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Ju$tifying th€
  Digita£ Health
Content Investment
Why It Matters | How to Do It
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
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.




                 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                        Page 3
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)
                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                              Page 4
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
                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                              Page 5
A Single CDC Blog Post Captured the World's Attention,
but Did It Change Behavior?                                                            Figure 1.
Just prior to the 2011 hurricane season, the Office of              Did OPHPR's Post Impact Preparedness Behaviors?
Public Health Preparedness and Response (OPHPR)
published a somewhat tounge-in-cheek blog post
focusing on the importance of preparing for a Zombie
Apocalypse. (3) The post was designed to raise
awareness about the importance of being prepared for
disasters.

CDC was unprepared for the massive reaction the post
received. Soon after a tweet announcing it was
published to Twitter, the agency's website was
inundated with visits. Unprepared for the traffic, the
CDC's website crashed for a brief period.

Although the public's response to the post was
unanticipated, its creation was well planned. According
to OPHPR's Margaret Silver:

"CDC’s Joint Information Center [JIC] was actively
monitoring social media to track conversation about the
[2011 Japan Earthquake] and provide accurate
information where appropriate. JIC noticed that people
were responding to questions about what disasters they
would prepare for with 'zombies.'

In our planning sessions about how how to get people
thinking about preparedness as hurricane season
approached, we talked about the possibility of doing
something around zombies." (4)

After OPHPR's director, Rear Admiral Ali S. Khan, signed                                           Source: Enspektos, LLC, © 2012
off on the idea, the famous post went live.
                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                              Page 6
A Single CDC Blog Post Captured the World's Attention,
but Did It Change Behavior?
                      Figure 2.                                        Daigle's query highlights a question sometimes asked
   OPHPR Achieved Its Goal of Generating Awareness                     before, during and after digital health content initiatives.
                                                                       Web and social media have the potential to reach billions
                                                                       of people. But does reach translate into changed hearts
                                                                       and minds?

                                                                       In the case of the Zombie Apocalypse post, convincing
                                                                       more people to prepare for hurricanes could have had a
                                                                       significant economic and human impact. A few months
                                                                       after the post was published, the Eastern U.S. was
                                                                       pounded by Irene, one of the worst tropical storms on
                                                                       record. Irene was expected to do more damage to the
                                                                       coast, but hit inland areas such as upstate New York and
                                                                       Vermont hard.

                                                                       Many people in these regions were unprepared for the
                                                                       storm's ferocity. However, because of CDC's Zombie
 Source: Enspektos, LLC, © 2012                                        Apocalypse post, did some in these areas prepare? If so,
                                                                       what would have been the economic benefits of these
Overall, OPHPR was pleased by the success of the blog                  preparedness activities? It is likely they would have been
post. For a modest $87 investment (plus staff time), it                significant.
generated tremendous awareness — especially via sites
like Twitter (Figure 2). This demonstrates the power of                The Zombie Apocalypse story illustrates why it is so
social media to quickly spread information globally and                important we begin to routinely measure the behavioral
generate a massive response.                                           impact of digital health content initiatives. If we don't, we'll
                                                                       never know the economic value generated by a single,
However, OPHPR wanted to know more. Shortly after                      massively popular blog post.
the post appeared, the agency's Dave Daigle remarked:
"Measuring hits and views is great, but did people make                Until now we have assumed digital health content can play
a plan, did we really affect behavior?" (Figure 1)                     a role in behavior change. Below we'll address whether this
                                                                       is truly the case.


                                  Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                                         Page 7
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.

                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                              Page 8
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)



                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                              Page 9
Can Digital Health Content Change Behavior?
                                         Figure 4.
                   How Digital Health Content Supports Behavior Change




                                                             Source: Enspektos, LLC, © 2012



         Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                               Page 10
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.


                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 11
Can Digital Health Content Change Behavior?
                                            Figure 5.
                                The Health Behavior Levels Matrix
                                                                                          Source: Enspektos, LLC, © 2012




         Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                               Page 12
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.

