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Live Life Love | Volume Thirty-Five

Hi Everyone,

Roy Amara, a systems engineer who worked at the Stanford Research Institute, is credited for establishing Amara’s Law: We tend to overestimate the effect of a technology in the short run, and underestimate the effect in the long run. This sentiment has now been repackaged by many in motivational and coaching occupations and repurposed to serve as a testament of our inability to accurately estimate human effort. Back in March 2011, I indicated it was the beginning of a new chapter. Today, six years later, I am grateful to share that chapter is closed. The starting line was no job, no kids and an ambitious goal. The finish line is a Ph.D., two healthy kids and recently being honored as one of the top 50 influencers in digital health. Unfortunately, there is no secret sauce to share. Advice from Gary V. and Grant Cardone failed me. Instead, I found diligently and constantly working smarter was better (for me, at least) than trying to work harder. I truly respect those that hustle, but in the final analysis of this “chapter,” when I gunned it looking for short-term wins I consistently fell flat (maybe why I have always been terrible at sales). This long play, though — pretty happy with the end result.

Business, Innovation and Entrepreneurship: This quarter’s interview is with John Gengarella. John is a Harvard graduate, well-known for customer-centric design and application development. In 2015, John was appointed the CEO of Netpulse, one of the market leaders in mobile technology for the fitness industry. My interview with John focusing on the business of fitness technology can be read here.

Health and Wellness: My interview around health and wellness this quarter is with Jill Gilbert. Jill is a lifelong entrepreneur. She created the first comprehensive online directory and resource for senior care, Gilbert Guide. Jill also produces the Digital Health Summit at CES, as well as several other prominent digital health events year round. My interview with Jill about health technology can be read by clicking here.

Life Experience: I traveled to Jackson, New Jersey, to log this quarter’s life experience, which was to ride the largest roller coaster in the world, the Kingda Ka. Reaching a height of 456 feet, there is not a taller roller coaster in existence. I got to enjoy the experience with my brother, which made it even better.

Kingda Ka roller coaster

Contribution: Some great opportunities to log contribution this quarter, which is always gratifying. I was a benefactor for the following charities: Dare to Bare, Cystic Fibrosis Foundation and March for Babies.

If you feel like contributing this week, here is a good deed that will not cost you a thing. One of my neighbors here in Alameda, Dan Goldfield, is extremely passionate and selfless about helping others. He teaches at-risk youth and is trying to get a small grant from Farmers Insurance to take his students to the Point Reyes National Seashore. If this is something you can get behind, please think about supporting him with a vote by clicking here (you need to search Alameda, CA, for his name to come up). You can vote once every day for the next week.

Wishing you a very prosperous summer. Reach out if you are up for a burrito and/or a beer. I have a little more time for either/both than I have had the past few years and I’m really looking forward to the next chapter. Hope to see you in it.

In health,
Dr. Rucker

Interview with John Gengarella about Fitness Technology

John Gengarella is known for his extensive experience in global operations, customer-centric design and application development. He has been connected with highly successful enterprise software businesses for over 25 years. However, John began his career in the fitness industry. Outside of the fitness industry, John has held executive roles including vice president of C3 Energy, Chief Revenue Officer for 24/7 Customer and CEO of Voxify. In 2015, John was appointed the CEO of Netpulse, a company that has been viewed as one of the market leaders in mobile technology for the fitness industry. In addition to his professional work, John is the lead mentor in the non-profit organization StartX, which focuses on the development of Stanford’s top entrepreneurs through experiential education. He is also an angel investor and advisor to various early stage technology ventures.


1) One thing that consistently surprises me is that it usually takes a while for emerging tech companies — ones that specifically focus on health clubs — to realize that the total addressable market (TAM) regarding health clubs is actually fairly modest. In this regard, what lessons can you pass down to anyone thinking about creating technology that caters to health clubs?

I do not agree that it is a small total addressable market. I actually believe it’s enormous.  I think if you look at what’s out there today, you’ve got a handful of groups doing over a billion dollars in sales. If you look at the spend over the entire industry, there are testaments of over a $70 billion TAM. Folks are investing serious money to engage their members. I believe there are 185,000 clubs globally, that’s an enormous market. MINDBODY got a $450 million evaluation, a company that’s focusing on a niche segment of the market — studios.

