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Insights from Activate2018: How Data and Conversational AI Drive Behavior Change

Activate2018 was mPulse Mobile’s second industry event focused on leading strategies and mobile programs to drive healthy behavior change. Over 100 attendees from 44 companies attended the event to engage with industry thought leaders and innovative healthcare executives that are leveraging Conversational AI capabilities to drive behavior change across their populations. 

Using Technology to Promote Healthcare Data Accessibility

Aneesh Chopra, former Chief Technology Officer of the United States and President of Care Journey, gave a powerful keynote address focused on how to achieve a lower cost, higher quality healthcare system through technology innovation, open data and consumer activation. He highlighted that success in improving healthcare can only be achieved through consumers taking a more active role in navigating the health delivery system. But to do this they need to be empowered with greater access to their own data to help them make better decisions at each stage of their health journey.

Chopra stressed the importance of developing API-based interop standards similar to those that have proven effective in other industries (such as the banking industry) as a way to drive innovation and more consumer-centric solutions. He used the CMS Blue Button 2.0 initiative as an example, highlighting CMS’s widely expected requirement for Medicare Advantage plans to adopt data release platforms “meet or exceed” the capabilities of Blue Button 2.0 FHIR API by 2020. He also discussed the importance of cultural shifts in addition to technology advancements. Weaving together technical expertise with rich anecdotes, Chopra painted an inspirational view for healthcare’s path forward.

Activation in Action

In a panel of mPulse customers sharing their stories of successful behavior change, Kaiser Permanente and Home State Health presented the results of their Conversational AI programs. They were joined by Rena Brar Prayaga, mPulse’s lead Behavioral Data Scientist, who provided further detail on how the programs were optimized to impact behavior change.

Dr. William Woo, Assistant Chief Family Medicine at Kaiser Permanente, shared how he is using mPulse’s Conversational AI capabilities for his Diabetes Self-Management program to drive healthy behavior change and improve maintenance of A1c control in his diabetic population. Dr. Woo demonstrated the importance of understanding the specific challenges and health needs faced by individuals, and using these insights to tailor the most appropriate dialogues to educate, motivate and drive change. During the Kaiser Permanente program, more than 276,000 dialogues were sent to 11,238 members over a six-month period. Leveraging a broad range of data inputs from Kaiser Permanente’s system information and patient-generated data, these dialogues were dynamically tailored to advance the consumer’s health activation levels. The program achieved a significant improvement in A1c control. Commenting on the results, Dr. Woo spoke to the efficiency of the program and how it freed up his care team’s resources to focus on higher risk segments of his patient population.

Andrew Dietrich, Director of Telehealth Services at Home State Health, walked through the sophisticated health engagement program that he deployed to engage his diverse Medicaid population. Home State Health covers over 250,000 lives, of which 85% are <18 years old, and over 95% are in the Temporary Assistance for Needy Families (TANF) program. Dietrich discussed the need to engage members across a broad range of health topics including care gaps, healthy living, pregnancy, plan services, finding a PCP, redetermination and ED avoidance among many others. Historically, the plan had used mailers and phone outreach to address only the most pressing of these topics. Home State Health partnered with mPulse to develop a library of content dialogues covering all potential health topics and use mPulse’s Conversational AI solution to assign those dialogues to each member based on a dynamic profile of their preferences, health status, previous engagement and Home State Health’s priorities. In addition to delivering over 240,000 dialogues to 17,208 members over a 12-month period, Dietrich highlighted the program’s impact on key quality measures—members that participated in the health engagement program had significantly higher Well-Child and Adolescent Well-Care visit rates.

A recording of the complete panel can be viewed here. 

Technology Overview

Ram Prayaga, mPulse Mobile’s Chief Technology Officer, presented on the direction of mPulse Mobile’s Conversational AI capabilities. He spoke to three key themes: Data, Growth and Empathy.

