Flagships – ETP 2014 · 2018-11-14 · FLAGSHIPS – ETP 2014 Date February 16, 2015 Author(s) Marieke Klaver and Robin de Haas - Cyber Security Anja van der Hulst - Applied Gaming

FINAL REPORT FLAGSHIPS 2014

FINAL REPORT FLAGSHIPS 2014

Corporate Staff Schoemakerstraat 97 2628 VK Delft P.O. Box 6005 2600 JA Delft The Netherlands www.tno.nl T +31 88 866 00 00 F +31 15 261 24 03

TNO report

FLAGSHIPS – ETP 2014

Date February 16, 2015 Author(s) Marieke Klaver and Robin de Haas - Cyber Security

Anja van der Hulst - Applied Gaming Ernst Meijer - Smart Cities Ivana Bobeldijk - Innovation in Healthcare

Editor Koen Wapenaar Copy no No. of copies Number of pages 47 (incl. appendices) Number of appendices Sponsor Project name Project number All rights reserved. No part of this publication may be reproduced and/or published by print, photoprint, microfilm or any other means without the previous written consent of TNO. In case this report was drafted on instructions, the rights and obligations of contracting parties are subject to either the General Terms and Conditions for commissions to TNO, or the relevant agreement concluded between the contracting parties. Submitting the report for inspection to parties who have a direct interest is permitted. © 2015 TNO

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Contents

1 Introduction ..................................................................................................................... 3

2 Management review ........................................................................................................ 5

3 Cyber Security ................................................................................................................. 9

3.1 Cause and objective .......................................................................................................... 9

3.2 Flagship Cyber Security: Enabling technology project and results ................................. 10

3.3 Outlook 2015 and beyond ............................................................................................... 16

4 Applied Gaming ............................................................................................................. 17

4.1 Cause and objective ........................................................................................................ 17

4.2 Enabling technology project and results ......................................................................... 19


5 Smart Cities ................................................................................................................... 27




6 Innovation in Healthcare .............................................................................................. 36




7 Signatures ...................................................................................................................... 47

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1 Introduction

In TNO, it is believed that knowledge, developed in specific niches, always has a potential for broader application areas. Mid 2012 the former TNO Bestuursraad discussed what (high potential) topics would transcend and link various research themes, thus providing TNO with a strong and unique position within the European arena and enabling an orchestrating role in the Grand Challenges. A set of criteria was decided on, so as to make a selection of ideas possible. This set contains the following items (a) a recognized societal need, (b) a potential breakthrough, (c) a favourable position for TNO and finally (d) a business plan for implementation in TNO roadmaps. In due course four subjects, called flagships that could accelerate innovation efforts, were identified: Cyber security The Stuxnet and Diginotar incidents and digital attacks on energy companies or Lektober have demonstrated their disruptive effects on society. ICT disturbances might also have a direct physical impact e.g. the untimely closure of traffic lanes and tunnels or payment systems. Cyber security aims at decreasing risks and upgrading the robustness of ICT infrastructures by combining risk and security management, human factors and cyber crime experience. Applied Gaming The gaming industry in the Netherlands is creative and successful. For gamers who are looking for fun and enjoyment, there is certainly no shortage of entertainment games produced here. Simultaneously, a growing number of gaming companies are active in the field of applied games. Applied games are widely used for training and education, but they are also key enabler of business- and behaviour transformations that are in the core of complex system transformations. Compared to entertainment games, applied games have different requirements in terms of design. Whatever the purpose of a game – training, education, behavioural influence, empowerment, or decision-making on complex issues – the designer must make sure its design and content are ‘fit for purpose' and that is has been proven effective. Hence, there must be “Transfer of Gaming”. Smart Cities The objective is to provide an integrated methodology for smart city solutions. This entails a comprehensive approach that connects strategic, tactical and operational aspects of a smart city. Strategic decision making concerns urban planning and policy making; tactical concerns dedicated projects, living labs, and R&D programs, and operational deals with everyday operations, such as traffic management and maintenance of infrastructures. Also it is a system’s approach that connects the domains of a city: energy, governance, environment, mobility, social and physical quality. The methodology consists of ICT, decision support tools, knowledge based systems.

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Innovation in Healthcare The current healthcare system is considered to be unsustainable in terms of costs. A new integrated approach is needed aiming for a new balance between health outcomes, quality of care and costs, both at the population and individual level. Many actions are being taken by the stakeholders (government, health insurers, healthcare organizations) to control these, but a more fundamental transformation is needed. A systems transformation is needed in which the healthcare system shifts the current focus on disease and cure towards a new focus on health and behavior. This requires the adoption of a new definition of Health (Huber e.a.: the ability to adapt and self-manage in the event of social, physical and/or emotional challenges) and the implementation of this concept in new processes, incentives, systems, responsibilities and organization structures. Here we propose a vision (P4 Health) and an approach to arrive at sustainable innovations in healthcare combining technological and social innovations.

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2 Management review

Cyber Security : For the governance of the Cyber Security Flagship a steering committee with representatives of the TNO themes and expertise areas has been established: Information Society Erik Peeters (Chair) Defense, Safety and Security Ida Haisma Energy Richard Beekhuis Mobility Paul van de Avoort Defense, Safety and Security Kees d’Huy Behavioral Social Sciences Eric Veldkamp Technical Sciences Saskia Vlaar The committee discussed the project plans for the work streams which covered knowledge development, market/business development, communications, ETP Cyber Security and the Cyber Security Lab, and monitored the progress of the work streams and the flagship project. Integrated Performance management showed track of order intake and revenue realization. In addition, progress and outlook has been presented to the Management Board and formal decisions on Innovation budget and go/no-go were taken by the Management Board. In order to align in an optimal way with the new foreseen organization of TNO and a cost reduction target, the Flagship Cyber Security was terminated at the end of 2013. As of November 2013, the flagship propositions were embedded within the theme Defence, Safety and Security as a project. The efforts in 2014 were aimed at consolidating the achieved results of the Flagship by extending the collaboration with the universities and with main stakeholders in the cyber domain and by developing tools that combine areas of expertise from both the technical and the organizational perspective. The results of these efforts are shown by the newly developed Shared Research Program in close collaboration with the financial sector, and five new collaboration projects that were developed in the NWO call on Cyber Security Research (refer to 3.2.3). Each of these projects shows a close collaboration between universities, public and private organizations, and TNO researchers. The results of the Flagship activities have been integrated fully in the newly developed TNO roadmap Cyber Security and Resilience (CS&R) . This roadmap will build on the Flagship results by focussing on further extending the eco-system in the cyber domain, in close collaboration with universities, public and private organisations and the law enforcement community. Applied Gaming For the governance of the Applied Gaming project a management board with representatives of the TNO themes and expertise areas has been established: Expertise Peter Schulein (chair) Information Society/Networked Information

Eric Fledderus, Henk-Jan Vink

Work and Employment Paulien Bongers Defense, Safety and Security Henk Geveke Mobility & Logistics Michiel Jak

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The management board has convened 2 times in 2014. The board monitored the progress, discussed the project results and the strategy for the follow-up in 2015 and further. In the period 2013- 2014, the Applied Gaming Flagship established its role as enabling technology-provider both internally and externally. Internally to the different themes/transitions within TNO, externally to partners in academia, industry and government. Within TNO, the AG Flagship generated presence by providing several Master-classes both at beginners and advanced level, briefings at the various TNO locations and by providing assistance to business development on acquisition and proposals. External to TNO, industrial parties were reached by means of Master-classes tailored to specific branches of industry and a substantial series of dedicated briefings (see section 4.2). New connections to academic institutions were established, e.g. by providing support to the development of the first Master track in Applied Gaming in the Netherlands, by supervising master theses on AG design or validation (7 total) and by providing guest lectures to the main Dutch universities that run gaming courses (UU, TU Delft, UvA, VU, Tilburg U, and the Amsterdam University College). In the international arena, 2 international awards were won (Engagement game and Gaming for Sudan programme).12 scientific publications (partially) funded by the Flagship Programme were accepted with several more under review, 5 invited talks were held and more than 10 researchers contributed to international conferences, frequently with new international relations and leads as result. With regard to knowledge development, significant steps were made to further the knowledge on Transfer of Gaming, i.e. AG Design and Validation. The so called Goal Design Alignment Framework for AG Design was developed and tested in 2013 in a 120 hour pilot and validated in 2014 within a 100 hour trial with 25 Game Study Master students. The framework is now part of the theoretical basis of the master programme Game Studies at the UvA and being applied increasingly in externally funded design projects. A Framework for AG Validation was developed and tested within 7 externally funded validation studies (Bakhuys-Roozeboom, Visschedijk and Oprins, under review). In 2014, AG Validation framework was finalised (Oprins e.a., under review). An Applied Gaming Lab was completed and this lab is since then considered a very valuable asset in generating presence in the field. The developments of the Flagship Applied Gaming have been consolidated in a Value Center Applied Gaming (VCAG) with a number of external partners from industry and academia. Underlying this collaboration, a letter of intent between TNO, the “Hoge School voor de Kunsten”(HKU), and the Dutch Game Garden covering cooperation in strategic research on Transfer of Gaming. Further development of the VCAG is partially funded by the long term (2013-2016) stimulation programme Growing Games of the Economic Board Utrecht. Within TNO, 3 themes and a programme (IV, Healthy Living, Mobility(logistics) and Network Information) have agreed to fund the further development of the field of Applied Gaming. Hence, we will continue to act as an enabling technology-provider to the different branches within TNO and to our partners in academia, industry and government and expand our presence in the field. Smart Cities For the governance of the Smart Cities project a steering committee with representatives of the TNO themes and expertise areas has been established:

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Built Environment Dick Schmidt (chair) Information Society Eric Fledderus Mobility and Logistics Leo Kusters Energy Suzanne van Kooten Healthy Living Niek Snoeij Behavioural Social Sciences Peter Schülein Earth, Environmental and Life Sciences Diederik Zijderveld The steering committee has convened four times in 2013. The committee discussed project plan, overall vision and strategy of the flagship project, monitored the progress and approved the plan for 2014. In addition, progress and outlook has been presented to the Management Board three times in 2013. Formal decisions on budget and go/no-go were taken by the Management Board. In 2013 the project focused on a modeling approach for integrative metropolitan solutions and started with an approach for enabling collaborative decision making. In doing so, the project combined existing TNO expertise on subdomains of the urban system and combined it with operation research. This resulted in an integral model-based approach of the complex urban system, which is unique. Most, if not all, smart city initiatives focus on a specific subset of the city (for instance the energy or mobility system), or the ICT aspects of smart city concepts. Another novelty is the enablement of decision-making, while most smart city concepts focus on optimization. The model-based approach has been supplemented with an innovation process tool that supports in selecting the most suitable innovation model with corresponding questions and checks. First results have been presented at the “Innovatie Estafette 2013” and were well received. In 2014 the project focused on use cases in corporation with external parties. The rationale of this approach was to validate the tools, developed in 2013 and to tailor them to specific (market) needs. The use cases were: • Smart Policy Making Delft: Developing and maintaining a smart program for municipalities.

