designing

for longterm
decision making
exploring the entanglement
of healthcare options
Designing for long-term Decision making:
exploring the entanglement
of healthcare options
sidney fritts
Submitted in partial fulfllment for the degree of Master of Graphic Design.
May 4, 2010
meredith davis
Committee Chair and Professor
Graphic Design
kermit bailey
Associate Professor
Graphic Design
santiago piedrafta
Head and Associate Professor
Graphic Design
id like to thank
acknowleDgements
Designing for long-term Decision making:
exploring the entanglement
of healthcare options
sidney fritts
sgfritts@gmail.com
Master of Graphic Design
Department of Graphic Design
College of Design
North Carolina State University
how can the structures from game Design
be useD to help recent graDuates make
Decisions about health care?
Planning and managing health care has become increasingly complex, as the old A-or-B
system evolves into an ever-increasing series of options. While there has never been one
solution for all customers, increased tailoring of these services has made understanding
their nuances more diffcult. In the process, consumer education has not kept pace. These
products and services are usually necessary for modern life, so the act of responsible
consumer education also becomes a necessity.
The transition from college to the work force is diffcult for young adults for a number of
reasons. One of the most critical steps is learning to decide, purchase, and manage services
and products that carry long-term consequences. Examples include retirement funds,
mortgages, and healthcare packages. College graduates of today have grown up engulfed by
technology and schooled in interaction. They have spent their free time mastering various
forms of interactive information structures, often in the form of game design. These
structures vary from reward and incentive to social and adaptive interfaces; they prove
successful at gaining young adults attention and training them in the use of complex
systems. The success of the medium has made the game industry larger than Hollywood
in both the time and dollars that this age group spend. I believe that using the structures
of game design to engage users in decision-making about healthcare will create informed,
practiced, and responsible consumers of complex products and services.
In preparation to design a service environment, I researched decision-making, foresight,
intrinsic motivation and game design. Through the process I found three overlapping
principles: autonomy, competence, and relatedness. These became the organizing principles
for an online system that informs and assists young adults in deciding on an appropriate
health care plan.
Autonomy
Competence Relatedness
Project
[fg 1]
table of
contents
assumptions & limitations
the future of healthcare
to the cloud
engagement economy
lost in fow
making decisions
mental time travel
motivating behavior
game mechanics
the current lanDscape
ehealthinsurance.com
nchealthplans.com
aetna beneft adviser
mint.com
artifact
organizing principles
4 compartments
user archetypes
experience map
system explanation
system walkthrough
evaluation
bibliography & literature review
2
3
4
6
9
13
15
18
1
21
22
23
24
25
26
27
30
32
36
59
60
20
1
Assumptions and
Limitations
a few things to keep in minD
this is not a commercial application
I deliberately positioned my project as a system to help individuals make informed decisions
about healthcare, not to sell them a specifc plan or to promote one provider over another.
auDience
I chose recent college graduates as an audience for a number of reasons. First, they are the
frst wave of individuals to have grown up as digital natives, immersed in computers and
interactive technologies. Research has shown that this shapes the way they understand
and approach technology and, in turn, has defned their cognitive processes, to some
extent. Second, they are at a crossroads. They have recently completed a degree program
and are taking on many adult responsibilities for the frst time. Unfortunately, a number
of the decisions they encounter involve topics and legacy systems that are unfamiliar,
complicated, and poorly adapted for their patterns of interaction and learning.
Digital Natives
Individuals who have grown up in
the digital world using technology
as a way to communicate, record,
educate, and understand society.
2
genetics existing conditions health insurance lifestyle prevention
Health
Proactive Reactive
which is
obtained through
Diet
Fitness
Profession
Upbringing
Avoidance
which is
Responsibly Managed
Unknown
Ignored
Government
Employer
Self Purchased
can be
Any activity undertaken by
an individual who believes
himself to be healthy for
the purpose of preventing
or detecting illness in an
asymptomatic state
The way a person lives.
a pattern of individual
practices and personal
behavioral choices that
are related to elevated or
reduced health risk.
A pathological condition
caused by an absent or
defective gene or by a
chromosomal aberration.
Also called hereditary
disease, inherited disorder.
Any personal illness or
health condition that was
known and existed prior to
the writing and signing of
an insurance contract.
which is
The Future of
HealthCare
from reactive to proactive
can be
[fg. 2] A gradient of health behaviors
3
clouD
you
ban
{boDy area network}
environment
{preexisting}
Body Area Network
The network of devices you
carry in or on your person that
communicate with one another.
boDy area network
I have placed genetics, pre-existing conditions, health insurance,
lifestyle and prevention on a spectrum of health from reactive to
proactive based on my understanding of various aspects of health. In
the United States, healthcare typically revolves around reactions to
acute treatment. Moving forward, the power, control and responsibility
is expected to shift from the doctor being the gatekeeper towards
collaboration between patient and doctor.
As we carry more powerful technological devices with us, our Body
Area Network (BAN) becomes increasingly able to measure, present,
and transmit data about our lifestyles and behaviors. This condition,
along with increased awareness of our genetics and environments,
provides users/patients with the tools to work with doctors in managing
an active lifestyle and preventative health care. Emphasis is on daily
routines and prevention while physicians serve as educators and
coaches. This project acknowledges the shift in emphasis towards
lifestyle and prevention.
to the
cloud
ubiquitous monitoring
[fg. 3] Connecting to the cloud
4
Over the past few decades, traditional media (television, radio, print) and advertising
have accelerated the electronic competition for individuals attention. Americans have
been happy to sit idly and gorge themselves on entertainment and information as these
technologies for consumption spread across our cultural landscape. The amount of time
spent watching television has ballooned to over two hundred billion collective hours a year
(Shirkey 2008: Gin, Television, and Social Surplus). Author of Here Comes Everybody, Clay
Shirkey believes that the sitcom has functioned as a heat sink for the past few decades,
masking a cognitive surplus that has grown as our modern lifestyle has expanded free
time. More recently the rise of interactive media, social networks, and open source projects
have allowed users to produce and share as well as consume information. In the process, we
have entered an era of experimentation with social and interactive outlets as our society
discovers how to use our cognitive surplus as an asset (Shrikey 2008).
Under these new circumstances, it is no longer enough to attract viewers attention. Instead,
experiences compete for users engagement (McGonigal 2008, 2). Engagement is defned
The Engagement
Economy
Heat Sink
An outlet for excess energy, in this
case for excess cognitive output.
Engagement
Activating an individuals cognitive
cycles or interactive bandwidth.
Heres something four-year-olds know: A screen
that ships without a mouse ships broken. Media
thats targeted at you but doesnt include you may
not be worth siting still for. Those are things that
make me believe that this is a one-way change.
Because four year olds, the people who are
soaking most deeply in the current environment,
who wont have to go through the trauma that
I have to go through of trying to unlearn a
childhood spent watching Gilligans Island, they
just assume that media includes consuming,
producing and sharing.
Shirkey 2008
the fight for cognitive cycles
5
as activating an individuals cognitive cycles or interactive bandwidth (McGonigal 2008,
2). The engagement economy is deeply rooted in emotional impact and rewards activities
that produce positive emotions; feelings like accomplishment, curiosity, and camaraderie
(McGonigal 2008, 12). New ways to augment traditional media have successfully leveraged
the active participation that the web has enabled. Popular shows such as LOST weave
incredibly complicated narratives that users dissect, discuss, and diagram online. These
serve as cognitive aids, and without them, fewer individuals would be able to follow the
multiple plot lines.
Other intellectual properties have taken it even further. The Matrix story unfolded in three
movies, but was feshed out and expanded by other media including comics, animated
flms and video games that covered other periods of time and other areas of the fctional
world. While each could be enjoyed on its own merits, its fans were rewarded with a better
understanding of the world of the Matrix as they explored extended media.
Further, modern game design shows itself capable of retaining a players attention. On
April 15, 2010, Electronic Arts, one of the largest game publishers around the world, joined
the Fortune 500 list. There are over 11 million monthly subscriptions to World of Warcraf
alone, not to mention millions of other gamers participating in other games on and offine.
World of Warcraf is a Massively Multiplayer Online Role Playing Game (MMORPG) in which
users advance their characters through common everyday activities, such as harvesting
crops, as well as slay foes in teams. Why are these players spending time and money on
a subscription service that includes a number of activities they would not do in the real
world? First, it serves as a cognitive heat sink, or an outlet for pent up cognitive energies.
Second, they are in the pursuit of fero, or immediate pleasure from success (McGonigal
2008, 12).
In order to provide users with the potential to achieve fero, designers must juggle user
