Pioneering Ideas

Now that’s Progress

1899

 

2009

 

My family dog, Chance, testing the latest prototype. 

Credit to my wife, Naomi, for the idea.

The back story: Chance is about seven months old. He learned to swim in a local creek the other day. Then, in his excitement, he jumped off a bridge and landed on ground 10 feet below. I think he figured if he could swim, then he could also fly. We spent a good five hours at the emergency room, most of it waiting. The vet on call wanted a specialist to see him. The specialist, a doggie ortho surgeon, thought they would need to operate—to the tune of $4,000.  Additional x-rays showed no broken bones, but some torn tendons. It was just like a visit to a human ER, only with a lot more fur. Chance should be ok in three or four weeks.  In the mean time, he claims to be receiving podcasts from New Zealand.

Can a Reduction in Hospital Acquired Infections Cut Health Care Costs?

There is no denying that hospital acquired infections (HAIs) are an expensive drain on the system and impact the lives of an estimated 1.7 million hospital patients a year – killing nearly 99,000 annually. Is it possible that simply instituting best practices in infection control can substantially reduce these infections and save the nation’s healthcare system billions of dollars a year?  Yes, according to an article in last week’s Roll Call by Ramanan Laxminarayan of the Extending the Cure initiative, a Pioneer grantee, and Ed Septimus from HCA Healthcare System.  Laxminarayan and Septimus propose several ideas and incentives, which they believe will reduce the rate of resistant HAIs and control the rise of antibiotic resistance. 

Are hospital acquired infections really the low hanging fruit that will benefit patients and cut health care costs?  Check out the article and then come back here and let us know what you think.   

 

Using Games to Support Children's Healthy Development: Opportunities & Challenges

We welcome Ann My Thai to our guest blogger series.

Ann My Thai is the Assistant Director of the Joan Ganz Cooney Center at Sesame Workshop and the co-author of Game Changer: Investing in Digital Play to Advance Children’s Learning and Health. Ann leads the Center's strategic partnership efforts with high tech and gaming industries, and oversees organizational growth and strategy. Before joining the Center, she served as a consultant for Education for Development, Vietnam, a nonprofit organization that develops informal educational programming for disadvantaged children in Ho Chi Minh City, Vietnam. Thai received her bachelor's degree in Political Science from Yale University and a master's degree in Business Administration from the Ross School of Business at the University of Michigan.

Readers of the Joan Ganz Cooney Center’s latest report, Game Changer: Investing in Digital Play to Advance Children's Learning and Health might be asking why we chose to discuss how digital games could advance both children’s learning and health in the same paper. Named for its founder, the Center’s roots lie in Sesame Street’s “whole child” approach, which encourages learning that supports many different aspects of a child’s healthy development—from literacy skills, to social and emotional development, to practicing healthy habits.  A solid base of research tells us that children who eat healthfully and are more physically active are also able to learn more easily.  It also tells us that children who suffer from health threats such as obesity do worse in school and are less successful later in life.  Given the inextricable ties between learning and health, and the parallel efforts in each field to harness the power of games, we wanted to address the potential role they might play in health and education reform together.

The idea that digital games might actually help improve children's learning and health is, in some quarters, a radical one, but for authors of the report, it is also a pragmatic one. The medium has a high penetration, with 97% of American teens playing computer or video games.  Furthermore, digital games are reaching children at younger and younger ages for longer periods of time.  The average child begins playing games at age 6, down from 8 years old a few years ago, and the amount of time a child plays on average more than doubles between age 6 and 9.  This level of play shows that it is no longer a question of whether we should enlist games in our learning and health efforts but how we may do so.  Game Changer aims to spark a productive dialogue about the opportunities and challenges of using games to support children’s healthy development.

To kick off this dialogue, we unveiled the report on Tuesday with the Woodrow Wilson Center for International Scholars at an event in Washington, DC.  It featured a panel of experts from industry, research, and policy and hosted nearly 100 participants and a web audience from these key sectors. 

A key insight raised at the event was the lack of training available to health researchers to engage in the type of multi-disciplinary game R&D requires. Dr. David Abrams, Executive Director of the Schroeder Institute at the American Legacy Foundation, which focuses on accelerating the reduction in tobacco use, especially for young people in the U.S. population, said that the health care sector has “not looked beyond itself” to consider the whole child in advancing children’s health. The current generation of health researchers is too often isolated from the broader perspectives or tangible incentives to engage in a multi-disciplinary approach.  