A collaboration of TNO, Municipality of Delft and Min. IenM. In a meeting of B&W of Delft with the TNO Board, Delft expressed their contentment with the TNO Smart City approach and their intention to continue the collaboration.

• Towards a circular economy of Almere. A data flow observatory to establish waste flows and economic activities. A collaboration with Almere and Big Data Value Centre Almere. Currently continued in a direct B2B project.

• Smart Infrastructure Management Almere. Making infra management smarter: decision making based on big data, not only looking to costs, but also to socio-economic value. A collaboration with Almere and the Economic Development Board of Almere. Follow-up is intended, project proposal is under development.

• Mobility Dashboard Rotterdam. Smart mobility operations for ‘s Gravendijkwal Rotterdam in order to meet air quality regulatory requirements (NO2 / PM normen) and optimal traffic flows. Continuation in a direct B2B project.

• Towards a Smart City Operating System: A smart city operating system needs to be scalable and flexible, and should be able to connect to independent ICT systems. The approach was demonstrated for smart lighting in a building. Continuation in EU Artemis project ACCUS.

• App for air quality. Citizen involvement is crucial for successful smart city approaches. RIVM, DCMR, and special interest groups such as Longfonds and Milieudefensie are

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struggling with citizen involvement. We developed an air quality app to demonstrate potential and pave the road for new initiatives. Continuation in B2B project for RIVM.

The results are well-received by the various stakeholders of the use cases. In fall 2014 TNO has reorganized and created a new line Smart Cities (Program Director Kees d’Huy).. The outcomes of this flagship project are adopted by the new program line. Continuation is therefore established within a VP program. One of the objectives was to start shared value centre “Smart City Plaza”; a place where stakeholders meet to jointly work on smart city solutions and where TNO provides the necessary tools and methods. As such this has not been established yet, however we have contributed to several start-ups that have the promise to grow to such a value centre: TNO is partner of the Amsterdam Institute of Advanced Metropolitan Studies (AMS), Knowledge Centre Healthy Urban Living (KC HUL) and the partnership of TNO and Almere is centred around Smart City approaches. Innovation in Healthcare For the governance of the Innovation in Healthcare project a steering committee with representatives of the TNO themes and expertise areas has been established: Healthy Living Niek Snoeij (chair) Healthy for Life Nico van Meeteren Prevention Work & Health Paulien Bongers Food & Nutrition Peter van Dijken Flexible Free Form Products Jaap Lombaers Innovation High Tech Systems Egbert-Jan Sol Information Society Berry Vetjens Close alignment has also been established with the Enabling Technology Programs Systems Biology, Innovation and Behavior, and the respective steering groups. The steering committee convened on a quarterly basis and reviewed financial and scientific progress. Biannually, the executive team reported to the managing directors of Healthy Living, Industrial Innovations and ICT. The original goals of the Flagship Innovation in Healthcare were to develop a scientifically sound vision and strategy to drive innovation in the healthcare system. The healthcare system is a complex multi-stakeholder environment where each stakeholder has specific interests that do not necessarily contribute to improvement of the system as a whole. The nature of this transition requires a multidisciplinary approach where technical innovation needs to go hand in hand with social innovation in order to achieve any improvements in the ecosystem. The Flagship has conducted research how these innovations need to be interconnected and has developed a scientifically sound vision that has allowed the Theme Healthy Living to acquire and conduct innovative projects that fit within the vision of the Flagship, leading to innovation in Healthcare. This has led to tangible new approaches, interventions and tools that will be developed further in the strategy period 2015-2018 within the Theme Healthy Living.

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3 Cyber Security

Marieke Klaver and Robin de Haas

3.1 Cause and objective

Information and Communication Technology (ICT) is playing an ever more important role in our modern societies. Many of the critical infrastructures such as electricity, water management, and transport, use ICT as an essential element in their main processes. In addition to the large benefits of the increased use of ICT, this also poses some threats to society.

Serious disruptions and attacks on the ICT infrastructures may have a major impact on society. The following types of malicious cyber activities can be distinguished that drive societal cost: • The loss of intellectual property. • Direct financial loss from cybercrime. • The loss of sensitive business information (such as negotiating strategies), including

possible stock market manipulation. • Opportunity costs, including service disruptions, reduced trust online, the spending

required to restore any “lead” from military technology lost to hacking, and the realignment of economic activity as jobs flow out of “hacked’ companies.

• The additional cost of securing networks and expenditures to recover from cyber attacks. • Reputational damage to the hacked company1.

These drivers and the opportunity to strengthen the proposition of TNO, led to the initiation of the Flagship Cyber Security. The combination of different technologies, markets and propositions makes TNO uniquely positioned to capitalise and expand its Cyber Propositions, both with respect to impact and revenue in the upcoming period. The Cyber Security domain is so broad and so closely connected, that close collaboration with all stakeholders is required. The flagship has therefore put a lot of effort in establishing a close collaboration with the main actors in the cybersecurity domain, both with public and private organisations, e.g in the context of the National Cyber Security Research Agenda (NCSRA) and in collaboration with the Hague Security Delta (HSD).

1 THE ECONOMIC IMPACT OF CYBERCRIME AND CYBER ESPIONAGE Report Center for Strategic and International Studies July 2013

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3.2 Flagship Cyber Security: Enabling technology project and results

3.2.1 Main research lines The flagship activities started by identifying the main technologies needed. In order to strengthen TNO’s technology position in the area of cyber security, a number of knowledge focus areas were identified.

From these focus areas a selection was made of three topics in which TNO’s technology position should be strengthened in the Enabling technology Project Cyber security: • monitoring and response: to develop methods and tools to detect advanced cyber attacks

by using anomaly detection, • modelling and simulation: develop models and tools to analyse the impact of cyber attacks

in complex chains and networks of critical infrastructure, • facts, figures and economics: collecting data on the current status of cyber security and

analysing new modes of operation. In 2013, the Enabling Technology Project (ETP) was focussed on extending each of these separate technologies which led to the following results: • a new method for sensor fusion for detecting Advanced Persistent Threats, • the development of an open and integrated modelling environment for modelling

infrastructures, • an analysis of information on parts of the dark web, including the discovery and analysis of

over 5000 anonymous market places. Each of these research lines has led to follow-up activities (refer to section 3.2.7).. In 2014, the Enabling Technology Project focussed on integrating two of these technologies in the context of a Security Operation Centre (SOC). A SOC is a relatively new organisational element that monitors cyber threats within the own organisation’s networks and organises the response to these threats.


In addition to optimising the performance of these SOCs, much benefit can be gained by collaboration between SOCs. This collaboration may lead to a better situational awareness on threats and risks involved. For this increased level of collaboration, a common understanding is needed of SOC operations, the tools and processes involved and the main challenges. All of these aspects should be covered not only from a technical but also from an organisational perspective (including people and processes). The ETP covered the following research lines: • Assessment of the SOC tools and systems: SOC tools and systems are rapidly

developing. There is no generally accepted method to assess the capabilities of the tools. A method to assess these tools supports organisations that want to develop a SOC for their own networks in choosing the tools that are most useful for their own organisation.

• Models in support of assessing SOC processes: in support of the SOC processes, it is important to assess the possible impact of possible ICT disruptions, and to evaluate the impact of different response actions.

3.2.2 Results of the ETP project in 2014 As a starting process for an assessment SOC tools and processes, a classification was made of the main capabilities and functionalities of a SOC. Capability Function Information Exchange Communication medium Incident info exchange automation Incident message exchange format interoperability Management reporting Internal documentation Vulnerability Management Vulnerability relevance classification Vulnerability severity classification Vulnerability impact classification Vulnerability reporting Monitoring and detection Level of incident detection Level of host based incident detection Level of network based incident detection Event correlation …. (11 other functions) Incident Response Automatic response malware Internal ticketing system Incident analysis Forensics malware analysis File detection Automatic incident investigation

For each of these functions, different levels of maturity were described. 1 Baseline – the standard level 2 Best Practise: the level used by most organisations 3 State of the Art: the best level that can be used 4 Future Tech: new and innovative approaches used by the top organisations


The levels were described based on experiences with the assessment of SOC tools in a benchmark that TNO performs yearly for ETIS, the international IT Association for Telecommunications. For each of the SOC functions identified, the levels of maturity were described for the specific functions. As an example we show the description for information exchange Information exchange incident information exchange automation Baseline tool can export shareable information Best practise tool can export shareable information in common format State of the art tool can export and automatically share information Future Tech This model was used to assess several tools and systems to show the benefit of the approach. The results were integrated into an Excel based database, that assesses the main SOC tools to maturity levels for the capabilities and functions. In order to assess the processes in the SOC, a simulation model was developed. Based on the main SOC capabilities and functions, the main processes were modelled in a System Dynamic based simulation environment, AnyLogic.

