RWJF ExerWellness: Bend Oregon

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Connecting with resources across a community allows existing efforts to be connected with new technology and game strategies

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RWJF ExerWellness: Bend Oregon

  1. 1. Proposal: ExerWellness Bend OregonWhile lifestyle accounts for up to 3/4 of healthcare costs, most people do not find exercise fun.Some have tried numerous diet and exercise programs with the primary goal of weight loss,only to fail and become discouraged, resulting in worse health outcomes over time. In thisproposal, we build on research around crucial elements in consumer engagement that can leadto improved health outcomes. The work of team member, David Kil, (HealthMantic) deploysdata mining algorithms to understand the impacts of various interventions, such as socialnetwork, visual dashboard, event processing, games and challenges, on health outcomes.Much of the data was obtained from a clinical trial. Davids decades of experience in" whatworked, what did not work, and why" supports Shaseks experience in developing a culture ofactive wellness in a geographic community. This proposal underscores salient attributes ofsocial health games that are crucial in both consumer engagement, influence on physicalactivity, improvement of social nudging and health outcomes.Software description: "ExerWellness: Bend Oregon" will use HealthMantic developed (fullpatent) Sensor informatics that include: Smartphone sensing of all activities including motion-based interval training, heart rate, and location context for ambient intelligence. Motionexercise programs are designed to improve balance, flexibility, strength, and cardio with built-inrelaxation, which promotes body-fat burning and muscle strengthening--ideal for elderlypopulation and the obese with diabetes and other lifestyle ailments. These short motions arebeing embedded into gesture- and motion-based brain fitness games, along with microrandom-reward board games.Quantified data measures and outcomes include: weight, body fat, HRR/HRV, brain fitness and mood.Many chronic conditions, including the very costly Type 2 Diabetes and co-morbidities, have anemotional challenge embedded in the condition which can sabotage both treatment, prevention andmanagement. We address mood in our games, intervention, social nudges and data because of itspowerful influence on engagement and habit/choice change.Mind-body games: Game design and game play are crucial to the success of any "gamification" add to awellness strategy or program. The expertise and experience of our team is solid in this respect. Areas offocus include: relaxation, brain fitness and social nudging. Rewards are designed for motion validation.We can use proven 3rd party games on an open platform.Team leader, Judy Shasek, has been actively designing for community wellness for over sevenyears, both in the school/education community and the greater geographic community.Developing key partnerships with all stakeholders in community wellness is crucial to asuccessful community deployment of any intervention model. By adding value and providing aturn-key model for data gathering for existing efforts the community deployment becomes awin-win for all.Background: Our efforts toward wellness are challenged by a "perfect storm" of preventablepoor health that has continued to threaten quality of life and productivity for millions. Ourcollective predictive and preventive capacity remains remarkably under-developed in
  2. 2. overcoming this challenge. The passive and unintended consequences of modernization andresultant social and lifestyle behavior choices have changed habits and have driving resultingchronic conditions to unmanageable levels.In the research paper, “Nudging lifestyles for better health outcomes: crowd-sourced data andpersuasive technologies for behavior change” (Piniewski, Codagnone, Osimo, 2011) a case ismade for taking a supply-side approach. They propose that advancing health care deliverycannot be expected to impact health outcomes effectively. According to the authors, “Themalignant spread of obesity in genetically stable populations dictates that gene disposition isnot a significant contributor as populations cannot receive a new shipment of genes in only 2-3decades.” In addition, “Preventable poor health is by definition preventable. We haveunwittingly supported the choice architectures that overwhelmingly enable poor lifestylechoices in preference to optimal choices.”We currently depend upon Health Information Technology (HIT) for many of the decisions andparadigms around our healthcare and medical models. The goal is often, “better care.” Bettercare sets the stage for more care, yet it remains largely impotent in returning individuals todisease-free states. Participation in physical activity is the first step in preventing the diseasesand conditions. Long term participation is the first step to prevention, and is the cornerstoneof "ExerWellness: Bend Oregon."Encouraging physicians to prescribe specific exercise programs has long been a mission of manyhealth, wellness, medical-fitness and government agencies. Yet fewer than 15% of physiciansprescribe specific exercise. Current payment models (more procedures equate to largercompensation, pharmaceutical reimbursement and compensation), are sick-care reinforced anddon’t promote a change in paradigm to prevention. Physicians rarely know what exerciseprogram to specifically prescribe nor do they have time to investigate the most trusted andeffective options available locally."ExerWellness: Bend Oregon" will engage a geographic population using David Kil(HealthMantic) proven strategy of social nudging for the target populations through:  persuasive technologies;  Use of sensor informatics, mind-body games and quantified outcomes (full patent filed)  serious gaming to sustain individual health behavior change and  intuitive visualization with reliable simulation to evaluate and direct public health investments and policies in evidence-based ways  Active wellness does not occur in isolation.  Crowd based approaches are the foundation upon which evidenced-based successful policy decisions depend.Many attempts at improving health care delivery (supply side) have left us remarkably inept attransforming the health as well as the health costs of crowds. This almost singular focus ofHealth Information Technology (HIT) on care delivery may be largely responsible for the