competency and diffculty during an interactive experience. This sets up a stimulus-
reward loop, pulling in players through increasingly diffcult tasks by consistently
paying off their effort with positive feelings (Lazarro 2004, 3). Donald Norman and Jane
McGonigal have directly compared this to Csikszentmihalyis concept of fow.
Fiero
Italian for the immediate
pleasure from success.
Flow
The state of happiness we
experience when we are fully
engaged in an activity.
6
lost
in Flow
low
high
boredom apathy
worry
anxiety arousal
fow
control
relaxation
high
c
h
a
l
l
e
n
g
e
skills
Experimental psychologist Mihaly Csikszentmihalyi proposed fow, or
optimal experience, as the state of happiness we experience when we
are fully engaged in an activity. Donald Norman explains it best: In the
fow state, you become so engrossed and captured by the activity being
performed that it is as if you and the activity were one: You are in a
trance where the world disappears from consciousness. Time stops. You
are only aware of the activity itself. Flow is a motivating, captivating,
addictive state (Norman 2004, 48). In order to achieve fow,
Csikszentmihalyi illustrated an ideal matching of skill and challenge
throughout an experience. If too far removed from this sweet spot of
interaction the experience could deteriorate into boredom or anxiety;
neither of which can sustain engagement.
While it is easier to achieve and maintain fow during experiential
cognition, letting the external stimulus pull you in, it is also possible
during the refective mode. Flow during refective cognition is more
the task at hanD
[fg. 4] Diagram of Flow
7
self-controlled and, therefore, internalized and less dependent on external stimulus
(Norman 1993, 31). The enemy of fow is distraction. Distractions can be external or
internal, a phone ringing or daydreaming; any stimulus or thought that can pull the focus
away from the activity at hand. We should not confuse fow with isolated thought; instead
we should think of it as a series of small task leading to the successful completion of a
specifc activity.
Telescoping, a term used by media author Steven Johnson, describes a state when users are
conscious of multiple objectives at multiple levels, and is an effective form of multitasking
(Johnson 2005, 54). While traditional multitasking involves multiple unrelated activities
such as listening to music, surfng the web and writing a paper, telescoping is about
managing a hierarchical order and a necessary sequence of events to achieve a desired
outcome (Johnson 2005, 55). The video game Zelda is used as an example to illustrate this
concept. While the goal is to complete the game, there are a number of smaller tasks that
must be completed in a loose sequencesuch as fnding specifc weapons, increasing the
characters abilitiesthat are all working towards the larger goal of completing the game.
Will Wright, developer of popular and open-ended games such as Sim City and the Sims,
adds some additional conditions to creating an interface that provides the conditions for
fow. He describes advancement ladders, or learning curves, that involve incremental
increases in diffculty throughout the duration of play as small steps with visible potential
for success and progress. It is also important for the consequences of failure to be low. This
provides a safe environment for experimentation and allows the players to test the limits
of the simulated world. Limiting the consequences of failure, and the disruption failure has
during the interaction, should make it easier for players to reach and sustain fow over the
long term.
Some requirements for fow are built-in goals, feedback, rules and challenges (Norman
1993, 33) which are found as core principles in interactive media. Knowing the rules, limits,
and objectives for both short and long-term play allows players to navigate the complexity
of modern interactive environments. Normans discussion of fow presents clear design
Telescoping
Being aware of both short and
long-term objectives simultaneously.
8
principles that are necessary for the interface to be effective. These include a layout free
from other distractions found on the typical PC desktop, a progression of information that
moves into increasingly complex details or options, and a focus on individual activities
inside the frame of a larger task. The interface itself needs to be dynamic and encourage
initial participation with a stimulating display and feedback. Through a steady progression
of information that requires more skill to meet the challenge, software design can pull the
user into a refective state that allows him/her to think deeply about a decision.
The current presentation of health care plans and options focuses on what customers can
and cannot do or have. This is a one-dimensional perspective on a complex system that
does not fully illustrate the give-and-take relationship between coverage, cost, and other
conditions. By expanding the representation to include goals, feedback, and challenges
consistent with approaches to games, designers can help users engage with the information
by achieving fow. Then users can participate in their own healthcare choices, engage in the
process of deciding what tailored choices will be best for them, and make long-term choices
that work towards their long-term goals.
9
Daniel Kahneman and Donald Norman have both proposed explanations for our cognitive
processes during decision-making, relating outcomes to intuition and deep reasoning.
I prefer Normans terms experiential and refective cognition, as he links them to the
use of designed products. Experiential cognition happens automatically and seems
effortless; it is the thinking behavior of experts. Refective cognition, on the other hand,
requires concentration and more effort to focus than does experiential cognition. Skilled
experiential thinking can occur, but only after a certain expertise has been gained and
an individual is able to pull, subconsciously, from his/her experiences. While neither
experiential nor refective cognition is superior to the other, each is appropriately suited
for certain tasks. The design and delivery of information infuences the way we approach
decisions (Norman 1993, 27) and the amount of cognitive effort we exert. Most digital
environments require that young adults multi-task and skim, so design intervention is
necessary to engage users in deep refective cognition during a task that might not seem
immediately enjoyable or an ideal use of ones time.
Decision-Making
A refective cognitive activity that an
individual goes through involving the
comparison and evaluation of options.
Experiential Cognition
Thinking is automatic and seems
efortless; it is the thinking
behavior of experts.
Refective Cognition
Deep reasoning, and analytical.
Often aided by external artifacts.
making
decisions
frames & references
10
Expected utility theory was an early model of the decision making process which predicts
an individual will make a rational decision by evaluating and selecting the option with
the highest utility, when utility is defned as the most ideal end-state. Prospect theory, a
descriptive model of the decision-making process proposed by Amos Tversky and Daniel
Kahneman, modifes the previously used expected utility theory to account for reference
dependence and loss aversion (Tversky, Kahneman 1981, 453). Reference dependence
explains that decisions are contextually based on gains and losses, while loss aversion
asserts the human tendency to avoid loss at high cost. While prospect theory emphasizes
short-term emotional outcomes (Kahneman 2003, 706) over the long-term rational decision-
making that is favored by expected utility theory, we know that people do not always make
rational decisions. With an audience accustomed to immediate gratifcation, incorporating
short-term thinking as a step in long-term planning provides a well-paced model for more
effective decision-making.
Prospect theory refers to positioning something as either a gain or loss through framing,
the frst part of the decision making process. The way a prospective option is framed will
prime an individual for a specifc approach or mindset toward that option. An individuals
frame is also affected by details in the description that initially may seem irrelevant or
superfcial, such as the order in which they are described or variations in word choice.
Effects of various framing strategies on the decision process have been observed by
researchers, We use the term decision frame to refer to the decision-makers conception
of the acts, outcomes, and contingencies associated with a particular choice. The frame that
a decision-maker adopts is controlled partly by the formulation of the problem and partly
by the norms, habits, and personal characteristics of the decision-maker (Tversky 1981, 1).
Typically, individuals most readily available approach is often diffcult to break away from,
which is why it is referred to as bounded rationality. Framing occurs for acts, outcomes, and
contingencies and can occur independently or concurrently with adjacent decisions. While
for the sake of cognitive effciency it is often easier for an individual to evaluate an option
independently, a holistic perspective will most likely shift the evaluation of acts when the
effects are measured concurrently. Contingencies, or various possibilities that could occur
affect the outcomes, are also accounted for. We are predisposed to favor and heavily weight
Expected Utility Theory
When faced with a choice, a rational
decision-maker will prefer the prospect
that ofers the highest expected utility.
Prospect Theory
A two-phase model of the decision-
making that accounts for reference
dependence and loss aversion.
Reference Dependence
Decisions are based on gains and
losses, not fnal outcomes.
Loss Aversion
The observation that out-of-
pocket losses are much more
distressing then foregone gains.
Framing
The way an option is approached and
understood.
Bounded Rationality
An individuals default frame or
approach to evaluating options in
the decision-making process .
11
options that reduce or eliminate risk from the equation. Outcomes are measured against a
pre-existing state. It is either better or worse, more or less, etc By reframing something,
it is possible to completely shift the perception of an outcome. To restate an advantage as a
disadvantage is one of the simplest examples of shifting our frame.
Framing has shown that perception is reference dependent, or refective of the contrast