By modelling the impact of both cyber threats and SOC interventions on the ICT infrastructure and on the critical business processes, the model provides tools to evaluate the possible impact of ICT disruptions and to assess the impact of possible courses of action. The model contains sub models of the following components: - Company model: this model contains the following components

o Primary business processes of organisation. � Service: the business process is represented by one or more services that

are provided.


� Performance Indicators that provide an evaluation of company performance. The performance indicators are typically linked to the business processes for example via the quality of service.

o IT/communication infrastructures that are required for the business processes. o SOC Model consisting of detection and recovery capabilities. These capabilities

influence the impact of the threats and incidents. - Threat scenario / Alerts: Threats or incidents that have an impact on the infrastructures

and therewith on the business processes. - Time: the model should be able to run scenario’s. - Sensitivity analysis: the model should be able to run many times in order to analyse the

impact of system parameters for instance operator skills and availability, intrusion detection capabilities, repair time, etc.) on performance indicators (i.e. affected number of services and business processes).

This figure depicts the top level view of the SOC Operation Centre model. This model consists of various processes in the workflow. The processes are modelled in separate building blocks: • Internal and external alerts (the upper left blocks) • Alerts are passed on to the IntakeAlerts process • After that they go to SelectIntakeAlertHandling that decides whether the alerts go to

o IncidentMonitoring o AntiDDos o Vulnerability_monitoring

• When the alerts are obsolete and the cyber attack is mitigated, they go to their final stage in the workflow where statistics on the SOC process is collected (for instance the end-to-end delay):

By changing the main parameters of these processes, the model is able to show the impact under varying threat conditions of the way that the SOC operations are organised. Both the assessment of SOC tools and the process models will be used to strengthen the knowledge position of TNO in the evaluation and benchmarking of monitoring architecture and


SOC organisations. This research topic will be further developed in the TNO applied research programme under the top sector HTSM (“VP Security”) and in the research programme in support of the Ministry of Security and Justice (“VP Veilige Maatschappij”). These follow-up activities will be performed in close collaboration with the SOC working group of the “Centrum Informatiebeveiliging en Privacy (CIP)”. This working group is a public-private collaboration between the following organisations: CIP, Capgemini, Hewlett-Packard, CAK,

UWV, DJI and TNO.

3.2.3 Collaboration with universities and follow-up projects The complexity of the cyber security domain requires close collaboration between all research organisations. Therefore, the ETP project also had the objective to intensify the contacts and interaction with universities that are active in the cyber domain. For this task prof. dr. Pieter Hartel, a professor of Information Security and Crime Science of the University of Twente, was appointed at TNO as a liaison with the scientific community. In the past year steps were taken towards a more close collaboration with Dutch universities, with a focus on the University of Twente and the Technical University of Delft. One of the instruments for this is a new collaboration model for structural cooperation of TNO and the NWO Cyber Security Research community, the “TNO Cyber Security Cooperation”. This collaboration model has led to eleven project proposals for the NWO call on cyber security research. Of these, five proposals have been granted. All of these projects will combine a close working relation between the PhD researchers and TNO researchers, as well as the use of the Cyber Lab. The projects are: • Security Autonomous Response with programmable networks (SARNET), in collaboration

with the University of Amsterdam, KLM and Ciena; • CRitical Infrastructure Protection Through cryptographic Incident Management (CRIPTIM),

in collaboration with the University Twente and NCSC; • Security requirements for serious Apps (SERIOUS), in collaboration with the University

Twente and Centric; • More secure SCADA networks using self-awareness (MOSES), in collaboration with

University Twente and ENCS; • Patterns for Privacy (P4P), in collaboration with Radboud University. In addition this collaboration has also triggered a research project on financial malware. This research project is a collaboration between the Technical University Delft, VU Amsterdam, TNO, Team High Tech Crime of the national police, FOX-IT and the financial sector ING, ABN AMRO and Rabobank. The NWO research projects are linked closely to the relevant TNO research programmes (VP Security, VP Veilige Maatschappij) and have been integrated in the TNO roadmap Cyber Security and Resilience.

3.2.4 Collaboration with MKB Parallel to the NWO call on Cyber Security, an SBIR-call on cyber security was established. In this call TNO participated actively, which has led to the following proposals: • Innovative (awareness) Toolbox, in collaboration with Infosecure, • Cyber Security Intelligence with Businessforensics, • Cryptovaluta-inlichtingen with Coblue, • Rumour Control (Marktet disruptive social media) with Digital Intelligence, • Cyber Metrics & Insurance with Coblue.


3.2.5 Collaboration with critical sectors The Flagship has identified in an early stage, that Cyber security is of rapidly increasing importance for organisations that are part of Critical Infrastructures. In order to assess the opportunities for collaboration in this area, an initial market study was made of the following sectors: finance, energy, telecom and process control industry. Of these sectors, the most promising opportunities were identified for the financial sector. This has led to the development of a Shared Research Programme Cyber Security, that starts with research focused on the financial sector.

3.2.6 Collaboration with stakeholders in the Cyber Security Lab In order to facilitate a close collaboration with all stakeholders in the cyber domain, TNO has created a secure and trusted environment in the Cyber Security Lab. TNO’s Cyber Security Lab offers highly promising cyber-innovation projects not only its expertise but also the technical facilities and a secure working environment. TNO co-develops innovative solutions with pertinent parties in the CSL to give a pre-emptive boost to digital security and learn lessons from real incidents, focusing not only on the technology side but also on the human, process, organisation and control aspects. In 2014, the location at TNO at the Waalsdorperweg, was extended with a Cyber Security Lab at the Hague Security Delta. This more open environment will make close collaboration with all stakeholders even more easy to achieve.

3.2.7 Follow-up activities Each of the research lines has led to follow-up activities. Follow-up on the research on detection algorithms The research on new algorithms for the detection of Advanced Persistent Threats has led to the following follow-up activities: • CADENCE (EIT ICT Labs): this project will optimise the proposed methods and the CAD

detector for operational use and identify the main opportunities for further exploitation. The project is a partnership with IMDEA (Spain) and Reply Group (Italy);

• A project on Advanced Persistent Threat detection commissioned by the European Defence Agency (EDA): the project aims to specify and implement a proof of concept of a multi-sensor detection framework for APTs. The project is a partnership with the Royal Military Academy (Belgium) and FKIE Fraunhofer (Germany).

Follow-up on the analysis of the dark web The dark web activities have created a large impact with stakeholders. The results have attracted large interest from especially the financial sector and law enforcement. The Dark web research of TNO aims to provide more knowledge on TOR hidden services. Our research results have shown that more than 60% of the content in this dark side of the Internet concerns illegal activities. During the ETP project, already a broad and active community of interest was developed, including organisations from the financial sector and the law enforcement community. The research results have led to several follow-up activities including projects to perform practical research in support of the financial sector, the Openbaar Ministerie (OM) and the Belastingdienst. Furthermore, close collaboration has been developed with Europol and Interpol in Signapore. Follow-up on the modelling and simulation results


The activities on modelling will be further developed in close collaboration with the University of Twente in the NWO research project Moses. The key idea of this proposal is to build process-aware intrusion detection techniques for Smart Grids, which requires, next to state-of-the-art network intrusion detection, an accurate model of the physical processes that can be evaluated in real time. TNO’s contributions will be aimed at validation of the developed systems in the Cyber Lab and evaluation of the impact on cascading failures and on other infrastructures. Furthermore, the simulation framework and CI engine will be used to integrate models of other organisations, such as the Technical University of Delft, and with models from project partners in the EU FP7 project CIPRNet Fraunhofer (Germany), ENEA (Italy) and CEA (France).

3.3 Outlook 2015 and beyond

The Flagship Cyber Security had a focus on cyber security for critical infrastructures. The Flagship activities have led to a closer collaboration with Universities, private organisations with a focus on critical sectors, and the law enforcement community. This has provided a basis for the main follow-up activities in 2015 and beyond. The research on SOCs will be further developed in the TNO applied research programme under the top sector HTSM (“VP Security ”) and in the research programme in support of the Ministry of Security and Justice (“VP Veilige Maatschappij ”). These follow-up activities will be performed in close collaboration with the public-private SOC working group . The close collaboration with the critical sectors, will be further developed in a Shared Research Programme Cyber security . The SRP will initially focus on the financial sector, and contains the following research lines: transaction fraud, monitoring and response, controlled resilience, cyber intelligence and secure transactions 2.0. In a later stage, the energy and insurance sectors will be integrated. The results of the flagship project Cybersecurity have been integrated fully in the newly developed TNO roadmap Cyber Security and Resilience (CS&R). All research lines of the Flagship CyberSecurity are integrated in the product portfolio’s of this roadmap: • Detection & Response, this product portfolio will further develop the methods and tools to

detect advanced cyber attacks by using anomaly detection and will further develop the maturity model for SOC tools;

• Cyber Intelligence, this product portfolio will further develop the methods and tools for the analysis of the dark web.

