Have

you ever found yourself at the beginning of something big, and not realized it un7l later, when you could look back? I am lucky enough to have experienced this 3 8mes. First, while building 2 dental prac8ces, one of which focused on the mind/body connec8on for behavior change, Second, while working as a healthcare analyst on Wall Street and, Third, most recently, when I became a digital health analyst and consultant Beginning in 2009, my curiosity led me to interview over 100 experts across mul8ple diverse disciplines. While researching Mobile Social Games for Health, I met a variety of academics, hardware and soJware engineers, behavioral and cogni8ve psychologists, as well as gaming and entertainment professionals. Next, in researching Big Data in Healthcare - Hype and Hope, I met technology people along with data scien8sts and analy8c experts. Most recently, I have goMen to know leaders in neurogaming, as well as those in cogni8ve health and well-being communi8es. It is no secret that I love the gaming community; who, alongside technologists, have reignited sparks of crea8vity that have become dimmed in healthcare.

My Ahah moment in my original research, was when I found an emerging ecosystem of experimenters trying to trigger behavior change across the disease spectrum- from health and wellness to chronic disease and addic7on

Star8ng at your leJ at the Wellness side of this visual, I found an expanding deni8on of health to include life balance and self-improvement. The societal shiJ in aQtudes toward health and wellness, with consumers leading the way, shows in the rise of employer-sponsored employee wellness games. Social networking can bring people together within a trusted environment to share informa8on and work toward common goals. Social games encourage three behaviors: teamwork, friendly compe88on and accountability. Brain Games is an exci8ng applica8on of game technology that takes advantage of a new understanding of brain plas8city. Disease Management: Interes8ng to us provider types is whether these principles will work in chronic disease management. Early signs are posi8ve: Mobile games are nding a place in disease management, making mundane tasks more fun: glucose monitoring, diet, exercise, insulin and other drugs; and developing a support network of like people.

Of note, back in 2009 I no8ced an expanding deni8on of health and wellness, which included habit design and self-care. Remember this theme, we will see how it has evolved. 2

My latest research tapped into a fountain of innova7on in the mobile social games for health space. WHY? A convergence of many factors: Ease of entry, technology advances, Recep8ve end-user markets (smart phones, ubiquitous connec8vity), Access to capital and increasing interest from healthcare organiza8ons The gaming market has grown, especially among women and people over 30 yrs old with 55 percent of gamers playing games on their phones or hand-held devices. Gamica8on, ini8ally overhyped, may nevertheless be a useful engagement tool. According to a Gigya study of billions of user ac8ons with partners like Pepsi, Nike, and Dell, adding gamica8on to your site boosts engagement by almost a third. Albeit slowly, I think we are beginning to see a societal shiJ in the importance of health and wellness as shown by 1. the governments eorts -Mrs. Obamas campaign, Regina Benjamin 2. celebri8es such as Sanjay Gupta, Dr. Oz, Deepak Chopra at the CES are trying to make tness cool. 3. more self-insured employers are embracing health and wellness as part of a produc8ve culture.

This fountain of innova7on has fueled wild growth in our ecosystem, but it also means a high signal- to-noise ra8o for guring out what works.

Our new ecosystem has many more companies. Not only do we have those chasing cogni8ve health, but there has been a spurt in corporate wellness programs using social games. There are also next- genera8on companies rening their approach to behavior change.

New players include: Blue Marble Akili Interac8ve Cognit Fitocracy Mango Health, Lark Shapeup Limeaide Omada Health

I set the results bar high to select this years 4 case studies: Lumosity OneHealth

Lets step back and examine where pockets of evidence are building:

In childhood obesity - Zamzee, an ac8vity tracker with a mo8va8onal experience wrapped around it, did 12 studies with over 1000 kids and found that they those who used both the mo8va8onal experience and the accelerometer moved 60% more over a 6 month period than those who just had the accelerometer. With these results, the program is now being used as a tool along with exis8ng child obesity diet programs and camps.

In corporate wellness - Shapeup- invested in research early on - 5 peer-reviewed ar8cles in scien8c journals - with more in the pipeline. Showing that using teammates and social compe88on can help increase physical ac8vi8es and weight loss.

In addic>on relapse - One Recovery, now One Health, in Pilot with a Na8onal Health plan they found a 58% reduc8on in readmissions and a $1.4 Million in cost savings

In diabetes preven>on- Omadas Prevent, the digital version of a 2002 Diabetes Preven8on Program known as DPP, in a 27-center study with over 3000 pa8ents- they found that a modest weight loss of 5-7% could reduce type 2 diabetes by 58%.