between two states of a stimulus. Perceptual systems are incredibly adapted to enhance
the accessibility of changes or differences, and change triggers emotions that can affect
behaviors (Kahneman 2003, 706). Reference dependence places the decision process in an
individuals current context or situation and shifts the concept of utility from the outcome,
such as total wealth, to the amount of change, or gains and losses, a decision will incur.
Loss aversion is an observation that out-of-pocket losses are much more distressing than
foregone gains (Kahneman, 2003, 703). For example, if you had a 20% chance in a wager
for $10, the concept of reference dependence states you would be much more inclined to
place the bet than if you had $100 instead of $15 because the loss would be less signifcant in
relation to your total wealth.
As complex services often touch many facets of our lives, it seems rational that we evaluate
them from a holistic perspective. However, the opposite is most likely true. The complexity
of these decisions is often overwhelming and in the process, individuals tend to judge them
in isolation from adjacent decisions and consequences. While this compartmentalization
reduces the cognitive load, it also limits the ability of the decision-maker to account for
greater effects across the board. Losses are more heavily weighed than gains and are
refected in the way, a difference between options will loom larger when it is framed as a
disadvantage of one option rather than as an advantage of the other option (Tversky 1981,
456). In order to provide the most well-rounded and informative system, it is important to
allow the user to decide what is his/her preferred frame and then provide alternate frames
to expose unforeseen consequences.
Health is commonly discussed in abstract terms and as generic states of being healthy
Accessibility
The ease with which particular
mental contents come to mind.
12
or unhealthy, in shape or out of shape, etc. By comparing the benefts and consequences
concretely to an individuals current physical state, and positioning them as gains or losses,
it should be possible to assist individuals in making better decisions about healthcare.
Furthermore, by breaking these decisions about gains or losses into necessary steps, we
can also help individuals achieve the goals they have decided are important in the long-
term. This approach presents an opportunity to show relational shifts in states, not just an
abstract goal or number.
The number of options, personal history and perceived consequences all impose pressure
on the decision maker and affect the outcome. In The Paradox of Choice author Barry
Schwartz details the effects that increased options have on our decision making process.
While individuals usually believe they want as many options as possible, research has
shown that once they reach a specifc threshold they are overwhelmed and either abandon
the task, or go with a default solution (Schwartz 2004, 8). Schwartz also identifes two
primary types of decision makers, satisfcers and maximizers. Satisfcers are individuals
who settle for something that is good enough and not worry about the possibility that
there might be something better (Schwartz 2004, 78). Maximizers on the other hand seek
and accept only the best after a thorough evaluation process (Schwartz 2004, 77). When
designing environments for long-term decision-making, it is important to understand that
rational evaluation is easier said than done and management of cognitive stress on the
user is necessary to avoid them abandoning the task. The discussion of prospect theorys
effects on an individuals refective cognition illustrates specifc problems with the display
and manipulation of tools designed to help in these situations. This discussion provides
principles for designing and presenting information for decision-making.
Satisfcer
Individuals who setle for
something that is good enough
and not worry about the possibility
that there might be something
beter. (Schwartz 2004, 78)
Maximizer
Individuals that seek and
accept only the best after a
thorough evaluation process.
13
Throughout an average day an individual is greatly served by the ability to recall past
events and project future outcomes for even the smallest of behaviors. From minor choices
about what we want to eat to how fast to drive, anticipating outcomes shapes the decisions
we make and the behaviors we exhibit. Professors Thomas Suddendorf and Michael
Corballis have framed their discussion of foresight as mental time travel, or the human
ability to project themselves backwards in time to re-live, or forwards to pre-live, events
(Suddendorf 2007, 299).
mental
time travel
present
future past
serve as building blocks for
episodic
experience become less concrete the further from present you go
episodic
must present a signifcant
share of their emotional
impact to infuence the
episoDic emotions
[fg. 5] Mental time travel
14
Mental time travel is a function of declarative memory, or the part of the human mind that
can be triggered through refective cognition, and can be further divided into episodic and
semantic memory. These episodes are not generic regularities but moments that contain
particularities and emotional weight. Semantic memory is based on general knowledge
or understanding. Knowing that fre will burn you is a function of semantic memory, but
recalling the pain from being burned earlier in life is a function of episodic memory. Past
events, or personally experienced episodes, serve as raw material from which to construct
and imagine possible futures (Suddendorf 2007, 302). By combining and reassembling
these elements in particular ways we are able to emotionally experience future events as if
they were currently happening.
Suddendorf and Corballis go on to discuss the beneft humans gained by developing the
ability for mental time travel. They see foresight as an advantage that provides fexibility
in novel situations and the versatility to develop and adopt strategic long-term plans to suit
individual selected goals (Suddendorf 2007, 302).
George Ainslie, author of Pico Economics, agrees but raises the question of how to interest
the present agent in long deferred prospects (Suddendorf 2007, 313). Most people are
not very skilled at foregoing immediate gratifcation for greater rewards in the end
(Suddendorf 2007, 313). The present self chooses the most rewarding scenario and often
underestimates future gains for short-term satisfaction. By taping into the emotional
resonance of episodic memory, it is possible to provide a more affective future scenario.
This raises a diffcult problem for extended periods of forecasting as the further from the
present, either into the past or future, we mentally travel the less emotional impact it will
have.
Declarative Memory
Memory that can be triggered
through refective cognition.
Episodic Memory
Memory that concentrate on
particularities and emotions.
Semantic Memory
Memory based on general
knowledge or understanding.
15
Most of us can think immediately of activities we enjoy doing, and others that we do
because we have to. Often these two types of tasks are more similar to one another than
we would like to admit and it is only the circumstances or contexts under which the
activity occurs that have changed, not the underlying activity. Deci and Ryan proposed
self-determination theory, a model that differentiates between intrinsic and extrinsic
motivation and their effects on human behavior. Intrinsic motivation describes self-
propelled engagement; described as what someone chooses to do in his or her free time.
Extrinsic motivation, on the other hand, relies on rewards or threats of punishment to drive
completion of a task. Judging from the sheer number of incentives we encounter in a given
day, from coupons, credit card offers, and deals for signing contracts, one would think that
external motivators have proven to be the most effective. While external motivators do
encourage short-term compliance, they actually undermine long-term personal investment.
Deci and Ryan describe the purpose of human behavior as a means for need satisfaction.
Most Americans have achieved reasonable need satisfaction with basic food shelter and
comfort accounted for, and now pursue what they fnd interesting or important. To account
Motivating
behavior
self-Determination theory
Self Determination Theory
A macro theory of human
motivation concerning peoples
inherent growth tendencies and
their innate psychological needs.
Intrinsic Motivation
Self-propelled engagement,
what someone chooses to do
in his or her free time.
Extrinsic Motivation
Relies on rewards or threats
of punishment to drive
completion of a task.
16
for individual taste and interest, Deci and Ryan explain how these affnities have been
shaped by prior experiences of satisfaction or discomfort (Deci and Ryan, 2000, 229). For
example if someone has felt success at frst attempts at painting, he/she would most likely
try again. With this in mind, Deci and Ryan name three fundamental principles found in
intrinsically-motivated activities: autonomy, competency and relatedness.
Autonomy is described as the perception that one is acting on his/her own accord. People
need to feel self directed. We want to feel as though our desires, goals, and actions are self
directed and that we are in control. This is defned as ones perceived locus of causality
(PLOC) and it has a large impact on behavior. PLOC can be either internal or external.
Studies have shown that as when someone is confdent and has an internal perceived locus
of control (I-PLOC) he/she are more creative, cognitively fexible and are better at problem
solving. As the PLOC shifts to a more external perceived locus of causality (E-PLOC), such
as by threats or deadlines, it undermines the feeling of autonomy, confdence and control.
Providing options and acknowledging someones inner experience can provide a sense of
autonomy, I-PLOC and a more engaging experience that feels self initiated (Deci and Ryan
2000, 234).
We all strive to feel competent at the task we set out to accomplish. For instruction on
how to pace an experience for the user we can look back to the earlier discussion of
Csikszentmihalyis concept of fow. By correctly matching our skill with the challenge of
the task, we should feel satisfaction that we are able to complete the task. It is important
Perceived Locus of Causality
An understanding of where control lies.
self - DetermineD
intrinsic
regulation
internal
Intrinsic Motivation
[fg. 6] Spectrum of motivation
17
