This slideshow presentation was presented at the Games for Health Conference 2012 June 14, 2012 http://www.gamesforhealth.org/index.

php/conferences/gfh-2012/

Every day there is a new gizmo or gadget to entertain and delight us. Gaming has undergone dramatic changes in the past decades: from big clunky consoles to mobile social games in your pocket. Think how much this new technology has already changed the way you work, live and play. For me, these technology trends are converging with my own passions and interests. So much so, that back when I was a practicing dentist and then a Wall Street equity analyst, I would never have dreamed that I would be here today speaking about mobile social games and analytics in healthcare. Life, like games, comes with unexpected adventures, so let me take you on a journey of discovery: how game developers and healthcare providers are uniting to inject fun into the healthcare equation.

Our story starts with ubiquitous connectivity Both technical and social forces are driving the explosive growth in mobile social gaming. Technology: better, cheaper, faster, technology is enabling mobile connectivity anytime, anywhere. Smart phones and tablets put inexpensive 24/7 access into the hands of millions of consumers, including patients and health care practitioners. Technology plus human behavior means that social connectivity is becoming ubiquitous Its not just online social networking. The social support that we barely notice, but depend on in our offline lives, is being extended into online communities. Social gaming involves and expands our online social networks. Another social trend is the mainstreaming of computer games Once a geek niche, Gaming is now mainstream entertainment, bigger than the entertainment industry. Adding in the mobile component to gaming, Putting games in your pocket has disrupted the gaming industry, with faster development and low barriers to entry

Changes in mobile technology have enabled this explosion of new games 1. The app model: Low cost, decentralized development is producing an avalanche of mobile games 2. With you, the user, 24/7, offering a persuasive and persistent opportunity to playand connect Mobile phones have created millions of new casual gaming consumer through the simple content, easy entry and low-to-free price point of Angry Birds and Farmville. Mobile play is a huge part of the mobile experience. Flurry Research, a mobile apps analytic company, looked at how people in the US use their mobile phones: 79% of mobile users time is spent on social networking and games. Not surprisingly, games take up nearly half (49%) of U.S. users time. Summary: Gaming is now mainstream entertainment, attracting masses of new players with easy games on mobile devices. Consequently, we see gaming techniques, gamification applied in many industries and now in healthcare

The journey unfolds as our worlds collide in the form of new mobile health games. The healthcare system needs help and is finding new ideas in the technology associated with mobile social gaming. Driven by rising medical costs, an aging population and a shortage of providers, providers and payors are seeking new ways to help people help themselves stay healthy. Mobile social gaming is a platform for 24/7 personalized technology that can engage people and change their behaviors. The increasing power of computational sensors and data analytics, along with gaming mechanics, social networking and crowdsourcing, is enabling pioneering companies to develop mobile game applications for healthcare. Healthcare payors and providers are looking to harness consumer empowerment and personalized technology to drive patient engagement and behavior change. As you can appreciate, with ubiquitous connectivity building an expanding user base of mobile social gamers, healthcare and games are reaching a tipping point with the right mix of technology, innovation and motivation to power a whirlwind of change. As our worlds of gaming and healthcare are merging, some unlikely players are becoming bedfellows.

New ideas from people inside and outside healthcare create lively multidisciplinary collaboration and interesting partnerships and acquisitions. Inside Healthcare Payors, Medical device developers. Pharmaceutical companies, Providers Are all seeing their business models change and are looking for new ways to engage consumers. Payors are the first to respond to this consumer demand. A walk on the floor of CES--where Uniteds huge display was filled with health and wellness games--reflects this trend. Both United and Aetna have already been active acquirers. Outside Healthcare New players outside healthcare are entering the arena to proffer creative options for problem solving. People from the gaming and entertainment communities, hardware and software engineers, behavioral and cognitive psychologists, behavioral economists, designers, and communications experts all want to sprinkle fun into the healthcare equation and inspire lasting behavior change.

