Emotionally Responsive Virtual Coach Helps Address Patient Concerns in New Simulation

Kognito, a health simulation company, is applying its simulation technology to patient education, to address a gap in patient knowledge.

Educating patients regarding their health conditions can be challenging in today’s high-pressure medical environment. Providers need skills, time, and training to effectively provide patients with information in an accessible form that they can absorb.1 Some studies have suggested that between 40% and 60% of patients are unable to correctly report what their physicians expected of them, even an hour after they were provided with the information, and that 60% of patients interviewed immediately after visiting their providers misunderstood the directions they received regarding prescribed medications.2

Many healthcare professionals educate their patients through giving them printouts, flyers, or brochures about their condition. But these educational methods are limited by several factors, including language and cultural barriers or reluctance to obtain information through printed formats.3 Moreover, many patients need more human interaction, ongoing explanation, and a sense of support. Some clinicians offer patients suggestions of reliable websites that can provide more information. However, not all patients want to use the Internet to read articles or explanations of diseases.4

To address this gap, Kognito, a health simulation company, is applying its simulation technology to patient education. MPR interviewed Ron Goldman, Co-Founder and CEO of Kognito to learn more about their unique approach. In 2017, we interviewed Mr Goldman regarding the use of this virtual technology to educate healthcare providers in how to best communicate with patients.

Ron Goldman, Kognito
Ron Goldman, Kognito

What is Kognito?

Kognito is a health simulation company has been around for about 10 years and has concentrated on harnessing the power of conversations with virtual humans to improve health. Our view is that conversations have the power to transform how people think and act, to enhance empathy, and to change lives.

So what we offer is a blend that puts together the science of learning, the art of conversation, and the power of gaming technology. At this point, over a million healthcare providers, educators, and students across 500 organizations have used Kognito simulations to improve social, emotional, and physical health.

How have your offerings changed over time?

We began by using these virtual humans to model simulated conversations between clinicians and patients to help healthcare professionals in navigating conversations. We began with education about antibiotic use. But since then, we have built many simulations involving real-life type conversations regarding substance use, chronic disease, and medication adherence. Research has demonstrated that they have helped not only in skill-building but in changing the behavior of providers and their patients in measurable ways.

What type of research supports this approach?

Kognito is the only company with health simulations listed in the US Department of Health and Human Services National Registry of Evidence-Based Programs and Practices (NREPP). The evidence underlying the effectiveness of these simulations can be found on the Company’s website.

You say you “began” with simulations to educate healthcare providers about communication. How have you expanded your offerings since then?

In 2017, we partnered with the Centers for Disease Control and Prevention (CDC) and the National Association of Chronic Disease Directors (NACDD) to apply our simulation technology to patient education challenges in oncology. This approach is direct-to-patient and provides a patient with a virtual “coach.” On his or her own time, the patient engages in interactive conversations with the coach via an app that can be downloaded to a phone. The virtual coach provides information about the condition and helps the patient have the needed information to make the right treatment decision for them. The patient can also go online to access the coach and there are links to handouts that the CDC created, which can be downloaded. The app is accessible for free.

I should note that the app collects no identifiable data on the patient and thus fully respects the patient’s privacy.

What does this collaboration focus on?

At present, we are focusing on educating patients about triple negative breast cancer (TNBC), which represents 10% to 20% of all breast cancer diagnoses.5 Women with this type of cancer have a considerably lower survival rate, compared with women who have other types of breast cancer.6

The most effective treatment for TNBC is chemotherapy,7,8,9 which lowers mortality rates and the likelihood of cancer recurrence. But many women do not end up pursuing chemotherapy, leaving a significant gap in treatment. Our challenge was to create a more engaging, tailored, empathetic experience for those patients to learn about the condition — what it is, the different treatment options, what chemotherapy is, and what its side effects are.

The CDC, in particular the Division of Cancer Prevention and Control and the NACDD turned to us to help address this gap and we collaborated heavily with them.

Project sponsors from the CDC and NACDD connected our team with subject matter experts in the field of oncology, as well as actual TNBC survivors, to build a comprehensive understanding of the challenges faced by both providers and patients at the time of diagnosis and throughout their journey to achieve remission. We created our simulation based on their input.

How does your simulation approach fill the gap?

Patients can be overwhelmed when they receive a diagnosis of cancer. Often, a patient hears the word “cancer” and is unable to take in the remainder of the consultation. Even in the days and weeks after receiving the diagnosis, it remains difficult to absorb information or discuss the diagnosis, even with close family members.

Our innovative solution is to provide patients with an emotionally responsive virtual coach named “Linda,” who can provide patients with a critical outlet to express their true feelings and get clear and accurate information, and to increase their motivation to pursue treatment.

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How can a virtual coach provide empathy?

