GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 2, Number 5, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2013.0063
Continental Profile
A European Profile of Games for Health Moderator: Tom Baranowski, PhD1 Participants: Richard Coshott,2 Ilja Michaelis,3 Pier J. M. Prins, PhD,4 and Brenda K. Wiederhold, PhD, MBA, BCIA5,6
October is time for the Games for Health Europe meeting in Amsterdam, The Netherlands. Games for Health Journal would like to highlight exciting developments in games for health in Europe by asking European members of our Editorial Board to comment on what developments they see.
Tom Baranowski: In your opinion, what are the most exciting activities, products, or findings in games for health development and research in your country in the past year? Pier J.M. Prins: In The Netherlands there have been two important events related to the development of serious games for mental heath in the past year: 1. The Landelijk Kenniscentrum Kinder-en Jeugdpsychiatrie (an organization that serves seven major child psychiatric clinics in The Netherlands) has published an e-book on e-health that discusses and presents the various serious games that have been developed in The Netherlands. It also discusses critical issues, implementation and training issues, ethical issues, and economic implications. The book gives a nice view on the current state of affairs. If you want more info on this book, please contact Arielle de Ruijter at [email protected] 2. The Dutch Association for Scientific Research (Nederlandse Organisatie voor Wetenschappelijk Onderzoek) (www.nwo.nl), the largest funding organization for research in The Netherlands, has invested more than 10 million euros to stimulate the collaboration between the creative industries and various scientific disciplines (among others, psychology) to develop serious games. Three proposals from our Department of Psychology of the University of Amsterdam—among others—have received funding (one related to substance abuse in adolescents, one for attention deficit hyperactivity disorder [ADHD], and one for training children in arithmetic).
Ilja Michaelis: I am very excited to see that more and more research projects include health games and that awareness is continuously increasing in the German market. The topic of this year’s gamescom Congress held during gamescom 2013 (the world’s largest trade fair and event highlight for interactive games and entertainment) was game-based learning. There was no particular focus on health games; however, the agenda included several talks about health games. For example, one of the talks was about the beta release of our health game, which treats children with dyscalculia. It was developed on the basis of a research project by the Institute of Psychology at the University of Mu¨nster (Mu¨nster, Germany), which was funded by the German Government. Audience members consisted of many German teachers, who responded favorably to the fact that a fun game for children is based upon the newest scientific research in the field of dyscalculia. Richard Coshott: I am in the very fortunate position of joining the modern exergaming movement with my own company from the early days, and I have seen the sector grow and change (sometimes not for the better) over the last 8 years through the growth of Gamercize. In the past year, since the last Games for Health Europe Conference, there have been significant and exciting developments in the research arena. The growth of research into the largest of the health games genre, exergaming, in the United Kingdom has been a promising development. From a single United Kingdom university in publication we now have three major establishments, notably Coventry University, not only bringing exergames in for scrutiny, but significantly moving past basic energy expenditure studies towards research into
1
Baylor College of Medicine, Houston, Texas; and Editor, Games for Health Journal: Research, Development, and Clinical Applications. Gamercize, Southampton, United Kingdom. 3 Kaasa Health, Du¨sseldorf, Germany. 4 University of Amsterdam, Amsterdam, The Netherlands. 5 Virtual Reality Medical Center, San Diego, California. 6 Virtual Reality Medical Institute, Brussels, Belgium. 2
264
CONTINENTAL PROFILE sustainability and health benefits in practical settings. What impresses me about these modes of study is that the results can be practically reproduced as the methods can be directly translated into exergaming programs. Brenda Wiederhold: At the 18th annual CyberPsychology, CyberTherapy & Social Networking Conference, which was held July 1–2, 2013 in Brussels, Belgium, the Director General of DG-CONNECT, Mr. Robert Madelin, gave the opening Keynote Address. The ICT for Health and Well-being’s Head of Unit, Peteris Zilgalvis, chaired a symposium on new innovations in health and well-being, and Peter Wintlev-Jensen, Deputy Head of Unit, Digital Societal Platforms, chaired a symposium on Europe’s funding programs with participation by Belgian governmental officials as well as officials from the Health and Consumers Directorate General of the European Commission. Juriaan van Rijswijk, Games for Health-Europe, chaired an industry panel, with start-up games for health companies enlightening the audience about the future potential in this area. The Belgian