Archive for: September 2008

A few takeaways from the Project HealthDesign conference

Sep 30, 2008, 9:53 AM, Posted by Steve Downs

Over the last week and half I’ve had a chance to talk with people about Project HealthDesign’s New Frontiers in Personal Health Records conference and follow the blog discussions on the event. James Ralston, the principal investigator for the University of Washington’s Project HealthDesign grant, pointed out to me recently that we went the full range from the user-centered design issues (e.g. how to get the most out of a small cell-phone screen) all the way to policy implications such as the need to alter reimbursement policies. And the conference had a similar range – there were a lot of concepts crammed into an 8-hour session. So here’s my shot at distilling them.

It’s not the record, it’s what you do with it. It’s a simple mantra, but it seems to be catching on. The previously dominant idea of a PHR as a window onto a medical record seems to be fading as more and more people (including policymakers) are recognizing that applications building on the record hold more promise to improve people’s health.

When end users are engaged in the design, the designs look different. At the start of this program, we postulated that putting the end users (patients, consumers, pick your term) at the center of the design process, they would come up with a very different set of PHRs and that’s exactly what happened. The designs are much more mobile, action-oriented, and unobtrusive than earlier visions of PHRs. The grantee teams were constantly challenged to fit their designs into the flow of people’s lives, to free the user from their desktop PC, to work within an existing calendar, rather than creating a “medical calendar,” to make use of the devices people already carry. The nine project videos underscored an important theme – that health is but an enabler (or disabler) of the lives we lead – not an end in itself.

Not everyone gets the PHR ecosystem concept. We (and others) have been pushing this idea for a while now, but there was a fair degree of confusion about it at the conference. The jargon isn’t so important and different people use different terms, but there are basically three types of actors in this ecosystem: 1) the source data providers (e.g. pharmacies, physician offices, hospitals, insurers) that hold parts of a person’s medical record; 2) the PHR platform providers (e.g. Google Health, Microsoft HealthVault, Dossia) that can assemble and maintain a person’s record from multiple sources and that offer application programming interfaces (APIs) for 3rd-party application developers; and 3) the 3rd-party application developers that build the very specific applications (such as those designed by the Project HealthDesign teams) that people can use to take care of their health needs. There are plenty of nuances – for example, the same organization could participate in all three levels – but the key is to allow for the separation of these three functions. Separating the functions enables competition and innovation in the space that markets traditionally operate very well – in meeting the diverse needs of end users.

The policy implications are far-reaching. We could have spent a full day and then some on the policy implications of next-generation PHRs and the PHR ecosystem described above. There are issues about stewardship of personal health data (made even more complicated by data that are user-generated, such as a data on medication usage, diet, exercise, etc.), issues of asymmetric regulation, where different types of organizations providing the same services face different regulatory schemes (e.g. some are covered by HIPAA and others are not), and, most fundamentally, implications for how health care is delivered and financed. The applications demonstrated at the conference make possible a very different patient-clinician relationship, one in which a good deal of data exchange and communication takes place between visits, which could become fewer and further between. That kind of relationship is not well supported in most arrangements today.

We’ve come a long way in two years. Much has happened since the launch of Project HealthDesign two years ago. We’ve seen the emergence of HealthVault, Google Health, Dossia, the iPhone, the iPhone apps store, Android, PatientsLikeMe and the Health 2.0 movement. The key elements of the ecosystem are in place – more and more providers with electronic record systems, platform offerings from major companies with huge consumer brands, and a rapidly growing developer community.

But there’s a long way to go. The reality is that the pieces are in place, but only a precious few have access to them in a truly connected way. Only a few leading health care providers have announced links to GoogleHealth or HealthVault – and we’re not at the kind of plug and play stage where my apps run seamlessly on my handheld, retrieving data from my consolidated record which is constantly updated by my various health care providers.

All in all, though, it was a day for optimism. A day that showed what could be, a day that displayed creativity and ingenuity, and above all, a day that brought together a lot of people who want to make the vision a reality.

Modern Healthcare Reports on Pioneer's Work on Games

Sep 24, 2008, 9:52 AM, Posted by RWJF Blog Team

Recently, Modern Healthcare highlighted Health Games Research, Games for Health and Pioneer's overall interest in exploring games as a health care innovation. The magazine described the work of our grantees and reported on recent research into the interaction of games and health. We thought you'd like to see what they had to say:

The Games Patients Play

Whether it's for treatment, prevention or even provider education, health care is becoming more and more interactive. An article by Modern Healthcare.

By Jessica Zigmond

Improving 21st century healthcare is, unquestionably, an expensive, complex and vital endeavor for the U.S. But can it also be fun?

Researchers, hospitals and insurers think so, which is why they’re investing time and money to develop interactive games that could change behavior—and perhaps help cut costs—in healthcare.