Linda speaks to the real-life experience of a survivor, possesses extensive knowledge of TNBC, and tailors her messages to each patient’s level of knowledge, concerns, and overall motivation.

The virtual human technology that powers Linda has been shown to drive increased levels of engagement, potentially leading to sustained behavior modification. Of course, it was extremely challenging to imbue Linda with the compassion and first-hand experience of an actual breast cancer survivor. Our teams spent dozens of hours in conversation with patient advocates to achieve this unique feat. We dialogued, listened to their stories, and found out all the things they wish they had known at the start of their journey. It was eye-opening to us because actual patients were able to bring input to the table that oncologists or other experts wouldn’t even think about. We then shared their wisdom and input with other patients who would follow their footsteps.

Additionally, we learned how they expressed themselves — their manner, body language, facial expression, tone of voice, and cadence. This was important so that Linda wouldn’t be robotic, merely saying the right things but in a mechanical way. We wanted her to present things in a way that would gain the patient’s trust and demonstrate a level of understanding that only a survivor could possess.

Please tell us more about the virtual coaching experience.

Linda is the fist virtual coach who is able to respond to the emotional and motivational state of a newly diagnosed cancer patient with the wisdom and empathy of a true-life cancer survivor.

We built an immersive experience around Linda’s persona to establish a learning environment that meets the needs of a patient’s individual learning style. And we crafted a setting that created a soothing scene for the conversation that would allow the learner to calm the mind and focus on the information being imparted. Our specially designed motion graphics and animations are timed to the dialogue so that the person’s visual and auditory processing mechanisms are simultaneously engaged. This increases retention and further builds motivation for behavioral change.

Another benefit is that, unlike an actual human being — whether a healthcare professional, friend, or cancer survivor — Linda is available any time, anywhere. And the self-directed format enables each person to engage with the topics in the order and at the pace most meaningful, creating a truly personalized experience. Each patient has her own concerns about the treatment, such as cost, treatment success, length of time, or side effects, so education can’t be a one-size-fits-all process.

I’d like to emphasize that we are not conveying to the patient anything that an oncologist or other healthcare professional wouldn’t communicate. We simply give the patient a coach who is never rushed and can tailor the conversation to the patient’s unique needs, in her own time.

Is this program being implemented yet?

Yes, it is already being used by the CDC as a patient education tool, which is publically available at the CDC Website and also directly. Based on feedback we’ve received from cancer survivors, it has been remarkably successful. And the CDC is concluding a study in a local Atlanta hospital to look at the impact of this simulation on health outcomes, including the willingness of these patients to pursue chemotherapy treatment. We are anticipating study publication at the end of 2019.

This has been a tremendous process for us as a company. It sets the path to show how conversations with virtual humans can be impactful and effective in conducting patient education. We are extending this model into other areas, such mental health, opioid use, and chronic disease.

Link to simulation

Trailer about the app:


1.    Marcus C. Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health Psychol Behav Med. 2014 Jan 1;2(1):482-495.

2.    Jimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. 2011;26(3):155-9.

3.    Centers for Disease Control and Prevention (CDC). Beyond the Brochure: Alternative Approaches to Effective Health Communication. Available at: https://www.cdc.gov/cancer/nbccedp/pdf/amcbeyon.pdf Accessed: February 20, 2019.

4.    Salo D, Perez C, Lavery R, Malankar A, Borenstein M, Bernstein S. Patient education and the Internet: do patients want us to provide them with medical web sites to learn more about their medical problems? J Emerg Med. 2004 Apr;26(3):293-300.

5.    Johns Hopkins Medicine. Triple negative breast cancer. Available at: https://www.hopkinsmedicine.org/breast_center/breast_cancers_other_conditions/triple_negative_breast_cancer.html. Accessed: February 15, 2019.

6.    Gonçalves H, Guerra MR, Duarte Cintra JR, Fayer VA, Brum IV, Bustamante Teixeira MT. Survival Study of Triple-Negative and Non-Triple-Negative Breast Cancer in a Brazilian Cohort. Clin Med Insights Oncol. 2018;12:1179554918790563. Published 2018 Jul 27.

7.    Wahba HA, El-Hadaad HA. Current approaches in treatment of triple-negative breast cancer. Cancer Biol Med. 2015;12(2):106-16.

8.    Baselga J, Gómez P, Greil R, et al. Randomized phase II study of the anti-epidermal growth factor receptor monoclonal antibody cetuximab with cisplatin versus cisplatin alone in patients with metastatic triple-negative breast cancer. J Clin Oncol. 2013;31(20):2586-92.

9.    Morante Z, Ruiz R, De la Cruz, et al. Impact of the delayed initiation of adjuvant chemotherapy in the outcomes of triple negative breast cancer. Presented at the 2018 San Antonio Breast Cancer Symposium. December 5, 2018. Abstract GS2-05.

This article originally appeared on MPR