government provides many networking opportunities to allow small–medium enterprises opportunities to meet with funding agencies and larger corporations to disseminate their ideas and possibly team on research and grant proposals. As a small Belgian start-up utilizing games in treatment and training and game engines in software design, Virtual Reality Medical Institute (VRMI) is one such company, headquartered in the Brussels Life Science Incubator on the Catholic University’s Brussels campus in Woluwe Saint Lambert. A joint project with the Brussels Region, the incubator allows advanced technology and healthcare companies access to improved network opportunities. Selected as one of the companies to take part in the June 2013 Belgian Economic Mission to California, led by Prince Philippe (now King Philippe) of Belgium, VRMI was able to brief technology and gaming companies in California and discuss their ongoing work in the areas of behavioral healthcare and rehabilitation. Tom Baranowski: What is the extent of funding in your country for research and development of health games? Ilja Michaelis: There are several research projects, funded by the German Government, that include the development of a gaming component. However, in most cases the game itself is not the focus of the project, it is just a by-product. There is one case, our dyscalculia health game, where the State Government of North Rhine Westphalia funded the development of a health game directly. For the first time, a project was funded where the health game itself is at the center of attention. However, public funding in this area is still extremely low. We are talking about an annual total in the low one digit million euros range. And this is for all gaming projects together not just health games. But a seed has been planted! And we strongly believe that our health game will make an impact and create awareness in Germany. We were already invited to present it at the Bundestag (the German parliament). Politicians wanted to know what was necessary in order to get this type of technology into German schools. There are also several private trusts and foundations that are starting to fund smaller health game projects. These are
265 typically foundations, which were set up to foster research for a particular health condition. Richard Coshott: Funding for exergame interventions has taken a backseat in England owing to the focus on the London Olympics in 2012. Traditional sport has swept up the meager recession-hit opportunities, and tradition in the United Kingdom is measured in thousands of years, delaying changes in thinking for a relatively new medium for physical activity. We do, however, have an increase in participation in exergaming as a sport, through both my own Gamercize (and other United Kingdom companies) tournament events. I think we are a long way from having exergaming as an Olympic discipline, but I would never discount it, especially considering the much touted ‘‘gateway effect’’ of our Olympic legacy has not proved evident. Brenda Wiederhold: 2013 sees the end of the FP7 funding program by the European Commission in Belgium. The Directorate General for Communications Networks Content & Technology (formerly known as DG-INFSO) has currently funded products in the technology and mental health area. Six products are developing information and communications technology (ICT)-based solutions for persons with stress, depression, and bipolar disorders, combining new technological solutions with treatment models and multiparametric monitoring. The proposed systems aim to achieve objective and quantitative assessment of symptoms and, in some cases, the ability to predict manic and depressive episodes. Interaction between patients and their clinical providers, as well as a move towards mobile platforms and self-monitoring, is being emphasized. The current ongoing projects are as follows: MONARCA (for bipolar disorders), 3.67 million euros; PSYCHE (for bipolar disorders), 2.91 million euros; ICT4DEPRESSION (for depression), 2.71 million euros; INTERSTRESS (for stress), 3.01 million euros; OPTIMI (for depression and stress), 3.76 million euros; and Help4Mood (for depression and bipolar disorders), 2.82 million euros. This represents a total funding of 18.88 million euros. This year, meetings have begun to introduce the new 6-year funding program, Horizon2020, which will fund new technology and healthcare research from 2014 to 2020. The area of ICT for Health and Well-being under DG-CONNECT will look towards more patient-centric mental health solutions. Tom Baranowski: What is the extent of health game usage in each of these applications: (1) Training of healthcare professionals? Ilja Michaelis: Several clinics are starting to experiment in this area. One example is a serious game to train medical technical assistants. However, so far its use is not significant enough to generate any reliable usage data. Richard Coshott: The National Institute for Health and Care Excellence recently opened its doors to lay members to aid in the consultation for updating guidance in the National Health Service (NHS) exercise referral scheme in the United Kingdom. This opportunity, I would hope, should improve the situation, and although [the subject of ] health games was not initially on the agenda, it is now.