The Robert Wood Johnson Foundation, a not-for-profit philanthropy that focuses on the country’s most pressing healthcare needs, is leading these efforts through Health Games Research, an $8.25 million project funded through the foundation’s Pioneer Portfolio. Established about five years ago, the Pioneer Portfolio considers innovative ideas that could “break the current paradigms of healthcare,” says Chinwe Onyekere, a program officer at the foundation who works with the Pioneer team. In May, the foundation awarded more than $2 million to help bolster the evidence base that supports the development and use of interactive games for health purposes. A dozen institutions were granted up to $200,000 each to lead one- to-two-year studies of games that engage players who range in age from 8 to 98.

“We’re gaining insight into how people learn,” says Debra Lieberman, director of Health Games Research and a lecturer in the department of communication at the University of California at Santa Barbara, which is the program’s headquarters. “What I love is that people do this willingly. These games are so well-received,” she says, adding that it’s fun to watch how hard people try when playing a game.

Lieberman says she conducted a study of children ages 6 to 11 and asked if they preferred learning from a book, a video or a video game. She found that 49 of the 50 kids said they preferred a video game because it “lets you try things out.” She’s now trying to pull the over-30 generation into this world. “People say this will sugar-coat learning,” she says. “Learning is fun. Everyone loves to learn, but they need a reason to learn.”

The article continues after the jump.

Helping people stay healthy

Lieberman’s work has produced results that support her theory that games can be effective tools in improving healthcare. A 1997 study published in Medical Informatics evaluated the effects of Packy and Marlon, an interactive adventure video game that uses experiential learning to improve self-management of diabetic children and adolescents. Participants in both the treatment group and control group played their game for an average of about 34 hours over six months, or about 1½ hours per week, during their leisure time. After six months, the treatment group, but not the control group, experienced higher perceived self-efficacy—or people’s belief that they can achieve certain goals—for diabetes self-management, which includes increased communication with their parents about diabetes and improved daily self-management behaviors, such as monitoring blood-glucose levels, taking insulin as needed and eating the right foods. Also, the treatment group had a 77% decrease in diabetes-related emergency and urgent-care clinical visits, the study showed.

“The Internet pales in comparison in terms of interactivity,” says Lieberman, who received training in media and learning from instructors who helped create “Sesame Street,” the children’s educational program. “The Internet is incredible, but not as fast or interactive as a video game,” she says, adding that video games are also powerful learning environments because players receive feedback on their performance.

Lieberman oversees the Health Games Research program that funds studies in topics ranging from how motion-based games may help stroke patients progress faster in physical therapy to how people in substance-abuse treatment programs can practice skills and behaviors in a virtual world of a game to prevent relapses in the real world. Lieberman said the program received 118 applications, and this year’s grant recipients excelled in three areas: feasibility of the study, research design and team experience.

One 2008 grantee was the Communication Department at Cornell University in Ithaca, N.Y. Researchers there will explore how strategies of persuasion in a game can promote healthy behaviors in life through the “Mindless Eating Challenge.” In this “virtual pet game,” children between the ages of 10 and 14 choose from about a dozen pets and then must follow various tips in order to care for their pet of choice. The tips encourage kids to eat a hot breakfast, pause five seconds between bites, and avoid eating directly from a bag or container, according to J.P. Pollak, a Ph.D. student in information science at Cornell. The game is a cell phone application that kids can download.

“We’re designing game play that leads to higher motivation,” Pollak says. “The full study next year will last one full month, and we hope to see compliance with dietary tips.”

For older students, there is “BloomingLife: The Skeleton Chase,” an interactive game designed to promote physical activity and healthy lifestyles among college freshmen at Indiana University in Bloomington. The School of Health, Physical Education and Recreation received $185,000 for this study, which involves a mystery on campus that takes eight weeks to solve as it unfolds in a variety of media: e-mail, Web sites, phone calls from fictional characters and physiological monitoring. Two groups of 45 college freshmen—one collaborative, one competitive—will use this game as their laboratory component of their “Foundations of Fitness and Wellness” course. Jeanne Johnston, an assistant professor of kinesiology who is working on the study, says the project will develop a metric to evaluate the psychological aspect of the “game play” experience.

“I see a tremendous amount of applications in a variety of settings,” Johnston says. “One area where this would work well: the work-site setting. People are naturally competitive, and they enjoy being able to track what they’re doing and working as a team. So I think all of those components of health games you can apply to a variety of populations.”

That includes patient populations as well. In Redwood City, Calif., HopeLab was established in 2001 to develop a game that would give young people with cancer a sense of power and control over their disease, says Richard Tate, HopeLab’s director of communications and marketing.

“We engaged doctors, nurses, oncologists, game developers, game designers, patients and cell biologists to design a game that was accurate in a scientific perspective and also fun and entertaining,” Tate says.