Some of the biggest challenges of the day—such as childhood obesity or the fourth grade reading slump—are too broad and complex to be addressed by the expertise of any one discipline.   These are problems couched in layers of social, economic and other environmental factors, as well as developmental factors distinct to each child.  Responding to these issues from a whole child perspective will demand greater investment toward funding and collaboration models and infrastructure that support multi-disciplinary collaboration.  Such investment is essential if we are to tap into the digital media that surrounds today’s children in a purposeful way.  

Marketing the Concept of Games for Health

We continue our guest blogger series with Nedra Weinreich. 

Nedra Weinreich is a social marketing consultant who helps nonprofits and government agencies strategically promote health and social issues through her company Weinreich Communications. She is the author of Hands-On Social Marketing: A Step-by-Step Guide, writes on social marketing issues at the Spare Change blog and is the director of Social Marketing University. Nedra has an MS degree in Health & Social Behavior from the Harvard School of Public Health.

Games for health intrigue me because they have such potential for achieving the behavior change-related objectives we in public health often struggle to reach - changing awareness and attitudes about an issue, educating people with key facts, building necessary skills, and even the holy grail of engaging in healthful behaviors during the course of the game. Health gaming shares the roots of its success with other entertainment education approaches (like health topic "product placement" in television plotlines) by engaging its players emotionally, embedding learning opportunities within fun activities, and allowing people to try out new skills (either vicariously or in actuality).

Forward-thinking people in the behavior change business know all this. Unfortunately, many others hear the words "digital health games" and either say, "Ho-hum, how exciting can a game about health be?" or immediately conjure up the negative stereotypes of video games as a cause of violence or sedentary behavior. Whether it's parents, teachers, children, health professionals, game producers or funders, all need to be on board for these products to be viable. Let's explore how to market the idea of games for health as a serious intervention for many different public health and medical challenges.

Good marketing is always based on research with the target audience, so a key first step should be to learn more about how each group views digital health games for children. What do they see as the key benefits? What would stand in the way of their adopting or supporting them? How might games for health best fit into their personal or professional lives? Clearly, each of the groups listed above would need different approaches to persuade them of the merit of these products. In fact, within each audience may be several subgroups; for example, parents of young children likely have very different concerns and experiences with digital games than those with teenagers. Teachers at each grade level have different learning objectives for their students. In any case, the more individuals from each audience are involved in the actual development of the games, the more likely they will be successful.

Let's look at the product itself. The way health games should be framed depends on to whom you are talking. For health professionals and funders, positive research results are the key. Focus on the games as an intervention that has demonstrated success (and work hard to accumulate the hard evidence to back up your claims). Parents and teachers will respond best to an emphasis on learning and skills building that will serve to help the kids stay healthy as they navigate through life. For kids? It's got to be all about fun. If it's not fun, the game needs at least to be interesting enough to capture their attention. And game producers will be concerned with one thing: are games for health marketable? The Wii and Wii Fit have been game-changers (pardon the pun) in their popularity and may open up many more doors in this direction.

We also need to determine the main barriers that stand in the way between each audience and its unbridled support and use of health games. Adults will need to give up their views of what games are and what they can be. Many may feel that information conveyed in the form of a game means that the importance of an issue is being downplayed, or may worry about these being just another video game with negative behavioral effects. Again, the way to break down these barriers is by emphasizing results in the form of health outcomes, compliance, patient satisfaction, or positive changes in other measures of knowledge, attitudes and behaviors. For kids, the kiss of death for any activity is if it's perceived to be boring, especially if it's billed as "good for you." Health games must be banana splits, not broccoli, and promoted to kids with the emphasis on "game" rather than "health."

From a marketing perspective, let's think about how best to fit games for health into people's lives. What are the times and places they will be most able and interested in playing or prescribing these games? Some key ideas, many of which are already being implemented, include making them portable so people can use them anywhere, making sure that the games fit with the consoles or equipment they already have, and finding ways to combine digital games with real-life situations. Health professionals need to know what games are available for various health conditions so they can match their patients with the right interventions, perhaps via a centralized database. And when the idea comes from their doctor, a parent can feel more comfortable with letting their kids play.