266 Brenda Wiederhold: VRMI uses virtual reality, augmented reality, and real-life mock-ups to train civilian first responders and military medical personnel. Although headquartered in Belgium, VRMI works with other members of the European Union to augment traditional training with advanced techniques. In the new Horizon2020 program at the European Commission, headquartered in Belgium, there should be funding available, as there was in the Framework 7 program, for serious games. It is not that serious games are being showcased, but rather they are very forward-thinking and understand that there are issues/problems that can be addressed by adding advanced technologies to current methods. The European Commission looks towards the ability of new technologies to more cost-effectively and efficiently train and retrain medical personnel. Tom Baranowski: (2) Child and youth diseases and illnesses such as obesity, cystic fibrosis, diabetes, etc. Ilja Michaelis: There are reports and studies conducted in Germany that show that the use of Microsoft Kinect or the Nintendo Wii can reduce obesity in youths. However, these studies are typically based upon existing commercial games, such as Wii Fit. Specific health games are very rare and are primarily used on a research or university level. Thus there is no significant usage in the health system. Richard Coshott: The United Kingdom, in common with most of the Western world, I presume, has yet to fully accept obesity as an illness despite the efforts of independent research groups to highlight the risks. School authorities are motivated by government activity guidelines to reach out to exergaming as an intervention, while the dots are yet to be joined up in common public opinion. Brenda Wiederhold: In 2004, 2005, and 2006, there was an emphasis placed on controlling advertising of high fat-saltsugar food to children, promoting physical activity, and encouraging a reduction of harmful use of alcohol. This was done under the Health and Consumers Directorate General of the European Commission. Since that time, DG-CONNECT has also placed an emphasis on using new technology platforms to communicate to children on healthy and active lifestyles as well as researching both the positive and negative effects new technologies can have on children’s behavior. The Strategic Approach for the European Union for 2008–2013 stated that ‘‘health is the greatest wealth’’ and that ‘‘health is important for the well-being of individuals and society, but a healthy population is also a prerequisite for economic productivity and prosperity.’’1,2 The strategy of European healthcare envisions innovation coupled with new technologies to solve many of our healthcare difficulties from birth to end of life. Tom Baranowski: (3) Rehabilitation for stroke, trauma, Parkinson’s, etc.? Ilja Michaelis: The situation is similar as above. Several solutions are in the process of development as part of research projects. What is interesting is the fact that new technology developments outside of the healthcare or gaming industries
CONTINENTAL PROFILE are being used to help speed up the health game development process. We are in the planning phase to develop a much more sophisticated version of our simple stroke rehabilitation game (‘‘SensoMove’’) by integrating a new and affordable device by Leap Motion. Richard Coshott: The nature of my involvement in health games with my company Gamercize lends itself more towards the moderate to vigorous levels of non-impact physical activity, so I have limited sector knowledge of rehab interventions. Brenda Wiederhold: Multiple projects are funded under divisions of DG-CONNECT, including the Future and Emerging Technologies Program. These solutions include the use of videogames for cognitive and physical rehabilitation. One large-scale program is a European Innovation Partnership on Active and Healthy Ageing that will seek solutions to provide added quality of life years to older individuals using advanced technology solutions. VRMI utilizes virtual reality, videogames, and augmented reality as solutions for cognitive rehabilitation following stroke or traumatic brain injury and for physical rehabilitation following stroke, injury, or amputation. Tom Baranowski: (4) Wellness, including diet management and exercise/fitness? Ilja Michaelis: This area has seen some increased activity in Germany. In particular with regards to fitness and the debut of applicationss such as ‘‘Zombies, Run 2!’’ What particularly interests consumers in this field is that gaming companies are finding new and innovative ways to motivate people who would otherwise not consider diet management or exercise as part of their daily routine. Digital health devices, such as the Mio Alpha Watch, a strapless heart rate monitor, are quickly gaining popularity with early adopters in Germany, but the big breakthrough in gaming is still pending. Richard Coshott: While exergaming met the mainstream media head-on as an inactive children’s intervention, the wider application of weight management and wellness has seen massive growth in the United Kingdom. As our economy picks up we are seeing the competition in workplace wellness as real factors in attracting the most suitable employees. Furthermore, as corporate budgets are still tight, we see value for money and maximizing employee health (and therefore happiness) as emerging business tactics to maximize return on investment. Brenda Wiederhold: As of July 2012, a unit under DGCONNECT, the European Commission, is dedicated to ICT for Health and Well-being. There is an increased awareness on changing the emphasis from a disease model to a wellness model, and more funding emphasis in the areas of health promotion/disease prevention is being supported. The individual citizen is being encouraged to become an active participant in his or her own health and well-being; however, it is realized that the proper resources need to be put in place to allow this to occur. VRMI is currently the dissemination/exploitation workpackage leader on a 3.2 million Euro research
