Pioneering Ideas

Health Games Research in D.C. Talking to NIH Today

As you may recall, we posted a brief update on Pioneering Ideas a couple of weeks ago on the Health Games Research database launch. Today, Debra Lieberman, national director of Health Games Research, and Paul Tarini, Pioneer team director, are in Washington, D.C., delivering a presentation to the National Institutes of Health on the benefits of health games and some of the evidence we’re seeing that suggest they can make a difference in people’s health and behaviors. Before heading to Washington, Debra was able to submit the below post, which provides more detail on the database:

The newly launched online searchable Health Games Research Database contains more than 1,200 items related to the research, design, development, publishing and implementation of digital games aimed at improving health and health care.  At the Health Games Research national program, we decided to create the database because there is great demand for information about our field.  We wanted to be able to point people to a dynamic resource they could explore to find the information they need.  Our hope is that the database will spark new ideas and collaborations that will help the field grow in constructive and exciting directions.

We welcome community input to the database.  It has a recommendation form, where people can suggest new content or revisions to existing content, and we would be very pleased to hear from our colleagues in a variety of fields who have more items to suggest.

The information in the database was gathered and organized by the Health Games Research staff with the help of 10 student assistants at the University of California, Santa Barbara.  I especially want to thank our team's project manager for the database, Erica Biely, and the deputy director at Health Games Research, Maria Chesley Fisk, for their diligent work and valuable ideas.  Erica has been the driving force of this project and we appreciate her many contributions.  The three of us are excited to have the database to use ourselves and to share with our colleagues in the wide-ranging health games field.  We are very grateful to the Pioneer Portfolio team that works with us, led by Paul Tarini, for their financial and collegial support for this project.

We've been thrilled by the positive response we've seen on Twitter and in other social media spaces, and appreciate these efforts to spread the word about the database.

CleanMed Conference Takes on Health Care’s Environmental Impact

Health care facilities create more than two million tons of waste annually and routinely dispose of dangerous pollutants, resulting in a disturbing irony: The hospitals and clinics we rely upon to keep us healthy may be contributing to poor health in the first place.

Fortunately, there is an increasing awareness of this issue. Health Care Without Harm leverages the green movement’s momentum to advocate for eco-friendly design, building, purchasing and disposal practices in the health care sector. More than 430 organizations in 52 countries have joined together in this initiative, to demonstrate their commitment towards improving environmental and human health.

As part of Health Care Without Harm, we’re supporting a series of research papers directed at the intersection of environmental, patient, and worker safety issues related to building and operating health care institutions. The first paper, published last year, addresses resilient flooring, evaluating potential health impacts of vinyl flooring and the leading alternatives – synthetic rubber, polyolefin and linoleum — currently in the health care marketplace. By simply switching flooring materials, health care facilities can dramatically decrease staff and patient exposure to bioaccumulative toxins while significantly scaling back the demand of environmentally harmful compounds like PVC.

Transformative ideas are crucial to create change within health care. To learn about some of these ideas and participate in the conversation, Pioneer Senior Program Officer and Team Director Paul Tarini will participate in a panel discussion at the 2010 CleanMed conference May 11-13 in Baltimore. CleanMed seeks to accelerate the health care sector’s commitment to environmental sustainability and regenerative health to improve the health of people and the environment.  This year’s event also features Health Care Without Harm Executive Director Gary Cohen as a speaker.

Paul will post a few highlights on Pioneering Ideas following the conference. Until then, we look forward to hearing your ideas about how the health care industry can improve its environmental footprint.

Project HealthDesign's Patti Brennan Emphasizes Value of Patient-Generated Data, ODLs at Meaningful Use Workgroup Hearing

Project HealthDesign’s national program director Patti Brennan testifies today at the HIT Policy Committee, Meaningful Use Workgroup’s hearing on patient and consumer engagement.  You can find Patti’s testimony here. 

Patti makes a key point that reflects Project HealthDesign’s current work: patient-generated data are not simply traditional clinical data (like blood pressure or glucose) collected by patients.  Instead, patient-generated data could include a whole host of observations about health behaviors, symptoms and environmental factors that are relevant to someone’s health.  As we’ve discussed over the past couple of years in various posts (see here or here), “observations of daily living” on diet, activity, sleep, pain, mood and others can help paint a clearer picture of one’s health and the factors that influence it and also drive an incredible variety of applications that give people valuable feedback.

