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Games For Health Conference 2013

This document discusses digital health tools and games that aim to improve cognitive functioning and health behaviors. It provides examples of companies developing brain training apps and games for memory, focus, and problem solving. It also outlines business models for corporate wellness programs, consumer apps, and chronic disease management tools that utilize games, incentives, and data analytics to engage users and promote behavior change.

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Games For Health Conference 2013

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Bonnie Feldman, DDS, MBA -‐ Business Development for Digital Health www.drbonnie360.com | @DrBonnie360 | [email protected]
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An Emerging Ecosystem
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An Evolving Ecosystem
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Wake Up Your Brain Lumosity Pinball game Playing Koi
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© 2013 -‐ All rights reserved. USER CONSUMER PATIENT Engage User with Interface Capture Data Provide Feedback User Changes Behavior Further Feedback and Reinforcement Behavior Change Persists Repeat Feedback & Behavior Change
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© 2013 -‐ All rights reserved. • IncenDves • Carrot versus sNck-‐ intrinsic versus extrinsic • Point, badges, money, reducNon in premium • AnalyDcs • Brain games to get the right level quesNon • Iterate the product based upon customer feedback PersonalizaDon is EssenDal
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4 Case Studies with Nimble IteraDon
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© 2013 -‐ All rights reserved. Venture capital funding in digital health (millions) Source: Rock Health Mobile health apps downloads (millions) Source: Allied Health World Global revenue from mobile healthcare apps (billions) Source: Allied Health World Where’s the Money?
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© 2013 -‐ All rights reserved. Using game design to help consumers manage their health Earn points for taking meds safely and on Nme Using elements of game mechanics and automated posiNve coaching Have world’s largest sleep database Combining best in neuroscience with best in video games CreaNng a new kind of cogniNve acNvaNon Founders are gamers turned bodybuilders Strong social community has over 1 m downloads dfsj]s Up and Comers
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+1.310.666.5312 [email protected] www.drbonnie360.com @DrBonnie360 Bonnie Feldman DDS, MBA Business Development for Digital Health
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© 2013 -‐ All rights reserved. Sources •  Ellen M. MarNn, Freelance Writer/Editor with extensive corporate communicaNons background in healthcare and technology •  Lumosity •  Finn, M., & McDonald, S. (2010). Improvement in Sustained visual a_enNon following CogniNve Training in a sample of older people with Mild CogniNve Impairment. Presented at the Australian AssociaNon of Gerontology Conference, Brisbane, Australia. •  Gyurak, A., Ayduk, O., & Gross, J. B. (2010). Training execuNve funcNons: emoNon regulaNon and affecNve consequences. Presented at the Determinants of ExecuNve FuncNon and DysfuncNon Conference, Boulder, CO. •  Hardy, J. & Scanlon, M. (2010). Analysis of cogniNve performance in worldwide sample of over 200,000 people reveals new disNncNons in age-‐related cogniNve decline. Presented at the Society for Neuroscience Conference, San Diego, CA. •  Hardy, J. L., Drescher, D., Sarkar, K., Kelle_, G., & Scanlon, M. (2011). Enhancing visual a_enNon and working memory with a web-‐based cogniNve training program. Mensa Research Journal, 42(2), 13–20. •  Kesler, S., Lacayo, N., & Booil, J. (2011). A pilot study of an online cogniNve rehabilitaNon program for execuNve funcNon skills in children with cancer-‐related brain injury. Brain Injury, 24(1), 101–112. •  Kesler, S., SM Hosseini, C. Heckler, M. Janelsins, O. Palesh, K. MusNan, and G. Morrow. "CogniNve Training for Improving ExecuNve FuncNon in Chemotherapy -‐ Treated Breast Cancer Survivors." NaNonal Center for Biotechnology InformaNon. U.S. NaNonal Library of Medicine, 3 May 2013. Web. 30 May 2013. •  Omada •  "Diabetes PrevenNon Program (DPP)." NaNonal Diabetes InformaNon Clearinghouse. US Department of Health and Human Services, n.d. Web. 30 May 2013. •  Shape Up •  Leahey, Tricia M., Melissa M. Crane, Angela Marinilli Pinto, Brad Weinberg, Rajiv Kumar, and Rena R. Wing. "Effect of Teammates on Changes in Physical AcNvity in a Statewide Campaign." NaNonal InsNtute of Health. PreventaNve Medicine, July 2010. Web. 30 May 2013. •  Leahey, Tricia M., Rajiv Kumar, Brad M. Weinberg, and Rena R. Wing. "Teammates and Social Influence Affect Weight Loss Outcomes in a Team-‐Based Weight Loss CompeNNon." ArNcles: Behaviour and Psychology. Nature Publishing Group, Jan. 2012. Web. 30 May 2013. •  Wing, Rena R., Angela Marinilli Pinto, Melissa M. Crane, Rajiv Kumar, and Brad M. Weinberg. "A Statewide IntervenNon Reduces BMI in Adults: Shape Up Rhode Island Results." NaNonal Center for Biotechnology InformaNon. U.S. NaNonal Library of Medicine, May 2009. Web. 30 May 2013. •  Wing, Rena R., Melissa M. Crane, J. Graham Thomas, Rajiv Kumar, and Brad Weinberg. "Improving Weight Loss Outcomes of Community IntervenNons by IncorporaNng Behavioral Strategies." American Public Health AssociaNon -‐. N.p., 15 Mar. 2010. Web. 30 May 2013.