CONTINENTAL PROFILE project, entitled INTERSTRESS, which is developing stress management games fused with physiology on iPads and iPhones to allow individuals to deal with stress anytime/ anywhere. A recipient of the 2012 United Nations World Summit Award in the category of m-Environment & Health, the project was also featured during European Brain Week in Brussels. Tom Baranowski: What is the acceptance of health games by healthcare providers and insurers? Ilja Michaelis: The acceptance among healthcare providers is quite high. In particular, the rehab sector is quite openminded in this regard. Dr. Becker Klinikgruppe, which has eight rehab clinics throughout Germany, is constantly exploring new ways to integrate gaming in all facets of their specialties. At least once a month I receive a call from a doctor asking us whether we would be interested in developing a game for a certain medical condition. Unfortunately, we have to turn down most of them as external funding is hardly available, and in many cases, in particular with rare medical conditions, financing through sales won’t be viable. Richard Coshott: The United Kingdom is lagging behind the United States in this respect, and I predict it will continue to be a minor factor. The reason for this is the free healthcare system that has existed since 1948, which has no limit in terms of quality or availability to the United Kingdom public. Private health insurance is not a significant factor for the United Kingdom as a result, and the NHS is somewhat protected intrinsically from cost constraints at the clinical level. Brenda Wiederhold: Although it is still a small percentage of providers who are actually utilizing games and simulations in their clinical practices, increasing numbers of providers are acknowledging and beginning to embrace the advantages of adding advanced technology solutions to existing clinical protocols to extend the reach and efficacy of services provided. In a recent study we conducted under our INTERSTRESS Project, 75 percent of surveyed behavioral healthcare providers acknowledged an increase in efficacy when using new technologies, and 83 percent acknowledged an improvement in access. While 75 percent also point to the need for training prior to usage, healthcare providers also indicated that patient awareness and system standardization must occur in order for widespread use to become a reality. Respondents also pointed to cost as a current barrier to implementation. Cloud computing was also offered as a possible solution to increase adoption by both healthcare providers and individual consumers.2 Tom Baranowski: Many exciting G4H developments have been identified in Europe by our European Editorial Board members. Those of us attending the meeting in Amsterdam will be exposed to even more! See you there! References 1. Lawton M, ed. Neelie Kroes: ‘Our cloud strategy is not mature.’ September 27, 2012. www.dw.de/neelie-kroes-ourcloud-strategy-is-not-mature/a-16269684-1 (accessed September 27, 2013).
267 2. Wiederhold B. From clinical to cloud. Public Serv Rev Health Soc Care 2013; 35:76–77.
Brief Biosketches Richard Coshott, is the CEO and Founder of the internationally successful exergaming company Gamercize and the Co-founder and Director of the influential advocacy group ‘‘The Exergame Network.’’ Richard’s passion for exergaming was born over 10 years ago, looking for a parental solution to his own two sons becoming unfit playing videogames. After trying many ideas to get them back outdoors, he finally created a solution that worked for them in Gamercize. A company to share this innovation was created, and Gamercize products now sell worldwide. He is a long-term serial gamer himself, recognizing the importance that the immersion of gameplay has to offer exergaming. Ilja Michaelis, the COO of Kaasa Health, with a degree in economics and law, has worked since his graduation in 2001 in different areas related to information technology and health. Apart from being involved in the development of healthrelated software and inline projects, he also manages several research projects funded by the European Union and the German Government.
Piers J.M. Prins, PhD, is professor of clinical child psychology at the University of Amsterdam (The Netherlands) and known for his research in the domains of childhood ADHD and anxiety disorders. He is director of the research program ‘‘Mechanisms of Change and Psychosocial Treatments for Behaviorally and Emotionally Disordered Youth.’’ He has a long record of (inter)national peerreviewed publications in the area of clinical child psychology and childhood cognitive behavioral interventions. Over the past decade, he has been project leader of several large-scale, multisite treatment-outcome projects dealing with childhood ADHD, aggressive behavior, and anxiety problems, and most recently he has been involved in the development, evaluation, and implementation of a computer game (‘‘Braingame Brian’’) to remediate executive functions in children with ADHD and cognitive control problems. Dr. Prins is on the editorial board of Behavior Therapy, Clinical Child and Family Psychology Review, Child and Youth Care Forum, and Games for Health Journal.
268 Brenda K. Wiederhold, PhD, MBA, is a licensed clinical psychologist in the United States and Europe, a professor at the Catholic University in Milan, Italy, and an entrepreneur. Dr. Wiederhold is the CEO of the VRMI in Belgium and the Executive Vice-President of the Virtual Reality Medical Center in California. She completed the first randomized, controlled clinical trial to provide virtual reality (VR) medical therapy for war veterans suffering from posttraumatic stress disorder (PTSD). Her most recent achievement is working with coalition troops to provide stress inoculation training prior
CONTINENTAL PROFILE to deployment. These are in addition to her VR work since the mid-1990s with the civilian sector of patients. She works to inform and educate policymakers, funding agents, and both the scientific community and general public to advance the medical field with technology. Dr. Wiederhold is recognized as a world leader in the treatment of anxiety, panic, phobias, and PTSD with VR exposure and cognitive behavioral therapy, objectively measuring results with physiological monitoring devices. She is the founder of the international CyberPsychology & CyberTherapy Conference, now in its 18th year, and the Editor-in-Chief of the MedLine-indexed journal CyberPsychology, Behavior, & Social Networking. She has given invited lectures on the topic of advanced technologies and health care in 24 countries throughout Europe and Asia and has published more than 150 articles and 12 books on the subject.