The importance of data was a consistent theme throughout the event. Driving behavior change requires a deep understanding of individuals’ socioeconomic environment and the psychographic factors that influence their behaviors. Some of these insights are sourced from customer information systems. For example, a zip code yields rich data about Community Need and key Social Determinants of Health factors. However, almost all psychographic factors have to come directly from the consumer. Prayaga spoke to how these complex data points can be sourced directly through conversational interactions.

The second theme, Growth, covered the necessary capabilities to deliver Conversational AI solutions at scale. Obviously, a basic requirement is the ability to handle large volumes of concurrent dialogues. However, Growth also describes mPulse’s expanded solution offering to address additional health challenges, new segments of the population and international languages. As many of mPulse’s solutions leverage Natural Language Understanding (NLU), Growth requires building out new language domains to support new engagement areas and deepening conversational capabilities to have more meaningful dialogues. These capabilities support Prayaga’s third area of focus, Empathy.

Empathy, describes the ability to understand consumers, their health situations and engage with them in a way that provides the support they need. Prayaga highlighted the importance of empathetic solutions, particularly when engaging diverse populations segments. He used the examples of senior populations and how they like to engage, which is very different from millennials. Empathy enables mPulse to engage with these members as individuals in a way that minimizes abrasion and contributes significantly to the consumer experience.

Customer Perspectives on Implementation

In the second customer panel, The Milestones of Implementing Mobile Health Engagement Solutions, leaders from Cambia Health Solutions, Trusted Health Plan, Healogics and Healthx presented on their mobile health engagement programs and the milestones they each experienced over the first 12-18 month period to demonstrate key learnings for the audience. Each speaker walked through how their program was developed to address key engagement challenges, and their unique approach to drive success.

Michael Novotny, Technical Product Manager at Healogics, provided an excellent example of rolling out a major health engagement initiative across multiple sites and how they focused on success to identify best practices, as well as identify program champions. It was key to the success of their implementation, as their operation includes over 800 clinics.

In contrast, Jason Thomas, Director of Corporate Facilities and Special Projects at Trusted Health Plan, focused on identifying their biggest engagement pain points. In their case, a significant proportion of members lost coverage as a result of not completing the necessary redetermination process. Lost coverage impacted members’ ability to get care, and also added significant administrative costs to get the member re-enrolled. The text program drove a significant improvement in redetermination rates. This validated the effectiveness of the text channel, which helped expand programs into other engagement areas.

As a leader in a large complex healthcare organization, Lynn Dusek, Director of Consumer Relationship Marketing at Cambia Health Solutions, talked about the importance of internal alignment. In her role it is critical to coordinate the mobile health engagement strategies across multiple departmental stakeholders. A key milestone for her program was establishing the necessary program governance processes to enable coordination of consumer engagement initiatives from multiple departments.

The final presentation was by Mike Rowe, CTO of Healthx. Their partnership with mPulse focuses on providing mobile solutions that fully integrate with their core portal capabilities to drive true consumer engagement. In his presentation, he stressed the importance of data; both understanding in detail what data is available and leveraging the data in a way that allows micro-segmentation and orchestration best practices for member engagement.

A recording of the complete panel can be viewed here.

Activate Awards

In closing Activate2018, mPulse’s CEO Chris Nicholson announced the winners of the inaugural Activate Awards. Designed to recognize key areas of program impact and innovation, the awards recognized 4 categories to which companies had submitted applications prior to the event.

The winners were:

  • Home State Health: Most Innovative Program
  • Docent Health: Most Improved Consumer Experience
  • Kaiser Permanente: Best Use of Conversational AI
  • Healogics and Ieso Health (joint winners): Most Significant Outcome

The awards demonstrated the impact health activation can have on key health outcomes and how successful programs enable healthcare organizations to achieve key business outcomes. As well as demonstrating leadership in the space, these organizations set the benchmark for some healthy competition at Activate2019.

For details, read the press release.