to remember that we must feel responsible for our success, otherwise our victory will
be undermined by safety-nets, cheating, or too much assistance. In this sense, it cannot
override their perceived autonomy, or it will erode their intrinsic motivation.
Deci and Ryan defne relatedness as the fundamental desire to feel connected to others. This
refects a human characteristic to seek attachment and feelings of security, belongingness
and intimacy with others (Deci and Ryan 200, 252). While relatedness is not as central to
the concept of intrinsic motivation as are autonomy and competence, it still supports these
types of activities. Many intrinsically-motivated activities take place in isolation however,
so it is important to discuss relatedness as a supportive backdrop that an individual
understands. For example, while a child might need to know his mother supports his
artistic endeavors, she does not have to be there in the moment the activity takes place.
Currently, healthcare information and options are presented as a mandatory, utilitarian
choice. This process relies on the external threat of fnes, unforeseen accidents, and their
cost to motivate a user to move through the necessary steps. These can lead to decisions that
were not completely thought through because the user was not engaging in the decision
process. Studies have shown that when users engage in intrinsically motivated activities
they are more cognitively fexible and better problem solvers. Responsible designers can
instill the key factors of intrinsic motivation in an effort to engage the user and allows him/
her to feel invested in the material, choices and outcomes.
Moving into the design phase, designers must ask themselves what would compel a user
to interact with an interface? By combining the discussions of autonomy, competence,
and relatedness, the designer can create a system that matches the available information
in a contextual environment. As the system adapts to the users preferences, information,
and interaction pattern, it can provide enough moments of satisfaction by letting the
user discover specifc outcomes. It is important to return to the concept of perceived locus
of causality and remember that while the user must perceive it is his/her own actions
and outcomes, the designer can shape the experience through pacing, behaviors, and
information.
Relatedness
The fundamental desire to
feel connected to others.
18
Ive already discussed the growth of the game industry and its resonance with my audience,
but what specifc approaches or techniques can assist in the decision making process?
Ian Bogost, a video game theorist, critic and designer, discusses the basic affordances of
digital interaction through his defnition of procedural rhetoric, or the art of persuasion
through rule-based representations and interactions (Bogost, ix). His writings focus on
the potential for video game mechanics to persuade and educate individuals through their
coded rules for interaction. Sim City is cited as a successful demonstration of moving players
through an extended experience. The game tasks the player with creating a functioning
city. Bogost, Johnson and others have discussed the game as a milestone in interaction
design because it builds a nested system of interaction.
At the onset of the game, the player has a few simple controls and must make systematic
choices if his/her city is to survive. Over time, the interface adds layers and complexity as
the system grows to refect the players choices in managing the population and neutralizing
the natural disasters that occur. Through this process, the procedural rhetoric educates
Game
mechanics
Important things when designing
engaging interactions:
5 second feedback loop of interaction
Success and failure are equally important. If
failure can become enjoyable, it will encourage
exploration and repeat eforts.
Importance of metaphorical ideas that focuses
eforts and alludes to predetermined knowledge,
schema and previous episodic memories
A good game gives the simplest set or rules
that provides the widest possible breadth of
experiences. -Will Wright
proceDural rhetoric
Procedural Rhetoric
The art of persuasion through
rule-based representations and
interactions (Bogost, xi)
19
the player on the rules, consequences, and interconnections that develop in the system
as the game progresses. It is remarkable that such a complex, seemingly tedious system
engages, rather than intimidates, the player. Essentially, the player encounters the system
as entertainment, with all the qualities that defne an emotionally engaging experience,
but in the process he/she has laid the groundwork for understanding the basic concepts of
economics, management, and politics. While not an exact replication of real-life municipal
management, it still carries the fundamental ideas of hierarchal interactions that are
important for the player to remember.
As users become more familiar with the patterns of interaction, predictable responses
from the interface are important, while still allowing for surprise, delight and increased
complexity. The ability to facilitate simple functions for the novice, but provide a deep,
nested system for the experienced user, is critical for rewarding interaction. Nested and
context sensitive interactions that walk the fne line between predictable and surprising
offer the strongest experiences for the user and quite possibly a new model for educating a
generation defned by progressive interactions.
In the past, we expected to see how rules of the real world affected the behaviors and norms
of the digital realm. We are beginning to see the effects of a generation that has grown
up with interactive media. Wired magazine recently ran an article on the changes taking
place in the NFL due to the increased role of Madden, the most popular football game/
simulation, on the sport. Incoming players are passing more, better at reading plays, and
learning strategies from the game they grew up playing. The article also recounted a story
of a footballer player running back and forth in front of the inzone to run down the clock,
a popular method in Madden to run the clock down and conquer an opponent (Suellentrop
2010). The give and take of the digital and physical world is going to become increasingly
intertwined as augmented reality allows mobile devices to overlay information in the
environment at any given time.
Types of Player
(Bartle 2003, 130)
Explorers
People who come to see what is there and to map it for
others. They are happiest with challenges that involve
the gradual revelation of the world. They want the world
to be very big, and flled with hidden beauty that can
only be unlocked through persistence and creativity.
Socializers
People who come to be with others. They are the happiest
with challenges that involve forming groups with others
to accomplish shared objectives. They want the world to
have extensive social infrastructure and shared activities:
towns, clubs, arenas, weddings, hunting parties.
Achievers
People who come to build. They are happiest with challenges
that involve gradual accumulation of things worthy of
social respect. They want the world that allows all kinds of
capital accumulation and reputation building. They want
the ability to increase the power of their avatar, to build new
structures, to hoard wealth, and to change the world itself.
Controllers
People who come to dominate other people. They are
happiest with challenges that involve competing with
others and defeating them. Also described as griefers,
they want worlds that allow users to intervene in the
activity of others, so that a record of domination and
control can be established. To them it is all sport.
20
the current
landscape
analysis of current systems
None of these current tools addresses a progression or learning curve as users gain
more knowledge or skill. There are also very few affordances for discovery, relying
on either a complete walk-through or one screen that bombards the users with all the
information at once.
21
ehealthinsurance.com
eHealthinsurance.com is an aggregator that provides comparison and
shopping options among multiple insurance companies based on very
little personal information and a few preferences. It is a for-proft
service, that after an initial test run through their system follows up
with a sales phone call. The initial screen with recommendations is in a
list form that begins with sponsored suggestions at the top. From there,
the user can select up to four plans for comparison. While the task of
comparison-shopping is essential in the decision process, the way the
information is displayed, in long word-based tables, makes it incredibly
diffcult for the user to assess quickly the differences in the options.
[fg. 7] eHealthinsurance.com evaluation
22
nchealthplans.com
NCHealthPlans.com offers similar sorting and comparing options but
was created by Blue Cross Blue Shield NC to browse their available
plans. The number of options and amount of information on the screen
are poorly managed and make it diffcult to assess the benefts of
various options.
Both eHealthInsurance.com and NCHealthplans.com are overwhelming.
They bombard the user with dense text and little concern for the way
individuals understand and compare information. They also base these
recommendations on generic information such as age, gender and
dependents, which doesnt account for the nuances of an individuals
medical needs.
[fg. 8] NCHealthPlans.com evaluation
23
aetna benefit aDviser
Aetna Beneft Advisor makes an effort to walk users through a multi-
modal interaction that relies on conversation-style audio and visuals
to explain details of jargon and the health insurance system today.
While this seems like a more approachable solution, it also becomes
boring very quickly. The slow pace of the interaction makes skipping
information diffcult and digging into specifc topics nearly impossible.
This feels as though it wants to be everything to everyone, but is only
truly viable for the complete novice who needs the basics about health
insurance, and doesnt offer any way to explore deeper.
[fg. 9] Aetna Beneft Adviser evaluation
24
mint.com
Mint.com is a web-based service that pulls in users existing fnancial
information including various accounts, assets, debts and investments
to create a holistic view of the users fnancial state. While this is not
directly related to healthcare, I feel as if this is the closest thing on the
market to the environment I am interested in developing. It manages
