The proposal is for an exercise and wellness program called "ExerWellness: Bend Oregon" that will use data mining algorithms and sensor technology to encourage physical activity and social support among residents. It aims to improve health outcomes in a sustainable way through gamification, social nudging, and real-time feedback on participants' activity levels, weight, and other health metrics. The program founders have experience developing similar community wellness initiatives and believe this comprehensive approach can help change behaviors and reduce healthcare costs over the long term by preventing chronic conditions.

1. Proposal: ExerWellness Bend Oregon
While 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 this
proposal, we build on research around crucial elements in consumer engagement that can lead
to improved health outcomes. The work of team member, David Kil, (HealthMantic) deploys
data mining algorithms to understand the impacts of various interventions, such as social
network, visual dashboard, event processing, games and challenges, on health outcomes.
Much of the data was obtained from a clinical trial. David's decades of experience in" what
worked, what did not work, and why" support's Shasek's experience in developing a culture of
active wellness in a geographic community. This proposal underscores salient attributes of
social health games that are crucial in both consumer engagement, influence on physical
activity, improvement of social nudging and health outcomes.
Software description: "ExerWellness: Bend Oregon" will use HealthMantic developed (full
patent) Sensor informatics that include: Smartphone sensing of all activities including motion-
based interval training, heart rate, and location context for ambient intelligence. Motion
exercise programs are designed to improve balance, flexibility, strength, and cardio with built-in
relaxation, which promotes body-fat burning and muscle strengthening--ideal for elderly
population and the obese with diabetes and other lifestyle ailments. These short motions are
being embedded into gesture- and motion-based brain fitness games, along with micro
random-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 an
emotional challenge embedded in the condition which can sabotage both treatment, prevention and
management. We address mood in our games, intervention, social nudges and data because of its
powerful 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 a
wellness strategy or program. The expertise and experience of our team is solid in this respect. Areas of
focus 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 seven
years, both in the school/education community and the greater geographic community.
Developing key partnerships with all stakeholders in community wellness is crucial to a
successful community deployment of any intervention model. By adding value and providing a
turn-key model for data gathering for existing efforts the community deployment becomes a
win-win for all.
Background: Our efforts toward wellness are challenged by a "perfect storm" of preventable
poor health that has continued to threaten quality of life and productivity for millions. Our
collective predictive and preventive capacity remains remarkably under-developed in

2. overcoming this challenge. The passive and unintended consequences of modernization and
resultant social and lifestyle behavior choices have changed habits and have driving resulting
chronic conditions to unmanageable levels.
In the research paper, “Nudging lifestyles for better health outcomes: crowd-sourced data and
persuasive technologies for behavior change” (Piniewski, Codagnone, Osimo, 2011) a case is
made for taking a supply-side approach. They propose that advancing health care delivery
cannot be expected to impact health outcomes effectively. According to the authors, “The
malignant spread of obesity in genetically stable populations dictates that gene disposition is
not a significant contributor as populations cannot receive a new shipment of genes in only 2-3
decades.” In addition, “Preventable poor health is by definition preventable. We have
unwittingly supported the choice architectures that overwhelmingly enable poor lifestyle
choices in preference to optimal choices.”
We currently depend upon Health Information Technology (HIT) for many of the decisions and
paradigms around our healthcare and medical models. The goal is often, “better care.” Better
care sets the stage for more care, yet it remains largely impotent in returning individuals to
disease-free states. Participation in physical activity is the first step in preventing the diseases
and conditions. Long term participation is the first step to prevention, and is the cornerstone
of "ExerWellness: Bend Oregon."
Encouraging physicians to prescribe specific exercise programs has long been a mission of many
health, wellness, medical-fitness and government agencies. Yet fewer than 15% of physicians
prescribe specific exercise. Current payment models (more procedures equate to larger
compensation, pharmaceutical reimbursement and compensation), are sick-care reinforced and
don’t promote a change in paradigm to prevention. Physicians rarely know what exercise
program to specifically prescribe nor do they have time to investigate the most trusted and
effective 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 at
transforming the health as well as the health costs of crowds. This almost singular focus of
Health Information Technology (HIT) on care delivery may be largely responsible for the

