on-line to gather information about their own personal health. Of course, this is not a bad thing, but increasingly, online information can become a source of obsession and anxiety.

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 A recent story on CBS This Morning interviewed psychiatrist Janet Taylor who is an expert on this type of situation. She commented about the afflicted: “They look for self treatment and they don’t go in and see their doctor or they go in and see their doctor too much and the fact is, they don’t have anything diagnosable.”

 As an evangelist for mHealth and remote monitoring technologies, I always think of increased engagement as a good thing. But do we run a risk of creating an entire generation of cyberchondriacs?  Could it be that having a device attached to your chest or wrist will cause patients to take significant risks that they should not take?  Hopefully not, but the laws of unintended consequences should always be considered. Will remote patient monitoring be the final tipping point in our obsession about our own health.

 It is highly unlikely that patients who wear some type of monitoring device will ever become the subject of device envy. More likely, increased usage of these devices will become routine and accepted. Just this past week I talked with a co-worker who had been prescribed a cardiac monitoring device because of a stroke that he had had last month.

 Having said that, cyberchondria does seem like a legimate concern.  We must always remember that monitoring devices and engagement solutions are extensions of the doctor’s conversation with the patient.  They should never replace that interaction.  By always having that central principle in front of us, we will not go wrong in how we interact with patients.

Data Privacy and Mobile Health


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Data Privacy and mHealth are not naturally coexistent. Data Privacy in general, refers to the collection; storage and usage of data, often personally identifiable, such that if used improperly could cause financial or reputational harm to an individual. The sheer amount of data that can be collected from a device or application is mind-boggling. Much of this data can be extremely useful in determining a patient's behavior and compliance to their care plan, monitoring for disease related trigger events, trending for possible disease states, prevention and above all, life saving. The data can actually provide a doctor with a view into the patient's behavior and the possible stimuli that may produce an event, thus bridging the gap between the truth and the patient's comments to the doctor. Data can help paint a clearer picture of a patient's condition when utilized properly.

mHealth medical devices and applications can provide millions of pieces of data very quickly. Application developers often see data as point of purchase type collection of raw data that can be shared and used with just about anyone. Unfortunately, healthcare data is different from other types of data collected like purchases at the grocery store, driving habits and history, claims data from property insurers, etc. Healthcare data must be kept private and secure during its entire lifecycle. It must be controlled, validated, secured and made available to a patient upon request. Plus, the "holder" of the data must be able to prove that they have policies and procedures in place, and that they are following them in order to maintain the privacy and security of the data in their possession and that they share. This is where HIPAA comes in. Under HIPAA providers must regularly disclose privacy practices to patients, and parties must also disclose information to the Department of Health and Human Services if they’re under investigation. In addition, it gives patients the rights to their records, and that has always been the most important aspect.


The patient is the driver of how their health care data, known as Protected Health Information (PHI), is shared, used and disclosed for any purpose other than for their treatment, payment to the provider or other specific uses in healthcare operations (aka TPO). Protected health information (PHI) is defined as individually identifiable health information transmitted or maintained by a covered entity or its business associates in any form or medium (45 CFR 160.103). PHI can be a confusing concept for some. For example, a name or address by itself is not considered PHI; but, when it is combined with a visit, a diagnosis code, a medical device serial number, claims data or other piece of information, it becomes PHI and falls under the protection of the HIPAA and HITECH Privacy and Security regulations, among other Country specific, federal and state regulations.

If data is to be used for anything other than the standard purposes of "TPO", or other reason for which the patient has given clear consent in writing, then the data must be must be completely de-identified by removing 18 defined pieces of information before sharing. New guidance under HIPAA was just issued last week and can be found here.

Entities sharing healthcare data must be able to account for the disclosures and the subject of the data has a right to request a log accounting for the disclosures. Time frames for maintaining the accounting were adjusted under the HITECH act. If an entity uses an electronic medical record, the accounting must be for 3 years.

Of particular note under the HITECH Act is the new Breach Disclosure Rule. The regulations, developed by OCR, require health care providers and other HIPAA covered entities to promptly notify affected individuals of a breach, as well as the HHS Secretary and the media in cases where a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals should be reported to the HHS Secretary on an annual basis. The regulations also require business associates of covered entities to notify the covered entity of breaches at or by the business associate. There are specific time frames and methodologies in the handling of a breach of unprotected PHI depending on the number of data subjects possible, involved. A clear understanding of responsibility is necessary to provide the correct response. Everyone involved in the use, processing, storing, collection or sharing of healthcare information bears responsibility. Extreme fines have been issued for noncompliance. Data breaches can now cost companies up to $250,000 or more in some cases.