Editor's Notes

#3 My Ahah moment in my original research,was when I found an emerging ecosystem of experimenters trying to trigger behavior change across the disease spectrum- from health and wellness to chronic disease and addiction Starting at your left at the Wellness side of this visual, I found an expanding definition of health to include life balance and self-improvement. The societal shift in attitudes toward health and wellness, with consumers leading the way, shows in the rise of employer-sponsored employee wellness games. Social networking can bring people together within a trusted environment to share information and work toward common goals. Social games encourage three behaviors: teamwork, friendly competition and accountability. Brain Gamesis an exciting application of game technology that takes advantage of a new understanding of brain plasticity. Disease Management: Interesting to us provider types is whether these principles will work in chronic disease management. Early signs are positive: Mobile games are finding a place in disease management, making mundane tasks more fun: glucose monitoring, diet, exercise, insulin and other drugs; and developing a support network of like people. Of note, back in 2009 I noticed an expanding definition of health and wellness, which included habit design and self-care. Remember this theme, we will see how it has evolved.
#4 My latest research tapped into a fountain of innovation in the mobile social games for health space. WHY? A convergence of many factors: Ease of entry, technology advances, Receptive end-user markets (smart phones, ubiquitous connectivity), Access to capital and increasing interest from healthcare organizationsThe gaming market has grown, especially among women and people over 30 yrs old with 55 percent of gamers playing games on their phones or hand-held devices.Gamification, initially overhyped, may nevertheless be a useful engagement tool. According to a Gigya study of billions of user actions with partners like Pepsi, Nike, and Dell, adding gamification to your site boosts engagement by almost a third. Albeit slowly, I think we are beginning to see a societal shift in the importance of health and wellness as shown by the government’s efforts -Mrs. Obama’s campaign, Regina Benjamin celebrities such as Sanjay Gupta, Dr. Oz, Deepak Chopra at the CES are trying to make fitness “cool.” more self-insured employers are embracing health and wellness as part of a productive culture. This represents an emerging model of prevention, enabling people to proactively drive their own behavior change more through iterative, personalized engagement rather than passive participation in data-driven disease prevention. But this is only possible with a continuing convergence of data analytics and ubiquitous social mobile connectivity
#5 This fountain of innovation has fueled wild growth in our ecosystem, but it also means a high signal-to-noise ratio for figuring out what works.Our new ecosystem has many more companies. Not only do we have those chasing cognitive health, but there has been a spurt in corporate wellness programs using social games. There are also next-generation companies refining their approach to behavior change.New players include: Blue Marble Akili InteractiveCognifitFitocracyMango Health, LarkShapeupLimeaideOmada HealthI set the results bar high to select this year’s 4 case studies:LumosityOneHealthShapeupOmada.