You can easily build a $100 million company in this space. But it depends on how you define the market. Thirty years ago or so, I had a few clubs. We had index cards that had member’s names on them and you stuffed envelopes with monthly invoices that looked like the things you get at Denny’s. So, if you were assessing the fitness market at that time as an entrepreneur, did you say, “Hey, I’m going to make money on index cards and envelopes,” or did you say, “Hey, I can build a CRM solution, or automated billing system, and completely change the dynamics in a new set of investments in that segment?” I think you have got to look at the market overall and how we’re solving problems. I think if you look at IT spend, for example, that might be a small number. That might only be a billion dollars. But what does an average club spend on marketing? It’s 10x that spend. I bet worldwide clubs spend close to 10 billion annually on member acquisition. I think there is an enormous opportunity for the right entrepreneur in this space. The challenge is you have to go solve a problem. What do I do to engage members? What do I do to attract new members? What do I do to increase my retention? …the same core tenets exist from 30 years ago.

So my assessment is I think the market’s huge. And then, where do you draw the line? Is it Fitbit? Is it Under Armour? I mean the lines are blurring every day, there are tens of billions invested annually in fitness. As a software guy, I’m not as interested in treadmills and those kind of things. The Precors and the Matrixes will make their money selling equipment. 30 years ago, we talked about what was inside our four walls. Today, now we are talking about engagement with members outside of those four walls, as well. The club brand is still alive and well… on your app… on your T-shirt — but the market is changing. It is no longer necessarily simply what is happening in those three hours a week inside the club anymore.

2) As the head of a company that makes a great fitness mobile app — specifically regarding fitness — what is the role of activity trackers as they exist today, when the modern smartphone often rivals the internal hardware of commercial fitness devices?

That’s interesting. There is no question that the Apples and the Samsungs are going to be battling the Fitbits of the world very soon in terms of tracking. You have a few pieces that you’re solving for in this space:

  1. You need a form factor that works
  2. You want as complete of a data set as possible
  3. You want accuracy

I think the biggest challenge for smartphones is form factor. Especially since phones are getting bigger as they also are turning into mini entertainment centers. Also, women often leave their phone in their purse, so it is not constantly tracking activity. I think form factor is a challenge for phones today. What this means is you are also not getting a complete data set. For those who want all their activity tracked, you need to have your phone glued to you 24/7. Accuracy is also an issue. Without separate peripherals you are not going to get heartrate information, at least not accurately. There is still skepticism, even if smartwatches take, that they can accurately track heartrate. 

Phones do have a phenomenal advantage in that they are ubiquitous, and adoption is exceptional. I don’t know anybody that does not have a smartphone today. But what do I get out of that? Do I get the accuracy of my heart rate? Do I get other capabilities that I want to see… capabilities I can get from a wearable that I am in touch with the entire time. Given what we are trying to solve for, it will prove to be an interesting battle.

3) Looking past current wearables on the market today, where do you see digital health taking the health club industry five years from now?

That’s a really interesting question because the potential has become enormous, but just as it has been for the last 30 years, the next five will still be about relationships. What’s the relationship that I have today with my club (as a member)? What’s the relationship that I have with the other members? What’s the relationship that I have with my employer? What’s the relationship I have with my healthcare provider? My doctor? My coach? My team? I think when you look at the evolving way we engage in relationships through technology, you’ll see the digital aspect of that becoming more pervasive. I am not addressing just the customer relations concerns here, but also the relationship an employee has with their employer —  a financial relationship that plays a role in the person’s well-being. The big challenge is going to be the exchange of value. To me, there is a two-way value exchange. For instance, I (employee) let you see my steps on a daily basis, you (employer) give me $300 towards my monthly insurance bill. People love to discuss privacy concerns, but quickly forget it was only a few years ago they were hesitant to store credit card information with Amazon.com. Privacy issues aside, annual healthcare spend is the largest line item on our country’s P & L! Follow the money — over the next five years there will be enormous energy around a digital understanding of each consumer, each member, each employee. I see this evolving into some greater level of personalization that simply does not exist today. How do I get to know a specific person in a meaningful way and understand their needs, provide them value for that exchange, and capitalize on the value associated with that understanding in an ethical way? We’ll answer that question.