                        Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                              Page 13
ROI: Important, but Often Misunderstood and
Misapplied                        Figure 7. Calculating ROI




                                                                     Source: Enspektos, LLC, © 2012



          Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                Page 14
Why Focusing on ROI Is a Mistake in Health

We've spent a lot of time defining ROI and talking about
its importance, but using ROI as the sole means of                         Figure 8. ROI-Oriented Thinking:
evaluating digital health content investments is a                           How Do Benefits Flow to Us?
mistake. Health is different. Here's why.

Promoting health is not just about increasing
profits. The ultimate goal of any marketing or
communications initiative is to convince people to
change or sustain positive health behaviors.
Government, pharmaceutical companies and managed
care alike have a shared goal of helping people live
longer and more productive lives. They disagree on how
to get there, but there is a shared consensus that
improving health can deliver significant economic
benefits to society.

Moreover, health organizations are being
financially incentivized to demonstrate they
improve overall health and wellness. For example:

 •   Pharmaceutical companies: Private and public
     sector payers have the most influence on drug
     firms' financial fortunes. To succeed, companies
     must prove their medications (and support
     activities) deliver economic benefits to society.

 •   Hospitals: Increasingly, hospitals with high in-
     hospital infection rates, readmissions and poor-
     quality care are being financially punished.
                                                                                                  Source: Enspektos, LLC, © 2012
 •   Government: Programs that fail to improve
     health are being eliminated.

                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 15
Quantifying Digital Health Content's Economic Benefits

In this context, health organizations cannot afford to
                                                             A new metric for evaluating digital health
engage in ROI-oriented thinking (Figure 8). For the
private sector, having executives evaluate digital health    content: Return on Health Behavior.
content investments solely on whether benefits are
flowing from customers and stakeholders to the               Developed by Enspektos, LLC, ROhB quantifies
company is a mistake. More importantly, turning a profit     the aggregate economic benefits associated
isn't what motivates organizations such as non-profit        with activating and sustaining positive health
hospitals, government and charities.                         behaviors via digital content.
If ROI isn't appropriate, what metric should we use?
We suggest the health industry adopt a metric called                        Figure 9. ROhB-Oriented Thinking:
                                                                       How Do Benefits Flow Between Us and Others?
Return on Health Behavior or ROhB. ROhB was
developed in 2012 by the health marketing
communications innovation consultancy Enspektos, LLC.
It measures the aggregate short- and long-term
economic value associated with activating and
sustaining positive health behaviors via digital
health content. ROhB's benefits include the following:

 •   ROhB recognizes the new financial reality:
     It quantifies how the economic benefits of digital
     health content flow between organizations and
     society (Figure 9).

 •   Both the public and private sectors can use
     ROhB: It allows the public and private sectors to
     speak the same language when quantifying digital
     health content's benefits.

 •   ROhB encourages innovation: It can help
     justify experimental or long-term investments.
     Positive ROhB = worthwhile activity.                                                          Source: Enspektos, LLC, © 2012



                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 16
Quantifying Digital Health Content's Economic Benefits
                                                                             Figure 10. The Pros and Cons of ROI
ROI, ROhB and Health Behavior

To help you understand why ROhB is a more
appropriate metric for digital health content, we discuss
it in the context of the Health Behavior Levels Matrix
introduced earlier (Figure 6).

As outlined in Figure 10, ROI is primarily designed to
help organizations determine if people are buying or
donating. Because of this, it is best suited for
measuring Level II health behaviors associated with
making purchases or donations.

To properly calculate ROI, one has to accurately
attribute digital content consumption directly to a
purchase or donation. Digital attribution analysis is a
complex subject, but companies like Adobe and IBM
have designed tools to help organizations conduct it
more easily. (10, 11)

However, ROI does not provide information on whether
digital health content impacts short- and long-term
non-purchase health behaviors. As discussed
previously, understanding this is an imperative for the
health industry.

