The App Gap


Why there are so many apps and wearables, but so few successes.

By Anita Burrell, Former Head, Commercial Operations
Effectiveness, Sanofi Global Diabetes


In March 2014 there were more than 100,000 health apps available on the Apple and Android app stores. Think about that: 100,000, and that’s only health apps. But less than 10% have the ability to retain a consistent user base, and more than 50% have achieved fewer than 500 downloads. In fact, only 5% account for over 15% of all downloads.

So why is this? Consider that when the IMS Institute for Healthcare Informatics rated health app functionality on a scale of 1 to 100, more than 90% of all healthcare apps received a score of 40 or less. With all the geniuses working in IT and the reach of mobile technology, what’s going wrong? Bottom line: in order to get sustainable uptake of mHealth, stakeholder engagement is key. That means an app has to be connected, credible, meaningful and easy to operate. It would not seem like a high hurdle, but most aren’t making it.

Digital is playing an increasing role in health outcomes, but what we have to recognize at the same time is that we’re still learning a lot about how. With 72% of US adults searching online for health information and 19% using a health app, plus a wearables market estimated to grow from $5B to $50B in 3-5 years, we need to get smarter faster.


What’s missing in the design of many apps is very simple: consideration of the people factor. Not patients—people. We have become fond of the term patient-centric, but that may be an impediment. What if we thought of patients as people just like us, and examined their behavior appropriately? Could we incentivize people appropriately to create behaviors which would lead to improved health outcomes?

One way is to understand that people often act with biases. For example, we are more likely to accept a service if it is a default: in other words, to reject the service we need to “opt out”—why is this? Effectively we are experiencing inertia, which means that providing a default option which we want people to accept is more likely to lead to the behavior and outcome desired. Similarly, we also know that people discount future events, overestimate certainty, and are reluctant to discard learned behaviors. The good news is that all of these innate biases can be incentivized to healthy behaviors if we understand them, particularly if we can make it fun (social) and easy (automated).

Encouraging healthy behaviors

This may all sound obvious and intuitive, but it isn’t necessarily simple to put into practice. Behavioral economics has been able to help in providing some examples which can promote or utilize behaviors based on understanding innate biases:

• Using positive statements will make an offer more attractive, particularly relating to certainty: e.g 1 in 5 chance of winning $100, if behavior is tracked

• Once a user “owns” a status (think airlines) or has been given something of value (either explicit or implicit) they will regard it with greater respect than before it was offered

• Peer mentoring and social norms can provide competition and motivation to increase or participate in behavior changes

• Simplicity in choice means that people are more likely to take up the offer rather than be overwhelmed, and using relevant language (e.g. instead of talking about a drop in blood pressure from an intervention we can talk about life days added)

• Always remember data automation is key to providing value (through feedback) to stakeholders—manual entry kills apps!

Wearable vs. affordable

One of the exciting options to automate data collection and thus make applications more likely to influence behavior and change health outcomes is the growing market in wearables. Some examples are:


Each of these exciting advances can open the doors to a more engaging application but are people interested in actually buying and using them? The chart above shows what consumers said when asked whether they would be likely to purchase these wearables in the next year:

So it does seem like wearables could provide an opportunity to automate data collection, but how much are people willing to pay for the privilege of wearing them? The answer is not as much as you may think. In one study, 5% or less said they would buy a fitness band over $300, and only 38% would be willing to go to $100 (which is where most are priced today).

Other challenges facing mHealth

And it’s not only price that’s keeping people from adopting the technology. Other factors include:

• The reliability of bio sensors to provide accurate and reproducible data over time for blood pressure, pulse, respiration, etc.

• Acceptance and capability to manage data streams by healthcare professionals


• Potential to integrate data from different platforms (although HealthKit may help in the future here)

• Reluctance to share health information, particularly when security of cloud-based storage is questioned

• Regulatory acceptance of wearables and other mobile technologies when these can affect patient care

• Gaining reimbursement for mHealth services and devices when they replace traditional fee-for-service payments

Indeed, we also need to acknowledge that technology (including wearables) alone is not the answer to changing health outcomes. As Sara Siegel, a Deloitte partner in Healthcare Strategy and Consulting, says: “Technology alone, such as the smartphone, is not a silver bullet for healthcare. Instead, success lies in the convergence of digital health and human interaction. It also relies on developing partnerships which harness technology, while providing trust-based, patient-centered care; and balances person-to-person engagement with the efficiencies provided by technology.”

To cite one example of a successful effort, Telcare understands that people living with diabetes can become more engaged in controlling their disease if they are supported by coach counselors as well as being given a blood glucose meter, which allows monitoring of remote compliance and provides immediate feedback for the patient. Indeed, they have been able to show that this integrated approach can reduce claims by an average of $3,384 vs. a control group of similar diabetes patients.

What have we learned?

Mobile technology can serve a purpose of improving outcomes and decreasing costs — if we remember that stakeholder engagement is key. Apps and wearables are a key component of this engagement, and will only increase in importance especially as the challenges to mHealth reduce over time. However, to be effective in changing behavior and affecting health outcomes, they need to be part of a more integrated cohesive care environment.

So the key questions to be asked, right after someone has the great idea for an app or wearable, but before you start designing, are:

• Who are we trying to motivate?

• What do we want them to do?

• What do we know about the triggers that inspire that behavior?

• How do we get them to perceive the value?

• How does the technology integrate into the healthcare environment in order to provide support over time?

As we noted earlier, factors such as privacy of information and regulatory hurdles are a challenge to mHealth, but are surmountable. In order to have greater impact, we need to put the people back into the equation. Time to think—patient focused activities can change behavior. •

1 research2guidance, The mHealth app market (Vol. 1-4)

2 Pew Center Research 2012

3 Credit Suisse

4 research2guidance (as of March 2014)

5 Lowenstein G., Brennan T. and Volpp K. (2007)

6 HRI/CIS Wearables consumer survey 2014

7 PwC Health Research Institute Survey 2014

8 Javitt et al US Endocrinology 2013

All opinions expressed in this presentation are those of the presenter and are not intended to imply that they reflect the position of Sanofi. All figures and data provided are available from public sources available on request.



Anita Burrell is a market access pioneer renowned for promoting multifunctional interaction and consistently delivering products to launch in advance of schedule. She has significant breadth of experience in establishing value evidence across the top 10 therapeutic areas. Ms. Burrell has headed multiple divisions at Sanofi, including Commercial Operations Effectiveness for Global Diabetes, Distinct Project Unit Multiple Sclerosis, Health Economics and Reimbursement, and Health Outcomes CNS/IM. She has also been Head of the Teriflunomide/MS Unit at Genzyme and Manager of Health Economics at Boehringer Engelheim. Currently serving as Adjunct Assistant Professor at Rutgers University, teaching the Health Outcomes, Policy and Economics Master of Science course, she is also a leader in the Healthcare Businesswomen’s Association.