Patti specifically offered the committee three things that she believes must be accomplished:

1. Health information that is selected and gathered by patients must be integrated into clinical care. The flow of information about an individual’s health should go both ways – not just from providers to patients – because patients are experts about their daily activities, and providers need their insights. 
2. Health information must be accessible to patients in a computable form. Project HealthDesign’s grantees and numerous private sector companies have been developing applications and services designed to let patients use health data in innovative ways, whether via PCs, mobile devices, online communities or other means.
3. Health information for patients must be actionable. Health information must be meaningful to patients as they make decisions about their own health care.

Project HealthDesign National Advisory Committee Chair Paul Tang co-chairs the Health IT Policy Committee Meaningful Use Workgroup; other speakers today included National Advisory Committee member M. Chris Gibbons of Johns Hopkins, first round grantee James Ralston of Group Health Research Institute, Dave deBronkart (better known as ePatient Dave), Eric Dishman of Intel and Scott Mackie of IDEO's health and wellness group. 

A landmark first for the Archimedes model

At the very end of March, study findings were released in the online edition of The Lancet indicating that it is more effective from a cost and detection standpoint to begin screening for Type 2 diabetes in people between the ages of 30 and 45 — 15 years ahead of what established guidelines had been recommending.  Subsequent screenings should take place every three to five years thereafter.

While this is an important result for the medical community, the most significant piece of this story, in our opinion, was not covered in the news.  What really caught our attention was the fact that this was the first time The Lancet has ever published a peer-reviewed paper for which the research was based entirely on a simulated population and treatment options existing within a mathematical model – in this case, the Archimedes model of human physiology, diseases, interventions and health care systems.

For the study, the researchers simulated a population of 325,000 nondiabetic 30-year-olds.  According to Archimedes President and CEO John Beasley, “This paper presents the results of an international study that would never have been possible using an actual clinical trial. It would have required enrolling and following more than a million people for 45 years; the cost would have been astronomical.  The study examined the criteria for deciding when to screen for diabetes and Archimedes was the only model that could conduct a clinical trial simulation at this advanced level.”

We’re excited to see validation of the strength of the Archimedes methodology at this level.  Watch the blog for more updates soon on the status of the ARCHeS project, which will make it possible for public and health policy leaders to access the model to conduct their own virtual clinical trials from their desktops.  The vision is that a wide variety of key decisions will be informed by equally strong results from the model’s predictive analyses, and the sharing of findings powered by Archimedes will become common practice in peer-reviewed journals.

When is it all fun and games, and when is it manipulation?

Note: See yesterday’s post to learn more about what the Pioneer team has been working on lately with Debra Lieberman and the Health Games Research program.  

Earlier this week I tweeted a link to a piece on VentureBeat featuring Norwest Venture Partners’ Tim Chang thoughts about the “game-ification” of life.

I shared the link with Debra Lieberman, national program director for our Health Games Research program. Debra is a passionate researchers who’s devoted much of her career to understanding how and why games can be effective and useful tools. She had some very thoughtful observations:

“I have noticed for a long time that many aspects of life are already made into games...with reward points for frequent flying and incentives for customer loyalty at all kinds of retailers (discount coupons, gifts). I am often asked to respond to surveys with the enticement that I will be entered in a sweepstakes as a reward. Contests are everywhere as an incentive to get people to share ideas. I like Tim Chang's observations that teams and a sense of loyalty to them can be very motivating.

The "gamification" of life can get us to do things just to gain rewards and avoid punishments (such as the taxes on junk foods, as the blog describes). But we must not forget the importance of intrinsic motivation. In the past it seems to me that we chose to do things because, at least to some extent, they were inherently valuable to us and our motivation came from internally-driven needs and interests, not from external rewards, points, and prizes. We need to help our kids figure out what they want to accomplish so they can reach for their own goals...and not be so manipulated by the extrinsic rewards offered with coupons, reward points, and prizes...and extrinsic punishments.

Health games can be designed to focus on and bring out the player's intrinsic motivation. Research tells us that people who are intrinsically motivated are much more engaged and interested in the task (e.g., developing the knowledge and skills they can gain from the game) than those who are trying to figure out a way to win the prize. An interesting experiment would be to compare one group in which each individual set their own healthy eating goals and developed their own plan and were shown the health rewards they were actually getting this way...versus a group that was given healthy eating goals and was spurred on by external rewards (e.g., pay them to do it). Then, see what happens when the study ends and the external rewards go away. I bet the people in the rewarded group will revert back to old eating habits while those in the intrinsically motivated group will be more likely to sustain the healthy eating habits.”