Continental Profile
A European Profile of Games for Health Moderator: Tom Baranowski, PhD1 Participants: Richard Coshott,2 Ilja Michaelis,3 Pier J. M. Prins, PhD,4 and Brenda K. Wiederhold, PhD, MBA, BCIA5,6
October is time for the Games for Health Europe meeting in Amsterdam, The Netherlands. Games for Health Journal would like to highlight exciting developments in games for health in Europe by asking European members of our Editorial Board to comment on what developments they see.
Tom Baranowski: In your opinion, what are the most exciting activities, products, or findings in games for health development and research in your country in the past year? Pier J.M. Prins: In The Netherlands there have been two important events related to the development of serious games for mental heath in the past year: 1. The Landelijk Kenniscentrum Kinder-en Jeugdpsychiatrie (an organization that serves seven major child psychiatric clinics in The Netherlands) has published an e-book on e-health that discusses and presents the various serious games that have been developed in The Netherlands. It also discusses critical issues, implementation and training issues, ethical issues, and economic implications. The book gives a nice view on the current state of affairs. If you want more info on this book, please contact Arielle de Ruijter at [email protected] 2. The Dutch Association for Scientific Research (Nederlandse Organisatie voor Wetenschappelijk Onderzoek) (www.nwo.nl), the largest funding organization for research in The Netherlands, has invested more than 10 million euros to stimulate the collaboration between the creative industries and various scientific disciplines (among others, psychology) to develop serious games. Three proposals from our Department of Psychology of the University of Amsterdam—among others—have received funding (one related to substance abuse in adolescents, one for attention deficit hyperactivity disorder [ADHD], and one for training children in arithmetic).
Ilja Michaelis: I am very excited to see that more and more research projects include health games and that awareness is continuously increasing in the German market. The topic of this year’s gamescom Congress held during gamescom 2013 (the world’s largest trade fair and event highlight for interactive games and entertainment) was game-based learning. There was no particular focus on health games; however, the agenda included several talks about health games. For example, one of the talks was about the beta release of our health game, which treats children with dyscalculia. It was developed on the basis of a research project by the Institute of Psychology at the University of Mu¨nster (Mu¨nster, Germany), which was funded by the German Government. Audience members consisted of many German teachers, who responded favorably to the fact that a fun game for children is based upon the newest scientific research in the field of dyscalculia. Richard Coshott: I am in the very fortunate position of joining the modern exergaming movement with my own company from the early days, and I have seen the sector grow and change (sometimes not for the better) over the last 8 years through the growth of Gamercize. In the past year, since the last Games for Health Europe Conference, there have been significant and exciting developments in the research arena. The growth of research into the largest of the health games genre, exergaming, in the United Kingdom has been a promising development. From a single United Kingdom university in publication we now have three major establishments, notably Coventry University, not only bringing exergames in for scrutiny, but significantly moving past basic energy expenditure studies towards research into
1
Baylor College of Medicine, Houston, Texas; and Editor, Games for Health Journal: Research, Development, and Clinical Applications. Gamercize, Southampton, United Kingdom. 3 Kaasa Health, Du¨sseldorf, Germany. 4 University of Amsterdam, Amsterdam, The Netherlands. 5 Virtual Reality Medical Center, San Diego, California. 6 Virtual Reality Medical Institute, Brussels, Belgium. 2
264
CONTINENTAL PROFILE sustainability and health benefits in practical settings. What impresses me about these modes of study is that the results can be practically reproduced as the methods can be directly translated into exergaming programs. Brenda Wiederhold: At the 18th annual CyberPsychology, CyberTherapy & Social Networking Conference, which was held July 1–2, 2013 in Brussels, Belgium, the Director General of DG-CONNECT, Mr. Robert Madelin, gave the opening Keynote Address. The ICT for Health and Well-being’s Head of Unit, Peteris Zilgalvis, chaired a symposium on new innovations in health and well-being, and Peter Wintlev-Jensen, Deputy Head of Unit, Digital Societal Platforms, chaired a symposium on Europe’s funding programs with participation by Belgian governmental officials as well as officials from the Health and Consumers Directorate General of the European Commission. Juriaan van Rijswijk, Games for Health-Europe, chaired an industry panel, with start-up games for health companies enlightening the audience about the future potential in this area. The Belgian government provides many networking opportunities to allow