The Cyber Lab that was established as part of the Flagship activities will be further developed into a Joint Innovation Centre (JIC) at the Hague Security Delta. This JIC will be focused on cyber security for critical infrastructures, starting with the financial and the energy sector. The JIC aims to provide an open innovation ecosystem, where all stakeholders in the cyber domain can collaborate closely in a trusted environment. The location at the Waalsdorperweg will serve as a separate location of the JIC, aimed at activities with a high level of confidentiality.


4 Applied Gaming

Anja van der Hulst


Applied games are a powerful means of intervention in almost every application domain. Applied games are a key enabler of business- and behaviour transformations that are in the core of complex system transformations. Serious Games are now successfully being developed and deployed worldwide and for a variety of applications. Decision-making for Complex societal issues: as a result of the globalization and digitization of society, the complexity and required speed of reaction has increased significantly. The socio-economic issues become more complex with more stakeholders involved in the decision-making which almost automatically entails competition on opposing interests. Decision making in these complex environments requires multidisciplinary knowledge and balancing of disparate effects. Expertise required for the solution of social issues is largely implicit, distributed and difficult to access. Applied gaming offers an approach that is attractive and provides them with a 'safe' environment to jointly find solutions. Applied Gaming provides a practical approach to decision making by experiencing and interaction based on what-if scenarios built on validated underlying knowledge and models. If desired, this can also involve or disseminate to a wide audience. Applications include: environmental and special issues, crisis management, scarce resources, marketing and reputation management, etc. Potential clients are board and management of large private or public organizations, policy makers, special interest groups, International organizations, NGOs, etc. Training and education: In today's complex society highly integrated competencies are essential; strongly linked combinations of knowledge, skills and attitudes acquired in practical application domains. The current school system is based on principles from the last century, mainstream education is still very focused on transferring cognitive theoretical knowledge, and directly on the transfer of application practice, with the result of pupils 'tuning out' and not adequately equipped with required skills. Innovations of the educational system involve alignment of students and trainees with the working practice. Applied Gaming has exceptional potential in this area. The acquisition of competences requires a 'constructivist' approach of exploration and experimentation. The exploration process in the game enables the player to discover new knowledge and develop the required skills and attitudes while being involved by the challenge. Applications include: Training and education of professionals (e.g. government, public safety, offshore, management training, ..), games for schools and educational institutions, manuals for consumers. Potential clients: Executives and Board of Management of public and private organizations, training agencies, industry associations. Participation and Empowerment: The welfare society as we know it today will become untenable due to the macro economic effects of the aging population and the impact of the economic crisis. While government withdraws on many terrains, an appeal is made upon the problem solving skills of the individuals. To participate individuals need to be empowered.


Applied Games support individuals in areas as health care, citizenship, mobility, education and employment to become aware of their situation, and built confidence in their own potential. Applications include: care and rehabilitation, self management in chronic diseases, self-reliance of citizens, vulnerable workers. Potential clients include: healthcare, homecare, reintegration (public private), etc. Market for Applied Games The international market for games is growing rapidly. The latest estimates (source PWC) indicate a global market growth from € 65 billion in 2013 to € 83 billion in 2016. Entertainment gaming forms the bulk of these sales, yet the market share for Applied Games is increasing significantly. Online and mobile games are growing and rapidly taking over the PC and console games. The Dutch gaming market is estimated to show a growth from € 599 million in 2013 to an estimated € 724 million in 2016. The Dutch gaming sector employs a total of some 3,000 people (source TNO). The NL gaming sector is doing relatively well in Europe especially on Applied Games with a remarkable 50% added value by the NL Gaming Sector in NL value (total € 200 million in 2011). The development and deployment of games takes place in the cross-over between the creative industries and application areas. The knowledge developed in the program is therefore both relevant to the gaming industry and the application areas. In the Gaming Industries the knowledge on Transfer of Gaming contributes to the development and standardisation of best practices around game design, game worlds and game validation. Gaming Industries In 2013 the focus of the knowledge programme was strengthening the TNO knowledge position on game design, game worlds and game validation. By the end of 2013 the TNO knowledge position was sufficiently crystalized and developed to start structural cooperation with other knowledge institutes. At the end of that year a Letter of Intent was signed with the HKU to jointly work on Transfer of Gaming. Cooperation with other universities is foreseen. In 2014, within the scope of the Value Center Applied Games and in close cooperation with game companies, this knowledge was made available to the gaming industries. In 2014, the market development has been on a somewhat higher ambition level: to create economic and social breakthroughs with Applied Games. To realize effective breakthroughs project development should involve the cooperation of all relevant stakeholders. This can only be realized when stakeholders in the gaming ecosystem are prepared to invest in cooperation. Issues Large scale introduction of Applied Games turns out to be problematic. Transfer of proven and successful games to other client setting is not obvious There are a number of reasons that hamper large scale introduction of Applied Games: • Applied Games as means of intervention are not yet widely known and recognized by the

application domains (clients). How do Games fit in the overall value chain? What are the standards, what is the business case? How do you determine the success of the game?

• The domain knowledge required to successfully introduce Applied Games in specific application domains is highly specialized and is not available within the gaming community.

• The multitude of providers and associated number of separate customized games make it difficult for a sector to acquire an overall set of supplementary applied games, based on requirements and standards.


• The validation by design and pre-validation by experiment after delivery to the deployment goals of a game are not yet well developed.

Value Center Applied Games To overcome these barriers TNO with HKU and Dutch Game Garden have established a cross-sectorial partnership: the Value Centre Applied Games. At present, the VCAG participates in initiatives such as Growing Games, the Hague Security Delta (Safety) and Vital Innovators (Care). Objectives To achieve this goal the Value Center Applied Games aimed at two targets:

• Significant Improvement of the development cycle: requirements articulation, game design and development process and game validation. On the basis of a SWOT, it was concluded that expertise development should focus on Applied Game Design and Validation.

• Accumulation, dissemination and expansion of the acquired value and the development of new knowledge and methods for knowledge gaps. (lessons learned, game repository, model base, shared research)

4.2 Enabling technology project and results

The Flagship Applied Gaming incorporates three research lines: • Applied Game Design • Applied Game Validation • Applied Game Technology

4.2.1 Research lines: Results

4.2.1.1 Applied Game Design Big Game Design Development of principles for organizational- and didactic embedding of Applied Gaming. Principles for didactic embedding of gaming (for complex decision making) have been documented in: • Hulst, van der A.H., Muller, T.J. Buiel, E., Gelooven, van D. & Ruijsendaal, M.

(accepted). Serious Gaming for Complex Decision Making: Training Approaches. Accepted to the International Journal of Technology Enhanced Learning, special issue on Serious Gaming.

Determinants for success and failure of organizational implementation of AG have been documented in: • Masterthesis Maxime Schulpen on the determinants of succes and failure of

implementation of Games in Education: “ Level up or game over? Een exploratief onderzoek naar de adoptie van serious games door leerkrachten in het primair onderwijs in Nederland”. Erasmus University Rotterdam.

• TNO report ‘Acceptatie van Serious Gaming.’ [DO programma V1313] The aforementioned Big Game principles have been applied to:


• The development of the game Balance-It [within the Enabling Technology Programme Behaviour and Innovation]

• The redesign of the Engagement Game (within the Business Line “Innovaties voor Gezond en Veilig Werken”). Modification of the overall concept from a stand-alone game to a game based workshop on managing work related stress.

Small Game Design This task aims at providing design principles for so called small game design, i.e. the design of the core game in terms of its scenario, world model and representation, its mechanics, narrative and user interface. A so called “Goal Design Alignment Framework” for AG Design was developed and tested in 2013 in a 120 hour pilot with 16 students and validated in 2014 within a 100 hour trial with 25 Game Study Master students. The framework is now part of the theoretical basis of the master programme Game Studies at the UvA and is being used increasingly in externally funded design projects. The validation has been documented in 5 UvA reports, each covering the rational reconstructions of 3 different games and an analysis of goal-design alignment.

4.2.1.2 Applied Game Validation A framework has been developed for the validation of applied gaming in various domains. This framework contains methods, indicators and tools, with as underlying principle that both learner characteristics, learning outcomes, learning process and design features should be measured to be able to obtain evidence on whether games are effective and, if so, why. The framework is based on literature research, expert workshops and practical experience and it has been developed, applied and validated in the context of the assessment of 7 games [all externally funded]: • Validation of Five serious games for education [in a Technology Cluster with 5 MKB.] • Validation of the ABCDEsim game [in cooperation with Erasmus Medisch Centrum]. • Validation of the VAST game [in cooperation with the Hogeschool Windesheim.] The validation framework is being published in: • Bakhuys Roozeboom, M., Visschedijk, G., & Oprins, E. (under review): Opening the black

box of learning with serious gaming: the effectiveness of three serious games measuring generic learning features. (accepted with minor modifcations to British Journal Educational Technology).

• Oprins, E., Visschedijk, G., Bakhuys Roozeboom, M., Dankbaar, M., Trooster, W. (under review). The Game-based learning Evaluation Model (GEM): measuring the effectiveness of serious games using a standardized method. Under review at International Journal of Technology Enhanced Learning.

4.2.1.3 Game Technology Development of guiding principles and identification of TNO’s network of excellence, methodologies and enabling technologies for the integration and disclosure of evidence based models in and by means of applied gaming methods. These results have been translated into a proposition within the Value Center Applied Games, see: • http://www.1mpress.nl/appliedgaming Development of a basic prototype of a technical framework for rapid prototyping and development of games and gamifications based on TNO’s Marvel modelling standard. The framework can be viewed here: • cool3.sensorlab.tno.nl/Marvelous/


The technical framework has been used to support the following projects in development of games and data visualizations: • Maatwerk in Ploegendienst; • Diabetes Type 2 gamification, [within project ePartners]; • Smart Cities Dashboard [within Flagship Smart Cities].