A new round of regulation known as the Omnibus Rule should be released soon. It gets complicated but it is safe to say that the bar on Privacy and Security in general will be raised. With the implementation of electronic medical records, mHealth, personal health records, new devices and applications, and the subsequent sharing of data electronically using new tools and E-reports, technology has exceeded the grasp of the regulations in a very short time. The new regulations will be a start in defining and regulating the data as we move forward.

The Role of Motivation and Goals in Keeping Consumers Healthy


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Its quite ironic that the things that are good for our health are most often the things that are of least interest to us,or in some cases, require that extra bit of effort that a lot of us don’t have the time or motivation for. For example-- medicine is never sweet, but it is there to help you recover. Similarly, staying fit and exercising takes a lot of push and effort, but it proves to be worthwhile in the long run. This begs the question: can technology help bridge this motivational gap?

 Over the past few years, we have seen how mHealth technology has become an integral part of the health care ecosystem. Even sports giants like Nike and Adidas have jumped into this mix with remote devices programmed to track everything from the speed, distance, time, heart rate and water levels. Most people would call this a Brand extension, simply another offering for their loyal customers. However, the underlying picture in this, is the fact that the Nike’s and Adidas of the world are realizing what Healthcare companies have been focusing on for a long time now. They have realized that the most important thing is to keep people engaged and healthy and help them lead healthier lives and prevent illness, sports professionals or not. At the end of the day all businesses are here to make profits, that’s not something we can deny, but that does not mean that we cannot do so while promoting a better lifestyle for our customers. Call it a win-win situation if you will, for both sides.

I've had the opportunity to work on a variety of health programs that are intended to change health behavior.  It is interesting to see first hand the impact that coupling behavioral science and motivational factors with the right delivery technologies could have on the problem. 

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   Organizations and individuals have come to understand just how effectively goal setting can drive major behavioral change. Most of the goals we set don’t materialize because we don’t give it enough shape. This is where a concept like SMART can help provide us with meaningful direction. SMART is an acronym for Specific, Measurable, Attainable, Realistic and Timely goals. While technology is generally used to drive efficiency, it can also guide individuals through a process:

  • Specific – Goals should have very discrete and attainable outcomes. A generic goal like “I want to lose weight” doesn’t do a lot to bring about the desired change. A goal like “I want to lose say 20 Pounds”, is more specific and actionable.
  • Measureable – Every goal must be capable of being measured. Weight can be easily measured using a weight scale and running can be measured using distance and speed, which is now possible with smart phones.  More sophisticated devices such as ECG monitors can help a participant be more specific.

  Now, I’m going to break the order of SMART and explain Realistic goals and Timely goals before explaining Attainable goals.

  • Realistic – Goals must be achievable with the available resources. A patient or consumer must choose goals accordingly to their own limitations.
  • Timely –Goals need to be achieved according to a specific schedule.  Incremental approaches work particularly well.  A good approach would be to decide to lose say 1 or 2 pounds every week for a 10-week period as opposed to 20 pounds in 3 months. Setting clear start and end points are important. Linking these discrete time periods together is also important. Having the next set of goals after the first are achieved is also important.
  • Attainable - This is one area that could completely affect the accomplishment of goals over and above the rest, which is why we dedicate this paragraph to it. Motivation is a huge factor when it comes to achieving set goals, especially if it requires consumers to break out of their cycle and push themselves to a better tomorrow. The key word here is rewards. Rewards give people an added incentive to work for something.Careful thought into the research around intrinsic rewards verses extrinsic rewards is important and perhaps worthy of a future blog post.  Extrinsic-rewards can serve an important role and provide for a short-term boost.  Though research has shown intrinsic rewards tend to lead to longer-term, ongoing results and technology has the opportunity to formalize a person’s individualized reward system.  The combination of the two becomes real interesting.
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If we can help patients and consumers choose a SMART goal, we can facilitate powerful behavioral change.The inclusion of all this is the key to getting people to lead the path to a better lifestyle and stay changed and motivated to maintain that lifestyle for a better tomorrow. And the icing on the cake is the fact that we have the power to do all of this, at the palm of our hands.  
  I would like to know what you, the readers, think about this. If you have any comments, view points or suggestions, please feel free to drop a comment in the section below. 
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