4) There is a modern-day narrative that fitness delivery is well-positioned, better than ever, to be on the forefront of the continuum of health care. However, this discussion has been going on for a few years now (e.g. Exercise is Medicine, Exercise is a Vital Sign, etc). In your opinion, do you believe technology has helped, or hindered, progress in this area? 

The challenge is the complexity around data privacy. What are the responsibilities around those that are in charge of the data? How do I protect the consumers’ willingness to share? What level of privacy should I expect in terms of dealing with any manufactured insight, i.e. new personal information generated about me that could effect my livelihood (e.g. credit score)? This problem doesn’t get solved with one “ah-ha” moment. There are going to be step-changes that go along with this because we are a cautious nation when it comes to privacy. There are credit card breaches all the time with little consequence. But, if I let somebody know what your blood pressure is, I can still go to jail. So, I think that we are cautious as a society about health data, but I believe you will see that loosen over time. What are the true risks if I share this information? Truth is, you probably have a great interaction with your doctor and she becomes wonderfully more insightful about your health.

There are valid, historic concerns about the consequences of having a preexisting condition. There’s a scare about how that data can be used and possible negative impacts that could come as a result of someone having that information. Again, fair value exchange becomes important. I’m willing to share, if there is limited risk and I get something in return. Few are going to share data for the fun of it. If people get better care, get a lower rate on insurance, get more personalized programs that are really consistent with their health, they will come around. You can see that today, in the volume of opt-in consumer apps that are out in the market. There will be dissection among the population: those that are willing to share health data and those that are not. There is always a sub-segment that’s going to believe in some conspiracy theory that, “data will always be used against me.” They are not going to participate willingly. Luckily there are many that have a willingness to take that risk. I think the more challenging issues are not around, “Can I collect data and generate insights around this woman’s health and well-being?” The challenges are more going to be around policies and protections that allow the consumers of that information to use it appropriately and ethically. To me it’s not technology that has hindered us so much… people have.  

5) The last couple of questions I have asked you what you think might be different in the future regarding fitness technology, a harder question might be the one I will conclude with: what is going to remain the same five years from now?

Five years from now, mobile will still be the center of our lives. It is the communication mechanism for any audience, whether you are talking about a health club member, you are a member of an airline, a hotel guest, or an Uber rider. Mobile will remain the primary platform for customer interaction in the near future. This bears repeating from my previous answer… thirty years ago, I used to have a few health clubs and the same mandates exist today: a need to acquire new members, a need to retain those members, and a desire to increase the contribution/benefit made to the member base. That’ll be the same in five years… probably for as long as health clubs exist.

With the pervasiveness of availability of information available to the consumer, the fitness industry, like any other mature industry, is becoming more and more competitive. So, the drivers of asset performance will be the same in five years. Mechanisms for personalization will evolve. There will be this quest for personalization. Whether I have a big box or a small box, I will be able to use technology to have the capability to differentiate my offering with personalization, but that is only filling the need that has always been there …building a meaningful connection with your member. 

Interview with Jill Gilbert about Health Technology

Jill Gilbert is a lifelong entrepreneur and the producer of the Digital Health Summit. Jill worked in the film industry for 15 years before moving on to health and technology. After leaving Los Angeles, her initial focus was the crossroads of aging and technology. She created the first comprehensive online directory and resource for senior care, the Gilbert Guide, for which she was praised as the champion of positive change in the aging services industry. In 2015, she launched another event at CES, Robots on the Runway, which focuses on the world of robotics. Her latest project is called Discover Baby Tech, a website and blog that will aim to bring together products and technology for new parents.


1) Behavior change and wearables are two buzz terms often talked about in the same conversation, yet many devices don’t truly deliver on the promise of actively helping someone change their behavior. What’s a favorite example of a digital health product that actively assists the user in building a desired habit?