Promoting the concept of health games will also have to be targeted to each audience. Perhaps they will become more acceptable as a health intervention as more "clinical trials" of their outcomes are published in peer-reviewed journals. Skeptical parents, teachers and children may become more convinced of the benefits of games when given the opportunity to try them out themselves. Many a person has been convinced of the exercise value of the Wii after trying it out at a friend's house and realizing their muscles are sore afterward. Game producers may need specific incentives from funders or investors to move into what they perceive as less robust markets until they see the demand from consumers.

Working with organizations and public agencies to craft policies friendly to these new interventions can help create fertile ground for health games to bloom. For example, when certain games have been proven to improve health outcomes would health insurers extend coverage for purchasing them with a doctor's prescription (and send a Wii-fund as reimbursement)? Can we increase the number of school districts that have incorporated Dance Dance Revolution into their physical education curriculum?

Finally, building partnerships that reach across categories will be beneficial to all involved. Working with trusted organizations or familiar characters creates games that start from a strong position with consumers in all categories. Thanks to the Robert Wood Johnson Foundation for cultivating these alliances with key partners and building the foundations for games for health to emerge as a pillar of health interventions.

Fun, Kids & Evidence-Based R&D = Games for Health Success?

We continue our guest blogger series with Richard Tate of HopeLab.

Richard Tate is the Director of Communications and Marketing at HopeLab and a blogger on Sticky Notes, HopeLab’s official blog. 

HopeLab, maker of the groundbreaking Re-Mission videogame for teens with cancer, is an innovative nonprofit harnessing the power and appeal of technology to improve the health of young people. Their evidence-based, customer-focused development process delivers fun, effective products that measurably improve the health and quality of life of adolescents and young adults.

More than 30 years ago, Joan Ganz Cooney began to build the evidence base for entertainment technology as a tool for good in the lives of young people. From Cooney’s work, the groundbreaking program Sesame Street emerged, and the show quickly demonstrated the incredible power of harnessing the appeal of TV technology to achieve specific goals in children’s educational, behavioral and social development. The approach worked, and TV producers, critics and generations of viewers were persuaded.

Can we do the same for digital games? Most definitely. What will it take to get there? The Sesame Workshop’s Joan Ganz Cooney Center released a new report offering a roadmap forward. Based on my work at HopeLab with our Re-Mission video game for cancer and my own experience as a kid watching Grover and Big Bird after school, three things come to mind as essential components: fun, kids’ input and evidence-based R&D.

Focus on Fun: There’s a reason 97% of American teens play computer or video games (hint: it’s not because they’re looking for educational opportunities). It’s because games are fun. And “fun” doesn’t have to mean “pointless”. Quite the contrary. The creative freedom afforded by today’s game technology gives us an opportunity to produce content that’s immersive, highly entertaining AND targeted at specific outcomes in the “real” world. But if games aren’t fun, kids won’t play. And if kids won’t play, we can’t achieve the outcomes we’re after. That’s where many “serious game” projects seem to stumble. Looking back, I didn’t watch Sesame Street because I wanted to learn the alphabet. I just had a blast singing “C Is for Cookie” with Cookie Monster.

Kids First: How do we know what’s fun for kids? We don’t – unless we ask them. Too often, the fun factor – the essential ingredient for games – is forgotten when adults begin to layer education and learning opportunities into entertainment media based solely on academic research. The best, most reliable way to gauge what’s truly engaging and fun for kids is to engage them directly. In our experience at HopeLab, kids are great at generating ideas and honest with their opinions when given an opportunity to contribute. It’s why we invite them into our development process and incorporate their feedback every step of the way. Talking to kids is the best way for us all to ensure we’re on track to deliver games that are fun and effective in improving kids’ lives.

Evidence-Based R&D: Commercial video games for entertainment are largely developed based on the creative vision of industry experts. Games that aim to do more than entertain require both creative vision and evidence to inform objectives and validate outcomes. Data – scientific evidence that games work – has been the critical missing piece in catalyzing broad, systemic and sustained engagement in digital games development for health and education. For example, demonstrating through research that games can enable patients to better manage their health and reduce healthcare costs is essential to engaging the healthcare industry in creating games as tools for consumers.