#6 Let’s step back and examine where pockets of evidence are building: In childhood obesity - Zamzee, an activity tracker with a motivational experience wrapped around it, did 12 studies with over 1000 kids and found that they those who used both the motivational experience and the accelerometer moved 60% more over a 6 month period than those who just had the accelerometer. With these results, the program is now being used as a tool along with existing child obesity diet programs and camps. In corporate wellness - Shapeup- invested in research early on - 5 peer-reviewed articles in scientific journals - with more in the pipeline. Showing that using teammates and social competition can help increase physical activities and weight loss.In addiction relapse - One Recovery, now One Health, in Pilot with a National Health plan they found a 58% reduction in readmissions and a $1.4 Million in cost savingsIn diabetes prevention- Omada’s Prevent, the digital version of a 2002 Diabetes Prevention Program known as DPP, in a 27-center study with over 3000 patients- they found that a modest weight loss of 5-7% could reduce type 2 diabetes by 58%. All of the companies agree that their established evidence base has been invaluable as it has provided them instant credibility during their discussions with insurance companies and self-insured corporations.
#7 One strand of evidence is adoption: Who is using these tools?I would have guessed that most of the apps are being used for diet and exercise, and I was surprised to find out that, according to a recent study of US broadband households conducted by Park and Associates, 70% are using these tools for memory training.
#8 The interest in memory training is spurring a robust ecosystem of brain training and brain fitness companies such as:LumosityDakimPositCognifitBrain Science Akili InteractiveAt the Consumer Electronics show this year, I began to think that consumer interest is expanding beyond brain games and brain fitness to a broader context of the mind/body connection and the desire to pursue cognitive health and wellbeing.I’m still working on that one, so stay tuned for my next report.
#9 Lumosity has created different types of games to train different areas of brain health, including problem-solving, memory, and brain flexibility.Lumosity was founded in 2005, raised 67.5 M, and is using the proceeds to fuel rapid growth. This direct-to-consumer brain games company now has 40M users, with 10 M unique visitors a month.Click above to enjoy a video demo of their 3 new games.There is new evidence in an independent study of “chemo brain” in post chemotherapy breast cancer survivors, that showed that Lumosity’s cognitive training led to significant improvements in cognitive flexibility, verbal fluency and processing speed.
#10 Now what is behavior change and why is it so important?Everyone engaged in health care is in the behavior change business: we are nudged to eat less and exercise more, follow recommended diagnostic screenings, take all your medicine on time, don’t put off a visit to investigate suspicious symptoms and of course floss your teeth every day.As shown in this visual, one way to think about using technology tools to nudge Behavior Change is as a series of cumulative small feedback loops. A simple feedback loop can be described as: the user engages with the mobile tool, data is captured, feedback is created. This could be a simple reward system for flossing your whole mouth one time per day. More complex feedback loops involve multiple iterations such as changing your sleeping routine or your eating and exercise patterns. The ultimate goal is to foster healthy behavior, but, as we know, changing patterns of behavior, or comfortable routines, is not easy. The question of using tech tools to nudge behavior change has recently become interesting to many more designers, so much so that there is a meet-up with over 1000 members called Habit Design.Kudos to Michael Kim who leads this group of imaginative professionals.
#11 Now that we have thought about getting started and getting going, we are now set to explore how we stay on track.Many of us think that social networks--peer pressure and support--plus user data analytics, could help us stay on track. Alcoholics Anonymous and Weight Watchers have been helping people offline for decades, with real success. As you can see in this visual, there are several different kinds of social networks which offer fluidity and flexibility not seen in the offline worldInformation networks such as Everyday HealthPatient support networks Alliance HealthResearch networks- Patients Like Me , GenomeraYet, people are complex, and influencing everyday choices is not a one-size-fits-all solution. Just as social networks come in many flavors so do data networksFor some, the output of biometric data, data coming from body sensors, will help them to find their way. For others of us, large sets of user data may also help developers understand human behavior and close the feedback loop.The key may be in experimenting with peer to peer support networks and data analytics with a mix and match approach- using more or less of each tool as needed and discovering which suite of tools will work for whom and when.