the information load on screen well, relying on a humanized aesthetic
and visualizations to explain trends and user habits. It synchronizes
multiple user accounts, which allows refection on the past, present and
future outcomes of ones behaviors.
[fg. 10] Mint.com evaluation
25
autonomy
Autonomy is a crucial factor in the discussion of both intrinsic motivation and game design.
It does raise the design problem of creating an experience that is compelling enough to
elicit initial engagement while sustaining use over time. In the context of deciding on
healthcare, a task that is usually perceived as a burden, I wanted to incorporate the ability
for self-discovery and the ability to dig into relevant information to the specifc moment of
interaction.
competency
By using adaptive structures and advancement ladders, it is possible to lead users through
an interface. In an effort to achieve fow and avoid boredom or frustration, the task and the
skill /knowledge of the user must match. Will Wright has given some guidelines of how to
develop engaging user experiences. These include the speed and scope of the task at hand,
small foreseeable steps and where the user is going.
relateDness
Making an unpleasant decision process refect an individuals current state and future goals
should allow the process to gain some much needed concreteness in a typically abstract
scenario. In order for individuals to feel invested in an activity, they must feel it is relevant
to them. In the context of making decisions about healthcare the interface refect their past
experiences and future goals to encourage refective thinking.
Organizing
Principles
Autonomy
Competence Relatedness
Project
[fg. 11]
26
project
I set out to develop a system that would engage, inform, and assist young adults make
informed decision about healthcare. Building from my research of the trajectory for the
health care industry, I envision a system that approaches the doctor and patient as equals in
a joint endeavor working towards a healthy and responsible lifestyle. This includes, making
informed behavior decisions with information that is generated on the fy, measuring
trends over time as your Body Area Network (BAN) collects data such as heart rate, blood
pressure, insulin levels, etc and proactive measures against genetic predispositions.
While the system is relevant to todays insurance models, it also points a way forward to
where I believe the policies and business models are heading, providing more metrics, self
monitoring, and doctors acting as coaches while still addressing unforeseen accidents. Ive
divided these services into 4 compartments that house various services with the emphasis
on prevention and lifestyle, and/or health management with the primary objective of
preventing chronic illness. According to the Center for Disease Control and Prevention
chronic illness accounts for about 75% of health spending in the United States and with
proper prevention and management techniques, the number of individuals that suffer could
be greatly reduced.
Providing education is an early and
fairly inexpensive way to change
behaviors in the long term. This could
include online resources, in person
classes, and sponsored events.
This includes preventative testing,
preventative procedures and a
litle coaching along the way to
promote proactive solutions to health
conditions and most importantly,
avoiding chronic disease.
As we age it might be necessary to
have a more continuous conversation
with your doctor/provider. Monitoring
allows both the doctor and patient
real time info and aggregation as well
as the Dr. being alerted.
As a last resort or when accidents
happen, there is the traditional short-
term acute treatment.
[fg. 12] The four compartments of healthcare
27
In order to grasp how a college educated young adult understands healthcare and health
insurance I conducted some interviews to help inform the systems structure. I was
surprised to fnd that while most of them understood that healthcare was an important
issue, most did not understand the nuances of insurance plans. I used these interviews to
create four types of users based on Schwartzs two types of decision makers, satisfcers and
maximizers. Reacter and worrier are both satisfcers, while manager and hyper manager
are maximizers. I want to emphasize that the archetype Hyper Planner is not the ideal.
Instead, we are trying to nudge users into the Manager role where change is understood
as a part of life and they are informed and ready to adapt when unforeseen events occur.
user
archetypes
maximizers
worrier reacter hyperplanner manager
Goes with the fow. Stressed about what might
happen.
Adapting is part of the plan. Stressed when things dont go
as planned.
satisfcers
[fg. 13] The four types of decision-makers
28
reacter worrier
kathryn, 22
Goes with the fow.
Kathryn, a graduate student with an undergraduate degree in graphic design,
grew up as the youngest child with two older sisters. The oldest sister is
currently an electrical engineer and the other an accountant. Kathryn traveled
a lot when she was younger and spent the 1st-6th grade living in China. While
there, she only had two television channels in English and remembers watching
the Simpsons, Mash, and Bay Watch. She did have access to a knock-of
Nintendo in the home and a GameBoy that she used while traveling. When Sony
released the Playstation she got one, but didnt play it much. Instead, she spent
her time with analog toys, particularly ones that focused on arts and crafts that
allowed her to build things. She even made clothes for her Barbies. When she
was in high school, her atention shifted to arts and sports, and now she plays
games, such as Guitar Hero, only in a social seting.
She is currently on her mothers health insurance, which is part of a state
teachers plan. She has not dealt with health insurance much but knows it is
necessary and expensive. To date, her biggest health care expense was when
she broke her foot while she was abroad in Italy and needed to have physical
therapy.
She goes about decisions casually, comparing herself to her peers. She might
ask for the advice of her parents or an expert, but she is more likely to follow
her gut or current trends. She loves a good challenge and is comfortable
researching options online. She has an internal perceived locus of control.
aimee, 21
Stressed about what might happen.
Aimee is an undergraduate student who grew up being home schooled with
her litle brother. She took piano lessons and has always enjoyed crafts and
creating things. Her younger brother is an avid gamer and her father, a doctor,
always had Apple computers, and products around the house. She was exposed
to television, computers and video games from an early age and remembers
playing educational games. She and her brother had video game consoles,
which she played but not as much as her brother. Even in the car, they would
watch movies or listen to their iPods. However, her favorite toy was still her
American Girl doll that she thought resembled her.
Shes still on her parents health insurance and because her father is a doctor she
usually goes to him for medical advice. She admits she knows very litle about
health insurance.
She approaches decisions by cross-referencing multiple sources including
friends, family and experts. She has an internal perceived locus of control. To
date her biggest decision was which school to atend and she did most of her
research online before speaking with the department head.
29
ben, 22
Being able to adapt is part of the plan.
Ben is an undergraduate student who was pushed toward reading, achieving
in school, sports, and other outside activities because his parents felt it was the
right thing to do. He seems to have developed a love/hate relationship with new
media. He grew up with an old computer and knew how to type the alphabet
before he could write it by hand. He always wanted a Nintendo but did not get
one until Sony released the Playstation. Most of the games he played were
puzzles or problem solving games. He actually had to stop playing Tetris after a
nightmare of falling cubes.
He has always liked puzzles, challenges and the sense of accomplishment
that comes from completing them. More recently, he has given games such
as the Sims a chance but ended up being more interested in the building and
customizing components. He was even able to fnd a work-around for his high
school network that allowed him and his friends to install and play games
during their lunch break. He deleted his Facebook page because he feels it is a
prime example of how computers do not work as they should.
He is still on his parents Blue Cross/Blue Shield health coverage and has been
lucky enough to never have to really worry about it. Even though he is not
familiar with the ins and outs, he has learned from the news coverage that
healthcare is a necessity and will probably afect his job hunt after school.
He approaches decisions from a methodical standpoint, trusting experts over
friends and family, and realizes that life will happen and plans will shift.
betsy, 27
Easily stressed when things dont go as planned.
Betsy is a graduate student who worked for 3.5 years before returning to school.
Growing up in a health conscious household, she was very aware of her health
habits. Nutrition, exercise, and playing outdoors were always important and
they actually did not have TV for most of her childhood. Her family played
board games including Monopoly and Life. Her exposure to video games
was limited to a few games on a DOS computer system. She used this same
computer system to fake a newspaper with her sister at age 10. She played
Nintendo once at her neighbors house but it did not hold her interest. During
road trips, her parents would use a points system they created to bribe her and
her sisters into behaving in the car.
It was not until high school that she began using computers for communication
and research and remembers being told to be skeptical of online sources.
When it comes to decisions, she prefers expert opinions to peer trends and
advice, but likes to talk through her thought processes with them. She has an
internal perceived locus of control but gets frustrated when things do not go as
planned.
She currently does not have health insurance and knows that might not be the
best decision, but due to the cost, it makes sense while she is in graduate school.
hyperplanner manager
30
Working from the archetypes I created, I mapped and evaluated the users fow through the
system based on motivation and methodology of decision-making and need. After an initial