A key theme of Activate2018 was the importance of data for successful behavior change programs. By using real-life examples of Conversational AI behavior change programs, the event highlighted how both source system data and patient-generated data are integral to the success of solutions. Discussions around these themes clearly established that open data sharing between healthcare organizations and technology companies such as mPulse and engaging consumers in a way that empowers them to share their health needs are fundamental requirements for successful health activation at scale.

Patient activation is critical to improve health outcomes and take costs out of the system. mPulse’s Activate series of events (look out for ActivateX and Activate2019 later this year) is unique in bringing together thought leadership in behavior change approaches and innovative mobile technologies to illustrate how organizations can achieve health activation at scale.

Stay informed about future Activate events.

Activate2018: Key Themes and Highlights

Activate2018 was mPulse Mobile’s second annual industry event, bringing healthcare leaders together to discuss the leading strategies and mobile programs that drive healthy behavior change. Throughout healthcare, there is a lot of buzz around conversational AI, chatbots and their role in consumer activation. Activate2018 showcased real-word examples of conversational AI programs, the data and technology that drives them, and most importantly, how they can be leveraged to drive healthy behavior change across a broad range of health challenges.


The importance of data was a core theme that permeated every session. In his Keynote session, Aneesh Chopra, the first Chief Technology Officer of the Unites States and President of Care Journey, discussed open data sharing as a requirement for patient activation.  Open data standards have empowered consumers in other industries, particularly finance with Intuit API-based interoperability standards. The equivalent approach for healthcare is needed, and with recent moves by regulators (CMS’ Blue Button initiative) and significant moves by industry players (Apple Health Records adopting FIHR standards), the technical change will happen. But he stressed there will need to be a cultural change, too. Technical capability is not enough alone to produce health outcome results. Health organizations must empower consumers to utilize their health data in a way that realizes potential, and mobile solutions that activate consumers in this area will be key to accelerating change across broad sections of the population.


During the panel “Activation in Action: Stories of Successful Behavior Change,” Kaiser Permanente and Home State Health both presented on their mobile programs that use mPulse’s Activation Intelligence product. Both programs, which are ongoing, rely on data-driven tailoring to deliver conversations that are meaningful to each individual. Kaiser Permanente improved rates of blood glucose control in diabetic patients, and Home State demonstrated the ability to engage hard to reach populations and increase attendance at key preventive health visits.

Both speakers addressed the need to harness both source system data and consumer generated data to tailor conversations.. Dr. William Woo, Assistant Chief, Family Medicine & Diabetes Champion, Kaiser Permanente, spoke to the power of mobile engagement to uncover key insights from the consumer such as barriers and health beliefs. Only by understanding these key psychographic factors can you effectively tailor programs to the individual.


Cambia Health Solutions, Healogics, Healthx and Trusted Health Plan discussed the programs they have launched in the last year during the panel, “The Milestones of Implementing Mobile Health Engagement Solutions.”  In each case, the companies started their programs by focusing on a single use-case. After demonstrating results and the impact of interactive text messages, there was broad interest across different departments in their organizations to launch additional programs. Having internal champions, demonstrating results and the importance of governance to ensure programs remain compliant were additional themes from the panelists.


Empathy is another key factor influencing consumer experience, particularly as more healthcare companies are delivering sophisticated conversational AI programs. Empathy is the ability to engage and react with consumers in a way that is natural, demonstrates understanding and adapts to the consumer . A powerful illustration of this concept was highlighted in mPulse Mobile Co-Founder and CEO, Chris Nicholson’s keynote, when he talked about emojis. Emojis are an important way that consumers express themselves. In many cases, use of emojis reflects consumer adoption to texting with their healthcare organization.

mPulse has received hundreds of thousands of messages that contain emojis. In fact, some messages only contain emojis. Surprisingly, the 60-70 year old segment is the biggest user. Having the technical capability to correctly interpret and react to emojis is important for healthcare organizations to engage in an empathetic way, which in turn drives activation.