#12 As consumers embrace Lumosity’s brain games, corporations are embracing games to spur employee wellness.What are social games in the workplace? Small teams, put together in the workplace can play social games which encourage teamwork, friendly competition and cooperation. Accountability is an interesting motivator, because people feel obligated to participate so they do not let down their team members. Building upon basic human nature desire for competition, status and peer recognition, social games can help support and promote a positive collaborative culture
#13 Exemplifying the power of social games, Shapeup’s participants have collectively lost one million pounds!Click on the link above to watch the video that shows how their programs use social networking, peer-to-peer healthcare, game mechanics and behavioral economics.As far as using social games, Shape-up is one of the oldest, clinically-proven, technology-based social wellness companies selling to large employers across the globe. The peer-to-peer networks form a grassroots campaign to recruit team participants, using social support and group motivation and accountability to create engagement. Now they have added individual and team coaching to their suite of services. As a data point relevant to corporate wellness, Rhode Island, in a state-wide wellness challenge, over the past seven years, found that more than 70,000 Rhode Islanders have participated in their programs- walking millions of miles, losing thousands of pounds, and proving that teamwork is a powerful prescription for taking control of our health. Shapeup began in 2006, covers more than 2 million lives across 200 employers and health plans, raised $5M series A in 2010, and they are now profitable.
#14 When I asked “What is working?” Three elements emerged in common across companies “EPI”- Engage, Personalize and Iterate; all united by a need to demonstrate effectiveness with some kind of evidence.First, capture people’s interest – engage them with the use of gaming elements such as reward, status, achievement, self-expression, competition and altruism. Once people are engaged, it is critical to create evidence that the tools work.The second element, is personalize, custom approaches are essential to successful behavior change. There is no one size fits all in behavior change, and giving people what they need at the time of need is crucial to keeping their limited attention.The third element is iterate and experiment. This concept is also well known in consumer products, but not yet much recognized in healthcare circles.
#15 Patient engagement has been a popular topic of late, with HIMMS publishing a book and conducting a Tweetup on the subject, Health Affairs devoting its entire February issue to the topic, and the RWJ Foundation and others suggesting new approaches. Reflecting upon my days as a provider, where each dental patient had a different view of their needs, it is not surprising to me that the definition and measurement of patient-engaged care differs depending on context. Now that the discussion has moved to engagement, evidence of effectiveness seems to be the power trigger.Health plans are demanding multiple pilots to prove that the tools will get patients engaged, and keep them active in treatment. Companies such as Shapeup, One Health and Omada who have evidence, can grow their businesses in the corporate market more quickly.
#16 To get engagement and behavior change, there is no one size fits all, so personalization is essential. Forms of personalization involve using incentives as well as data analytics.There is a lot of experimentation with incentives, such as money or premium reductions. A recent survey of 800 large and mid-size companies with more than 7 Million US employees, found that 83% offer incentives for participating in programs that help employees become more aware of their health status. Aon Hewitt's survey shows almost two-thirds (64 percent) of employers offer monetary incentives of between $50 and $500, and nearly one in five (18 percent) offer monetary incentives of more than $500.Although there is currently a lot of experimentation with extrinsic rewards- such as money- the literature suggests that intrinsic motivation is superior. This is an area that is still a work in progress. Analytics is another important element of personalization. In brain games, Lumosity’s machine-learning algorithms customize the questions- giving the player the right amount of challenge and in OneHealth, they use data to be better informed how to tweak the product features.
#17 All of our case studies have gone through multiple iterations of their product, while accumulating data used to both iterate the product and improve the experience.Onehealth, which began as OneRecovery, focused on addiction, has expanded their target markets to include people with multiple chronic conditions, such as obese diabetics.Noteworthy, Lumosity, through their research, called “The Human Cognition” project, is building the world’s largest database on human cognition to continue to improve and personalize their games.Shapeup began using social games in corporate wellness and has now added coaching Omada’s Prevent spent a lot of time iterating the consumer’s initial product experience, because they learned that good first impressions were a key element to establishing ongoing trust.
#18 Let’s see how these concepts work when you build a system with the patient in the center. OneHealthuses a mix of game mechanics and multiple online support networks, available 24/7. As we will see in the demo, game mechanics include badges to mark achievement levels, such as going to meetings, getting a sponsor, sharing a story, journaling. Emoticons help us share emotion and empathy.For social support, you can build your own support group with varying levels of privacy, customized to personal needs that can change over time. This is very important in the clinical world, where many people suffer from multiple diseases - such as the many patients who struggle with obesity, depression and addiction. These same principles have been applied to their new mobile products. One Health started in 2007, raised 16 M dollars to date with a 7 M dollar series A followed by $9M series B.