review, I noticed similarities among users paths and condensed them into the current
system. The goal is to have a fuid environment that shifts seamlessly among various
behaviors.
User
experience Map
Play With Variables
Adjust behaviors and variables to
discover the relationships between
lifestyle and health care
cost/coverage.
Compare It To Market
Compare your targets with available
plans and manage your needs versus
coverage.
Build Profle
Import medical history, build
family connections and synchronize
devices to provide a holistic personal
perspective.
the larger landscape
Creating a system that has fuid isolation of
various parts of the system.
Autonomy
Competence Relatedness
a three part system
[fg. 14] The user experience goal
31
Establish Baseline
Explore Trends
Developing Trends
Locale
Personal
Demographic
Family
Habits
prompt Found Themselves
Without Insurance
Gather Health
Records
Habits
Import Other
Metrics
Family History
Annual
Re-Evaluation
Needs To Switch
Confrm
Explore Options
Tailor
educate on the fly
Context Sensitive
Rollovers & Explanations
Using visual comparisons and change
instead of solid info when possible
About To Age Out
Of Parents Plan
Joins Company
With Health Plan
Monitor
Cross Reference
Concurrent Isolated
Cost Beneft
Macro Micro
Need Want
Specifc Average
Expert Opinion Peers
In process selection and building
Multiple selections lead to
later comparison
Recommendations
Alternatives
Averages
Plans
Providers
Balance
Change
Trajectory
Goals
Optimize
Incentives
Intervene
Coach
Feedback
Progress
Self Monitoring
Adjust Behavior
[fg. 15] The user experience map
32
establishing
a baseline
The point of this area is to build a well-rounded picture of the users health, lifestyle, and
habits in order to provide the most informed interaction throughout the environment. I
have design a digital environment that allows adding, subtracting, and adjusting various
information and behaviors in order to see the effect of your current health habits have on
your health care costs. The system also demonstrates what behaviors the user can change
that would affect costs in the future.
Ive designed this system with the assumption that electronic medical records will be the
norm and widely available. As the user encounters the system for the frst time he/she
is frst asked to input or confrm personal information. Users can pull this information
from services that already hold information, that they would provide their username and
password for, or it could be entered manually. If it is pulled from another source, the user
would be able to confrm and approve all the incoming data.
welcome to the system
Establish Baseline
Gather Health Records Habits
Import Other Metrics Family History
[fg. 16] Baseline options
33
An individuals genetics can be a wonderful indicator of predispositions to specifc
conditions. Family history and genetic screenings are two ways users have access to this
information. Users are prompted to build out a family tree. This too can be pulled from
previously held profles (such as digital medical records or Facebook) or constructed
manually. The system is a dynamic environment that allows repositioning, additions, and
edits. 23 and me is one genetic testing service currently available, and this too can be added
to the system, allowing the users personal genetic profle to be included.
I felt it was important to include other information that the user
might generate. More of our personal habits are being calculated
and stored. These can be through recreational devices such as
Nike+ and Wii Fit, or from more deliberate medical devices such
as Internet connected glucose monitoring systems. The scope of
physiological activity that can and will be measured by small,
always on devices, is set to explode over the coming decade. It is
realistic to predict that even nutritional habits might be monitored
without direct input from the user.
The fnal interaction would be to indicate any personal habits that
are not being measured but have proven to affect an individuals
well being. This could be smoking, drinking, and high-risk
activities such as skydiving. I tried to provide an environment that
prompted the user for specifc information while alluding to other
areas that the user could manually input.
By addressing the needs and wants of the user, I mapped a system
that shifts fuidly among areas of exploration and information.
Privacy and the Digital Native
There have been a number of articles and discussions that atack the
increase in personal information published online. Myspace, Facebook,
Twiter the list goes on. All of these services ofer means to disclose
thoughts, activities, and social connections to a nearly infnite number of
people. The disclosure decision model assumes that people decide what
personal information to reveal, how to reveal it and to whom based on
an evaluation of the rewards and risk. (Palfrey 2008, 24) In the context of
young people posting personal information online the most likely expected
rewards involve social approval, intimacy, and saving time or money.
Young people view these virtual outlets as extensions of their physical
lives. During this adoption of digital media, new social norms based on
reciprocity have been established. In this sense, young people willingly give
up personal information, understanding that by doing so they will beneft
from others sharing and posting as well.
Appropriate understanding of the risk and management of online identity
can augment threats from an online presence and increase the benefts of
shared metrics in a digital culture.
34
options
and trends
Once the user has established a baseline moving among options, trends,
and tailoring for the market is the primary activity. I want the users
to explore the give and take of healthcare systems, learning to adjust
and maximize their options and cost. It is important that they dig
deeper into specifc topics and industry jargon on the fy, telescoping
into a defnition or example in the current state of the environment.
This is intended to provide users with context-sensitive information
and just enough relevant information for their skill levels. In the
process this should help provide them with the sense of a self-directed
experience, appropriate to the competence level and relevant to their
particularities.
From my research and interviews it was apparent that the ability to
compare and cross reference options and trends visually was important
for users reach a decision.
37
Establish Baseline
Explore Trends
Developing Trends
Locale
Personal
Demographic
Family
Habits
prompt Found Themselves
Without Insurance
Gather Health
Records
Habits
Import Other
Metrics
Family History
Annual
Re-Evaluation
Needs To Switch
Confrm
Explore Options
Tailor
educate on the fly
Context Sensitive
Rollovers & Explanations
Using visual comparisons and change
instead of solid info when possible
About To Age Out
Of Parents Plan
Joins Company
With Health Plan
Monitor
Cross Reference
Concurrent Isolated
Cost Beneft
Macro Micro
Need Want
Specifc Average
Expert Opinion Peers
In process selection and building
Multiple selections lead to
later comparison
Recommendations
Alternatives
Averages
Plans
Providers
Balance
Change
Trajectory
Goals
Optimize
Incentives
Intervene
Coach
Feedback
Progress
Self Monitoring
Adjust Behavior
user experience map
[fg. 17] Trends, options, and cross reference map.
35
options
I wanted to sub-divide these into the four buckets visuallyeducation, prevention,
monitoring, and treatmentin an effort to contain their respective services. Knowing
that decisions are reference dependent, visual representations need to distinguish clearly
among various parts and between losses/gains relative to the users current states or goals.
These options include providers, plans, recommendations, and alternatives.
trenDs
Like options, I wanted the exploration of trends to be easily accessible to the user. First, I
wanted users to explore personal trends, and project into the future how certain behaviors
and decisions could affect their long-term well-being and their cost of healthcare. The
metrics that have been established and linked while creating users baseline would provide
up to the minute visualization of personal data. Human memory is fawed, by including
visual representations of behaviors and metrics the system can help individuals refect
throughout the decision process.
Seeing oneself in relation to a peer group or demographic is another useful frame that
could infuence decisions. Areas for comparison include family alerts and trend in family
health patterns or information related to locale. Locale may trigger widespread increases
of specifc conditions in the population, outside of the users immediate family. For example
if the air quality in the users city caused respiratory infections, the user would know to be
wary of specifc symptoms.
cross referencing
The cross referencing area is really where everything comes together. In combining
the information and selections in the other environments, the procedural rhetoric is in
place, and allows the user to make adjustments of goals and the necessary service level. It
allows a seamless environment for tailoring needs, projecting effects and evaluating cost
comparison and service options in the open market.
36
system
walkthrough
kathryns experience
37
Kathryn comes to the site after realizing that she is on the verge of aging out of her
parents plan. Her initial contact with the site gives her options to log in or create a profle.
She selects create a profle and begins. The screen pans, leaving some navigational
information in place while the digital environment shifts to accommodate the task.
nc+unuiuc uscn:
Logln cnco+c o vnoriLc
rins+ +inc:
Healthcare is complicated.
This site is designed to help manage your healthcare
decisions and records. It presents you with healthcare
options for the coverage that is best suited for your needs.
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
[fg. 18]
38
She is given the options to pull her data from preexisting profles or to enter the information
manually. Considering that she already has an eHealthRecord with a prominent company,
she imports the information and enters her login and password.
Add Existing Accounts
With just a little information we can pull your medical
records from your eMedical Records. Just tell us the
company that host your info and your login info. Youll be
asked a few questions as we import your data.
cHcnicoL Rcconns
username
assword
mall
slometrlc Y N
svuchnouizc
Kathryn Smith