small–medium enterprises opportunities to meet with funding agencies and larger corporations to disseminate their ideas and possibly team on research and grant proposals. As a small Belgian start-up utilizing games in treatment and training and game engines in software design, Virtual Reality Medical Institute (VRMI) is one such company, headquartered in the Brussels Life Science Incubator on the Catholic University’s Brussels campus in Woluwe Saint Lambert. A joint project with the Brussels Region, the incubator allows advanced technology and healthcare companies access to improved network opportunities. Selected as one of the companies to take part in the June 2013 Belgian Economic Mission to California, led by Prince Philippe (now King Philippe) of Belgium, VRMI was able to brief technology and gaming companies in California and discuss their ongoing work in the areas of behavioral healthcare and rehabilitation. Tom Baranowski: What is the extent of funding in your country for research and development of health games? Ilja Michaelis: There are several research projects, funded by the German Government, that include the development of a gaming component. However, in most cases the game itself is not the focus of the project, it is just a by-product. There is one case, our dyscalculia health game, where the State Government of North Rhine Westphalia funded the development of a health game directly. For the first time, a project was funded where the health game itself is at the center of attention. However, public funding in this area is still extremely low. We are talking about an annual total in the low one digit million euros range. And this is for all gaming projects together not just health games. But a seed has been planted! And we strongly believe that our health game will make an impact and create awareness in Germany. We were already invited to present it at the Bundestag (the German parliament). Politicians wanted to know what was necessary in order to get this type of technology into German schools. There are also several private trusts and foundations that are starting to fund smaller health game projects. These are
265 typically foundations, which were set up to foster research for a particular health condition. Richard Coshott: Funding for exergame interventions has taken a backseat in England owing to the focus on the London Olympics in 2012. Traditional sport has swept up the meager recession-hit opportunities, and tradition in the United Kingdom is measured in thousands of years, delaying changes in thinking for a relatively new medium for physical activity. We do, however, have an increase in participation in exergaming as a sport, through both my own Gamercize (and other United Kingdom companies) tournament events. I think we are a long way from having exergaming as an Olympic discipline, but I would never discount it, especially considering the much touted ‘‘gateway effect’’ of our Olympic legacy has not proved evident. Brenda Wiederhold: 2013 sees the end of the FP7 funding program by the European Commission in Belgium. The Directorate General for Communications Networks Content & Technology (formerly known as DG-INFSO) has currently funded products in the technology and mental health area. Six products are developing information and communications technology (ICT)-based solutions for persons with stress, depression, and bipolar disorders, combining new technological solutions with treatment models and multiparametric monitoring. The proposed systems aim to achieve objective and quantitative assessment of symptoms and, in some cases, the ability to predict manic and depressive episodes. Interaction between patients and their clinical providers, as well as a move towards mobile platforms and self-monitoring, is being emphasized. The current ongoing projects are as follows: MONARCA (for bipolar disorders), 3.67 million euros; PSYCHE (for bipolar disorders), 2.91 million euros; ICT4DEPRESSION (for depression), 2.71 million euros; INTERSTRESS (for stress), 3.01 million euros; OPTIMI (for depression and stress), 3.76 million euros; and Help4Mood (for depression and bipolar disorders), 2.82 million euros. This represents a total funding of 18.88 million euros. This year, meetings have begun to introduce the new 6-year funding program, Horizon2020, which will fund new technology and healthcare research from 2014 to 2020. The area of ICT for Health and Well-being under DG-CONNECT will look towards more patient-centric mental health solutions. Tom Baranowski: What is the extent of health game usage in each of these applications: (1) Training of healthcare professionals? Ilja Michaelis: Several clinics are starting to experiment in this area. One example is a serious game to train medical technical assistants. However, so far its use is not significant enough to generate any reliable usage data. Richard Coshott: The National Institute for Health and Care Excellence recently opened its doors to lay members to aid in the consultation for updating guidance in the National Health Service (NHS) exercise referral scheme in the United Kingdom. This opportunity, I would hope, should improve the situation, and although [the subject of ] health games was not initially on the agenda, it is now.