We hope developers take Debra’s insights into consideration when designing games that encourage healthy living habits. External rewards can lead to a temporary shift in behavior, but to create lasting change, motivation must come from within.

Health Games Database Launched

Earlier this week, Health Games Research (HGR), a national program of the Pioneer Portfolio, unveiled a searchable database tracking more than 1,200 resources related to digital health games. This online tool allows researchers, game developers, health professionals, educators, funding agencies and policy makers to access in one place a wide-ranging compilation of health games, research findings, publications, organizations and events in this growing field.

Several important studies have already found that health games have significant impacts on players’ health, but more research is needed. As such, we’re excited about the potential this database has to provide insight into how different people process various health game elements. Hopefully it will lead to improved collaboration and – ultimately – the development of games that make a real difference in people’s health and the quality of care they receive.

We encourage you to check back in the next couple of days for more thoughts on health games from Paul Tarini and HGR National Program Director Debra Lieberman.

Are voluntary medical courts a step in the right direction?

With the passage of the health care reform bill, it looks like health courts may finally be closer to becoming a reality. But as Harvard Professor Dr. Michelle Mello points out in a recent post on the AMN Healthcare blog, there are still lingering concerns about how these courts will be implemented.  

Through her work at the Harvard School of Public Health, and together with leaders at Common Good, Mello is at the forefront of the health court movement. Despite being initially optimistic about health courts being included in the initial drafts of legislation, she is concerned the final bill creates a voluntary court that has limited adjudication powers. As the AMN post points out, “the current system would remain in place as a backstop to (a) voluntary health court.”

What is the Role of the Physician in a Data Rich World?

Last week’s Project HealthDesign workshop, held at the Vanderbilt Center for Better Health in Nashville, focused on how clinicians could use “observations of daily living,” or ODLs – data associated everyday experiences such as diet, exercise, sleep and pain – to provide better care to people with chronic diseases.  The five Project HealthDesign teams are refining their plans to integrate ODLS into the treatment of premature infants and their parents, obese teens at risk for depression, adults with Crohn’s disease and its complications, adults with asthma and depression or anxiety disorder, and elders with mild cognitive impairment.

A presentation by Kevin Johnson, vice chair of the Vanderbilt University Medical Center Department of Biomedical informatics and the project director of a previous Project HealthDesign grant, raised interesting questions about how to present information captured through ODLs and who should interpret the information.  Johnson showed this graph, which represented a self-report of medication usage over a month’s period as compared with a schedule. 

Clearly, any of us can tell at a glance that the patient adheres to this medication schedule extremely well. The presentation conveys this information quite clearly and, frankly, it doesn’t take a great deal of clinical training to interpret the information. But consider two other cases.  First, if this chart showed a much poorer rate of adherence, the challenge would be to look for patterns in the missed, late and on-time doses to see if there were behavioral triggers or environmental factors that explained the results (e.g. a change in work schedule means the noontime dose is problematic, a Thursday evening softball game makes it unlikely to remember). In the second case, one could overlay on the medication chart other data, such as pain level, mood or even clinical signs like blood pressure and look for patterns that might lead to inferences about correlations and interrelationships.

In each of these three cases, one could ask what skills and training are needed to review, interpret and act upon the information (one can even take it a step further and ask which of the cases requires human vs. algorithmic interpretation). Of course, at some level, the answer is “it depends,” but thinking about the question gives some insight into the broader question we’ve been asking of late in the Pioneer Portfolio:  “What is the role of the physician in a data rich world?” I’m not a clinician, so I’m on shaky ground here, but it seems to me that only the third case requires clinical training – because it’s a case that requires integrating clinical knowledge into a pattern sensing activity. It’s a form of clinical problem solving. The second case doesn’t seem to require clinical knowledge so much as an understanding of some concepts from consumer behavior, design or even behavioral economics and an ability to motivate – to work with the patient to find a solution.  And the first case seems to lend itself to automated processing to determine if the behavior is within some predefined range.

The question gets even more interesting when one factors in the patient’s own engagement in these cases. One would hope that the patient is looking at the same data and developing her own questions and hypotheses. With whom should she discuss them?

What do these scenarios and questions imply for the way we currently primary care and the health professions that make up that enterprise? How will those professions need to evolve?  Will we need new professions? And are the right skills being taught to the right students today?