Pearl Leaves is developing software and games to improve medication adherence across populations. They currently have a smartphone app called Plan-it Med that provides reminders, education, and rewards points for medication milestones. They propose to: [1] Develop new car engine assembly and racing games to engage males, [2] Track blood glucose levels as additional metrics, [3] Add simulated challenges to educational content, and [4] Expand reward strategies. Data on engagement, behaviors, education effectiveness and more will be collected anonymously. Initial deployment will be with clinics in Kansas City serving varied demographics to test the system.

1. 2/22/13
RWJ Challenge

2. I. Background
Pearl Leaves is a health information technology company designing software and services to
enhance medical adherence. We are here to make engagement in healthy medical regimens
easier and more enjoyable and we intend to extend this reach to all populations. Over half of
the American public is now on chronic medications and chronic medication usage extends
across all demographics. For instance, 26-28% of children under 19 and up to 30% of women
aged 20-44 are on chronic medications. Lack of adherence to medical regimens is ubiquitous
and the resulting consequences both in terms of clinical outcomes and financial losses are
huge. These losses extend across multiple community segments and include patients,
hospitals, third party payers, and pharmacies. Increased death rates and decreased quality of
life can be directly attributed to lack of medical adherence, the severity and time course of
these consequences varying per disease entity. In diabetes, decreased adherence results in
an increased incidence of complications such as limb loss and end organ failure. In HIV+
individuals, increased conversion rates to AIDS can be attributed to failure to adhere to
prescribed medical regimens. There are significant financial losses associated with
nonadherence, the estimates ranging from 100 to 300 billion annually for the pharmaceutical
industry alone. Other associated financial losses can be attributed to increased complication
rates, increased readmissions to hospitals, and decreased productivity of the workforce.
Increased medical adherence would significantly decrease health care costs to the community.
Within this proposal, we intend to build on the existent Pearl Leaves platform and use further
development in gaming and gamification to enhance our engagement platforms. Our programs
will improve health care outcomes and healthcare quality, reducing overall spending on
community health, and improve overall community health.
Pearl Leaves’ existent platform focuses on addressing nonadherence to medical regimens with
the full complement of digital media resources: smart phone apps, eBooks, games, and web
worlds. We have developed a system that will allow for the customization of our content and
approach based on the needs, tastes, and skill levels of a patient, a system we feel will allow
us to approach and engage patients more effectively. Pearl Leaves has also identified a critical
and missing link in other approaches to adherence. The medical system currently lacks the
resources and capacity to monitor, analyze, and continuously update the information
necessary to provide optimal support to improve adherence to medical regimens. Pearl Leaves
is developing a system to provide these services. Though the mainstay of the system is an
automated component, these services are backed by significant clinical expertise.
Data demonstrates that one of the highest risk populations for nonadherence is lower income
individuals, and many have feared that the use of IT in adherence efforts would broaden the
economic divide. Ironically, however, it may be possible to use information technology to
bridge this divide more effectively than ever before. Data from the news business sector is
showing that news is now reaching lower socioeconomic groups more effectively than ever
before, and the channel for this reach has been through smartphones. We believe that the
medical industry should leverage this same access channel to reach previously poorly
accessible groups. It is critical, however, that in so doing, we devise engagement methods
tailored to the tastes and needs of these populations, in order that the success of these efforts
are optimized. In this grant, Pearl Leaves is refining the medical gaming platform that they