  3. 3. underperformance of our predictive and preventive capacity at this time. “Relying oninstitutional (hospital and clinic) data tracking care delivery to proactively manage the healthexpression of crowds may be similar to using a rear view mirror to drive a car.” i We cannot solve this problem using the same kind of thinking that created it (Einstein).Populations within a community, especially the least active and most costly for healthcare,often know what they should do for optimal wellness. In spite of this knowledge, theseindividuals often make choices that do not result in wellness, in fact many have long termbehavior and lifestyle choices that threaten their health, productivity and quality of life. Ourtarget population has a driving need for nudging, feedback and timely inputs that help sustain"doing the right thing." Both Shasek and Kil have worked in both real-world and clinical trials inorder to develop strategies that are both unique and can deliver necessary outcomes.Human beings are not usually rational planners. Both good and “bad” behaviors respond tonudges from our social network, preferences and daily interactions. Many objections to healthbehavior change, including regular physical activity (PA) are based on rationalthinking:  If I am healthy I see no direct reward in participation in exercise which I believe may not add to my basic quality of life or function - while costing me time.  If I am obese, non-disclosing my status may avoid stigma and social-psychological costs.  If I am in denial, anything or anyone reminding me of my behavior would not be welcomed.The New York Times article: ‘Health from a little help from my friends’ (18 September 2010)iiconfirms that the social network may have important negative and positive effects on health. Ifmost of our friends are obese we are more likely to be obese. But if some, the most influential,start losing weight or adding regular exercise they can drive bandwagon effects.Existing workplace wellness, physician prescribed or suggested wellness participation andindividual choice often occurs in "silos of effort." By using the right mix of local programs,experts at delivery and the technology a geographic community can be both connected and benudged into habit change. Social nudging by design will connect individuals or groups likely toset positive cascade effect into motion. That is the premise of "ExerWellness: Bend Oregon."Why now? The technology for participatory health is emerging and the overwhelming trend isfor many to engage to some degree. Currently, 9% of all cell owners in the US (virtually 9% ofthe US population) have apps on their phones that help them track or manage their health. iiiAccording to Gartner worldwide mobile application stores’ download revenue exceeded $4.2billion in 2009 and will grow to $29.5 billion by the end of 2013. Many of these apps are likelyto be health related. Consumer trends often run parallel with behavior trends. Please see theslide deck accompanying this proposal summary for an overview of the technology to be usedin "ExerWellness: Bend Oregon."
  4. 4. The business case: a preliminary sketch.Effectively managing the health process of crowds to prevent the preventable are expected togenerate benefits that dwarf, by orders of magnitude, previous effects on direct cost for payers(Insurers and employers). A conservative estimate of cost benefit might be a 25% reduction inannual health care [iv and v] cost. This equates to a 1:10 dollar return on investment. Thesefigures are based on a workplace wellness intervention. Imagine such an intervention thatbridges verticals across workplace, family, friends and leisure choices with a game-system ofimmediate, quantified feedback and social nudging. The ROI would grow exponentially whileproviding rich data and a "turn-key" process for scaling the technology to other communities.How would "ExerWellness: Bend Oregon" be implemented?Our solution embeds Healthy lifestyle choices into daily lives. Compliance over the long term,inclusion and development of social networks and incentives and aggregated data will bedelivered. Without those pieces, investment in even the most respected workplace or memberwellness initiative will deliver less than optimal ROI.Working with a partnership across medical centers and destinations in which physical activityprogramming is already being delivered will provide a source of participants across socialnetworks and various workplaces. Once enrolled, the participant will be nudged with ever morerelevant and valuable “nudges” over time. Valuable data about the patient can be voluntarilycollected. Quantified wellness outcomes and the unregulated data voluntarily provided bymember-participants are information required to validate a paradigm shift in how “health” ismanaged. HealthMantic will be positioned to provide regulated data.Decades of educating and raising awareness with the hopes of encouraging people to move inthe right health-directions have been largely unsuccessful. Education and information abound,yet changes in habits and choices rarely result by that intervention alone. The need to motivateindividuals through less rational-response-dependent persuasive technologies such as seriousgaming and social nudging makes sense. The potential of social nudging and real-time activityfeedback to produce positive cascade effects provide a proven means to spread desiredbehavior.  Education and motivation go hand in hand  Keeping people well will generate spending in other areas of society  People can then invest in better food, exercise and overall wellnessHealth data is needed: The public can become even more willing to share their health data withan honest broker with the ultimate goal of wellness in mindThe value of appropriately collected and brokered data is enormous. It is needed by healthpolicy-makers, insurance companies, medical professionals and many others.