An important concept demonstrated at the event was the power of asking questions. Direct questions to consumers through text messages are, in many cases, the only way healthcare organizations can uncover key insights and data outside of direct conversations between consumers and care staff.

The technological advances in conversational AI have created a wealth of opportunity in this area. Take consumer preferences around message frequency as one example. Commonly, healthcare organizations have message frequency rules that apply across all consumers segments, with frequency often set low due to fear of over messaging. When consumers are asked what frequency of messages they would like, there is a broad spectrum of preferences and the frequency is almost always much higher than companies expect. By not asking this question, companies are not meeting the needs of their consumers, and they are not taking advantage of valuable opportunities to engage their populations.

Message frequency is a simple concept, but AI allows much more complex insights to be gathered such as psychographic factors, goal setting and consumer reported outcomes. The data is so rich that the challenge becomes how to take full advantage of it. The power of asking questions was addressed by mPulse’s Chief technology Officer, Ram Prayaga. In his technology deep dive, he took the attendees through the concept using mPulse’s Activation Intelligence product. Using smoking cessation as an example engagement challenge, he demonstrated how the product uses questions to gather and store key insights on each individual consumer in a dynamic member profile, called the Activation Profile. The Activation Profile is referenced real-time to determine the most appropriate dialogues to deliver to individual consumers to uncover key insights and to drive specific behavioral outcomes.  The Activation Profile is also used to create an Activation Score which quantifies how activated a consumer is, which, when applied to a particular health engagement program, can be used as a predictor of how an individual through to a whole population is likely to behave.

Throughout the event it was apparent how important health activation was for the organizations in attendance. There was broad agreement that their health consumers want tailored and meaningful engagement from their trusted healthcare providers. The Activate2018 conference provided an important environment to dive into these topics, discuss best practices and create a pathway to success for all.

To be notified when we have posted the video recordings of Activate2018 sessions, please click here.

Brendan McClure is the Director, Solutions Marketing at mPulse Mobile. 

Reaction and Analysis: Office of Civil Rights Takes a Position on Text Messaging in Healthcare

If you ask a group of people that work in healthcare about whether texting is a compliant form of communication, you are likely to get a wide variety of answers: “you can,” “you can’t,” “you can, but no PHI,” “PHI is fine.” There has long been a desire for clarity on this grey and murky topic.  At HIMSS 2018, Roger Severino, Director of the US Department of Health and Human Services Office for Civil Rights (OCR), shed some much welcome light on compliance around healthcare texting.

Before we get to Severino’s comments, let’s address why everyone is so confused.

Two types of texting defined

There are two different types of texting that operate very differently and serve very different needs but are both commonly referred to as the same term, “texting.” The first type is what general consumers think of as texting, or Short Message Service (SMS) to use its technical term. This is the texting that is a default app on your phone and paid through your carrier that many people use to send and receive texts every day. It is unsecure. For clarity, I will refer to this as SMS. The second type is proprietary app based, with multiple different app providers. It is used by healthcare providers (mostly doctors and nurses) to communicate to one another on patient-related care inside and outside the walls of the health center. It can also be used by providers to communicate with patients provided the patient has downloaded and created an account for the app being used. It is secure. For clarity, I will refer to this as Secure Texting.

PHI and texting

Handling PHI through texting is the source of a lot of confusion and debate. Because of their Provider-to-Provider focus, Secure Texting needs to meet certain technical standards for HIPAA compliance:

  • encryption of message data in transit and at rest
  • reporting/auditability of message content
  • passcode enforcement
  • authentication
  • permissions management capabilities

With these safeguards in place, PHI of all risk levels can be communicated through that channel.

SMS is an unencrypted channel, so one might assume no PHI can be sent. Actually, that is not true. Encryption is not mandated. Instead healthcare companies must assess whether encryption is a reasonable and appropriate safeguard in its environment, when analyzed with reference to the likely contribution to protecting PHI. If encryption is not deemed reasonable and appropriate, the covered entity must implement alternative safeguards.

