I’m always a bit disappointed when I pitch Backtrack to someone, they seem to love the idea and nod along in agreement, and then cap our discussion with: “Imagine the potential when you break out into a bigger market, like fitness tracking!” I’m disappointed in these situations because it means I’ve failed at communicating our biggest talking point: the magnitude of the problem we’re tackling, and how much bigger the rehab opportunity is than they realize.

In a recent meeting with Helge, our General Partner at TandemLaunch, he brought up an important aspect of investor psychology: if investment upside = value x volume, you need to pitch an investment that brings a large amount of value (and is priced accordingly, i.e. in enterprise sales), or one that can reach a huge market (“Everyone with a smartphone!”). Having a medium-sized opportunity in both value and volume, though, can lead to more tepid reactions. When we think of how wearable technology can improve health, we often tend towards these same notions: “Our addressable market”, gushes many a wearable tech cofounder, “is everyone who wants to be healthier!” The optimist interprets that market to be everybody, and naturally gets very excited about how big a deal wearable health is about to become. The realist sees two big problems with this approach.

Problem one is that “everyone who wants to be healthier” is a very different market from “everybody who wants to strap on a fitness tracker that nags them about taking their 10,000 steps every day.” I’ll leave it to you to figure out which market is a few orders of magnitude smaller.

Problem two is that from a health perspective, wearable fitness trackers are limited in their impact by profound selection bias. If you’re the type of person who goes out and buys a FitBit, guess what? Odds are you’re making healthy choices anyway. Activity trackers may be useful tools at helping people meet goals they’re already trying to achieve, but not so useful at altering human behaviour at its root cause.

Modifying human behaviour is no small challenge: most of the serious, chronic health care conditions we struggle with in developed countries have to do with behaviour in some way. Behaviour matters in two ways: as a contributor to the cause of a condition (addiction, obesity, Type II diabetes, heart disease) or as an obstacle to recovery (all of the above, plus anything that requires hard work and long-term rehab effort such as back pain). Rehab in particular is a very tricky problem: most people going through rehab for a physical condition or injury truly want to improve, yet ultimately drop out and fail to recover in the long run. Why? Because recovery isn’t something you can easily see. Faithfully going through rehab exercises day after day without seeing or feeling any progress is discouraging, leads to disengagement, and ultimately to dropout and long-term disability. It’s a different kind of behaviour problem than obesity or addition, but it’s a really big one, and one that’s waiting for real innovation to shake things up.

Part of the puzzle with innovating in this area is that there’s no clear road map for how to build a good solution. Broadly speaking, you could take one of two approaches: the consumer route, full of lean, agile innovation and market-driven solutions, or the medical device route, with its rigorous, scientifically-backed tools that have deep buy-in from the research, medical and regulatory communities. Both approaches have their merits and their drawbacks. The medical device approach is a tried-and-true method for building upmarket, highly targeted devices, but is usually slow, capital-intensive, and inherently based on waterfall development: not great for radical innovation. On the other hand, the consumer approach (where most of wearable health is now) may draw great inspiration from the Lean Startup and Lean Hardware movements; yet the problem is that MVP-driven, agile/iterative product development is really good at finding product market fit somewhere– but likely something other than the original health problem you set out to fix.

Behaviourally-dependent health problems are especially curious because neither of these approaches works very well. The research-based, medical device approach can be a good way to develop scientifically validated tools that work in controlled clinical trials, but immediately fail in the marketplace because customers aren’t motivated to use them. (Or, often enough, motivated to not use them: remember Antabuse?) The consumer approach will get you something that people happily use, but the process of customer discovery and product iteration may likely lead you towards product market fit somewhere else, solving some easier problem. That’s why we have dozens of different activity-tracking wrist bands, none of which solve the issue of how to motivate people who aren’t Kickstarter-browsing, fitness-minded quantified selfers to exercise more. That’s the real problem. 

We keep talking about how wearable technology will help keep us active and healthy; yet that scope squanders the biggest true opportunity of mobile health. A wearable monitoring tool, at its core, is a behaviour modification device: if we keep optimizing these tools for people who already want to stay in shape, keep fit, feel alive, et cetera then we’re iterating towards solving an easier problem, not the hard problem that truly needs solving. Recovery; rehab; getting people back on their feet and back to work after an injury- that’s a much bigger issue facing difficult behavioural obstacles. This is where mobile health can truly make a difference.

A behaviour-change tool can only succeed if it gives the user something they want. The old-fashioned, medical device approach can’t build a tool like this: that’s just not how the development pipeline works. If we’re going to build wearable tools to solve our behaviourally dependent health conditions, it’ll have to come from the developer community, and it’ll have to feel like a consumer product; at least at first. But it’ll also take discipline, it’ll take scientific rigour and patience, and it’ll require a creative new approach to launching and iterating on a product. The team that pulls this off will need to surround themselves with great advisers from both the scientific and startup community, building a team that is equally focused on the scientific data and adaptive to the customer. It’ll be a fun challenge, that’s for sure. 

Sounds like something we could try with Backtrack, yeah?