  5. 5. The program that can successfully engage a target population and collect data about thatpopulation in an approved manner will generate the ability to drive a revenue stream fromthe very information providers, employers and communities need - and will pay for.There are many examples of research and grant projects that tie a nutrition/exerciseintervention with guidance/coaching and measured changes in physical markers or biometrics.Too often, the successful participants in such interventions of 6-8 weeks, on average, relapseback to prior behaviors, choices and habits once the program period ceases.The challenge: Impacting long term choices and habit change around wellness in order to:  Positively reduce healthcare costs  Improve quality of life  Create a "wellness culture" across a community  Generate long term data and information needed for distribution and scale of the solution model"ExerWellness: Bend Oregon" is designed to connects online and on site "nudges" toward long-term habit and behavior change. The goal is to generate intrinsic motivation among the targetpopulation for "nudging" themselves and others in their social network across the greatercommunity.For the most part, individuals - particularly the most costly or at-risk in a population, do notproperly understand the impact that individual decisions have on their health. There needs tobe immediate feedback letting them know the impact that their choices have on their healthand the health of their social network.Many consumers are motivated by the effect that their behavior has on others (in particularthose with whom they have strong social ties). We plan to make consumers more aware ofthese effects and enlist their social ties to help them stay on trackThe medical establishment only sees a patient a couple times a year. There is very little thatthey can do during those visits to change behavior or even properly educate a patient about theimportance of daily decisions. There needs to be a mechanism to provide real time data back tothe medical establishment so that they can get involved and support people with their decisionmaking before problems appear. The HealthMantic solution can provide that communication.In an era of ballooning health care costs and federal deficits, a program that improves healthand provides cost savings should be a top public priority. But to realize the potential savings,this program must be national in scale, with a strong infrastructure capable of being deployedacross the country. Programs that are dependent upon a top-heavy staff of coaches andcounselors advising and motivating behavior change cannot be easily distributed acrosscommunities.
  6. 6. The HealthMantic health science solution and technology could be the cohesive community-incentive-behavior support and social network piece that could create better outcomes forthe financial investment in the RWJF Games Challenge initiativeFor decades, various programs, devices and "games" have been designed with a focus on"steps" or running. Changes in BMI have been the cornerstone for success - or failure. In arecent wellness activity program conducted over 5 months by Shasek in Bend, Oregonparticipant feedback provided an interesting reaction to the bluetooth pedometer device used.This cost effective device (ActiPed by FitLinxx) had to be worn on the shoe. That was notpopular for many reasons. More importantly, the participants felt "cheated" when they didactivity like yoga, swimming, elliptical walking, weight/strength workouts and other "non-stepping activity.It was burdensome enough for most of the participants to make the choice to be active. Then itwas frustrating for them not to get real time feedback for all types of activity. This was in spiteof significant, group-selected rewards (gift cards, movie passes etc).When the focus is on the data rather than on engagement, the dropout rate rises exponentially.David Kil provides a very different approach that we will use in "ExerWellness; Bend Oregon."Over the years of developing the hTRAC activity monitoring device to be among the mostunique and effective, he has also developed key engagement strategies.Kils approach insures that participants are engaged in:  Enough movement  Enough eating  Motions designed to burn body fat & build muscle  Emphasis on measurable youthfulness metrics  Social brain and relaxation games  Micro random rewards“If we knew then what we know now...”It’s the mantra of frustrated health professionals theworld over who crave real-time, actionable data that leads to meaningful improvement in thedelivery of patient care. All stakeholders around the patient care and cost challenge recognizethat prevention is the intervention that will deliver the most ideal outcomes for all. Physicalactivity powers prevention and drive social and habit change across a community."ExerWellness: Bend Oregon" is designed to enhance existing efforts toward more valuable andmeasurable data and outcomes around patient care and prevention.Oregon Health Leadership Councils (OHLC) overall model is designed to provide coordinated,high-quality care to patients with chronic and complex conditions and achieve shared savingsfor medical groups and payers. The model of care was based on the successful demonstrationproject launched by the Boeing Corporation. The evaluation of cost savings will occur at the endof the demonstration.