Because the SMS format is fundamentally incapable of encryption, companies have the discretion to make a case-by-case determination under HIPAA whether it is reasonable and appropriate for SMS texts to contain PHI.  A key factor is the nature of the PHI to be disclosed. Many healthcare companies are comfortable including low risk PHI in SMS texts, such as a patients first name, the fact the patient has a medical appointment, or has a medical condition (without specifying what the medical condition is). So, under current policy, while it is not explicitly defined, low risk PHI can be sent through the text channel within the boundaries of HIPAA guidelines.

The 2017 Clarification on Secure Texting and Patient Orders 

Since 2011, there has been considerable back-and-forth on whether Secure Texting can be used for communicating patient orders. In December 2017, the Joint Commission issued a clarification explicitly stating the use of Secure Texting for patient orders is prohibited. The document also recommended healthcare organizations should have policies prohibiting the use of SMS for communicating PHI. Expanding on this statement, the Joint Commission explained ‘Organizations are expected to incorporate limitations on the use of unsecured text messaging in their policies protecting the privacy of health information’ Joint Commission 2017. This position is in-line with the broader HIPAA Security Rule policy requiring healthcare organizations weigh the risks and benefits of sending unencrypted text messages.

The HIPAA Omnibus Final Rule

In 2013 the HIPAA Omnibus Final Rule allowed healthcare providers to communicate PHI with patients through unencrypted e-mail as long as the provider informs the patient that their e-mail service is not secure, gains the patient’s authorization to accept the risk, and documents the patient’s consent. This clarified the use of email for provider to patient communications. (Just to be clear providers cannot communicate PHI to one another using unencrypted e-mail).

Notably, the rule did not mention anything about SMS, which is somewhat frustrating as SMS is the most widely adopted communication channel by just about everybody. Some interpret the rule as applying to SMS as well because both are unencrypted electronic channels. Others want more clarity.

Clarity from OCR

Speaking at the HIMSS health IT conference in Las Vegas on March 6, Roger Severino, said that healthcare providers may share PHI with patients through standard (SMS) text messages. Providers must:

  • warn their patients that texting is not secure
  • gain the patients’ authorization
  • document the patients’ consent

Severino’s comments are yet to make it into policy, but the OCR has long-promised guidance on this topic. As the country is in a period of intense deregulation, it is reasonable to assume a ruling on the topic is imminent.

What does this mean for healthcare companies?

That depends on whether the healthcare company is already using SMS to reach and engage their patients. Many companies have well-established SMS programs. SMS has bubbled to the top as the most effective channel to engage patients about their health:

  • Increased chronic condition medication adherence from 30% to 44% in a non-adherent Medicare population read more
  • Reduction in members reporting they would use the Emergency Department for a minor condition from 11% to 4% read more
  • Reduction in procedural no-goes by 50%

Many healthcare companies are comfortable with the unencrypted nature of the channel and include PHI in line with their compliance department’s requirements. For these companies my advice would be to continue to drive as much value through the SMS channel while meeting current compliance guidelines. These companies will then be in a position to capitalize most when there is a change in policy that increases the breadth of use cases for which SMS can be used to engage patients and health plan members.

For companies that are not using the SMS channel to engage patients, I see this as clear notice that SMS is a channel where you should invest. 95% of the adult population uses the SMS channel and 98% of SMS texts are read. No other channel has that level of adoption and engagement. Because of this reach, the impact of the SMS on both clinical and administrative outcomes is well established and will only go up with policy that increases the breadth of use cases for which the channel can be used.

Takeaways from Activate 2017: Connecting Health Activation and Conversational Business

Our Director of Solutions Marketing, Brendan McClure, shares his key takeaways from the keynote presentations at our inaugural event. This blog is the first in a series of Activate 2017 posts.