All of the companies agree that their established evidence base has been invaluable as it has provided them instant credibility during their discussions with insurance companies and self- insured corpora8ons. 5

One strand of evidence is adop7on: Who is using these tools? I would have guessed that most of the apps are being used for diet and exercise, and I was surprised to nd out that, according to a recent study of US broadband households conducted by Park and Associates, 70% are using these tools for memory training.

The interest in memory training is spurring a robust ecosystem of brain training and brain tness companies such as: Lumosity Dakim Posit Cognit Brain Science Akili Interac8ve At the Consumer Electronics show this year, I began to think that consumer interest is expanding beyond brain games and brain tness to a broader context of the mind/ body connec8on and the desire to pursue cogni8ve health and wellbeing. Im s8ll working on that one, so stay tuned for my next report.

 Lumosity has created dierent types of games to train dierent areas of brain health, including problem-solving, memory, and brain exibility. Lumosity was founded in 2005, raised 67.5 M, and is using the proceeds to fuel rapid growth. This direct-to-consumer brain games company now has 40M users, with 10 M unique visitors a month. Click above to enjoy a video demo of their 3 new games. There is new evidence in an independent study of chemo brain in post chemotherapy breast cancer survivors, that showed that Lumositys cogni8ve training led to signicant improvements in cogni8ve exibility, verbal uency and processing speed.

 Now what is behavior change and why is it so important? Everyone engaged in health care is in the behavior change business: we are nudged to eat less and exercise more, follow recommended diagnos8c screenings, take all your medicine on 8me, dont put o a visit to inves8gate suspicious symptoms and of course oss your teeth every day. As shown in this visual, one way to think about using technology tools to nudge Behavior Change is as a series of cumula8ve small feedback loops. A simple feedback loop can be described as: the user engages with the mobile tool, data is captured, feedback is created. This could be a simple reward system for ossing your whole mouth one 8me per day. More complex feedback loops involve mul8ple itera8ons such as changing your sleeping rou8ne or your ea8ng and exercise paMerns. The ul8mate goal is to foster healthy behavior, but, as we know, changing paMerns of behavior, or comfortable rou8nes, is not easy. The ques8on of using tech tools to nudge behavior change has recently become interes8ng to many more designers, so much so that there is a meet-up with over 1000 members called Habit Design. Kudos to Michael Kim who leads this group of imagina8ve professionals.

Now that we have thought about geNng started and geNng going, we are now set to explore how we stay on track. Many of us think that social networks--peer pressure and support--plus user data analy>cs, could help us stay on track. Alcoholics Anonymous and Weight Watchers have been helping people oine for decades, with real success. As you can see in this visual, there are several dierent kinds of social networks which oer uidity and exibility not seen in the oine world Informa8on networks such as Everyday Health Pa8ent support networks Alliance Health Research networks- PaCents Like Me , Genomera Yet, people are complex, and inuencing everyday choices is not a one-size-ts-all solu8on. Just as social networks come in many avors so do data networks For some, the output of biometric data, data coming from body sensors, will help them to nd their way. For others of us, large sets of user data may also help developers understand human behavior and close the feedback loop. The key may be in experimen8ng with peer to peer support networks and data analy8cs with a mix and match approach- using more or less of each tool as needed and discovering which suite of tools will work for whom and when.

10

As consumers embrace Lumositys brain games, corpora7ons are embracing games to spur employee wellness. What are social games in the workplace? Small teams, put together in the workplace can play social games which encourage teamwork, friendly compe>>on and coopera>on. Accountability is an interes8ng mo8vator, because people feel obligated to par8cipate so they do not let down their team members. Building upon basic human nature desire for compe88on, status and peer recogni8on, social games can help support and promote a posi8ve collabora8ve culture

11

Exemplifying the power of social games, Shapeups par8cipants have collec8vely lost one million pounds!

Click on the link above to watch the video that shows how their programs use social networking, peer-to-peer healthcare, game mechanics and behavioral economics.

As far as using social games, Shape-up is one of the oldest, clinically-proven, technology-based social wellness companies selling to large employers across the globe. The peer-to-peer networks form a grassroots campaign to recruit team par8cipants, using social support and group mo8va8on and accountability to create engagement. Now they have added individual and team coaching to their suite of services.