  7. 7. “We wanted to provide more timely and actionable information about the care enrolledpatients are receiving,” said Denise Honzel, executive director of the OHLC. To accomplish this,the OHLC turned to Quality Corp to provide this information. “By providing claims based reportson utilization of services, we provide value added information about care that is happeningoutside clinic walls,” said Mylia Christensen, executive director, Quality Corp.The goal of "ExerWellness: Bend Oregon" is to provide an engaging and quantified interventionthat will positively impact "outside clinic walls" to further provide ROI for all stakeholders. As allmembers of the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Qualityinitiative hope to defragment information, we can support that data and informationaggregation on the "prevention" side. As cost-reports are developed, it is crucial that the costsavings of preventive interventions like HealthMantic can offer become a participant in the datamix.Data collected around "health care" that does not have a broad base of prevention and relatedwellness activities of the population cannot provide the best value. “The real fundamentalvalue of reports is finding out about utilization opportunities you didn’t know about before,”said Dr. Pranav Kothari, founder of Renaissance Health, a developer of innovative health caremodels that OHLC hired to support this work. “It’s not necessarily revealing a gap in care, but amissed opportunity to know something or to take action, like who had a hospitalization Ididn’t know about? Who is not filling all of their prescriptions? A month could be missed. It’simportant because you can talk to the patient about it or do something to improve.”The added responsibility of tracking enrolled patients on a monthly basis has been tough formedical groups, project managers say. But there is now a unified understanding of its necessityand value for timely, accurate reports and per-member-per-month payments.There is probably no more expensive "missed opportunity to know something or to takeaction" than the opportunity about prevention.Critical to generating data is providing valuable and novel application of that data. Usingexisting shared-data and information reports and utilization "ExerWellness; Bend Oregon" candemonstrate a scalable model for delivering prevention and cost-effective management ofmany chronic conditions. These can be deployed toward the goals of improving communityhealth and healthcare quality.“Getting the health delivery system to change is a huge mountain to climb,” said Steve Hill,director of the Washington State Department of Retirement Systems. “I think there is greatpotential, and the state is one of the big players. This makes intuitive sense, and it has hugepotential, particularly if we direct incentives toward systems integration and carecoordination.” One key piece of the potential for this information is in implementing habits andchoices across a geographic community that positively impact their health via active wellnessand the resulting prevention and chronic condition management benefits.
  8. 8. Kils technology and apps can help community leaders improve Aligning Forces communityhealthcare. Combining that technology with Shaseks expertise and experience in connectingwellness resources and stakeholders throughout a geographic community will serve to deliverthe new model of full healthcare. By including a patient-driven prevention and conditionmanagement game to the mix we have a unique solution for success. Both Shasek and Kil havedeep experience in the power and application of gamification and engagement.The team:Judy Shasek: http://www.exer-wellness.com/about-us/who-we-are.htmlDavid Kil is the founder and CEO of HealthMantic, focusing on lifestyle-medical informatics andsensor-based health gaming. Prior to founding HealthMantic, he was Chief Scientistat SKT Americas and Chief Science Officer at Humana, responsible for the development anddeployment of healthcare informatics applications. At SKTA, he founded the iWell project andbuilt an integrated wellness platform consisting of sensors, platform, and informatics. Thesystem underwent a successful clinical trial at PeaceHealth with promising results. At Humana,he led the design and development efforts in enterprise knowledge engine, predictivemodeling, and outcomes analytics while working with Samsung on U-Health initiatives. Theenterprise insight engine won the best-of-breed technology award from the ComputerWorldmagazine. He co-authored a book entitled “Pattern Recognition and Prediction withApplications to Signal Characterization” by Springer-Verlag, published over 30 papers, and holds9 US/European patents. He graduated from the University of Illinois at Urbana-Champaignwith BSEE/Chemistry (Highest Honor and Bronze Tablet), the Polytechnic University of NewYork (MSEE), and Arizona State University (MBA).vii “Nudging lifestyles for better health outcomes: crowd-sourced data and persuasive technologies for behaviorchange” (Piniewski, Codagnone, Osimo, 2011)ii See: http://www.nytimes.com/2010/09/19/health/research/19stream.html?_r=2&adxnnl=1&emc=eta1&adxnnlx=1284908452-A1LZH5m05lalCE7/YuAzWQiii Plaisant, C., et al., Searching electronic health records for temporal patterns in patient histories: acase study with microsoft amalga. AMIA Annu Symp Proc, 2008: p. 601-5.iv Anderson, D.R., et al., The relationship between modifiable health risks and group-level healthcare expenditures. Health Enhancement Research Organization (HERO) Research Committee. AmJ Health Promot, 2000. 15(1): p. 45-52.v Wright, D., et al., Comparing excess costs across multiple corporate populations. J Occup EnvironMed, 2004. 46(9): p. 937-45.vi ii D. Kil, F. Shin, B. Piniewski, J. Hahn, and K. Chan, "Impacts of health data on predicting weight loss and engagement," OReillyStrata Rx conference, San Francisco, CA, Oct 2012.

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