3. underperformance of our predictive and preventive capacity at this time. “Relying on
institutional (hospital and clinic) data tracking care delivery to proactively manage the health
expression 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, these
individuals often make choices that do not result in wellness, in fact many have long term
behavior and lifestyle choices that threaten their health, productivity and quality of life. Our
target 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 in
order 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 to
nudges from our social network, preferences and daily interactions. Many objections to health
behavior change, including regular physical activity (PA) are based on rational
thinking:
 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)ii
confirms that the social network may have important negative and positive effects on health. If
most 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 and
individual 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 be
nudged into habit change. Social nudging by design will connect individuals or groups likely to
set 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 is
for many to engage to some degree. Currently, 9% of all cell owners in the US (virtually 9% of
the US population) have apps on their phones that help them track or manage their health. iii
According to Gartner worldwide mobile application stores’ download revenue exceeded $4.2
billion in 2009 and will grow to $29.5 billion by the end of 2013. Many of these apps are likely
to be health related. Consumer trends often run parallel with behavior trends. Please see the
slide deck accompanying this proposal summary for an overview of the technology to be used
in "ExerWellness: Bend Oregon."

4. The business case: a preliminary sketch.
Effectively managing the health process of crowds to prevent the preventable are expected to
generate 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 in
annual health care [iv and v] cost. This equates to a 1:10 dollar return on investment. These
figures are based on a workplace wellness intervention. Imagine such an intervention that
bridges verticals across workplace, family, friends and leisure choices with a game-system of
immediate, quantified feedback and social nudging. The ROI would grow exponentially while
providing 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 be
delivered. Without those pieces, investment in even the most respected workplace or member
wellness initiative will deliver less than optimal ROI.
Working with a partnership across medical centers and destinations in which physical activity
programming is already being delivered will provide a source of participants across social
networks and various workplaces. Once enrolled, the participant will be nudged with ever more
relevant and valuable “nudges” over time. Valuable data about the patient can be voluntarily
collected. Quantified wellness outcomes and the unregulated data voluntarily provided by
member-participants are information required to validate a paradigm shift in how “health” is
managed. HealthMantic will be positioned to provide regulated data.
Decades of educating and raising awareness with the hopes of encouraging people to move in
the 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 motivate
individuals through less rational-response-dependent persuasive technologies such as serious
gaming and social nudging makes sense. The potential of social nudging and real-time activity
feedback to produce positive cascade effects provide a proven means to spread desired
behavior.
 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 wellness
Health data is needed: The public can become even more willing to share their health data with
an honest broker with the ultimate goal of wellness in mind
The value of appropriately collected and brokered data is enormous. It is needed by health
policy-makers, insurance companies, medical professionals and many others.

5. The program that can successfully engage a target population and collect data about that
population in an approved manner will generate the ability to drive a revenue stream from
the very information providers, employers and communities need - and will pay for.
There are many examples of research and grant projects that tie a nutrition/exercise
intervention 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, relapse
back 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 target
population for "nudging" themselves and others in their social network across the greater
community.
For the most part, individuals - particularly the most costly or at-risk in a population, do not
properly understand the impact that individual decisions have on their health. There needs to
be immediate feedback letting them know the impact that their choices have on their health
and the health of their social network.
Many consumers are motivated by the effect that their behavior has on others (in particular
those with whom they have strong social ties). We plan to make consumers more aware of
these effects and enlist their social ties to help them stay on track
The medical establishment only sees a patient a couple times a year. There is very little that
they can do during those visits to change behavior or even properly educate a patient about the
importance of daily decisions. There needs to be a mechanism to provide real time data back to
the medical establishment so that they can get involved and support people with their decision
making 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 health
and 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 deployed
across the country. Programs that are dependent upon a top-heavy staff of coaches and
counselors advising and motivating behavior change cannot be easily distributed across
communities.

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 for
the financial investment in the RWJF Games Challenge initiative
For 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 a
recent wellness activity program conducted over 5 months by Shasek in Bend, Oregon
participant 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 not
popular for many reasons. More importantly, the participants felt "cheated" when they did
activity 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 it
was frustrating for them not to get real time feedback for all types of activity. This was in spite
of 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 most
unique and effective, he has also developed key engagement strategies.
Kil's 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 the
world over who crave real-time, actionable data that leads to meaningful improvement in the
delivery of patient care. All stakeholders around the patient care and cost challenge recognize
that prevention is the intervention that will deliver the most ideal outcomes for all. Physical
activity powers prevention and drive social and habit change across a community.
"ExerWellness: Bend Oregon" is designed to enhance existing efforts toward more valuable and
measurable data and outcomes around patient care and prevention.
Oregon Health Leadership Council's (OHLC) overall model is designed to provide coordinated,
high-quality care to patients with chronic and complex conditions and achieve shared savings
for medical groups and payers. The model of care was based on the successful demonstration
project launched by the Boeing Corporation. The evaluation of cost savings will occur at the end
of the demonstration.