ROI is also being used inappropriately. There are
instances where the immediate goal is not to drive
revenue. However, if a project does not demonstrate
short-term ROI, a worthwhile initiative may be ended
prematurely. Moreover, ROI is not an appropriate
metric for non-profits and government.                                                                  Source: Enspektos, LLC, © 2012




                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 17
Quantifying Digital Health Content's Economic Benefits

ROhB is a more flexible metric, as described in Figure                    Figure 11. The Pros and Cons of ROhB
11. Most importantly it does the following:

 •   Recognizes Financial Reality: ROhB does not
     ignore the fact that private sector organizations
     must turn a profit.

 •   Refocuses Non-Profits and Government from
     Evaluations Based on Activity to Economic
     Benefit: Sometimes non-profits and government
     executives are rewarded based on how much they
     produce and distribute. ROhB realigns the focus
     from what was made to health outcomes with
     proven economic benefits.

 •   Justifies the Use of Digital Media to Shape
     the Market and Build Relationships: ROhB
     enables health organizations to quantify activities
     such as relationship building or shaping the
     market. For example, proving that building an
     online community boosts medication compliance
     has many economic benefits, including these:

           - Preventing illness (reducing medical costs)
           - Improved adherence (increasing drug
              revenue)
           - Improved productivity (boosting profits)

See Figure 12 for a sample ROhB calculation. Profits
plus quantified economic benefits to society are
compared to digital health content's costs to generate a
ROhB figure.                                                                                            Source: Enspektos, LLC, © 2012



                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 18
Quantifying Digital Health Content's Economic Benefits
   Figure 12. Calculating ROhB (Thanks to Jane Sarasohn-Kahn of THINK-Health for Assistance with This Calculation)




                                                                                                     Source: Enspektos, LLC, © 2012



                    Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                          Page 19
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.

                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 20
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."


                         Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                               Page 21
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?


                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 22
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.

                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 23
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.




                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 24
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

                      Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                            Page 25
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.




                      Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                            Page 26
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.




                       Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012
                                                             Page 27