4.2.2 Market developments TNO focussed on the following application areas: Healthcare and work, Defense&Safety and Training&Education and Networked Information. Later on mobility and logistics joined in. Some examples of projects that have been acquired in 2013-2014: Healthcare and work • “Samenwerken voor betere zorg, een serlous game”. (ZonMW). • Validation study on game for emergency care.(Contract). • Vitavalley Game based care for the elderly (Technology Cluster) • Botlek 2, innovations in game based training for worker in the Botlek (contract). Education and training • E-Learning Sudan (programme [email protected], Unicef). • 5 validation studies on gaming in education (Technology cluster). • Validation study game for language learning (Contract). • 1 day a week lecturing at Game Studies UvA.(Contract). Networked Information • MOBS, game for reputation management (EL&I-co). • Gamification for internal branding (TC). Safety & security • Development of a Game for training of crisis-communication. (Grant from the Haque

Security Delta). • TOKO Training environment for large scale multidisciplinairy crisis management) (Subsidy

Ministry of EL&I). • AG Cold case game expert evaluation for the Netherlands Police. (Contract). • Driver: Innovations in training for crisis-management (EU grant). • Coping Flex Game for resilience training (NTP). • Training needs analysis and specification of CBRN game (Contract). • Training needs analysis and verification of Mid range anti tank simulation/Game (Contract). Mobility and Logistics: • Chain Game Dissemination of innovation principles for chain logistics by means of gaming

(EU funded). • Game for Complex decision making in Synchromodal transport (Contract with industry). • Ecomobility game (EL&I- co). General • Growing Games, (stimulation Programme by Economic Board Utrecht.)


4.2.3 Dissemination

Awards 2 international awards were won: • The Engagementgame won the ‘International Media Award for Prevention’ in the category multimedia at the International Media Festival for Prevention at the XX World Congres on Safety and Health in Frankfurt. Of the 290 submissions from all over the world, the international jury unanimously decided to award the Engagement game the first prize for being a very powerful asset for training and prevention. • E-Learning Sudan E-Learning Sudan is a partnership that includes the Ministry of Education, Ahfad University for Women, War Child Holland and UNICEF – aims to reintegrate children into schools through an accelerated e-learning programme. The project was acknowledged as one of the top projects of UNICEF. It received an additional grant of 80000$ and was featured in UNICEF’s State of the World Children’s 2015 Report.http://sowc2015.unicef.org/stories/learning-at-their-fingertips/ .

Publications Documentation of Applied Gaming based innovations has resulted in the following publications (that were (partially) funded by Flagship means): 2014 • Bakhuys Roozeboom, M., Visschedijk, G., & Oprins, E. (under review): Opening the black

box of learning with serious gaming: the effectiveness of three serious games measuring generic learning features. (accepted with minor modifcations to British Journal Educational Technology).

• Cremers, A.H.M., Stubbé, H.E., Beek, D. van der, Roelofs, M. & Kerstholt, J.H. (2014). Does playing the serious game BSaFe! make citizens more aware of man-made and natural risks in their environment?. Journal of Risk Research, , 1-13. doi:http://dx.doi.org/10.1080/13669877.2014.919513.

• Hulst, van der, A.H., Boonekamp, R. & Homberg, van den, M. (2014). Field-testing a Comprehensive Approach simulation model. ISCRAM 2014.

• Hulst, van der A.H., Muller, T.J. Buiel, E., Gelooven, van D. & Ruijsendaal, M. (accepted). Serious Gaming for Cognitive Flexibility in Decision Making: Training Approaches. Accepted to the International Journal of Technology Enhanced Learning, special issue on Serious Gaming.

• Hulst, van der A.H. (2014). Serious games in de militaire beroepsvoorbereiding. Anja van der Hulst. 4W Kennisnet Uitgave 1-2014.

• Oprins, E., Visschedijk, G., Bakhuys Roozeboom, M., Dankbaar, M., Trooster, W. (under review). The Game-based learning Evaluation Model (GEM): measuring the effectiveness of serious games using a standardized method. Under review at International Journal of Technology Enhanced Learning.


• Stubbé, H., J.G.M. van de Ven, M. Hrehovcsik (2014). Games for Top Civil Servants: an integrated approach. In Dana Ruggiero (Ed.) Cases of Societal Effects of Persuasive Games (in press). Igi-global.com

• Stubbe, H. Oosterbeek, S. (2014). Formative evaluation of an arithmetic game for out-of-school children in Sudan. Proceedings of the second Asia-Europe Symposium on Simulation and Serious Games. Oct 2014, Zwolle, The Netherlands.

2013 • Blanson Henkemans, O., Knulst-Verlaan, Heuvelink, A. en Speksnijder, C.(2013). Hoe

halen ouderen the next level? Fysiopraxis 2013; 22(12): 18-21. • Buiel, E., Hulst, van der, A.H, Voogd, J. & Oprins, E. (2013). Maintaining public order in a

virtual world. Proceedings of the Nato Modelling Simulation and Gaming -111 Multi-Workshop, Sydney, Australia, 17-18 October 2013.

• Hulst, van der, A.H., Muller, T.J., Besselink, S.J., Vink, N. (2013). The Potential of Serious Games for Training of Urban Operations. Proceedings of the Nato Modelling Simulation and Gaming -111 Multi-Workshop, Sydney, Australia, 17-18 October 2013.

• Hulst, van der, A.H., Boonekamp, R. & Homberg, van den, M. (2013). Field tests of a gaming approach to raising awareness and creating a deeper understanding of the comprehensive approach. Panel of 'The Pathway to Professionalizing the Humanitarian Sector: Training and Certification of Humanitarian Responders. World Conference of Humanitarian Studies (WCHS) 2013, 24-27 October 2013, in Istanbul, Turkey.

• Visschedijk, G.C., Lazonder, A.W., Hulst, van der A.H., Vink, N. & Leemkuil, H. (2013). Emotions for tactical decision games. Modeling human emotions for tactical decision making games. British Journal of Educational Technology.

• Wiezer, N., Bakhuys Roozeboom, M. & Oprins, E. (2013). Serious gaming used as management intervention to prevent work-related stress and raise work-engagement among workers. In 4th Int. Conf. on Digital Human Modeling and Applications in Health, Safety, Ergonomics, and Risk Management: Human Body Modeling and Ergonomics, DHM 2013, Held as Part of 15th Int. Conf. on Human-Computer Interaction, HCI 2013, 21 July 2013 through 26 July 2013, Las Vegas, NV(Vol. 8026 LNCS, (pp. 149-158). doi:http://dx.doi.org/10.1007/978-3-642-39182-8_18.

Invited talks: • Unesco Conference , New York, Invited talk Hester Stubbe MsC, E-Learning Sudan,

formal learning for out-of-school children. • Gameon 2013, Brussels Invited talk dr. Anja v.d. Hulst Good Game Design: lessons

learned from the military. • ‘Jubileumconferentie 40 jaar Militaire Pyschosociale Dienst’ , Breda. Invited Talk dr.

Anja v.d. Hulst: ‘Serious Gaming in Militaire Context’. Contributions to conferences: • Second Asia-Europe Symposium on Simulation and Serious Games. Oct 2014,

Zwolle [paper] • XX World Congres on Safety and Health 2014, nov. Frankfurt [Paper, Award] • ISCRAM International Conference on Information Systems for Crisis Response and

Management ISCRAM 2014, Penn State PE. [paper, demo’s, hands-on sessions, co-chairing gaming track 2015].

• Experience Design Event , Oct 2014, Eindhoven [Talk]; • Connections War Gaming Conference - Quantico Virginia, august 2014; [Paper, panel

and co-chair international collaboration.]


• ITEC 2014 International Training & Education Conference-May 2014, Cologne, Germany.[Talk]

• CVi Conferentie voor onderwijsvernieuwing en ICT , April 2&3 2014, [talk] Brabanthallen, Den Bosch.

• IPON2014, 19&20 March, Jaarbeurs, Utrecht. [Talk] • Control Conference 2014, [workshop]. • Connections NL, Bussum 2014. [Talk, Hands-on session] • Games for Health Europe 2014 [Workshop] • Games for Health US 2013 , [Paper] • Games for Health Europe 2013 , [Presentation] • Games and Learning Alliance conference , Paris (GALA 2013):[Presentation and hands-

on session , Expert panel research agenda for Horizon2020]. • IMTA Conference , Korea. Military Psychology in a Time of Transition, Uncertainty, and

Complexity. [hosting Workshop] • 15th Int. Conf. on Human-Computer Interaction, HCI 2013 , Las Vegas [Paper]. • World Conference of Humanitarian Studies (WCHS) 2013, Istanbul, Turkey. [Panel,

paper] • Nato Modelling Simulation and Gaming -111 MULTI-WORKSHOP , 2013 Sydney.[2

papers]. New cooperation’s with academic institutions • Strategic research cooperation on Transfer of Gaming with the “Hoge School voor de

Kunsten”, signed Letter of intent; • Mastertrack Game studies UvA , TNO provided a member to the steering board,

contribution to the design of the curriculum and a guest lecturer for 1 day/week (payed). • Supervision of students Erasmus Univ. and UvA. • Guest lectures Applied Gaming University of Utrecht, Post Academisch Onderwijs

Gaming (Delft), Mastertrack Game Design (Delft), Amsterdam University College (Liberal arts) and Free University and to the Royal Military Academy.

• ISCRAM summerschool, Tilburg, aug. 2014 [ Lecture, workshop, supporting 2 day crisismanagement game with students from UvA].

