The document discusses 6 ideas from social and behavioral sciences that could be useful for health technology strategy and design. The ideas are: (1) using choice architecture and nudges to influence decisions, (2) considering negative incentives, (3) how ubiquitous computing could enable more passive decision-making, (4) understanding how social networks operate through loose vs tight connections, peer support/pressure, and norms, (5) harnessing peer effects in tight networks, and (6) changing norms over time. The document questions what will be asked of patients/consumers as outcomes determine provider pay and technology enables greater accountability.

1. Six Useful Ideas (Maybe!)
on Health Decision-Making
Healthcare Unbound 2011
July 11, 2011
Michael J. Barrett
Managing Partner
Critical Mass Consulting
www.CriticalMassConsulting.com
© Critical Mass Consulting 2011

2. Your basic shameless grab for credit
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3. Six ideas
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4. Six useful ideas
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5. Six useful ideas (maybe – let’s keep
watching)
• From the social, behavioral and economic (SBE) sciences …
• … useful in health technology strategy and design.
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6. Six useful ideas
Behavior
• Decision-making
1. Choice architectures and nudges
2. Negative incentives
3. Ubiquitous computing and passive selves
4-6. Social networks and decision-making
4. How networks operate (i): loose vs. tight
5. How networks operate (ii) peer support / peer pressure
6. How networks operate (iii): norms
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7. Behind the matter of usefulness,
a question looms in the background
As good outcomes begin to determine
provider incomes,
as cost containment pressures intensify
for all of us, and as technology enables
us to assign accountability, what do we
ask of the patient/consumer?
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8. Looming in the background …
“What’s the future of
patient responsibility?
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9. Two ideas that didn’t make the cut
• Do Malcolm Gladwell-style connectors route our communications with one
another?
 Contra: See Duncan Watts, Everything is Obvious, Once You Know the Answer (2011)
• Do Facebook-style social networks affect our views of choices and preferences?
 Contra: See Nicholas Christakis and James Fowler, Connected: The Surprising Power
of our Social Networks and How They Shape Our Lives (2009)
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10. Possibly useful idea #1:
ID choice architecture, insert nudge
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11. Choice architecture
• “A choice architect has the responsibility for organizing the context in which people
make decisions.”
1. “If you are a doctor and must describe the alternative treatments available to a
patient, you are a choice architect. “
2. “If you design the form new employees fill out to enroll in the company health
care plan, you are a choice architect.”
• “ … seeming small features of social situations can have massive effects on people’s
behavior…”
• “It is legitimate for choice architects to try to influence people’s behavior in order to
make their lives longer, healthier and better.”
• “There is no such thing as neutral design.”
Source: Richard Thaler and Cass Sunstein, Nudge
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12. “There is no such thing as neutral design”
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13. Nudges
“… any aspect of the choice
architecture that alters people’s
behavior in a predictable way without
forbidding any options or significant
changing their economic incentives.”
Source: Richard Thaler and Cass Sunstein, Nudge
(Updated Penguin paperback edition, 2009) at 6.
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14. Nudges in the break room
• Experiment: In the break room at Manhattan Mortgage Company, Good
Morning America elevates the fruit plate closer to eye level
• Result: Fruit gets eaten in less than a third of the time it normally takes.
• Experiment: GMA moves donuts away from the center, off to the side.
• Result: Donut consumption drops by 10%.
Source: http://abcnews.go.com/GMA/story?id=7127723&page=1
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15. Anxiety about neo-nudges in the 1950s
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16. Anxiety about neo-nudges in the 2000s
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17. Anxiety about neo-nudges intensifies
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18. Anxiety about real nudges fuels politics
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19. Possibly useful idea #2:
Let’s have a big hand for penalties?
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20. At first it’s all about rewards
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21. But feelings about personal responsibility
are complicated …
Who gets hurt when I over-eat?
Good question. We’re not sure.
• “the causes are too complex”
• vs. “no one can save you if you don’t save yourself”
• “obesity is a disease”
• vs. “so get a grip on the disease”
• “I’m only hurting myself”
• vs. “well, actually, you’re costing us, too”
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22. … and frustrated doctors are talking
about negative incentives …
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23. Possibly useful idea #3:
Post-mobile, it’s all about ubiquitous …
As computing becomes
more ubiquitous,
doesn’t the quantified self become
more passive?
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24. If it can stick, it’ll sense
June 7, 2011:
“Proteus’ personal
monitoring technology
[measures] heart rate,
physical activity and sleep
patterns. “
“Avery Dennison Medical
Solutions is providing
adhesive and material
technologies and
developing the
manufacturing platform to
mass produce the
wearable sensors for the
companies’ respective
customers.”
11/1/2011 © Critical Mass Consulting 2011 Source: Joint press release,
June 7, 2011

25. As computing becomes ubiquitous,
won’t the quantified self become passive?
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26. Possibly useful idea #4: Networks --
(i) sort out loose from tight
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27. Possibly useful idea #4: Networks --
(i) sort out loose from tight
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28. Possibly useful idea #5: Networks –
(ii) in tight networks, harness peer effects
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29. … and master the tipping points
New research:
• Initiation: At the onset of a new interest or “market,” researchers find
that variety-seeking prevails
• Contagion: When a specific approach draws the support of 30% of the
group, adoption takes off
• Saturation: But when group adoption hits 80%-90%, individualism
re-surfaces; the adoption curve flattens out
• Takeaway: When something new gathers steam, people join in (at least
until the new practice builds to stifling conformity)
Source: Pascale Quester and Alexandre Steyer, “Revisiting Individual
Choices in Group Settings: The Long and Winding (Less Traveled)
Road?” Journal of Consumer Research, Vol. 36, No. 6 (April 2010)
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30. Obesity’s on the rise?
So I’m not an outlier if I’m over-weight!
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31. Harnessing peer effects: If the norm
seems legit and I am an outlier …
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32. Possibly useful idea #6: Networks --
(iii) segue from peer effects to norms
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33. Mechanisms of transmission
• When peer pressure operates, people externalize others’ behavior …
• But when norms take hold, people internalize others’ values and beliefs.
Behavioral economists performed the experiments:
1. Priming: Exposing people to small but well-timed cues can change behavior
2. Conformity effects: People look to others for such cues
3. Anchoring and adjustment (inertia): Once people have a point of reference, they don’t
depart from it very much
Neuroscientists find preliminary indications of “hard wiring” for norms
1. Mirror neuron system: Watching lights up the same part of the brain as doing
2. Agreement alone lights up the ventral striatum, strongly associated with emotional
and motivational aspects of behavior.
Source: See, e.g., Campbell-Meiklejohn et al, “How
the Opinion of Others Affects Our Valuation of
Objects,” Current Biology 20, 1-6, July 13, 2010.

34. Mechanisms of alteration?
How do you change a
norm?
And how do you
change it back?
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35. Behind the issue of usefulness,
a question looms in the background
As good outcomes begin to determine
provider incomes,
as cost containment pressures intensify
for all of us, and as technology enables
us to assign accountability, what do we
ask of the patient/consumer?
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36. My standard disclaimer
“I have opinions of my own,
strong opinions, but I don’t
always agree with them.”
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37. Thank you!
Michael J. Barrett
Critical Mass Consulting
781-674-0097
mbarrett@criticalmassconsulting.com
visit criticalmassconsulting.com
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38. … targetting “outlaws” and free riders
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