ksmith@gmail.com
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
[fg. 19]
39
While the system synchronizes information in the background, she is asked to approve
basic information to ensure that the system is collecting the right fles. As she approves
them, her detailed medical history fades in.
cHcnicoL Rcconns
Username
Password
Email
Biometric?
svuchnouizc
N
Kathryn Smith

ksmith@gmail.com
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
is voun uonc ko+hnvu aunv sni+h:

[fg. 20]
40
Kathryn now has her medical history displayed and is able to explore peer trends.
1985

chiLnhoon oncsi+v
nnokcu roo+
oLLcncics
snokiuc
hich oc+ivi+v LcvcL

5 10 15 20
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
Peer Trends
Your
Tobacco
Use
Medical
History
Obesity
Rates
Activity
Level
Below is the information we found in your records.
Feel free to explore your metrics and trends. Turn on and o
your peers measures or zoom out and look at the trajectories
of particular personal behaviors.
[fg. 21]
41
She turns on tobacco use and activity level to look at the average trends for
her age group.

1985

nnokcu roo+

hich oc+ivi+v LcvcL

5 10 15 20
Peer Trends
Your
Tobacco
Use
Medical
History
Obesity
Rates
Activity
Level
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
Below is the information we found in your records.
Feel free to explore your metrics and trends. Turn on and o
your peers measures or zoom out and look at the trajectories
of particular personal behaviors.
[fg. 22]
42
She then zooms out to have a view of a longer timeline which includes an interactive
trajectory that refects specifc changes in behavior relevant to her records that can impact
her health care cost and coverage.

quoLi+v
or Lirc
hcoL+hconc
uccn
1985

5 10 15 20 25 30 35 40
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
Explore how shifts in your behavior can have
long-term eects.
ull down a tab to see how lt adjusts your wellness trajectory.
[fg. 23]
43
After Kathryn has fnished exploring her personal trajectory and peer trends she moves on
to build her family connections.
+

aovcc
nin+hnov : .)._(
nin+hnov : .)._(
nin+hnov : .a._
Double check the lamlly members weve ulled lrom
your le. Add any that mlght not be shown.
Build your family connections.

conL
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
[fg. 24]
44
Her sister Susan was missing from the data, so she selects + sibling and flls out
information to search for her.
+

aovcc
nin+hnov : .)._(
nin+hnov : .)._(
nin+hnov : .a._
Double check the lamlly members weve ulled lrom
your le. Add any that mlght not be shown.
Build your family connections.

conL
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
onn o sinLiuc
Are you mlsslng
a slster or brother
Name
eHall
slrthday
sconch
susan smlth
ssmlthggmall.com
o_]a]8a
slster
Brother
[fg. 25]
45
Susan is added and the family connections are confrmed.

non
nnn
cnnntr
susnw
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
Double check the family members weve pulled from
your le. Add any that might not be shown.
Build your family connections.
[fg. 26]
46
Kathryn is prompted to consider how much information she wants to share with her family.
She uses the slider to select some which provides general metrics and medical results but
omits overly personal details from specialist doctor visits unless authorized.

How much information do you want to
share with your family?
occcss LcvcLs
sc+
Syncs your personal metrics and general medical results.
Omits visits to specialists unless you authorize the information.
uouc sonc
cvcnv+hiuc
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
[fg. 27]
47
After her family data has been imported, a few fags were found throughout their medical
histories. These concerns are shown with information pulled from Kathryns records and
three important health items are highlighted. She could consider these items in making
proactive decisions about her future healthcare needs.

1985

nnokcu roo+
oLLcncics
snokiuc
hich oc+ivi+v LcvcL

5 10 15 20
Some ags went up showing some trends and
histories that might be able to help plan your
health management.
Breast Cancer
Both your grandmother and your
aunt were diagnosed with breast
cancer. We recommend frequent
screenings for early detection.
Childhood Asthma
We noticed that you seem to have
recovered from your childhood
asthma. If youve experienced any
symptoms within the past year
please let us know.
Smoking
Smoking is a proven health hazard.
Consider your options to see the
eects this behavior has on your
healthcare costs and needs.
chiLnhoon oncsi+v
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
5 10 15 20
[fg. 28]
48
Kathryn continues and answers some simple questions about her lifestyle. As she answers
the questions the bar on the left adjusts to show her base level insurance cost and optional
costs which can be infuenced by lifestyle choices.
Now a few questions about your lifestyle.
some hablts can have a large lmact on your health and the
cost ol healthcare coverage.
now many drlnks do
you have a week
Tobacco?

Diet? Fitness?
s_
so
sa_
+onocco
$2500
_
noscLiuc
nou+hLv
cos+ or
covcnocc
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
[fg. 29]
49
After answering questions about her lifestyle, Kathryn moves to an area where she can turn
behaviors off and on to see how they affect the cost of her healthcare, how they shift the
balance among the four components of health, and what to expect as a monthly premium,
deductible, co-pay, and out of pocket expense.
Adjust the various variables to create an ideal
balance of services and cost.
s_
ou+ntv vnciu
sa_oo

o%
-
so,ooo
--
s_
$30
sa

s)
oLcohoL
$2500
noscLiuc
nou+hLv
cos+ or
covcnocc
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
kee an eye to the rlght to see what turnlng lllestyle behavlors
on and o wlll do to the balance ol your healthcare lan.
[fg. 30]
50
covowcw+s
or ncnt+ncnnc
4
Education is an early and fairly inexpensive way to change
behaviors in the long term. This could include online resources, in
person classes, and sponsored events.
Prevention includes testing, procedures, and a little coaching
along the way to promote proactive solutions to health conditions
and most importantly, avoid chronic disease.
As you age, conversations with your doctor are more important.
Monitoring alerts the doctor to conditions that need immediate or
continuous attention.
As a last resort or when accidents happen, there is the traditional
short-term acute treatment.
Kathryn zooms in to learn more about the four components of health care packages and
what is included. Comfortable with the amount of information she has been given, she
zooms out and continues.
[fg. 31]
51
so
ou+ntv vnciu
sooo

o%
-
so,ooo
--
s_
sa_
$2500
so
+onocco
$17

noscLiuc
nou+hLv
cos+ or
covcnocc
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT TREATMENT
Adjust the various variables to create an ideal
balance of services and cost.
kee an eye to the rlght to see what turnlng lllestyle behavlors
on and o wlll do to the balance ol your healthcare lan.
She continues to explore the give-and-take of lifestyle choices, costs, and coverage.
[fg. 32]
52
$3500
nou+hLv vncniun
ncnuc+inLc
$1500
$5000
$2500 $2500
sa_
s(o
s6o
soo
s8o
sao
s(o
so_
s(o
s_
s_
$30

noscLiuc
nou+hLv
cos+ or
covcnocc
$17

s_
covoucu+s
or ncnt+ncnnc
4
EDUCATION
PREVENTION
MONITORING
TREATMENT
After deciding that she wants to compare her baseline to what is available on the market she
is shown four recommended plans.
[fg. 33]
53
$3500
nou+hLv vncniun
ncnuc+inLc
$1500
$5000
$2500 $2500
s)
s(o
s6o
soo
s8o
sao
s(o
saa
s_)
sa
s_
$30
covoucu+s
or ncnt+ncnnc
4
noscLiuc
nou+hLv
cos+ or
covcnocc
s)
oLcohoL
sa

EDUCATION
PREVENTION
MONITORING
TREATMENT
She still has the ability to turn lifestyle choices on and off to see how the market cost
responds, as well as the balance of the coverage.
[fg. 34]
54
$3500
nou+hLv vncniun
ncnuc+inLc
$1500
$5000
$2500 $2500
s(o
s6o
soo
s8o
sao
s(o
s_
EDUCATION
PREVENTION
MONITORING
covoucu+s
or ncnt+ncnnc
4
noscLiuc
nou+hLv
cos+ or
covcnocc
s)
saa
s_)
sa
$30
s)
oLcohoL
sa

TREATMENT
Kathryn selects treatment on the right in order to compare the treatment coverage of the
various plans.
[fg. 35]
55
$3500
nou+hLv vncniun
ncnuc+inLc
$1500
$5000
$2500 $2500
s_
s(o
s6o
soo
s8o
sao
s(o
so_
s(o
s_
s_
$30