• PhD project on Serious gaming for complex decision making (U Twente). • PhD project on E-Learning Sudan, UvA and UU. 4.2.4 Game lab

Facilities In august 2013 the Applied GameLab was installed. This lab has elaborate presentation facilities, fixed game consoles and two rooms with 12 flexible game positions. The lab has been used increasingly since then for Briefings, Workshops and Master classes.


Master classes

• 1 day Masterclass on ‘Veiligheid & Serious gaming’ for 17 companies from the Botlek area,

2014. • 1 day Masterclass on ‘Veiligheid & Serious Gaming’ for trainers of Emergis (large mental

health care organisation), 2014. • Half day masterclass on Applied Gaming in Defense, 2014. • 1 day Masterclass on ‘Serious gaming in healthcare’, 2014. For the Netherlands

organisation for education in healthcare. • Half day Masterclass on gaming in food safety (TNO internally) • Half day Masterclass on gaming for work and health (TNO internally) • 2 day Masterclass Introduction to Applied Gaming in a professional context (Beginner

level) 2013. • 2 day Masterclass Applied Game Concepts (Advanced level), 2013. • 1 day Masterclass for 10 Non Governmental Organizations, applications of Applied

Gaming to humanitarian aid. [Several leads are currently being pursued].2013. Briefings • Briefings to the Brazilian ministry of internal affairs on the use of virtual environments for

training for Safety and Security. (In anticipation to the WC soccer 2014 and Olympics 2016.) [Lead to a large (+ 500K) contract].

• Visit Remco van Lunteren, ‘gedeputeerde’ provincie Utrecht, to the Gaming lab, briefing on Transfer of Gaming.

• Briefing Marc Hameleers, ‘Regioambassadeur Noord-West’ of the ministry of Economische Affairs on Transfer of Gaming.

• Presentation Transfer of Gaming during the Get Connected assembly of the Economic Board Utrecht. The above visits lead to the Growing Game contract (+150K).

• Briefing to the ‘Commisaris van de Koningin’ van Beek (Utrecht) on Urban lab and Gamification.

• Briefings to the city board of Amsterdam in anticipation of the use of games in their Amsterdamse school (education of 20000 civil servants) and to support Change Management processes. Lead under development.

• Several briefings to the Vita valley consortium, resulting in a Technology Cluster on gaming for elderly people.



The developments of the Flagship Applied Gaming have been consolidated in a Value Center Applied Gaming (VCAG) with a number of external partners from industry and academia. Underlying this collaboration is a letter of intent between TNO, the “Hoge School voor de Kunsten”(HKU), and the Dutch Game Garden covering cooperation in strategic research on Transfer of Gaming. Further development of the VCAG is partially funded by the long term (2013-2016) stimulation programme Growing Games of the Economic Board Utrecht. In addition, within TNO, 3 themes and a programme (IV, Healthy Living, Mobility(logistics) and Network Information) have agreed to fund the further development of the field of Applied Gaming. Also, several Horizon 2020 proposals have been submitted and a proposal for TNO funding for knowledge development for the next 2 years is under discussion and is likely to be awarded. Hence, we will continue to act as an enabling technology-provider to the different branches within TNO and to our partners in academia, industry and government and expand our presence in the field.


5 Smart Cities

Ernst Meijer


Who does not want to live in the smartest city? The smart city promises cities to be truly sustainable and attractive with a high quality of life and a thriving economy. This will be achieved by new integrated ICTs that enable intelligent management of the city with optimal efficiency of its resources and balancing collective with individual needs. Understandably, smart city concepts are increasingly popular. In 2012 more than half of the world’s population lives in an urban area and this trend is continuing towards the future. By mid-century 70% of the world population of 9 billion people will be living in cities. Cities are the nerve centres for economic development, social interaction and innovation. Already the world’s 100 largest cities generate almost 40% of global GDP. On the other hand, such growth rates pose huge challenges on economic development with increasing demands on natural resources and pose a burden on the environment and the liveability of cities. While TNO is active at many aspects of the urban system, such as the energy system, mobility and logistics, (built) infrastructures, ICT, quality of life and economics, TNO was lacking an overarching Smart City approach. In order to develop such a Smart City approach, the flagship project Smart City has been launched in 2013. It has an impulse character that is limited in time, ending by 31/12/2014. Within the smart cities concept, TNO strives for more efficient use of resources, better interaction and cooperation between all city stakeholders, leading to a boost in the cities’ competitiveness. Smart cities are able to attract citizens, fuel economic development and minimise its negative impact on natural and environmental resources. Technology alone will not suffice, as conflicting objectives will hamper efficiency. Shared values and collective demands need to be elucidated and balanced with individual demands. Furthermore, these needs have to be the starting point for technological solutions to guarantee the usefulness and adoption of these solutions. This asks for active citizen participation, new ways of governance and new business models. All this is the smart city philosophy. Yet, realizing this philosophy is not an easy task. Nowadays many smart city initiatives exist, but they all lack the comprehensive approach depicted above. Besides the comprehensive approach, these initiatives often have a strong emphasis on the implementation of new technologies, while more focus on organizational aspects and overcoming social barriers are required to realize the smart city philosophy. In there is insufficient attention for

(1) an integral approach, (2) cooperation, and (3) the impact assessment of solutions.

Making cities smarter requires an integral approach that is both trans-sector and multidisciplinary. An integral approach results in more effective solutions. All cities share


common goals on a generic level, that is, they all seek sustainable economic development and a high quality of life with minimal burden on the environment. Obviously each city has its own specific circumstances that can be explained in threats, opportunities, weaknesses and strengths. Making these circumstances explicit, asks for a systems approach that forms the starting point for developing strategies and action plans. Furthermore, it should be possible to explore different options and evaluate their effects (ex ante) and to assess the impact once they are implemented (ex post). Although these requirements seem trivial, it is far from obvious how to relate different smart city solutions to their effect on the economy, environment and liveability of a city. Currently this requirement is not met in existing smart city initiatives. Without cooperation, different stakeholders of the city (businesses, citizens, policy makers, city leaders, knowledge institutions) will act according to their individual needs and perspectives. Conflicting actions and strategies cause inefficient usage of the cities resources. To reach optimal solutions, the different stakeholders account for their different perspectives and balance between collective and individual needs in order to derive collective objectives. It is the ambition of the flagship project Smart City to develop an actionable and concrete approach that allows collaborative development of integral smart city solutions that have a measurable impact on sustainable economic development and high liveability standard with minimal pressure on natural resources and the environment. TNO has an excellent starting position to work on smart cities. Various TNO-themes already work on many aspects of smart city solutions: smart energy, smart mobility, smart society, smart urban development. In those contexts TNO deploys various case studies, pilots, and living labs. These initiatives are crucial for developing new smart city concepts, for providing proof-of-concepts, inspiring and fostering a culture of innovation. The flagship Smart City will enrich these practices with an overarching methodology with concrete tools: data, models, innovation processes and value case methodology. These tools form the necessary conditions to create practical value. They are the ingredients of the integral, collaborative approach and provide methods to assess the impact on economy, environment and liveability. It is a place to meet customers and strategic partners. Customers, notably city leaders and policy makers have the possibility to articulate their needs and explore possible solutions, including new ways of governance and allowing citizen participation. City leaders, policy makers will benefit from the assessment tools to develop long-term policies to develop their cities and enables to translate their long term goals in tangible solutions. Entrepreneurs, companies, SMEs, will be able to bring in new products and solutions that contribute to the cities goals. In cooperation these parties will develop new solutions and create shared-value. Proof-of-concepts and the transposable lessons derived from them will be exported from one city to another. Finally the smart city plaza will serve as a setting in which research initiatives can be set-up in a pre-competitive setting.


Figure 1. TNO Smart City Plaza concept.


5.2.1 Smart City Toolbox In 2013 we developed the Smart City Gameboard, a smart city system dynamics model and a smart city innovation process. Based on experiences in use cases we continued the Smart City Gameboard and have further developed this tool. It has been expanded with a Smart City Dashboard and Urban Strategy. Together these instruments constitute a coherent tool box: − Smart City Gameboard describes the city as a system with causal loops within the energy,

economy, environment, social and physical quality, governance and mobility domains. The Gameboard allows to investigate dependencies and to explore cross-domain solutions.


Figure 2. Smart City Gameboard. Lines indicate causal loops, the coloured spaces indicate the specific domains, such as energy and mobility

− Smart Dashboard is data-driven and is for monitoring the city (situational awareness and predicting trends). It connects strategic (policy making, urban planning, and project, pilots and city operations) in terms of key performance indicators.

Figure 3: Screenshots of the Smart City Dashboard

− Urban Strategy is a tool for providing information of the city detailed in space and time. It allows for interactive evaluation of plans and measures. So it allows for detailed planning. Also Urban Strategy is able to use real-time data, making it suitable for monitoring and decision making on operational tasks (e.g. traffic management).


Figure 4. Screenshots of Urban Strategy

The tools are complementary: − The Smart City Gameboard is exploratory and qualitative of nature, whereas the Smart

City Dashboard quantifies effects and impacts. − The Smart City Dashboard shows indicators on an integrative (system) level, whereas

Urban Strategy shows results in time and space (e.g. traffic flows per road in Urban Strategy and total annual car movements and CO2 footprint in the dashboard).

Together they offer a comprehensive approach cross-domain and for multi-stakeholders in a plan-do-check-act cycle.

5.2.2 Smart Policy Making Delft Developing and maintaining a smart program for municipalities. A collaboration of TNO, Municipality of Delft and Min IenM. In a meeting of B&W of Delft with the TNO Board, Delft expressed their contentment with the TNO Smart City approach and their intention to continue the collaboration. In collaboration with municipality of Delft and Ministry IenM we have constructed a smart program for Delft. Six running projects of Delft were selected for embedding in their smart city program. We have organized two workshops with experts of TNO, Min IenM and policy makers of Delft to develop a new smart city approach. Focus was on smarter planning towards strong economy, zero energy and a climate proof city.