266 Brenda Wiederhold: VRMI uses virtual reality, augmented reality, and real-life mock-ups to train civilian first responders and military medical personnel. Although headquartered in Belgium, VRMI works with other members of the European Union to augment traditional training with advanced techniques. In the new Horizon2020 program at the European Commission, headquartered in Belgium, there should be funding available, as there was in the Framework 7 program, for serious games. It is not that serious games are being showcased, but rather they are very forward-thinking and understand that there are issues/problems that can be addressed by adding advanced technologies to current methods. The European Commission looks towards the ability of new technologies to more cost-effectively and efficiently train and retrain medical personnel. Tom Baranowski: (2) Child and youth diseases and illnesses such as obesity, cystic fibrosis, diabetes, etc. Ilja Michaelis: There are reports and studies conducted in Germany that show that the use of Microsoft Kinect or the Nintendo Wii can reduce obesity in youths. However, these studies are typically based upon existing commercial games, such as Wii Fit. Specific health games are very rare and are primarily used on a research or university level. Thus there is no significant usage in the health system. Richard Coshott: The United Kingdom, in common with most of the Western world, I presume, has yet to fully accept obesity as an illness despite the efforts of independent research groups to highlight the risks. School authorities are motivated by government activity guidelines to reach out to exergaming as an intervention, while the dots are yet to be joined up in common public opinion. Brenda Wiederhold: In 2004, 2005, and 2006, there was an emphasis placed on controlling advertising of high fat-saltsugar food to children, promoting physical activity, and encouraging a reduction of harmful use of alcohol. This was done under the Health and Consumers Directorate General of the European Commission. Since that time, DG-CONNECT has also placed an emphasis on using new technology platforms to communicate to children on healthy and active lifestyles as well as researching both the positive and negative effects new technologies can have on children’s behavior. The Strategic Approach for the European Union for 2008–2013 stated that ‘‘health is the greatest wealth’’ and that ‘‘health is important for the well-being of individuals and society, but a healthy population is also a prerequisite for economic productivity and prosperity.’’1,2 The strategy of European healthcare envisions innovation coupled with new technologies to solve many of our healthcare difficulties from birth to end of life. Tom Baranowski: (3) Rehabilitation for stroke, trauma, Parkinson’s, etc.? Ilja Michaelis: The situation is similar as above. Several solutions are in the process of development as part of research projects. What is interesting is the fact that new technology developments outside of the healthcare or gaming industries
CONTINENTAL PROFILE are being used to help speed up the health game development process. We are in the planning phase to develop a much more sophisticated version of our simple stroke rehabilitation game (‘‘SensoMove’’) by integrating a new and affordable device by Leap Motion. Richard Coshott: The nature of my involvement in health games with my company Gamercize lends itself more towards the moderate to vigorous levels of non-impact physical activity, so I have limited sector knowledge of rehab interventions. Brenda Wiederhold: Multiple projects are funded under divisions of DG-CONNECT, including the Future and Emerging Technologies Program. These solutions include the use of videogames for cognitive and physical rehabilitation. One large-scale program is a European Innovation Partnership on Active and Healthy Ageing that will seek solutions to provide added quality of life years to older individuals using advanced technology solutions. VRMI utilizes virtual reality, videogames, and augmented reality as solutions for cognitive rehabilitation following stroke or traumatic brain injury and for physical rehabilitation following stroke, injury, or amputation. Tom Baranowski: (4) Wellness, including diet management and exercise/fitness? Ilja Michaelis: This area has seen some increased activity in Germany. In particular with regards to fitness and the debut of applicationss such as ‘‘Zombies, Run 2!’’ What particularly interests consumers in this field is that gaming companies are finding new and innovative ways to motivate people who would otherwise not consider diet management or exercise as part of their daily routine. Digital health devices, such as the Mio Alpha Watch, a strapless heart rate monitor, are quickly gaining popularity with early adopters in Germany, but the big breakthrough in gaming is still pending. Richard Coshott: While exergaming met the mainstream media head-on as an inactive children’s intervention, the wider application of weight management and wellness has seen massive growth in the United Kingdom. As our economy picks up we are seeing the competition in workplace wellness as real factors in attracting the most suitable employees. Furthermore, as corporate budgets are still tight, we see value for money and maximizing employee health (and therefore happiness) as emerging business tactics to maximize return on investment. Brenda Wiederhold: As of July 2012, a unit under DGCONNECT, the European Commission, is dedicated to ICT for Health and Well-being. There is an increased awareness on changing the emphasis from a disease model to a wellness model, and more funding emphasis in the areas of health promotion/disease prevention is being supported. The individual citizen is being encouraged to become an active participant in his or her own health and well-being; however, it is realized that the proper resources need to be put in place to allow this to occur. VRMI is currently the dissemination/exploitation workpackage leader on a 3.2 million Euro research