3. have developed to create a system that would be optimally engaging for all socioeconomic
groups. Indeed, at risk populations will have different needs, tastes, and skill sets, and these
factors should be taken into account in both the activity elements and visual elements of
games. The overall mission of Pearl Leaves is to induce a culture change in reference to the
integration of medical behavior into our lives, beginning with the young, and establishing
patterns that should last a lifetime. Within this mission, Pearl Leaves intends to leave no
population behind.
For this challenge, we describe the development of a new game, that will allow collection of
data critical to optimizing digital media approaches to health outcomes. We show a community
deployment program that will be piloted in Kansas City, one of the 16 AF4q areas, but that is
easily scalable across the diverse geographies of the US.
The CEO of Pearl Leaves has a significant history in academic medicine, is chairman of
committees in international organization, and has far ranging contacts in diverse fields, both in
terms of mentors and trainees. She works for Pearl Leaves full time. The Director of Software
Architecture has over 15 years of experience in medical IT systems, including software design
and project management and is working for Pearl Leaves full time. Our director of Creative has
over twenty years of high level experience in the creative arts, including 12 years of experience
at Hallmark and over 10 years of experience as a successful freelance artist and works for
Pearl Leaves 35-40 hours a week. We have extensive contacts within the business
community. Notable among these contacts are those through the Kauffman Center and the
addition of Blake Williamson, past VP and CMO of Blue Cross Blue Shield Kansas City, to our
advisory board.
There is approximately $150,000 invested in the development of our systems to date. We are
currently in the final stages of due diligence with a group of angel investors for an ask of
$500,000. Funds from this ask will be used to drive further development, the investment dollars
have not been apportioned to development further development of strategies for the
disadvantaged. Pearl Leaves will continue to actively seek additional funding for this goal.
II. Software Development
A). Established Software Infrastructure. Pearl leaves has already developed a smart phone
multicomponent application called Plan-it MedTM that approaches adherence upon the platform
of addressing four components that have been shown in meta-analyses to be important in
adherence. A central element of the application is customizable reminder functions for multiple
medical elements including meds, appointments, labs, and educational milestones (Figure 1).
When a patient does not make a medical milestone, they are given the option of providing data
as to why this milestone was not met (Figure 2). The educational/motivational elements made
available with this program include facts (pearls), motivational quotes, and ebooks. With each
educational fact, there is also an multiple choice question that will allow for educational
assessment and the ability to decrease the chance that the patient clicked that they read the
fact without processing the data. (Figure 3). There is also a section that allows the import of
customizable content from individual health groups/ institutions or import of data in other
formats which may be important for education in a specific disease state. There is a
component called “Team” that allows for facilitated contact with individuals the patient has

4. designated to be on their team
(Figure 4). Finally, points are
tracked within the app and are
used to cash in on rewards within
our system. This system was
developed for native iOS (in beta
testing) and development for
native android systems is in
process (Scheduled to be
completed by May).
There are several gaming schema
that have already been developed
under the name Play-it MedTm.
These schema are centered
around strategies in which patients
are allowed to move through a
game after a medication or series
of medication administrations or a
task is completed. These games,
included under the name of “Play-it MedTM” are intended for
release to the general public in April and are currently targeted at kids aged 2-5. They were
designed with medication administration for acute conditions in mind such as the treatment of
urinary tract infections and ear infections and were conceptualized by the CEOs daughter.
B). Expanded Functionality/Features Specific for this Project
1). A New Game Schema. A masculine game schema is described. The scheme of this game
will be to design an engine. We intend to develop multiple levels of this game.
The first level is shown, and
involves the assemblage of a
standard car engine. Some of the
technical art developed for this
project is shown. When a patient
reaches various milestones within
their treatment, they are allowed to
proceed with creation of an
engine. it is also of note that the
game is designed with an
educational component. Each
engine part is named and its
functionality described. When
pieces of the engine are missed,
construction of the engine cannot
proceed. Multiple gaming goals
can be monitored with this game
including the number of steps
required to create the engine and

5. the speed with which the engine is created. These elements can be used to allow very basic
social gaming.
In the second level, multiple different engine types are possible. It will require knowledge of
these parts and compatibilities to proceed with engine design and development. There will be
learning modules to prepare for this development. Elements of not only engine capabilities, but
body design and aerodynamics will come into play. When construction is completed, preset
algorithms will be used to determine the speed capacity or energy efficiency of the engine.
BUILDING THE CAR ENGINE
STEP 3
STEP 1-ADD OIL PAN STEP 1-ADD ENGINE BLOCK STEP 3-ADD CRANKSHAFT AND PISTONS
CRANKSHAFT AND PISTONS:
The pistons go up and down, they transfer this power to
the crankshaft through the piston arms. They do this
with special joints that encircle the crankshaft. The
crankshaft sends power forward to the fan belt. The
rotational energy is then transferred to the wheels via
other systems
ENGINE PIECES BELOW MAIN SCREEN
STEP 4-ADD CAM SHAFT AND VALVE SPRING STEP 5-ADD CRANK CASE STEP 6-ADD CAM COVER
CORRECT PIECE HIGHLIGHTS IN GREEN
STEP 8
FAN AND FAN BELT:
The fan belt is connected to the cam shaft on the
engine and uses the power of the engine to turn
different devices on the car such as the Water pump to
keep the engine cool. The fan draws air through the
STEP 7-ADD WATER PUMP STEP 8-ADD FAN BELT AND FAN STEP 9-ADD OIL FILTER
radiator to cool the engine when the car is stopped
and when driving.
STEP 10-ADD SPARK PLUG STEP 11-ADD EXHAUST MANIFOLD STEP 12-ADD GAS PUMP
STEP 14
ENGINE
COMPLETE
STEP 13-ADD DISTRIBUTOR AND LINES STEP 14-ADD AIR FILTER