We tailored the Smart City Gameboard to the Delft situation and implemented the 6 projects as policy interventions. Outcome of this is a comprehensive overview of the impacts of the


projects, possible side-effects and missing opportunities. In particular, the Delft policy for sustainable energy focused too much on e-deals for rental housing, missing clear other possibilities on mobility and industry. The Ministry of IenM has developed the so-called Ontwerpend Onderzoeken, a creative process to develop new smart city initiatives in an early stage. We have enriched this approach with the tool Urban Strategy, allowing for much more evidence-based planning. Thirdly, we have developed a dashboard for Delft. It integrates policy with pilots/projects.

5.2.3 Towards a circular economy of Almere. A data flow observatory to establish waste flows and economic activities. A collaboration with Almere and Big Data Value Centre Almere. Currently continued in a direct B2B project. We have constructed the metabolism of Almere, including waste flows. This involved collecting data and coupling data bases of different sources. The data was loaded in a new visualization tool, based on the TNO CommonSense platform.

5.2.4 Smart Infrastructure Management Almere. Making infra management smarter: decision making based on big data, not only looking to costs, but also to socio-economic value. A collaboration with Almere and Economic Development Board of Almere. Follow-up is intended, project proposal is under development. In order to demonstrate the potential of a smart city approach for asset management, we tailored the instrument Urban Strategy for Almere Road Management. Based on asset information combined with traffic data and environmental models, it has been demonstrated how assets management planning can be evaluated with this tool. Not only taking the asset itself into account, but also the impact of maintenance in terms of nuisance, for instance. The Smart City Gameboard was applied to investigate the socio-economic value of roads and how they can be taken into account for asset management.

5.2.5 Mobility Dashboard Rotterdam. Smart mobility operations for ‘s Gravendijkwal Rotterdam in order to meet air quality regulatory requirements (NO2 / PM normen) and optimal traffic flows. Continuation in a direct B2B project.


Urban Strategy was developed to read-out real-time traffic data (from VRIs and the like) and to calculated traffic flows, air quality and noise. For further development, an ICT design has been developed for data-mining and enriching to information, coupling to city models (Urban Strategy) and visualization (CommonSense). A set of possible interventions on different time-scale (from hour to daily) have been implemented.

5.2.6 Towards a Smart City Operating System In a smart city new ICTs will be developed for specific applications, yet they need to be connectable and scalable to other ICTs across applications and domains. A Smart City OS gives this functionality and allows for a scalable and flexible ICT for an entire city. Then a Smart City OS drives innovation with new cross-domain services and solutions:

To demonstrate such an OS, a smart lighting concept has been set-up. Based on existing technology (smart light bulbs, such as the HUE Philips) were applied in an office setting. Installing new lights and assigning user rights was based on smartphone technology. Bluetooth technology was used to determine the location of each HUE light. In a normal situation employees can use lighting to their personal preferences, in case of emergency, the lights can be used to guide personnel to the emergency exits. In short, existing technology that needs to be connected with a CityOS.


We built the first prototype of a Smart City OS for this case. Based on Docker container technology and XMPP communication. Continuation in EU Artemis project ACCUS.

5.2.7 App for air quality. Citizen involvement is crucial for successful smart city approaches. RIVM, DCMR, and special interest groups such as Longfonds and Milieudefensie are struggling with citizen involvement. We developed an air quality app to demonstrate potential and pave the road for new initiatives. Continuation in B2B project for RIVM. The prototype is accessible through: http://wk2014.lohman-solutions.com/AirApp.apk (for Android only). The app shows NOx concentrations for Rotterdam/ Rijnmond (NOx is an indicator for traffic pollution.) It shows zoomable maps at a resolution of 25x25 and it gives an air pollution forecast from 0-48 hrs.

5.2.8 Cooperation Ministry of Infrastructures and the Environment on National Roadmap Smart Cities, and input on the Strategic Implementation Plan of the European Partnership Smart Cities and Communities. VTT Technical Research Centre of Finland and AIT Austrian Institute of Technology on a joint modeling strategy anticipating the H2020 calls on Smart Cities and Communities.

5.2.9 Project and Proposals Artemis EU project ACCUS RIVM project Air Quality Netherlands APP Project « Almere Afvalvrij » Project « Smart City Dashboard Rotterdam » Proposal “Smart Infra Almere”, in development Proposal “Regional Smart Grid for the Zuidvleugel”, in development


Proposal for AMS Design Contest for an institute of technology in Amsterdam. Our proposal has been adopted by the winning consortium (TU Delft, Wageningen, MIT) and we are currently contributing to the further development of the plans. (not granted) Proposal for H2020 call Smart Cities and Communities (SCC1) (not granted) Proposal Stakeholders Platform Smart Cites for the EU (not granted)

5.2.10 Publicity Strategic Implementation Plan of the European Partnership Smart Cities and Communities, October 2013 (contributions). Presentation at VNG Beurs Presentation at Innovatie Estafette, 2013 “Smart City: Hart voor de stad”, Meijer, Willems, Laarakkers, TNO-Time. Veldhuis, G. et al., Development of a generic Smart City model using MARVEL, The 32nd International Conference of the System Dynamics Society, Delft, Netherlands, July, 2014 Massink R. en Meijer E., White paper Smart Policy Making, December 2014. Willems, R., Notitie Smart Infra Beheer, December 2014. Doorn J., Memo Flow Observatory Waste (FLOW), Dec. 2014 Werkman E., WIKI documentatie Smart City OS: http://gitlab.servicelab.org/iot-lab/registry/wikis/home Eindpresentaties Smart City, December 2014, (PPTS). Meijer E., TNO rapport Flagship Smart City, Jan. 2015. Whitepaper “Regionaal Smart Grid als Economische Motor”


One of the objectives was to start shared value centre “Smart City Plaza”; a place where stakeholders meet to jointly work on smart city solutions and where TNO provides the necessary tools and methods. As such this has not been established yet, however we have contributed to several start-ups that have the promise to grow to such a value centre: TNO is partner of the Amsterdam Institute of Advanced Metropolitan Studies (AMS), Knowledge Centre Healthy Urban Living (KC HUL) and the partnership of TNO and Almere is centred around Smart City approaches. The results of this flagship project are well adopted by the new TNO Innovation Area Smart Cities (Program Director Kees d’Huy).


6 Innovation in Healthcare

Ivana Bobeldijk


The flagship initiative “Innovation in Healthcare” was launched in January 2013 to develop an integrated research agenda, roadmap and program to address the transformation challenges facing the Dutch healthcare system. This integrated agenda should give direction to a fragmented health care system and position and strengthen TNO as a strategic partner for innovators in the health (care) sector. The current healthcare system is considered to be unsustainable in terms of costs. A new integrated approach is needed aiming for a new balance between health outcomes, quality of care and costs, both at the population and individual level. Many actions are being taken by the stakeholders (government, health insurers, healthcare organizations) to control these, but a more fundamental transformation is needed. A systems transformation is needed in which the healthcare system shifts the current focus on disease and cure towards a new focus on health and behavior. This requires the adoption of a new definition of Health (Huber e.a.: the ability to adapt and self-manage in the event of social, physical and/or emotional challenges) and the implementation of this concept in new processes, incentives, systems, responsibilities and organization structures. To contribute to this need, TNO has formulated an innovation strategy based on P4 as a guiding principle for the transformation, improvement and innovation of the health care sector. These P4-principles are: − Participative: the passive patient is empowered to be an engaged consumer who takes

ownership of its own health. − Predictive: systems diagnosis will alert possible undesired health events/conditions in an

early stage. − Preventive: optimal advice will enable patients to make the choices that fit their unique

situation best. − Personalized: each individual will have a contextual assessment, diagnosis and therapy

that is tailored to their own, individual, health profile. Implementation of these principles will require the integrated use of technological, social, cultural and organizational innovations in order to empower citizens with the right knowledge, skills, tools and support from professionals to improve their health, vitality and participation in society and economy. The objective of the flagship is to organize, focus and strengthen the TNO knowledge portfolios, investments and partnerships with industry, knowledge institutes and health organizations towards this societal, economic, technological challenge. The concrete objective was to provide a scope and outline for an integrated TNO program and innovation agenda for this transition towards a P4- based health (care) system, allowing for: − Integrated knowledge development on the basis of a common vision, roadmap and

agenda. Relevant keywords for this agenda are medical technology, information technology, internet of things, sensor technology, pharmaceutical, nutritional and lifestyle technologies and innovations.


− Integrating role in the chain of development, validation and valorisation of the multidisciplinary knowledge and innovative solutions, using the concept of “proeftuinen” or field labs.

− Development of an integrated eco-system of partners to allow cooperation in open innovation programs: governments, industry, knowledge institutes, health (care) providers, consumer organizations, health foundations, health insurance and financers.