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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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 3
  • 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) Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 4
  • 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 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 5
  • 6. A Single CDC Blog Post Captured the World's Attention, but Did It Change Behavior? Figure 1. Just prior to the 2011 hurricane season, the Office of Did OPHPR's Post Impact Preparedness Behaviors? Public Health Preparedness and Response (OPHPR) published a somewhat tounge-in-cheek blog post focusing on the importance of preparing for a Zombie Apocalypse. (3) The post was designed to raise awareness about the importance of being prepared for disasters. CDC was unprepared for the massive reaction the post received. Soon after a tweet announcing it was published to Twitter, the agency's website was inundated with visits. Unprepared for the traffic, the CDC's website crashed for a brief period. Although the public's response to the post was unanticipated, its creation was well planned. According to OPHPR's Margaret Silver: "CDC’s Joint Information Center [JIC] was actively monitoring social media to track conversation about the [2011 Japan Earthquake] and provide accurate information where appropriate. JIC noticed that people were responding to questions about what disasters they would prepare for with 'zombies.' In our planning sessions about how how to get people thinking about preparedness as hurricane season approached, we talked about the possibility of doing something around zombies." (4) After OPHPR's director, Rear Admiral Ali S. Khan, signed Source: Enspektos, LLC, © 2012 off on the idea, the famous post went live. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 6
  • 7. A Single CDC Blog Post Captured the World's Attention, but Did It Change Behavior? Figure 2. Daigle's query highlights a question sometimes asked OPHPR Achieved Its Goal of Generating Awareness before, during and after digital health content initiatives. Web and social media have the potential to reach billions of people. But does reach translate into changed hearts and minds? In the case of the Zombie Apocalypse post, convincing more people to prepare for hurricanes could have had a significant economic and human impact. A few months after the post was published, the Eastern U.S. was pounded by Irene, one of the worst tropical storms on record. Irene was expected to do more damage to the coast, but hit inland areas such as upstate New York and Vermont hard. Many people in these regions were unprepared for the storm's ferocity. However, because of CDC's Zombie Source: Enspektos, LLC, © 2012 Apocalypse post, did some in these areas prepare? If so, what would have been the economic benefits of these Overall, OPHPR was pleased by the success of the blog preparedness activities? It is likely they would have been post. For a modest $87 investment (plus staff time), it significant. generated tremendous awareness — especially via sites like Twitter (Figure 2). This demonstrates the power of The Zombie Apocalypse story illustrates why it is so social media to quickly spread information globally and important we begin to routinely measure the behavioral generate a massive response. impact of digital health content initiatives. If we don't, we'll never know the economic value generated by a single, However, OPHPR wanted to know more. Shortly after massively popular blog post. the post appeared, the agency's Dave Daigle remarked: "Measuring hits and views is great, but did people make Until now we have assumed digital health content can play a plan, did we really affect behavior?" (Figure 1) a role in behavior change. Below we'll address whether this is truly the case. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 7
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 8
  • 9. Can Digital Health Content Change Behavior? In 2009, Fogg introduced the Fogg Behavior Model in What are the types of behavior digital health content can order to further describe how persuasive technologies influence? We answer this question below. change behavior (Figure 3). In the model, Fogg suggests behavior is a "product of three factors: Figure 3. motivation, ability, and triggers." (7) In order for The Fogg Behavior Model behavior change to happen (or be sustained), all three factors must be present. In brief: • Motivation refers to willingness to engage in the behavior; motivation can be manipulated • Ability is whether someone can actually perform the behavior; perceived ability can be changed • Triggers are reminders or cues to engage in the behavior, such as text messages or on-screen alerts Digital health content can support behavior change by delivering information triggers that motivate and increase perceived ability at the right time (Figure 4). Fogg has suggested the following best ways to activate behavior change: • Place "hot triggers" in the path of motivated people, i.e., starting with those who want to change first (8) • Reduce perceived difficulty level by making a task easier to complete or suggesting ways behavior change can be simple to achieve (8) Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 9
  • 10. Can Digital Health Content Change Behavior? Figure 4. How Digital Health Content Supports Behavior Change Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 10
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 11
  • 12. Can Digital Health Content Change Behavior? Figure 5. The Health Behavior Levels Matrix Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 12
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 13
  • 14. ROI: Important, but Often Misunderstood and Misapplied Figure 7. Calculating ROI Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 14
  • 15. Why Focusing on ROI Is a Mistake in Health We've spent a lot of time defining ROI and talking about its importance, but using ROI as the sole means of Figure 8. ROI-Oriented Thinking: evaluating digital health content investments is a How Do Benefits Flow to Us? mistake. Health is different. Here's why. Promoting health is not just about increasing profits. The ultimate goal of any marketing or communications initiative is to convince people to change or sustain positive health behaviors. Government, pharmaceutical companies and managed care alike have a shared goal of helping people live longer and more productive lives. They disagree on how to get there, but there is a shared consensus that improving health can deliver significant economic benefits to society. Moreover, health organizations are being financially incentivized to demonstrate they improve overall health and wellness. For example: • Pharmaceutical companies: Private and public sector payers have the most influence on drug firms' financial fortunes. To succeed, companies must prove their medications (and support activities) deliver economic benefits to society. • Hospitals: Increasingly, hospitals with high in- hospital infection rates, readmissions and poor- quality care are being financially punished. Source: Enspektos, LLC, © 2012 • Government: Programs that fail to improve health are being eliminated. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 15