As a data point relevant to corporate wellness, Rhode Island, in a state-wide wellness challenge, over the past seven years, found that more than 70,000 Rhode Islanders have par8cipated in their programs- walking millions of miles, losing thousands of pounds, and proving that teamwork is a powerful prescrip8on for taking control of our health.

Shapeup began in 2006, covers more than 2 million lives across 200 employers and health plans, raised $5M series A in 2010, and they are now protable.

12

When I asked What is working? Three elements emerged in common across companies EPI- Engage, Personalize and Iterate; all united by a need to demonstrate eec8veness with some kind of evidence.

First, capture peoples interest engage them with the use of gaming elements such as reward, status, achievement, self-expression, compe88on and altruism. Once people are engaged, it is cri8cal to create evidence that the tools work.

The second element, is personalize, custom approaches are essen8al to successful behavior change. There is no one size ts all in behavior change, and giving people what they need at the 8me of need is crucial to keeping their limited aMen8on.

The third element is iterate and experiment. This concept is also well known in consumer products, but not yet much recognized in healthcare circles.

13

Pa7ent engagement has been a popular topic of late, with HIMMS publishing a book and conduc8ng a Tweetup on the subject, Health Aairs devo8ng its en8re February issue to the topic, and the RWJ Founda8on and others sugges8ng new approaches. Reec8ng upon my days as a provider, where each dental pa8ent had a dierent view of their needs, it is not surprising to me that the deni8on and measurement of pa8ent-engaged care diers depending on context. Now that the discussion has moved to engagement, evidence of eec8veness seems to be the power trigger. Health plans are demanding mul8ple pilots to prove that the tools will get pa8ents engaged, and keep them ac8ve in treatment. Companies such as Shapeup, One Health and Omada who have evidence, can grow their businesses in the corporate market more quickly.

14

To get engagement and behavior change, there is no one size ts all, so personaliza7on is essen7al. Forms of personaliza7on involve using incen7ves as well as data analy7cs. There is a lot of experimenta8on with incen8ves, such as money or premium reduc8ons. A recent survey of 800 large and mid-size companies with more than 7 Million US employees, found that 83% oer incen8ves for par8cipa8ng in programs that help employees become more aware of their health status. Aon HewiM's survey shows almost two-thirds (64 percent) of employers oer monetary incen8ves of between $50 and $500, and nearly one in ve (18 percent) oer monetary incen8ves of more than $500. Although there is currently a lot of experimenta8on with extrinsic rewards- such as money- the literature suggests that intrinsic mo8va8on is superior. This is an area that is s8ll a work in progress. Analy8cs is another important element of personaliza8on. In brain games, Lumositys machine-learning algorithms customize the ques8ons- giving the player the right amount of challenge and in OneHealth, they use data to be beMer informed how to tweak the product features.

15

All of our case studies have gone through mul7ple itera7ons of their product, while accumula8ng data used to both iterate the product and improve the experience. Onehealth, which began as OneRecovery, focused on addic8on, has expanded their target markets to include people with mul8ple chronic condi8ons, such as obese diabe8cs. Noteworthy, Lumosity, through their research, called The Human Cogni8on project, is building the worlds largest database on human cogni8on to con8nue to improve and personalize their games. Shapeup began using social games in corporate wellness and has now added coaching Omadas Prevent spent a lot of 8me itera8ng the consumers ini8al product experience, because they learned that good rst impressions were a key element to establishing ongoing trust.

16

Lets see how these concepts work when you build a system with the pa7ent in the center. OneHealth uses a mix of game mechanics and mul8ple online support networks, available 24/7. As we will see in the demo, game mechanics include badges to mark achievement levels, such as going to mee8ngs, geQng a sponsor, sharing a story, journaling. Emo8cons help us share emo8on and empathy. For social support, you can build your own support group with varying levels of privacy, customized to personal needs that can change over 8me. This is very important in the clinical world, where many people suer from mul8ple diseases - such as the many pa8ents who struggle with obesity, depression and addic8on. These same principles have been applied to their new mobile products. One Health started in 2007, raised 16 M dollars to date with a 7 M dollar series A followed by $9M series B.