The result was “Re-Mission,” a video game introduced in May 2006. HopeLab conducted a randomized, controlled trial to test the effect of the game on adolescents and young adults with cancer. The study included 375 male and female cancer patients between the ages of 13 and 29 at 34 medical centers in Australia, Canada and the U.S. Preliminary findings showed that playing Re-Mission produced increases in quality of life, self-efficacy and cancer-related knowledge for adolescents and young adults with the disease.

Behavior modification

“I think the research demonstrates the potential impact of games—to engage customers and positively influence the way they behave in the course of their treatment,” Tate says. “One of the things we know generally: (They’re) really compelling forms of entertainment. We also know that healthcare companies who are responsible for the well-being of millions of people are very interested in new, effective ways to reach their customers, but there is not always a bridge between the folks who design games and the healthcare industry (that is) into scientific evidence,” he says, adding that he hopes the HopeLab study in the journal Pediatrics will contribute to this evidence base.

While researchers are developing games and gathering research, Banner Health has already started using health games as a rehabilitation tool at its Good Samaritan Rehabilitation Institute in Phoenix. Rehabilitation services for patients have not changed much in 30 years and tend to be boring, says Mark Smith, system director of simulation and innovation at Banner. In addition, there is generally an 80% drop-off rate in exercise after patients are discharged to the outpatient setting.

“Gamers are very shrewd,” Smith says. “They know how to build games that engage your attention. Instead of sitting by yourself, you can play bowling or golf with your daughter or husband.”

Smith says Nintendo’s Wii game console—which sells for about $300—is “revolutionary” because it makes people get up and move, and also because it has created new opportunities in science, such as training clinicians. Smith oversees Banner’s Simulation Education and Training Center, which chose the Wii to train surgeons about two years ago.

“The purpose is to train clinicians of any kind,” Smith says, adding that games can help train practitioners to insert an IV tube or intubate a patient. “We’ve trained them on mannequins, but this trains teams like in an operating room.”

Whether they’re helping patients or training clinicians, interactive games have the power to change behavior, which, in turn, could eventually lower the cost of healthcare, says Ben Sawyer, president of Digitalmill, a Portland, Maine-based consulting firm. Sawyer is also co-founder of Games for Health, a project produced by the Serious Games Initiative to develop a community of stakeholders as well as a best-practices platform for games being built for healthcare applications. According to Sawyer, Games for Health has received nearly $1 million from the Robert Wood Johnson Foundation for the next four years. The funding will help sustain the program and allow Games for Health to continue hosting yearly conferences that he says add legitimacy to the idea of healthcare games.

“Bottom line is they reduce the cost of providing care because people are fit,” Sawyer says of interactive games. “Or it helps people to manage a chronic illness or condition better, such that they don’t make trips to the emergency rooms,” he says. “The other thing would be to improve training and quality of care, which leads to less medical errors, lower lawsuits.”

Insurers get in the game

Sawyer says that Games for Health continues to raise awareness about the issue, and the concept caught the attention of certain insurers. One of those is Louisville, Ky.-based Humana, which helped sponsor the fourth annual Games for Health conference in Baltimore in May. Humana also introduced a new Web site as part of its strategy to affect consumers through games and the health benefits of game technology, and it launched a game called the “HorsePower Challenge” for 100 students at five middle schools in Louisville. The students wore pedometers for four weeks to measure and record their activity levels. By the end of the challenge, the students had walked a total of 6,364 miles, a 10% increase over the previous four weeks.

“In the Games for Health space, we have a large initiative; we are looking at the whole space of electronic games,” says Miguel Encarnacao, director of emerging technology applications at Humana’s Innovation Center. “You have certain games that make you physically move more. You have games of an educational nature. You have other games that are more entertaining but bring a certain point across in an ironic way. There is a huge variety of games—what platform, what genre, what audience. We’re trying to look at this old space and find out which game applies to which audience.”

One such audience is the elderly, which was the subject of a pilot project between Humana and the University of Pittsburgh. Seniors in an assisted-living facility played a dance-mat game that was tailored to their needs, as it included a rail around the mat and used music from their generation. Encarnação says the game has helped the seniors become more active, which can reduce depression. Left untreated, depression can lead to rapid health decline and higher costs for treatment, he says.

Given that health games research has taken off in the past three to four years, there are not yet enough developers to create different platforms for the wide range of diseases that exist, according to Encarnacao, who says that Humana has received more requests from vendors and developers in the past year.

Meanwhile, the Robert Wood Johnson Foundation continues to support additional research in this area and will issue its second call for applications in January 2009.

“We’re hoping to connect the evidence that we’re building and connecting that to practitioners in the field,” says the foundation’s Onyekere.

Used with permission of Modern Healthcare Copyright© 2008. All rights reserved.