As you know, Gaming has produced a new lexicon of terms like: gamification, game mechanics, game elements, game dynamics. Game Mechanics Motivate Behaviors Game mechanics are the actions and control mechanisms that gamify an activity. These include: points, levels, challenges, virtual goods, donations, leaderboards. Points - are rewards across multiple dimensions. Many studies have shown that people like points, even when they have no monetary value. Rewards also include trophies, badges, virtual money and goods, real gifts and charitable donations. Leaderboards - we like high score tables because we enjoy seeing our name in lights, showing we have achieved high status. In health, leaderboards can track and display desired actions using competition to drive behavior. Levels in a game challenge players to come back and play more. Challenges and competition appeal to basic human motivators. Game mechanics build game dynamics that play to basic human desires for: reward, status, achievement, self-expression, competition and altruism. Competition works in healthcare as in multiplayer games. As a practicing dentist who spent much time trying to get my patients to take care of their oral health, using game techniques is appealing. The traditional approach I was taught--threatening patients with dire consequencesbeing toothless -- did not help. 7

Demo:, Lumosity Lumosity has created different types of games to train different areas of brain health including problem solving, memory, flexibility Memory shapes- allow to remember the shapes as they go by Brain Shift- changing gears from recognizing even numbers and vowels

Keas is using games to help employees be healthier, happier and more productive. Elements of the power of play 1. Positive reinforcement 2. Shared affinity- sharing set of issues/challenges in this together with your employer 3. Team dynamics- social obligation, team depends on you 4. Feed- social suport ask for help 5. Game is fun

Whether training your brain or joining social games at work, When you think about it, behavior change is at the very heart of healthcare. Simply showing up is half the battle: Getting healthy people to show up for diagnostic screening is a big goal of public health, as is getting people to show up or bring their children for vaccinations A remarkably successful behavior change intervention has been getting payors to support and patients to show up for twice-a-year dental cleaning and evaluationand then using those sessions as opportunities to teach brushing and flossing habits. As a dentist I wondered, why is it so hard to get people to take care of their teeth? As a patient, who tries to brush and floss, but never well enough, how many times have I promised my hygienist to try harder, do better? fear doesnt work -- you need a sense of empowerment.

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Behavior change has fascinated not only dentists, but many psychologists for a long time. Remember Maslows famous hierarchy of needs? Safety, belonging, self-esteem and self-actualization. This is one way to classify the basic human motivators I referred to earlier. This hierarchy has been simplified by Mary Meeker to just food/water, shelter, internet and mobile phone. Of course, I would add games/fun on top of the mobile phone! With an hierarchy of needs in mind, questions around motivation and resilience are hot topics of research. Motivations are the reasons why we do things. There are two kinds of motivation- extrinsic, which comes from outside the individual, and intrinsic, internal movers. Many intrinsic motivators were once extrinsic: All of us progressed from having parents and dentists remind us to brush and floss every day, to reminding ourselves, to habitually brushing and flossing because it feels right, because we like the clean feeling. Creating motivation means finding tactics to move people along the continuum from extrinsic to intrinsic motivation, from reminders to habits.

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Transition: One of many motivational theories is the one developed by BJ Fogg, as shown here. He focuses on 3 factors to effect behavior change. Motivation + Trigger + Ability: Motivation relates to a desired goal: you want clean breath, healthy teeth and gums

the Trigger is a call to action- do it now!- like the toothbrush and toothpaste on the sink in your bathroom at bedtime
Internal Triggers could be your teeth feel dirty, mouth tastes bad To reach the goal you must have the Ability to respond to the Trigger: you know how to use a toothbrush. Motivation and ability are trade-offs - above the threshold things will happen, but not below the threshold: If action is easy and motivation is high - the behavior happens - brushing every night before bed If action is harder and motivation is low - the behavior does not happen- flossing after a long day If the behavior is hard, just boosting motivation will not work, one must make the behavior easier.

In his latest work, BJ thinks that baby steps area useful approach to behavior change.
So, if you want to floss, do these three steps: Step 1- Make it tiny - floss one tooth every night Step 2- Find a spot - put flossing into your daily pre-bed routine Step 3- Train the cycle- repeat flossing Putting triggers in the paths of motivated people may help them change behavior, but what does it take to make that into a habit that lasts? Questions around persistence and resiliency come up a lot in behavior change, because most people have difficulty sticking to a plan, fall off the wagon and find it hard to get back on the wagon.

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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. New online social networks catering to health topics offer elements of fluidity and flexibility not seen in the offline world. With no limits on geography or network size or number of networks - personalized networks can be custom-created, easily assembled and disassembled, depending on changing personal preferences and needs. So, social networks using personalized peer-to-peer networks could become useful external motivators for spurring healthy behaviors. Yet, people are complex, and influencing everyday choices is not a one-size-fits-all solution. For some, the output of biometric data, data coming from body sensors, will help them to find their way. As we will see, large sets of user data may also help developers understand human behavior and close the feedback loop. The key may be in experimenting with a mix/match approach.