6. (These functionalities will be further developed with a mechanical engineering group) The
ability to create differential capacities within these parameters will serve as the basis for
gamification. Patients will be allowed to compete based on these qualities. Team competitions
will also be facilitated.
In the third level, constructed vehicles will be allowed to race. A given patient may have a
variety of different vehicles, and may pick different vehicles to engage in different types of
races. There will be cross country races over rugged terrain, cross country road races, and
races along circular racetracks of various lengths. Ideally, racing through various terrains can
be portrayed in animation on devices.
In the forth level, races will be conducted with drivers allowed to pick their pit teams. Scenarios
will be created that will required racing and engineering knowledge and will need to be
addressed as members proceed. Patients can contact other members for advice.
A minimal viable product will be developed as Level 1. Interest, potential, and available funding
for the project will be assessed. The components necessary for progression to level two will be
in large part more content based. By the time that we move to Level 3 and Level 4, however,
significant additional programming and design will be involved.
2). Blood Glucose monitoring
Further Development of Points for: Completing educational components, Performing Blood
Glucose measurements,Having blood glucose measurement that are: Good for a given patient
(these can be tailored by the caregiver) or improving. Will follow standard blood glucose
measure and HgA1c, a more chronic marker of compliance.
3). Simulated Situations Added to the Pearl (Fact) A Days
Challenges will encourage quick thinking, thorough thinking, empathy, concentration, and logic.
Examples of simulated situations that will be added include: I can’t afford to buy my meds; I
have not insurance; I don’t know if I have insurance; They want my insurance card. I have no
idea what or where it is. What do I do?; My mom or dad is sick, where do I go?; My phone is
not working?; My phone plan ran out?.
4). Further Development of Rewards Strategies when gamification seems to be inadequate for
a given patient. The gamification will become more enjoyable for individuals better at gaming
or at higher levels in the game process. Additional elements that will be added to increase
engagement include: a). Audio positive reinforcement components: Maybe some fun, silly
voices when meds are taken: “You rock”, “Congratulations”, “Good Job”, “Great Job”, “sick”,
other idioms, musical choices, etc;
b). Random motivators to allow the element of surprise; c). Material rewards. Additional
partnerships with vendors in the area that have national counterparts to assess what material
elements may actually prove to be good motivators (iTunes point, etc).
Software Development Resources. We have spent the past year evaluating and developing
relationships with software development resources. Initial programming was performed by a
group in Milwaukee called Awesome Fat. Further development efforts will proceed with a
combination of the following groups: Creative Capsule (have designed GoMeals, ranked in
some listings as one of the top 10 medical apps), Propaganda3 ( a high end gaming outfit with

7. extensive experience in gamification and accommodation to large numbers of users) Bazillion
pictures (a highly developed animation and visual arts studio in Kansas City, 27 Global (a local
software development group that has recently developed FrontFlip), and Bodeefit ( a local
fitness start up that has developed an online fitness program that requires no gym
memberships and equipment and may benefit our populations immensely. Members of the
design team, the legal team, the clinical collaborators, the software development teams, and
the legal teams are well versed in COPPA.
III. Data Collection
All data collected will be very complementary to the current Alligning Forces for Quality data
set. These potential for data collection is vast and unique.
Engagement data will be collected on these populations that would otherwise not be collected.
The data is designed to be collected in a de-identified manner. At presents, patients are
enrolled through a third party, and PL does not have access to their names, though we do have
access and collect demographic data that we use to personalize the approached. Pearl Leaves
will have access to this data, but will make any data collected through programs developed
through these grants available to RWJ and if desired to the general public. We would also
actively seek partnerships with RWJ for continuous and unrestricted access to the data
accrued in the Pearl Leaves Database, even beyond that accrued through the apps developed
with this challenge.
The data that will be available from the Pearl Leaves Database is huge and could have
tremendous community benefits. Not only will we have access to personal daily habits data
and its correlation with health behaviors in a more detail than previously available, but we will
have access to the way such data affects medical education.
Examples of data than can be collected include but are not limited to:
Demographic and personality factors that correlate with showing up at the engagement
center,
Factors (behaviors and demographic data) that correlate with continuing engagement,
Rewards that this population prefers,
Diet patterns,
Diet patterns and ability to influence/change diet patterns,
How various diet patterns affect and more knowledge of the effects of these diet
patterns affect behavior,
What methods of communication with caregivers they prefer,
What sources patients use to ask for help,
What methods of communication with caregivers they prefer,
Activity levels and methods of influencing activity levels,
How involvement in a Health Engagement Center can improve Health.
Educational data
Additionally, a whole range of unique data points can be collected in reference to patient
medical education. Up to this point, very little data has been accumulated in the targeted
patient population with medical education, and little, if any has been accumulated with the