7. “We wanted to provide more timely and actionable information about the care enrolled
patients 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 reports
on utilization of services, we provide value added information about care that is happening
outside clinic walls,” said Mylia Christensen, executive director, Quality Corp.
The goal of "ExerWellness: Bend Oregon" is to provide an engaging and quantified intervention
that will positively impact "outside clinic walls" to further provide ROI for all stakeholders. As all
members of the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality
initiative hope to defragment information, we can support that data and information
aggregation on the "prevention" side. As cost-reports are developed, it is crucial that the cost
savings of preventive interventions like HealthMantic can offer become a participant in the data
mix.
Data collected around "health care" that does not have a broad base of prevention and related
wellness activities of the population cannot provide the best value. “The real fundamental
value 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 care
models that OHLC hired to support this work. “It’s not necessarily revealing a gap in care, but a
missed opportunity to know something or to take action, like who had a hospitalization I
didn’t know about? Who is not filling all of their prescriptions? A month could be missed. It’s
important 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 for
medical groups, project managers say. But there is now a unified understanding of its necessity
and value for timely, accurate reports and per-member-per-month payments.
There is probably no more expensive "missed opportunity to know something or to take
action" than the opportunity about prevention.
Critical to generating data is providing valuable and novel application of that data. Using
existing shared-data and information reports and utilization "ExerWellness; Bend Oregon" can
demonstrate a scalable model for delivering prevention and cost-effective management of
many chronic conditions. These can be deployed toward the goals of improving community
health 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 great
potential, and the state is one of the big players. This makes intuitive sense, and it has huge
potential, particularly if we direct incentives toward systems integration and care
coordination.” One key piece of the potential for this information is in implementing habits and
choices across a geographic community that positively impact their health via active wellness
and the resulting prevention and chronic condition management benefits.

8. Kil's technology and apps can help community leaders improve Aligning Forces community
healthcare. Combining that technology with Shasek's expertise and experience in connecting
wellness resources and stakeholders throughout a geographic community will serve to deliver
the new model of full healthcare. By including a patient-driven prevention and condition
management game to the mix we have a unique solution for success. Both Shasek and Kil have
deep experience in the power and application of gamification and engagement.
The team:
Judy Shasek: http://www.exer-wellness.com/about-us/who-we-are.html
David Kil is the founder and CEO of HealthMantic, focusing on lifestyle-medical informatics and
sensor-based health gaming. Prior to founding HealthMantic, he was Chief Scientist
at SKT Americas and Chief Science Officer at Humana, responsible for the development and
deployment of healthcare informatics applications. At SKTA, he founded the iWell project and
built an integrated wellness platform consisting of sensors, platform, and informatics. The
system underwent a successful clinical trial at PeaceHealth with promising results. At Humana,
he led the design and development efforts in enterprise knowledge engine, predictive
modeling, and outcomes analytics while working with Samsung on U-Health initiatives. The
enterprise insight engine won the best-of-breed technology award from the ComputerWorld
magazine. He co-authored a book entitled “Pattern Recognition and Prediction with
Applications to Signal Characterization” by Springer-Verlag, published over 30 papers, and holds
9 US/European patents. He graduated from the University of Illinois at Urbana-Champaign
with BSEE/Chemistry (Highest Honor and Bronze Tablet), the Polytechnic University of New
York (MSEE), and Arizona State University (MBA).vi
i
“Nudging lifestyles for better health outcomes: crowd-sourced data and persuasive technologies for behavior
change” (Piniewski, Codagnone, Osimo, 2011)
ii
See: http://www.nytimes.com/2010/09/19/health/research/19stream.html?_r=2&adxnnl=1&emc=eta1&adx
nnlx=1284908452-A1LZH5m05lalCE7/YuAzWQ
iii
Plaisant, C., et al., Searching electronic health records for temporal patterns in patient histories: a
case 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 health
care expenditures. Health Enhancement Research Organization (HERO) Research Committee. Am
J Health Promot, 2000. 15(1): p. 45-52.
v
Wright, D., et al., Comparing excess costs across multiple corporate populations. J Occup Environ
Med, 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," O'Reilly
Strata Rx conference, San Francisco, CA, Oct 2012.