#19 What if these tools of behavior change could be used to prevent one of the biggest cost drivers in healthcare?As shown in the landmark DPP trial back in 2002, pre-diabetes can be reversed through lifestyle changes. It was only recently, in 2011, that Omada cleverly figured out a way to digitize the program using digital tracking tools (e.g. weight scales, pedometers), personalized coaching, social support, and an interactive web-based curriculum to motivate healthy exercise and eating behaviors. Here is how Omada’s, 16 week course, called Prevent works:Upon sign up, users are matched into small groups of 12 in a private online environment, “based on age, body mass index, and location.” They are then sent a Path16 wireless scale that requires virtually no set-up and automatically syncs to Prevent, allowing them to transmit daily weigh-ins to their private personal profiles. The curriculum - 1x per week, its fun , and offers some interactive elements, with mini challenges in their skill center. Important aspects of the program include the peer-to-peer support from the group, as well as support from the health coach Evidence from last pilot includes:74% completed the pilot in 4 monthsMean weight loss similar to DPP - 5-7%40 of the 230 participants have applied to be coaches
#20 A handful of VCs I spoke with agree that it is still early in the cycle of business model evolution, however, in corporate wellness, we see 2 different approaches to revenue models:Shapeup and One Health charge employers per member per monthPrevent is a 2-tier success-based approach, where there is one payment when employees complete the program and another payment when they meet goalsOn the consumer side: Lumosity uses a monthly fee structure for consumersNoteworthy, Shapeup and Omada are profitable.(Shapeup- started in 2005 and has raised $5 M in venture capital funding.Omada- began in 2011 and has raised $5.5 M in seed and venture funding)
#21 As you can see in these graphs, all trends are positiveshowing an Increase in mobile health app downloads, global revenues and venture capital funding.For Mobile Health app downloads, 124 million people downloaded a mobile health app in 2011 and 247 million people downloaded one in 2012.In global revenue, there was 1.2 billion dollar global revenue from mobile healthcare apps in 2011 with 11.8 billion dollars expected in 2018For VC funding, there was 968 million dollars in 2011 and 1.4 billion in 2012.
#22 Reflecting back (in hindsight) this has been a year of rapid innovation, so let’s see the up and comers who are brave enough to take on the challenge Up and comers include:Fitocracy- The founders are gamers turned bodybuilders. The online fitness community awards you with points, the ability to level-up, badges and the strong social component has created community support with over 1 m downloads.Mango Health using game design to help consumers mange their health - earn points for taking medications safely and on time. Points can be redeemed by major retailers such as Target or by making charity donations Lark -using elements of game mechanics and automated positive coaching (with custom algorithms) to make sleep tracking more fun- and they have the world’s largest sleep database.Akili Interactive-combining the best in neuroscience, with the best of video games to create a new kind of cognitive activation, beginning in the area of executive functionWho would have guessed that game developers, once considered optional consultants in health related products, would be key members of product development teams?
#23 As we have seen in our 4 case studies -Lumosity, OneHealth, Shapeup, Omada - are mixing and matching elements of game mechanics and peer to-peer support using 3 common success factors: engage the user, personalize the experience and iterate the product.With this explosion of innovation plus new entrants such as Fitocracy, Mango Health, Lark, Akili Interactive, these are exciting times.This fan represents an ongoing trend to move the medical system from sickness intervention to “prevention” or “well care.” This is a model of prevention based on a continuing convergence of data analytics and ubiquitous social mobile connectivity. This convergence is enabling people to proactively drive their own behavior change through iterative, personalized engagement rather than passive participation in data-driven disease prevention.This is an extension of the expanding definition of health and wellness that we first noticed in 2009, as seen in our first ecosystem visual. But this concept is still so new that we don't yet have a word that replaces "patient" to describe individuals actively pursuing better health.
#24 What does this mean for the future?As we have seen in our 4 case studies, in our 4 up-comers, and others, with gaming and competitions taking center stage, perhaps it is time to individually and collectively think BIG. Leave it to Esther Dyson to have created HICUUP (Health Intervention Coordinating Council) that uses community wide efforts to get people competing to walk, exercise and eat better across cities and states. The council is spurring population health and proving the financial feasibility of preventive health on a larger scale

Games For Health Conference 2013

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Editor's Notes