The case for health consumer activation and strategies for driving activation were clear focuses at Activate 2017, the premier healthcare consumer-activation event. Presentations by our two keynote speakers, Dr Judith Hibbard, lead author of the Patient Activation Measure as well as listed in Thompson Reuter’s 2015 and 2016 editions of The Most Cited Researchers Globally, and Jason Brenier, Director of Strategy at Georgian Partners, worked in conjunction to show the positive health and business outcomes of activated healthcare consumers as well as how conversational business can be leveraged to better connect consumers with their health.

In her session, Dr. Hibbard demonstrated the link between activation and patient behaviors, outcomes, healthcare utilization and costs. The Patient Activation Measure (PAM) assesses patient ability to and likelihood of completing healthy behaviors. In effect, it is a predictor of whether a patient can and will do their part in the care processes. For example, if self-management services are offered, typically only more activated patients will participate. Importantly for care delivery systems, her research has tied higher PAM scores to improved outcomes and lower costs.

After controlling for demographics and health status, there is a $1987 per patient annual cost differential between those patients who stay high in activation and those who stay low in activation over time. That represents a 31% difference.

Dr. Hibbard stressed that care systems must meet patients where they are. Too often health systems focus on at-risk populations, yet many health behaviors being asked of these patients are complex and challenging. Patients with low activation not only fail to complete these tasks, but the act of failing can discourage them from trying other care interventions. Using PAM the least activated patients can be identified, so that support can focus on activation by improving their knowledge, confidence and teaching new skills.

Patient Engagement Outcomes Banner

When the burden to complete a task outweighs the benefit, the task will typically go undone. Dr. Hibbard explained that an individual’s self-perception influences this. Someone lacking confidence is unlikely to tackle a task that is complex. This connected well with Brenier’s discussion on how consumer behaviors are influenced by convenience.

Consumers are attracted to the path of least resistance. Convenience leads to increased consumer adoption, utilization and loyalty over the long-term. Brenier introduced this theme when describing the journey from Web to Apps and recently to chat. Mobile Apps added a whole new level of consumer convenience by bringing large amounts of functionality to the phone. But now mobile app usage is declining 20% YOY as consumers select messaging as the channel they are most comfortable engaging. Why? Chat is easy, humans are designed to chat and the interface is intuitive. In contrast, App functionality must be learned which contributes to App fatigue and ultimately non-use.

Similar to Dr. Hibbard’s comment on the importance of health organizations to meet patients where they are, taking into account their level of health activation, Brenier stressed that organizations must adopt conversational business to effectively reach their consumers. There is an expectation amongst consumers to access rich insights and services through a simple interface with minimal effort. Companies must adopt chat interfaces wherein the UX design is about language, dialogue and conversation experiences. This is how businesses meet consumers “where they are.”

Brenier developed 9 Principles for Conversational Business to help organizations figure out how to launch these initiatives.

9 Principles for Conversational Business - Jason Brenier

There was agreement amongst the attendees at Activate 2017 that conversational business was part of their consumer engagement plans. They highlighted both the potential to influence consumers and the cost effectiveness of the approach as key drivers for change. There was also consistency about the types of challenges conversational business posed, such as who creates the content (dialogues are different to outbound campaign-based copy) and how conversational business is managed across multiple channels. It was clear that the path to conversational business was a strategic goal for many organizations, though the healthcare industry is historically slow at adopting new technology. This in mind, the general consensus was that the best pathway to get there was by taking small steps at a time. As Allison Melun of Delta Dental of Colorado said, “you don’t have to do it all at once.”

Healthcare organizations are looking to other industries for cues on how to deliver a more consumer-focused experience. Brenier clearly demonstrated the potential for industries to meet consumers where they are using conversational business. Given the scale and complexity of healthcare, it naturally translates that there is an enormous number of areas where conversational approaches can deliver a more streamlined and tailored consumer experience. Improving health activation is one of these areas. Dr. Hibbard stressed the importance of healthcare systems tailoring their interactions with patients with low activation scores. By leveraging tailored conversational approaches, healthcare systems can lower the barriers for patient activation and truly meet their patients where they are.