  • 16. Quantifying Digital Health Content's Economic Benefits In this context, health organizations cannot afford to A new metric for evaluating digital health engage in ROI-oriented thinking (Figure 8). For the private sector, having executives evaluate digital health content: Return on Health Behavior. content investments solely on whether benefits are flowing from customers and stakeholders to the Developed by Enspektos, LLC, ROhB quantifies company is a mistake. More importantly, turning a profit the aggregate economic benefits associated isn't what motivates organizations such as non-profit with activating and sustaining positive health hospitals, government and charities. behaviors via digital content. If ROI isn't appropriate, what metric should we use? We suggest the health industry adopt a metric called Figure 9. ROhB-Oriented Thinking: How Do Benefits Flow Between Us and Others? Return on Health Behavior or ROhB. ROhB was developed in 2012 by the health marketing communications innovation consultancy Enspektos, LLC. It measures the aggregate short- and long-term economic value associated with activating and sustaining positive health behaviors via digital health content. ROhB's benefits include the following: • ROhB recognizes the new financial reality: It quantifies how the economic benefits of digital health content flow between organizations and society (Figure 9). • Both the public and private sectors can use ROhB: It allows the public and private sectors to speak the same language when quantifying digital health content's benefits. • ROhB encourages innovation: It can help justify experimental or long-term investments. Positive ROhB = worthwhile activity. Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 16
  • 17. Quantifying Digital Health Content's Economic Benefits Figure 10. The Pros and Cons of ROI ROI, ROhB and Health Behavior To help you understand why ROhB is a more appropriate metric for digital health content, we discuss it in the context of the Health Behavior Levels Matrix introduced earlier (Figure 6). As outlined in Figure 10, ROI is primarily designed to help organizations determine if people are buying or donating. Because of this, it is best suited for measuring Level II health behaviors associated with making purchases or donations. To properly calculate ROI, one has to accurately attribute digital content consumption directly to a purchase or donation. Digital attribution analysis is a complex subject, but companies like Adobe and IBM have designed tools to help organizations conduct it more easily. (10, 11) However, ROI does not provide information on whether digital health content impacts short- and long-term non-purchase health behaviors. As discussed previously, understanding this is an imperative for the health industry. ROI is also being used inappropriately. There are instances where the immediate goal is not to drive revenue. However, if a project does not demonstrate short-term ROI, a worthwhile initiative may be ended prematurely. Moreover, ROI is not an appropriate metric for non-profits and government. Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 17
  • 18. Quantifying Digital Health Content's Economic Benefits ROhB is a more flexible metric, as described in Figure Figure 11. The Pros and Cons of ROhB 11. Most importantly it does the following: • Recognizes Financial Reality: ROhB does not ignore the fact that private sector organizations must turn a profit. • Refocuses Non-Profits and Government from Evaluations Based on Activity to Economic Benefit: Sometimes non-profits and government executives are rewarded based on how much they produce and distribute. ROhB realigns the focus from what was made to health outcomes with proven economic benefits. • Justifies the Use of Digital Media to Shape the Market and Build Relationships: ROhB enables health organizations to quantify activities such as relationship building or shaping the market. For example, proving that building an online community boosts medication compliance has many economic benefits, including these: - Preventing illness (reducing medical costs) - Improved adherence (increasing drug revenue) - Improved productivity (boosting profits) See Figure 12 for a sample ROhB calculation. Profits plus quantified economic benefits to society are compared to digital health content's costs to generate a ROhB figure. Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 18
  • 19. Quantifying Digital Health Content's Economic Benefits Figure 12. Calculating ROhB (Thanks to Jane Sarasohn-Kahn of THINK-Health for Assistance with This Calculation) Source: Enspektos, LLC, © 2012 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 19
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 20
  • 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." Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 21
  • 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? Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 22
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 23
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 24
  • 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 Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 25
  • 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. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 26
  • 27. About Enspektos Founded in 2005, Enspektos, LLC is a digital health marketing communications innovation consultancy. We work with a range of health organizations, including pharmaceutical companies, payers, non-profits and government agencies. We exist to help our clients (and the broad health industry) use digital technologies to inspire patients, caregivers and others to take action around health and wellness. We achieve this goal by developing and deploying a range of products and services, including enmoebius, a patent pending digital surveillance and behavioral measurement engine that reveals the link between digital health content and behavior change. Learn more about Enspektos at www.enspektos.com. Ju$tifying th€ Digita£ Health Content Investment | Enspektos, LLC | April 2012 Page 27