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RallyOn is using corporate challenges to help employee wellness. Variety The RallyOn Solution delivers an infinite array of challenges that enable employees to work on all of their wellness goals. Almost any fitness or health activity can be turned into a challenge from steps, exercise and weight loss to nutrition, stress management, sleep or charity initiatives.

The basics of challenges include: Tracking Seeing where you stand on the leaderboard (individual and team) Seeing how others are doing on the leaderboard

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But the game experience can be a lot more Starting at the beginning: the draft for team formation Creating a team identity: photo, slogan, roster Visuals and animation bring the challenge to life Avatar moves when you track Notification/messaging when you reach milestones In addition to in-game messaging, RallyOn sends texts/emails Communication Participants can communicate on the public challenge wall or just with their team Whats working to drive engagement? Variety variants on the same game make it more interesting. Persistence of teams as well as new teams Not focusing on wellness, focusing on the game design Mobile devices: reaching people where they live and when they have a few minutes of found time Rallyon can be used on any web-enabled device, wherever employees happen to be.

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An example of a fun social way to learn more about healthy eating is found in the Eatery.

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With technological convergence, plus increasing interest from players inside and outside of healthcare, my Ahah! moment during my research is when I found an evolving ecosystem of experimenters trying to produce 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. In life balance, Mindbloom, brings together health, relationships, lifestyle, creativity, career, spirituality and finances providing a digital view of your total quality of life Habitual, the first massively multiplayer, mobile, behavior-change gaming platform for mastering simple daily habits, is backed by psychology research from Stanford, University of Pennsylvania, and the University of Washington. 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. Our demos of Keas and RallyOn show how companies could use social games to get their workforces moving. Brain Games An exciting application of game technology takes advantage of a new understanding of brain plasticity. Older people like fun, too. Dakim has designed entertaining brain exercises for the elderly. In fact, when I call my dad, who is 85, and ask him whats new?, he proudly proclaims his Dakim score for the day. 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. Some Examples include: Cellnovo, and now OneRecovery which has become OneHealth

Looking for solutions across the disease continuum, there is no one size fits all in behavior change. Behavior change is hard. Sure, there are theories, but we are still experimenting with a mix/match approach to using game mechanics and online support networks. What is the secret sauce? Can we find the best combination of game mechanics and online support? In self-help, Habitual uses points, levels, challenges, and peer-to-peer support to help us master simple daily habits. As with Keas and RallyOn, another mix & match approach is found in social games for corporate health and wellness programs. These include: earning points for activities, advancing through levels, acquiring individual virtual money and status rewards such as badges, as well as building teams, earning social rewards and applying social pressure. As we think about using game mechanics and online support networks- let me share with you the story of OneRecovery, now OneHealth.

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Discovering the work of OneRecovery was another Aha! moment, both last summer when I did my initial research again when I was doing an update for this talk. I had envisioned that this mix/match approach could be applied to chronic disease, but I could not find any robust case studies, until now. Using a mix of game mechanics and multiple online support networks, OneHealth began their work in addiction-related disorders and then expanded to other behavioral health conditions such as depression, anxiety, stress, smoking and weight loss. Now they are applying this approach to chronic medical conditions such as heart disease and diabetes. Just like a good game developer who puts the player in the center of the experience, OneHealth has created a user experience with the patient at the center and cleverly hid a series of game mechanics alongside clinical protocols. 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. There are emoticons- a series of happy/sad faces, to show how you are feeling and express empathy to your online support network. 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 a patient who struggles with obesity, depression and addiction. As you will see in the demo, this mix of game mechanics, and support groups is available 24/7 in your pocket. [after demo] For those of us dreaming of improving the lives of those with chronic disease, OneHealths mix is just what I had imagined and more!