EDUCATION
PREVENTION
MONITORING
TREATMENT
covoucu+s
or ncnt+ncnnc
4
noscLiuc
nou+hLv
cos+ or
covcnocc
$17

s_
She continues to explore the plans and their coverage in relation to her baseline cost and
lifestyle choices.
[fg. 36]
56
$3500
nou+hLv vncniun
ncnuc+inLc
$1500
$5000
$2500 $2500
s_
s(o
s6o
soo
s8o
sao
s(o
so_
s(o
s_
s_
$30

EDUCATION
PREVENTION
MONITORING
TREATMENT
covoucu+s
or ncnt+ncnnc
4
noscLiuc
nou+hLv
cos+ or
covcnocc
s)
oLcohoL
sa
[fg. 37]
57
s_oo
nou+hLv vncniun
ncnuc+inLc
$1500
$5000
$2500 $2500
$135
s(o
s6o
soo
s8o
sao
s(o
so_
$140
$95
s_
$30

EDUCATION
PREVENTION
MONITORING
TREATMENT
covoucu+s
or ncnt+ncnnc
4
noscLiuc
nou+hLv
cos+ or
covcnocc
s)
oLcohoL
sa
She makes a fnal decision for the coming year and selects a moderate plan. Her decision is
confrmed visually.
[fg. 38]
58
covoucu+s
or ncnt+ncnnc
4
trfntcs
a urvtcrs

trnfs
a fnrNus

After completing her selection she is zoomed out to a macro view where she can dive back
into any areas she feels she wants to continue exploring or to adjust any information.
[fg. 39]
59
evaluation
of artifact
looking back
The three organizing principles that I established at the onset of this projectautonomy, competence and
relatednessserved as successful ways to frame and approach the problem of long-term decision-making.
As an iteration, the artifact Ive created serves as a safe environment for the exploration of the myriad of
healthcare options as well as a cognitive aid to manage individual health, lifestyle and goals into the decision-
making process for healthcare.
The psychological principles of accessibility, reference dependence and framing, allowed me to display
information at various levels of complexity, allowing the user to zoom in and out of details in an intuitive
manner. The discussion of fow became increasingly important as I carried out my research and I was able
to plan a context-sensitive system that caters to the novice and expert alike. By allowing users to drill down
further into information, there are affordances of self-direction and discovery. I believe I created a system that
provides an enjoyable experience for many different user levels. By leveraging detailed personal information,
the experience is also relevant and concrete in comparison to the systems typically found in current healthcare
information.
When I chose to use video games as a departure point for my research I knew I wouldnt create a game. Instead
I set out to incorporate the intuitive training and just-in-time learning structures that I fnd useful in engaging
the next generation. Procedural rhetoric and telescopic thinking were the most literal contributions of video
games, but there are other aspects of games in the fnal iteration. Concepts such as comparison and competition
are represented in the evaluation of the users position against family and a peer group helps account for the
various process individuals go through while framing and making decisions. Throughout the environment Ive
established an internal logic and consistent norms that allow users to develop a familiarity with the behaviors
of the system with increased use.
60
literature
review
bibliography & literature review
culture
Castranova, Edward. Synthetic Worlds: The Business and Culture of Online Games. London:
The University of Chicago Press, 2005.
Discusses the infuence interactive media has on our behavior and norms in the real world and economic
impact these systems are having as they account for an increasingly large portion of economic activity.
Jenkins, Henry. Convergence Culture: Where Old and New Media Collide. New York: New York
University Press, 2006.
Analysis how stories, brands and experiences are woven through out multiple media channels. He uses
the Matrix as an example of singular experiences can build as users encounter more media points.
Johnson, Steven. Everything Bad is Good for You: How Todays Popular Culture is Actually
Making Us Smarter. New York: Riverhead Books, 2005.
Looks at the positive efects increased complexity and intellectually challenging
experiences have created through various media. Goes on to defne telescoping
and discuss how video games are shaping the way we learn and think.
61
McGonigal, Jane. Engagement Economy: The Future of Massively Scaled Collaboration and
Participation. Institute for the Future, 2008.
Frames a discussion of how video games ability to engage users is a result from cognitive and emotional
reward structures and how fow is used to maintain user engagement. She goes on to discuss the
importance of leveraging games as a way to get users involved in solving real world complex problems.
Palfrey, John G. and Urs Gasser. Born Digital: Understanding the First Generation of Digital
Natives. New York: Basic Books, 2008.
Provided a look into the diferences between digital natives and previous generations perspective
and cognitive abilities. Specifcally the discussion on privacy and identity was infuential.
Shirky, Clay. Here Comes Everybody. New York: Penguin Group, 2008
Shirky, Clay. 2008 Gin, Television, and Social Surplus. Here Comes Everybody Blog, entry
posted April 26, 2008. http://www.herecomeseverybody.org/2008/04/looking-for-the-
mouse.html (accessed Januray 20, 2010)
Discussed the concepts of cognitive surplus, heat sink and the benefts
of seeing the rise of user production as an advantage.
Decision making
Ariely, Dan. Predictably Irrational: The Hidden Forces that Shape our Decisions. 1st ed. New
York, NY: Harper, 2008. <http://www.predictablyirrational.com/>.
Provides a behavioural economist perspective on the irrational tendencies decision-
makers exhibit and includes psychological studies that help illustrate these trends.
Kahneman, Daniel. A Perspective on Judgment and Choice. American Psychologist 58, no.9
(September 2003): 697-720
Ofers a comprehensive discussion on framing, accessibility, reference dependence
and loss aversion in the context of the decision-making process.
62
Norman, Donald A. Emotional Design: Why we Love (Or Hate) Everyday Things. New York:
Basic Books, 2004.
---. Things that make Us Smart: Defending Human Attributes in the Age of the Machine.
Reading, Mass.: Addison-Wesley Pub. Co., 1993.
Norman ofered perspectives on the way users cognitively approach designed objects and
the signifcance of design details. He discusses how these details can afect use, atraction
and engagement with a product. He also defnes refective and experiential cognition.
Schwartz, Barry. The Paradox of Choice: Why More is Less. New York : ECCO, 2004.
Ofered a summary of the decisions facing individuals to day and how they
cope with the amount of choice available. His discussion included much more
approachable interpretations of the concepts Kahneman proposed.
Suddendorf, Thomas and Michael C. Corballis. The Evolution of Foresight: What is Mental
Time Travel, and is it Unique to Humans? Behavioral and Brain Sciences no.30 (2007):
299351
Defned and described mental time travel and a proposed many reasons for how and why humans
developed the ability to do so, which include the advantage to predict outcomes of actions.
Tversky, Amos and Daniel Kahneman. The Framing of Decisions and the Psychology of Choice.
Science 211 no.4481 (January 1981):453-458
An account of the psychological principles that afect the perception of prospects
throughout the decision-making process and their afect on the outcome.
63
game Design
Bogost, Ian. Persuasive Games: The Expressive Power of Videogames. Cambridge, Mass.: MIT
Press, 2007.
Argues for the procedural rhetoric inherent in the afordances of interactive
media and the ability for these to present compelling arguments.
Csikszentmihalyi, Mihaly. Flow: The Psychology of Optimal Experience. New York: Harper &
Row, 1990.
Proposes the concept of fow and describes the conditions for which one reaches and sustains fow.
Salen, Katie, and Eric Zimmerman. Rules of Play: Game Design Fundamentals. Cambridge,
Mass.: MIT Press, 2004.
Salen, Katie. The Ecology of Games: Connecting Youth, Games, and Learning. Cambridge,
Mass.: MIT Press, 2008.
These two books ofer an over view of games, game structures, and game
classifcation as well as aligns them with concepts of learning.
Suellentrop, Chris. Game Changers: How Videogames Trained a Generation of Athletes. Wired
Magazine Febuary 2010 http://www.wired.com/magazine/2010/01/ff_gamechanger/
(accessed February 23, 2010)
An article discussing the afects growing up with video games,
specifcally Madden, has had on athletes in the NFL.
other
Centers for Disease Control and Prevention. Chronic Disease Overview page. http://www.
cdc.gov/nccdphp/overview.htm. Accessed April 6, 2009.