Project HealthDesign Webcast now available

Sep 23, 2008, 8:48 AM, Posted by Susan Promislo

Click here for a complete Webcast from last week's Project HealthDesign forum on the future of personal health records.  The Webcast is broken down by sessions so you can check out as much or as little of the day as you like.  I also encourage you to check out a set of short videos that drive home what it might be like for patients to use next-gen PHR tools and applications in the future -- you can access them by clicking on the links to each grantee's summary. 

We hope you'll continue to give us your reactions to the day's discussions, whether you saw them live or on the Web. 

Blog talk post-Project HealthDesign event

Sep 21, 2008, 6:13 AM, Posted by Susan Promislo

More than 200 guests joined us for Wednesday's event, "New Frontiers in Personal Health Records: A 'Report-Out' from Project HealthDesign and Forum on Next-Generation PHRs." It was an exciting day -- the grantee teams rolled out their diverse PHR application prototypes and talked candidly about the themes that tied them together: focusing not just on the records but the actions you can take given the information; the power of looking beyond medical data to incorporate observations of daily living; and moving past PC-based access to practical, on-the-go IT tools that fit in your daily routines.  And we heard some provocative panels talk about common platform solutions to support a vibrant marketplace of such tools, key policy considerations, how health systems are harnessing the future of PHRs, and directions that industry leaders may take to meet consumers', employers' and others' needs.

Steve Downs will have more to write on Pioneering Ideas about his thoughts on the event, and where we go from here.  But in the meantime, bloggers at the event captured some interesting insights:

  • Keynote speaker Amy Tenderich of DiabetesMine summarizes many of the key themes that RWJF President Risa Lavizzo-Mourey presented at the start of the day, and which carried through the whole event.  Amy's great talk at lunch reminded us with urgency, and yet much hope and humor, that the health, IT and design communities should sit up and pay attention to the fact that devices should fit people's habits, preferences and styles in addition to the particulars of their health conditions. 
  • Lygeia Ricciardi live-blogged a couple of posts during the day on the Project HealthDesign blog.  She first commented on the morning grantee panels -- a key point that rang through all of their work was that illness happens to the whole person, not just a body part or system.  Designing tools through patients' eyes enabled very different breakthroughs as a result.  She later drove home a point that U. Rochester grantee George Ferguson stated -- that the field should be moving toward delivering a seamless ecosystem of PHR tools and technologies for consumers, not a plethora of stand-alone gadgets.
  • Vince Kuraitis of Better Health Technologies and the e-CareManagement blog moderated an afternoon panel with executives from Google, Dossia and Microsoft to tease out where the industry may be heading.  He writes on the evolution from PHRs to comprehensive PHR systems, and why this transition may take hold among patients more easily than providers.
  • Family physicial and patient empowerment champion Ted Eytan posted live from the opening session and shared a great set of photos from the event.
  • It was interesting to read why an attendee from the Center for Student Health and Life thought students might be the quickest adopters of PHR applications like the ones presented on Wednesday.  They think it's due to student's pervasive reliance on social networking tools and the promise that PHR technologies hold for wellness promotion. 
  • Federal Telemedicine News posted a range of points made by many of the grantees throughout the morning. 

Thanks to everyone who participated in the event.  Look for a link to a complete Web cast of the day on Monday.

FasterCures, Innocentive Crowd-Source Solutions for Biomarker Research

Sep 18, 2008, 2:10 AM, Posted by Susan Promislo

I mentioned in my post on FasterCures' Mid-Year Top 10 Watch List that they were working on an Innocentive competition to discover breakthroughs in disease research. Yesterday, that competition went live -- FasterCures will award a guaranteed payout of $10,000 for the two most promising ideas that encourage companies to invest and collaborate more in biomarker research and qualification.


Biomarkers are used by medical professionals to determine proper diagnosis, prognosis and the optimal course of treatment for a patient. Widely viewed as a critical technology to personalizing treatment choices and maximizing the impact of medical treatments, biomarkers are key to the biomedical research process and can shave years and millions of dollars from the research and development process.

According to FasterCures President Greg Simon, health care industries have "...little incentive to invest in biomarker research and development and keep the results of their investment in the public domain, where it can do the most good."  Hence the move to crowd-source solutions from the open scientific community that competes in Innocentive's online challenges. Their hope is to eliminate that "first-mover disadvantage" by throwing the search for solutions wide open -- Innocentive's network reaches 160,000 "Solvers" based in 175 countries and cutting across 60+ industry disciplines.

The biomarker challenge is posted in InnoCentive’s Global Health Pavilion, home to competitions that focus on solving some of the world’s biggest health challenges. The entry deadline is November 15, 2008. We'll be interested to see how this approach to discovering breakthrough ideas works for FasterCures.