CONTINENTAL PROFILE project, entitled INTERSTRESS, which is developing stress management games fused with physiology on iPads and iPhones to allow individuals to deal with stress anytime/ anywhere. A recipient of the 2012 United Nations World Summit Award in the category of m-Environment & Health, the project was also featured during European Brain Week in Brussels. Tom Baranowski: What is the acceptance of health games by healthcare providers and insurers? Ilja Michaelis: The acceptance among healthcare providers is quite high. In particular, the rehab sector is quite openminded in this regard. Dr. Becker Klinikgruppe, which has eight rehab clinics throughout Germany, is constantly exploring new ways to integrate gaming in all facets of their specialties. At least once a month I receive a call from a doctor asking us whether we would be interested in developing a game for a certain medical condition. Unfortunately, we have to turn down most of them as external funding is hardly available, and in many cases, in particular with rare medical conditions, financing through sales won’t be viable. Richard Coshott: The United Kingdom is lagging behind the United States in this respect, and I predict it will continue to be a minor factor. The reason for this is the free healthcare system that has existed since 1948, which has no limit in terms of quality or availability to the United Kingdom public. Private health insurance is not a significant factor for the United Kingdom as a result, and the NHS is somewhat protected intrinsically from cost constraints at the clinical level. Brenda Wiederhold: Although it is still a small percentage of providers who are actually utilizing games and simulations in their clinical practices, increasing numbers of providers are acknowledging and beginning to embrace the advantages of adding advanced technology solutions to existing clinical protocols to extend the reach and efficacy of services provided. In a recent study we conducted under our INTERSTRESS Project, 75 percent of surveyed behavioral healthcare providers acknowledged an increase in efficacy when using new technologies, and 83 percent acknowledged an improvement in access. While 75 percent also point to the need for training prior to usage, healthcare providers also indicated that patient awareness and system standardization must occur in order for widespread use to become a reality. Respondents also pointed to cost as a current barrier to implementation. Cloud computing was also offered as a possible solution to increase adoption by both healthcare providers and individual consumers.2 Tom Baranowski: Many exciting G4H developments have been identified in Europe by our European Editorial Board members. Those of us attending the meeting in Amsterdam will be exposed to even more! See you there! References 1. Lawton M, ed. Neelie Kroes: ‘Our cloud strategy is not mature.’ September 27, 2012. www.dw.de/neelie-kroes-ourcloud-strategy-is-not-mature/a-16269684-1 (accessed September 27, 2013).
267 2. Wiederhold B. From clinical to cloud. Public Serv Rev Health Soc Care 2013; 35:76–77.
Brief Biosketches Richard Coshott, is the CEO and Founder of the internationally successful exergaming company Gamercize and the Co-founder and Director of the influential advocacy group ‘‘The Exergame Network.’’ Richard’s passion for exergaming was born over 10 years ago, looking for a parental solution to his own two sons becoming unfit playing videogames. After trying many ideas to get them back outdoors, he finally created a solution that worked for them in Gamercize. A company to share this innovation was created, and Gamercize products now sell worldwide. He is a long-term serial gamer himself, recognizing the importance that the immersion of gameplay has to offer exergaming. Ilja Michaelis, the COO of Kaasa Health, with a degree in economics and law, has worked since his graduation in 2001 in different areas related to information technology and health. Apart from being involved in the development of healthrelated software and inline projects, he also manages several research projects funded by the European Union and the German Government.
Piers J.M. Prins, PhD, is professor of clinical child psychology at the University of Amsterdam (The Netherlands) and known for his research in the domains of childhood ADHD and anxiety disorders. He is director of the research program ‘‘Mechanisms of Change and Psychosocial Treatments for Behaviorally and Emotionally Disordered Youth.’’ He has a long record of (inter)national peerreviewed publications in the area of clinical child psychology and childhood cognitive behavioral interventions. Over the past decade, he has been project leader of several large-scale, multisite treatment-outcome projects dealing with childhood ADHD, aggressive behavior, and anxiety problems, and most recently he has been involved in the development, evaluation, and implementation of a computer game (‘‘Braingame Brian’’) to remediate executive functions in children with ADHD and cognitive control problems. Dr. Prins is on the editorial board of Behavior Therapy, Clinical Child and Family Psychology Review, Child and Youth Care Forum, and Games for Health Journal.
268 Brenda K. Wiederhold, PhD, MBA, is a licensed clinical psychologist in the United States and Europe, a professor at the Catholic University in Milan, Italy, and an entrepreneur. Dr. Wiederhold is the CEO of the VRMI in Belgium and the Executive Vice-President of the Virtual Reality Medical Center in California. She completed the first randomized, controlled clinical trial to provide virtual reality (VR) medical therapy for war veterans suffering from posttraumatic stress disorder (PTSD). Her most recent achievement is working with coalition troops to provide stress inoculation training prior
CONTINENTAL PROFILE to deployment. These are in addition to her VR work since the mid-1990s with the civilian sector of patients. She works to inform and educate policymakers, funding agents, and both the scientific community and general public to advance the medical field with technology. Dr. Wiederhold is recognized as a world leader in the treatment of anxiety, panic, phobias, and PTSD with VR exposure and cognitive behavioral therapy, objectively measuring results with physiological monitoring devices. She is the founder of the international CyberPsychology & CyberTherapy Conference, now in its 18th year, and the Editor-in-Chief of the MedLine-indexed journal CyberPsychology, Behavior, & Social Networking. She has given invited lectures on the topic of advanced technologies and health care in 24 countries throughout Europe and Asia and has published more than 150 articles and 12 books on the subject.