17

What if these tools of behavior change could be used to prevent one of the biggest cost drivers in healthcare? As shown in the landmark DPP trial back in 2002, pre-diabetes can be reversed through lifestyle changes. It was only recently, in 2011, that Omada cleverly gured out a way to digi8ze the program using digital tracking tools (e.g. weight scales, pedometers), personalized coaching, social support, and an interac8ve web-based curriculum to mo8vate healthy exercise and ea8ng behaviors. Here is how Omadas, 16 week course, called Prevent works: Upon sign up, users are matched into small groups of 12 in a private online environment, based on age, body mass index, and loca8on. They are then sent a Path16 wireless scale that requires virtually no set-up and automa8cally syncs to Prevent, allowing them to transmit daily weigh-ins to their private personal proles. The curriculum - 1x per week, its fun , and oers some interac8ve elements, with mini challenges in their skill center. Important aspects of the program include the peer-to-peer support from the group, as well as support from the health coach Evidence from last pilot includes: 74% completed the pilot in 4 months Mean weight loss similar to DPP - 5-7%

40 of the 230 par8cipants have applied to be coaches

18

 A handful of VCs I spoke with agree that it is s7ll early in the cycle of business model evolu7on, however, in corporate wellness, we see 2 dierent approaches to revenue models: Shapeup and One Health charge employers per member per month Prevent is a 2-8er success-based approach, where there is one payment when employees complete the program and another payment when they meet goals On the consumer side: Lumosity uses a monthly fee structure for consumers Noteworthy, Shapeup and Omada are protable. (Shapeup- started in 2005 and has raised $5 M in venture capital funding. Omada- began in 2011 and has raised $5.5 M in seed and venture funding)

19

As you can see in these graphs, all trends are posi8ve showing an Increase in mobile health app downloads, global revenues and venture capital funding. For Mobile Health app downloads, 124 million people downloaded a mobile health app in 2011 and 247 million people downloaded one in 2012. In global revenue, there was 1.2 billion dollar global revenue from mobile healthcare apps in 2011 with 11.8 billion dollars expected in 2018 For VC funding, there was 968 million dollars in 2011 and 1.4 billion in 2012.

20

Reec7ng back (in hindsight) this has been a year of rapid innova7on, so lets see the up and comers who are brave enough to take on the challenge Up and comers include: Fitocracy- The founders are gamers turned bodybuilders. The online tness community awards you with points, the ability to level-up, badges and the strong social component has created community support with over 1 m downloads. Mango Health using game design to help consumers mange their health - earn points for taking medica8ons safely and on 8me. Points can be redeemed by major retailers such as Target or by making charity dona8ons Lark -using elements of game mechanics and automated posi8ve coaching (with custom algorithms) to make sleep tracking more fun- and they have the worlds largest sleep database. Akili InteracCve-combining the best in neuroscience, with the best of video games to create a new kind of cogni8ve ac8va8on, beginning in the area of execu8ve func8on

Who would have guessed that game developers, once considered op8onal consultants in health related products, would be key members of product development teams?

21

As we have seen in our 4 case studies -Lumosity, OneHealth, Shapeup, Omada - are mixing and matching elements of game mechanics and peer to-peer support using 3 common success factors: engage the user, personalize the experience and iterate the product. With this explosion of innova8on plus new entrants such as Fitocracy, Mango Health, Lark, Akili Interac8ve, these are exci8ng 8mes. This fan represents an ongoing trend to move the medical system from sickness interven8on to preven8on or well care. This is a model of preven8on based on a con8nuing convergence of data analy8cs and ubiquitous social mobile connec8vity. This convergence is enabling people to proac8vely drive their own behavior change through itera8ve, personalized engagement rather than passive par8cipa8on in data- driven disease preven8on. This is an extension of the expanding deni8on of health and wellness that we rst no8ced in 2009, as seen in our rst ecosystem visual. But this concept is s8ll so new that we don't yet have a word that replaces "pa8ent" to describe individuals ac8vely pursuing beMer health.

22

What does this mean for the future? As we have seen in our 4 case studies, in our 4 up-comers, and others, with gaming and compe88ons taking center stage, perhaps it is 8me to individually and collec8vely think BIG.

Leave it to Esther Dyson to have created HICUUP (Health Interven8on Coordina8ng Council) that uses community wide eorts to get people compe8ng to walk, exercise and eat beMer across ci8es and states. The council is spurring popula8on health and proving the nancial feasibility of preven8ve health on a larger scale

23

I am grateful to the 100 plus companies and the 25 plus mee8ng organizers who have contributed to the analysis behind this presenta8on. I remain ravenously curious to see what will be next!

26

28