8. provision of medical education with mobile devices. Types of data that can be collected include
but are not limited to:
What educational data is affective in changing behavior patterns,
What educational methods are effective in transmitting education,
How “gaming” and “gamification” affects, encourages, and reinforces educational
targeted behaviors.
III. Community Deployment Approach
Pearl Leaves will leverage its knowledge of medical disease and treatment, knowledge of the
data on the components that are necessary for adherence, and its connections to the strengths
of the Kansas City community to complete this project.
Initial deployment efforts will be conducted at Hope Family Care Center on Prospect in Kansas
City, Missouri (http://hfcckc.org/). This site will serve as the primary beta testing site for the roll
out our system. These systems will also be rolled out with a group called Pediatric Associates
in Kansas City Missouri, the largest group of general pediatricians within this metro area, to
assess pertinent issues to a different socioeconomic demographic. A critical member of the
latter team is Natasha Burgert, who has recently been named one of the top five physician
experts in social media in the US. She will be a valuable resource as we continue to gauge all
safety issues as we move forward with the gamification aspects. All patients ages 13-30 with a
new or old diagnosis of diabetes will be given the “Create: NGN” app, provided with an
instructional video on app usage, and given 30 minutes of free play time if time permits in the
office prior to departure, during which questions will be addressed. After usability and feasibility
piloting at these sites, the system will be tested at wider locations throughout the city.
A larger and more long-range approach will be called KC Health Engagement and we intend to
bring in the support of the community with this effort. The intent is to eventually develop an
“engagement” assessment center, the Kansas City Health Engagement Center or KCHEC
(domain registered as KCHEC.org), where remote monitoring can guide patients through the
process right after they have been given their hardware and software. Patients at risk for
nonadherence will be referred for follow up at the KCHEC. The details of eligibility for this
recommendation will be determined after funding sources are assessed. There are a variety of
screening tools that can be used to determine those most at risk for nonadherence. The Merck
Health Adherence Estimator is one such tool. Others are emerging (reference to start up just
mentioned yesterday). Once a patient is referred to the center, they will either be taken through
an automated process in which Pearl Leaves designs a customized adherence system for
them. We estimate that up to 15-25% of patients will be at risk for not showing up to this first
appointment. We hope that the offering of yet another game upon their arrival will be an
incentive to overcome this barrier of entry. We also will have the phones to provide reminders
about the necessity of attending the nonadherence center. Eventually, we do hope to have
funds to allow patients to meet with a health adherence counselor. When this is possible, we
will even contact patients through Facetime, to encourage more attendance.
Then the gaming begins. The patient begins to engage in their medical regimen, and is
rewarded for good behavior both through the social engagement components, and the other
incentives that a given community can provide. We are in the early stages of developing
partnerships to support these programs. Initial efforts will focus strictly on the rewarding
process of the gaming itself.

9. We are engaging multiple resources within the community to help address the program. We
are a member of the KC start up village, and as such, have access to many programs that are
being developed within the city under the guidance of the Kauffman Foundation and the Big 5
initiative of Kansas City for support of entrepreneurship. As part of this relationship, members
of the start up village are eligible for reduced rate programs for phones and phone plans from
Sprint. Pearl Leaves will utilize this opportunity to make sure that our population has access to
mobile medical hardware and services. We also have contacts with an organization within our
community called the Archer Foundation that is supporting entrepreneurship in the community.
We will be using their advice as we furtherer define our business models and search for
funding sources.
Outreach/Scaling
This center could have multiple impacts upon our community. First of all, it would be key for
these kids to participate in designing something that is effective for their demographic.
Secondly, it could be a source of positive feedback that these kids get to see that their
thoughts and ideas do indeed feedback into the design of certain products that will be useful to
both themselves and their community. Finally, it will be a spring board into encouraging IT
education in a group that may normally not have access to all of the motivational elements that
may push someone to this space to which others may have access.
The scenarios described above related have been designed with an eye towards diabetes
management. It is of note, however, that programs can be designed with these tools to
address a wide variety of medical conditions. Distinct adherence packages can be designed to
take into account specific characteristics of various diseases, and unique characteristics of
given patients. For instance, “packages” could be designed as followed for the following
disease stages:
Parents or clinicians can select from prepackaged reward solutions that Pearl Leaves has
suggested.
1). Diabetes package
This adherence package would be tailored around diet, monitoring, and activity.
2) Childhood obesity package
This adherence package would be tailored around fitness and diet components.
3). Mental health package (Geared towards depression and ADD)
This package would be tailored around exercise, pursuit of positive behavior, and in
some cases medications.