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Early Days of User Data Analytics The use of data analytics is a topic that captured my imagination along the journey. If Zappos can know my shoe preferences, Amazon can suggest my next purchase, and Zynga can tantalize me with virtual currency, why cant my game deliver personalized healthcare information? The use of data analytics is in the early days, but putting on my equity research pith helmet, I found 3 fascinating case studies from The Eatery, Lumosity and OneHealth to share with you. The Eatery Built a dataset of 7.68 million user ratings over a period of 5 month post launch. They use data mining, machine learning, and artificial intelligence to identify patterns to determine and refine questions in an iterative analysis. A initial data findings: Users who eat breakfast eat 12.3% healthier throughout the day Users with a specific diet type (e.g. low fat, vegan, etc.) eat 15.2% healthier than those who eat everything Users eat 12.7% healthier at home but only eat at home 26% of the time There seems to be a perception gap where: Users eat 12.4% less healthy than they think they do Lumosity With 20 M users and over 320 million data points, uncovered findings on how cognitive function can improve with life style changes - some of which were surprising. This sample was a survey of 750,000 Lumosity users 1. Get enough sleep. For every extra hour of sleep each night up to 7 hours, users were 4% speedier, solved 4% more math equations correctly, and increased spatial memories by 1.2%. Surprisingly, performance actually declined after more than 7 hours of sleep. [was this statistically significant?] 2. Even being a little more active can make a difference. Users who reported aerobic exercise just once a week were 9.8% faster, solved 5.8% more equations, and had 2.7% better spatial memory than those who never exercise. 3. Drinking is okay in moderation! Users who had one drink per day outperformed those who had no drinks, but there was a decrease in performance on speed, problem solving and memory with three or more drinks per day. 4. People who reported participating in one or more of the following activities at least once a week scored higher overall than those who dont: Playing video games, word games, reading books, magazines or newspapers, or playing an instrument. One Health uses a different approach 2 sides of the api- social and clinical side Social side: user-generated content alongside the evidence-based research using user data (choice and language) to inform decisions about how they add new features in communities Thinking about 3 arenas Identify the activities that are of value to users

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It is too early in the business cycle to look just at mobile social health games, but considering the bigger context of mobile healthcare apps (most of which have some component of gaming elements and/or social support) there is a very positive growth trajectory.

App Downloads, Sales of apps and investment in apps are all trending up.

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These are early days. Current healthcare gaming tech is simple and 2-D, but we know that complex, realistic 3D games are already out there enticing players into immersive stories. We now expect tech to bring us a realistic 3D view and engage our emotions. Storytelling will be a necessary part of this future. Healthnutsmedia, which aspires to be the Sesame Street of healthcare kids education, using animation to get engagement is one example. Another is Mayo Clinic where people tell their health story via video. We are creating a new kind of reality, one in which physical and digital environments, media and interactions are woven together throughout our daily lives. It is a world where the virtual and physical are integrated, personalized, 24/7, and where fun is an important element in taking proactive steps to take care of ourselves. Features that make our mobile experiences more realistic will change the lens through we view healthcare. Some noteworthy examples: The USC Center for Body Computing Biosports Monitoring project is thinking about creating a virtual mobile fantasy league. Kaiser is using simulation in a prototype game called Dr. Hero, simulating an obstetrical hemorrhage to train physicians.

Taking artificial intelligence and virtual world to another level, Thrive Research is using virtual worlds in behavior research to treat post traumatic stress and autism.

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As you have seen, at the back end, we have emerging data analytics as a way to get personalized solutions At the front end we have seen, Elements of design- simplicity, beautifully executed in The Eatery Competition and teamwork as motivators of employee health we will see in Rallyon and Keas New ways to use technology to exercise the brain with Lumosity The use of avatars in behavior health in Thrive Research An effective use of game mechanics and multiple online support networks in OneHealth

Overall, these apps design for engagement, with an emphasis on simplicity and inviting user interfaces. Once drawn into the app, it puts triggers in the paths of motivated people as well as using social support and data analytics to expand and enrich participation, to help us to take better care of ourselves.

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Our worlds have collided with a shared goal to engage patients and providers. It is an action packed story of change and resilience, of pulling real rabbits out of virtual hats! As we have seen, the creative talents of this audience and others have jumped into creating mobile health games with online support to help engage patients and providers. The old adage of no pain no gain is being replaced by no fun no gain- a wonderful change. Using a mix/match combination of game mechanics and social networking, pioneers are experimenting with 24/7 and personalization to get engagement across the disease spectrum. Early uses of user data analytics and more robust game play are beginning to emerge. On a personal note, thank you for welcoming me and other healthcare providers to your world, where dreams and imagination freely reign without fear of failure. As my own journey has been from practicing dentist to Wall Street analyst to market researcher and consultant in mobile games and analytics, has been one of change and resilience, so too has been the journey in the gaming industry- from large consoles to mobile social games in the pocket, and now finding new applications in healthcare. It is my hope that the pace of change will continue to accelerate, so that we can continue to create these new tools to help each of us in our quest to find health and happiness.

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