Research also provides insights to the field on how to create games that work to achieved desired benefits.  Advances in health games research and development have largely been driven by the commitment and financial resources of major foundations like the Robert Wood Johnson Foundation, and individual philanthropists, like HopeLab founder and board chair Pam Omidyar. The government also has funded development of leading-edge, game-based virtual technology for training soldiers. HopeLab has generated compelling data on Re-Mission and how it works to improve kids’ health, but more needs to be done in the field. RWJF’s Health Games Research Project aims to do just that. It would be great to see others come forward in the public and private sectors to support more evidence-based development of health and education games in the coming years.

Games are a tremendously powerful part of our kids’ lives, and it’s within our control to make them tools for good. The new Cooney Center report is a timely assessment of how digital games might advance our efforts to improve the health and learning of young people. Wouldn’t it be great to look back on this time as the point at which digital games, like television, became a medium that both entertained us and improved our lives?

Developing and Sustaining Health Games—A Losing Battle?

We welcome Melanie Lazarus as part of our guest blogger series.  

Melanie M. Lazarus, MPH is the Director of Marketing for Archimage, a serious game developer with titles including Escape From Diab and Nanoswarm: Invasion from Inner Space. She is also editor of healthGAMERS, a blog designed to educate the public about the games for health field, and author of Monster’s Blog, the corporate blog for Playnormous Health Games. Melanie has a B.S. degree in Microbiology from UT-Austin and an MPH in Health Promotion and Behavioral Science from The University of Texas Health Science Center at Houston.

The video game industry is an influential one -- $13.5 billion influential. Improving the health of children through a messaging medium this big seems like an obvious idea. Unfortunately, as a developer in this space for several years, we’ve found that obvious does not always translate into easy.

Archimage began work in 2003 on two National Institutes of Health-funded video games for the prevention of obesity and type 2 diabetes in children: Escape from Diab and Nanowswarm: Invasion from Inner Space. Since then we have moved into the relatively unexplored area of online casual games for health with our subsidiary Playnormous Health Games. From our perspective, there are three significant barriers to the proliferation of health video games in today’s marketplace. I’m sure there are many more challenges to choose from, but the following have been the biggest we’ve faced.

Getting funded

Although there is strong interest in exploring video games for health among government funding agencies like the National Institutes of Health, many grant reviewers are not as committed. Video games for health use entertainment to deliver its medicine. The words “fun” and “games” are not universally appreciated in the medical and scientific research academies. We have been literally told (though the trend now seems to be on the decline) not to use those words in association with serious topics like “health” and “disease.” The press is full of negative comments about video games as both the cause and effect of teenage violence. Similar sentiments can be found in the hearts and minds of some grant reviewers. Getting funding for the creation and research of video games for health may be an uphill battle for some time.

Sustaining funds

As Director of Marketing for a serious game design firm, I always find it interesting to talk with decision makers about the health games market. More often than not I’m told, “Market? What market? No one can make money on these things. Why don’t you just try to get on Oprah? I bet she’d like health games.”

Indeed, Oprah probably would. But a market beyond grant-based video game research is a topic worth discussing in the business community too. No question about it, an economic foundation beyond grants must be found to sustain the video games for health movement. A working commercial model is also needed to provide the researchers and developers with health game experience with the means to produce ever more effective games. There can be huge funding gaps between formative research, product development, and the clinical trials required to get a video game tested and ready for market. This industry needs a commercial basis and viable distribution models. On a positive note, investors such as health insurance companies, pharmaceuticals, and the food industry giants are starting to look beyond the feel-good messages health games can provide. Unfortunately, that’s not the same as viewing video games for health as critical influencers on the lives of their patients, customers, and constituents.

Knowing what works, and why

The literature on how and why video games for health work is rather thin. Clinical efficacy trials are few and far between. There is no real history to give game developers the X + Y = Z formula needed to develop medically and cost effective health games. Some research has been conducted on how the brain reacts to violent games versus non-violent games via functional MRI studies, but what about other aspects of health games? Very little research has been done on what is fun, let alone how fun translates into positive health change. I hate to sound like a researcher, but more research needs to be done on this. And research takes funding.

Light at the end of the research tunnel

Investigators are starting to report their data on the effectiveness of health games, including Diab and Nanoswarm, which should be available in the next few months.  An increase in positive evidence for health games in the literature could underpin new rounds of funding, commercial interest, and venture capital support.  Furthermore, it is encouraging to see large institutions like the Robert Wood Johnson Foundation and the Joan Ganz Cooney Center showing an interest in the use of technology for the improvement of child health. The days of health games sitting on researcher back shelves may soon be over. Let’s move beyond initial formative research and start getting these games to market.