Activity trackers have become synonymous with the word “wearables.” These devices (activity trackers) will certainly change some people’s behavior, primarily through awareness. Oftentimes, though, they fall short when it comes to behavior change. I’m more excited about closed-loop wearables, devices that are often condition-specific that trigger — or better yet, assist — with the desired next action to treat a particular condition. When you can engineer the need for “change” out of the usage loop, you immediately get a lift with regards to device efficacy. Most behavior change — when it comes to wearables — is going to be as good as the prompt and/or stimulus. The closer we can get the stimulus to inspire (or be) the next desired action in the loop, the closer we get to behavior change being a non-factor. Until activity trackers move our feet for us, I believe they won’t be as successful as other innovations I have seen recently in digital health.

2) It’s clear that the industry is on the verge of some significant breakthroughs. In your opinion, what’s currently being underreported regarding health technology that deserves greater attention?

Mental health is an area where digital health really can play an important role. For instance, pharmaceutical adherence is a huge issue in mental health. Many people with mental health issues suffer when they are not regimented about taking their medication. We are also making strides with regards to digital therapeutics. Cost is a major factor in treating mental health, and advances in the way we can treat people through behavioral modification platforms that are scalable — made possible because of digital health — is exciting. Telemedicine is also making an impact, by allowing patients to benefit from doctors that have excess capacity. Health technology is allowing people to get treatment who are so unwell they cannot leave the house. It is opening up treatment options for those worried about stigma. There are a lot of great things happening here, but it is not getting as much attention as one would think. Look what Lantern is doing, look what Iodine is doing, this is great stuff and not talked about enough. There is also a lot of promising technology to help with addiction as well.

3) Digital health is well-positioned as a valuable tool to help people with their entire continuum of care, with the potential of assisting people in lessening the frequency of doctor visits. What needs to happen so that consumers can have a better coalesced health experience through digital technology?

Interoperability is key. It is so important, and its lack of existence creates so much friction. Because the problem is so complex, we see people design around it (data operability), and what you are left with is disparate solutions. Literally, digital health in a lot of ways is the Wild, Wild West. Yet, on the other side you have hospital systems with antiquated legacy systems that often don’t even have APIs. We are finally making some strides though… Cisco and UCSF have partnered to engineer an integrated health platform that will hopefully get us closer, but the problem is mammoth. We need smart minds and a lot of resources to solve this problem.

4) Technology is inherently always changing. That said, what have been the constants since 2010 that are facets and/or indicators of successful digital health products? In other words, what is foundational for innovators to get right, or avoid getting wrong, in order to be successful in this space?

This sort of piggybacks off my Wild, Wild West comment. This space is inherently complex, and so in a lot of cases processes that work for pure tech start-ups — like creating a minimal viable product (MVP) — fail in this space. Especially if you hope to get FDA approval, there is a lot to navigate and that’s why we always stress strong partnerships. That said, companies still need to be bold. True innovation and breakthroughs come from mavericks who accomplish what others say cannot be done. There is a balance. The good news for innovators is that it is hard for bigger companies to take risks, so often through the “right” type of partnerships a start-up can get significant help from a larger organization. Obviously, there will be unique considerations that depend on the product. A reimbursable product is probably going to have to rely more on outside help than a consumer box product. The good news is there are great partners out there, like Ximedica, whose primary purpose is to help these types of products figure out a proper strategic path and wade through the intricacies of regulation.

5) You have set your sights on baby tech. Why baby tech? And what benefits do you hope to deliver with this next endeavor?

My ideas around baby tech came about from CES, and getting a lot of products sent my way that were meant for babies, new moms, fertility, post-pregnancy, etc. There was/are enough interesting digital baby products out there, and it was clear this is a distinct category worth addressing. Also, I got enthusiastic about it because I was about to become a new mom myself when I first saw this category get exciting. There is so much amazing stuff out there. Moms can go it alone, we have for decades, but [digital products] might help ease some of the burdens. I am creating DiscoverBabyTech.com to share what I know, create a space for product reviews, report new developments in this space and generally create a resource for moms interested in this topic. The plan is to launch next month sometime. We hope to attract people like ourselves to the site, new moms who love tech.