Guest Blogger Series: Views on Increasing the Use of Digital Games for Health

We started June off with a look at games for health in preparation for the 2009 Games for Health Conference. We attended, we tweeted, and we shared updates on some of the incredible developments that took place this year. Now we’d like to end the month by looking at the opportunities that games have in creating positive health outcomes among children.

Yesterday, the Sesame Workshop’s Joan Ganz Cooney Center released a new report on the power that video games can have in addressing some of the most pressing health challenges facing America’s children. The report outlines some strong evidence that games can make a positive impact on the health of our children – a great step. However, we also recognize that there is still work that needs to be done to increase the use of digital games for health.

With that challenge in mind, we posed a question to a panel of guest bloggers and invited them to share their point of view:

“There is a growing consensus that digital games can be deployed to support learning and behavior change for positive health outcomes among children. What do you think needs to be done to increase the use of digital games for this purpose?”

Over the next week, they’ll be posting their thoughts right here – we encourage you to leave your comments and take part in the conversation. 

Catalyzing the app store for EHRs

Posted by Steve Downs and John Lumpkin, Senior Vice President, Health Care Group

Recently, Steve posted about the idea, floated by Ken Mandl and Zak Kohane, that EHRs (or health IT more broadly) could move to a model of competitive, substitutable applications running off a platform that would provide secure medical record storage.  In other words, the iPhone app model, but, for example, you could have an e-prescribing app that runs over an EHR instead of the Yelp restaurant review app on your iPhone.  We’re thinking about the provider side of the market here, as Google Health and Microsoft HealthVault are already doing this on the consumer side.

It’s nice to ponder these “what ifs,” but we’re a bit more action-oriented here and we’ve turned our attention to asking what it would take to make this happen.  It seems that there are two things that are needed. First, we need the platform.  Some of the most notable platforms started out as proprietary that were then opened up.  The IBM PC comes to mind as an example. Some were designed from the beginning to be open platforms with limited functionality until the market started developing applications.  A recent example is the development of iGoogle and the tons of applications that are available for free.  Finally, there was the purely public domain development from the beginning to end that we've seen in the Linux world.  Or perhaps we don’t need a common platform and maybe what is needed is to stimulate the market for health IT products that have open application programming interfaces (APIs) that allow for third-party application development?  Several ideas come to mind.

Engineering Errors Out of Health Care

In my first month as a new communications associate with the Foundation’s Pioneer team, one of the many glaring items on my task list has been to gain a solid working understanding of the power of disruptive innovation and what it takes to achieve it. While this may take a while, thankfully Susan Promislo has given me a stack of project briefs and proposals that illustrate different aspects of this equation in a pretty straightforward way.

 

In one intriguing new effort, a team led by Peter Pronovost– professor of anesthesiology and critical care medicine at Johns Hopkins and renowned patient safety expert – is looking to a collaborative model that has yielded huge improvements in commercial aviation safety, and testing whether the application of a similar method could do the same for hospital patients.

Hospitals have engaged in noteworthy work to improve quality and safety, but other approaches are needed to accelerate improvement. Pronovost’s project is honing in on a public/private partnership model that has been highly successful in preventing aviation deaths and disasters.

 

Between 1995 and 2003, 2,261 people died in “controlled flight into terrain” (CFIT) plane crashes. Based on recommendations from the White House and Congress, the formation of Commercial Aviation Safety Teams (CAST) has drawn on the knowledge of key leaders from all sides of aviation – major manufacturers and airlines to the FAA and DOD. One of CAST’s first major recommendations led to the commercial adoption of a “terrain awareness and warning system” for all airplanes registered in the United States, and an altitude warning system for ground radar. In 2004 there were no CFIT airplane crashes, and all such accidents since then have involved planes without the warning system. 

 

Update: Positive Deviance & MRSA Reductions on NYT Lede Blog

Kevin Sack interviewed the CDC's John Jernigan about the effects of the Plexus Institute's positive deviance MRSA prevention partnership and wrote a post on the New York Times "Lede" blog.  Check it out and comment away, either there or on Pioneering Ideas.