The flagship has run in the years 2013 and 2014. The activities in the year 2013, which have been reported previously, laid the conceptual foundation for the flagship which resulted in a vision document, a translation of this vision into a strategic roadmap and the first applications for competitive funding projects within the scope of the flagship. The critical next step was to turn this vision during the last year of the strategic period 20111-2014 into a shared vision and activity scheme of the contributing Themes, Innovation areas, Research Groups and Enabling Technology Programs. Issues in healthcare and therefrom derived work packages The Healthcare system is a complex ecosystem where multiple stakeholders work together and try to earn a living. Perhaps contrary to other Flagship subjects healthcare has both technical and social aspects that collectively define the playing field. For example, new drugs can cure people (technical innovation) but only if patients are motivated to take their medication (social innovation). Furthermore, innovations that have proven to be effective in controlled environments may show to be ineffective or cost-driving in real life situations. Based on this realization, work packages have been defined for both technical and social innovations. Since these two come together in real life situations a third work package has conducted research on the execution of field labs, since field labs allow us to test innovations in real life situations. The final work package was devoted to data since data in health care will be of increasing importance for all innovations, whether technical or social. A special emphasis has been given on how e-health systems that can be used to motivate and help individuals (e-coaches)


6.2.1 Aim and results in 2013 In 2013, the aim of the work plan was to define the scope, ambition and objectives of a shared program on P4 Health(care). To this end the project was structured into 4 work packages, addressing: a) strategy & coordination, b) vision & roadmapping, c) use case analysis diabetes type 2 d) partner & market initiatives. Examples of important deliverables from 2013 are (please see report 2013 for a complete list):

• A vision paper by the principle scientists: The TNO health (care) agenda towards 2020, outlining the need for an adoption of the P4-principles.

• A TNO publication “Innoveren voor Gezondheid”, introducing and outlining the underlying concepts, definitions, visions and suggestions of TNO with regard to in the basic needs of the healthcare market: innovation, prevention, quality. As well as a publication “Future of Healthcare” in collaboration with HCSS.

• Contribution to the book Diagnose Zorginnovatie. • An investigation into the application of the P4-paradigm to the use case diabetes type

2. This is rooted in the strong focus on metabolic health in the ETSB-program and a


collaboration with partners of “Expeditie Duurzame Zorg, te beginnen met diabetes”. This was continued under the associated ICOON project theme of “Nederland Type 2 Diabetesvrij”, see WP 1 in 2014.

• Realization of first steps towards the implementation of a regional P4 Field Lab as well as a P4@TNO project, an internal field lab to develop and test new personalized tools, technologies and programs with selected test groups. Identifying and integrating two major programs for these field labs: 1) metabolic health and 2) stress management. P4@TNO project was successfully executed in 2014 as one of the projects of the ETSB-Program.

6.2.2 Aim and results in 2014 In 2014, the objectives of the flagship were achieved by executing activities in 4 work packages. These work packages logically combined the various eco-systems that contribute to innovations in healthcare. These 4 work packages were:

WP1 has developed a work plan how food and pharma companies could work jointly on development of concepts, technologies and products that contribute to consumers health. During the year, the activities of this work package have been taken over by the “Icoonproject Nederland Diabetes Vrij”. Surprisingly, this work package has led to novel innovative projects with both food and pharma companies that form the basis of technological requirements for the strategic plan 2015-2018 of the Roadmaps Food & Nutrition and Predictive Health Technologies. However, it turned out impossible to gap the bridge between these two sectors by making them collaborate in a joined program. This underlines the need for two separate Roadmaps within the field of life sciences in Healthcare for both food and pharma companies.

• The results of WP 1 were presented in the following invited lectures: Oxford Global 9th Annual Biomarker Congress, 25 Feb 2014, Manchester. Invited lecture Alain van Gool: ‘Biomarkers in a changing world’.

• Health Valley Event 2014, 14 Mar 2014, Nijmegen. Invited lecture Alain van Gool: ‘Biomarkers in personalized healthcare, a changing world’.

• Global Engage Precision Medicine Congress, 19 May 2014, London. Invited opening keynote Alain van Gool: ‘Selecting and Managing Rx-Dx Partnerships’.


• JDRF symposium at FOCIS conference, 25 June 2014, Chicago. Invited lecture Alain van Gool: ‘Biomarkers in a personalized health(care), a changing world’.

• SelectBio conference, 8-9 July 2014, Cambridge. Invited lecture Alain van Gool: ‘Biomarkers in a personalized health(care), from discovery to clinical diagnostics’.

• Health Valley symposium, 20 Aug 2014, Nijmegen. Invited lecture Alain van Gool: ‘Personalized health(care) through integrated technologies’.

• OOR-ON symposium ‘De onderscheidende specialist van de toekomst’, 8 Sept 2014, Nijmegen. Invited lecture Alain van Gool: ‘Personalized health(care): a view in the near future’.

• ACI conference ‘Biomarker Utilisation & Commercialisation’, 10-11 Sept 2014, London. Invited lecture Alain van Gool: ‘Assessing the value of biomarkers in personalized healthcare’.

• MIPTEC 2014, 23-25 Sept 2014, Basel. Invited lecture Alain van Gool: ‘Biomarkers in personalized health(care), from discovery to clinical diagnostics’.

• LGC Autumn symposium ‘Biomarkers’, 15 Oct 2014, Cambridge. Invited keynote lecture Alain van Gool: ‘Biomarkers in personalized health(care), changing perspectives’.

Furthermore, the network built within WP 1 also resulted in invitations to participate in several advisory boards:

• Oxford Global Annual Biomarker conference 2014, 2015, Manchester (A van Gool) • Pharma-Nutrition 2015, Philadelphia (A van Gool) • Hanson Wade Companion Diagnostic conference CDx 2015, Frankfurt (A van Gool)

WP 2 has made an overview of the intervention tools that are available at TNO to be applied in a field lab setting that can contribute to health maintenance. This overview will form the basis for the field labs that are anticipated to be executed in the strategic period 2015-2018 within the Theme Healthy Living. Furthermore, within an extension of WP2 in the last months of 2014 we worked on the development of a working version of StressCoach. This WP collaborated with a KIP project under Biomedical Innovations. During the development, contacts with stakeholders and potential customers were set-up:

• MOVIR, Achmea, anonymous other insurance company • Adrenal gland foundation / Adrenal gland society • ‘Pienter meten’ foundation • Life Guard • PON • Diverse coaching & consultancy agencies (employability, high performance

empowerment) • P4@TNO


WP 3 has focused on describing the various field labs in which TNO is active and developing a business model that can be applied in field labs. This WP has laid the foundation for the field labs to be run with in the Theme Healthy Living for the strategic period 2015-2018. Furthermore, this work package has funded further development of various projects that develop technologies and intervention for potential use in field labs. These are among others “Better in, better out” and “Doktertas 2.0.”

Presentations: • Dr. Hanneke Molema, presentation, Integrated cure, care and community –

partnerships for innovation in living labs, ICIC 2014 Brussels • Drs. Ronald Mooij, presentation, Innoveren voor gezondheid en Triple Aim, Triple Aim

Conference 2014, Almere • Dr. Marjolein de Weerd, presentation, Personal health data managing population

health, EFPC 2014, Barcelona WP 4 has co-funded the development of data-based (coaching) tools that can be used to help individuals make the right decisions for their personal health status. The projects included an electronic Coach meant to help Diabetes Patients. These types of coaches have now reached a readiness level which makes it possible to deploy them in a real-life setting. Furthermore, they can be used for coaching individuals in the field labs which are planned in the next strategic period. In an early stage the project decided to use the Patient Coach consortium as a starting eco-system for a patient empowerment program. The Patient Coach platform and ecosystem has given access to a potentially very promising ecosystem for further development. Together with the existing partners in the research projects Admire, Periscope, etc (LUMC, TU-Delft, Nierstichting, ZonMW, Antonius Nieuwegein, Twente Almelo, AMC, Erasmus MC, Hogeschool Maastricht) this resulted in a first composition of a potentially interesting PPS-consortium. For this consortium a roadmap was developed to develop the Patient Coach Platform into a Prevention Coach, Vitality Coach and Health Coach version. The design of the Platform was conducted in an international consortium and resulted in a H2020 proposal technical document “Do It Your Health”. This document defined the architecture and design of a generic Personal Health Portal for Prevention (Prevention Coach), allowing a user to become co-manager of one’s own health and providing a portfolio of personalised exercise, nutrition and mental


interventions depending on personal data including lifestyle, genetics, phenotype and environment. Unfortunately, the project was not funded, but the established consortia are going to pursue further funding opportunities. Furthermore, within WP 4, visualisation, security and privacy issues were solved for the Nutritional Researcher Cohort, a unique initiative which is launching in several countries and for TNO will lead to exposure and will provide a solid base for testing of beta version of many health monitoring or lifestyle change support tools. The NRC and P4Health topics were presented in several conferences:

• B. van Ommen, Nutritional solutions and metabolomics diagnosis in type 2 diabetes – Biosynergy symposium, Daejeon Korea, 29 April 2014

• B. van Ommen, N=1 nutrition research – a revolution in science and healthcare – ISNN, Gold Coast Australia, 2 May 2014

• B. van Ommen, N=1 nutrition research – a revolution in science and healthcare – Nutrition and Medicine Conference, Gold Coast Australia, 3 May 2014

• B. van Ommen, Nutritional solutions and metabolomics diagnosis in type 2 diabetes – Nutrition and Medicine Conference, Gold Coast Australia, 4 May 2014

• B. van Ommen, De waarde van mijn gezondheid – Overleg Groen Links, Delft 25 Augustus 2014

• B. van Ommen, P4health: Personalized, Preventive, Predictive, and Participatory Healthcare – Nestlé Institute of Health Science symposium, Lausanne 26 March 2014

Other WP 4 deliverables are:

• Roadmap Patient Empowerment: from Patient Coach to Prevention Coach. • Patient Coach documents and proposals.

6.2.3 Highlights from the work packages

6.2.3.1 Highlight WP1. Ecosystem “NL Diabetes Vrij” on innovative technologies applicable in the Pharma Nutrition cross-over arena Systems biological understanding of metabolic health and disease allows the identification of many opportunities for achieving higher efficacies and lower side effects by combining drugs and specific nutrition components. Although the potential is well recognized, the business model, product risk considerations, and unclear regulatory position for these combination approaches are considered as major innovation hurdles. Therefore, there is a strong need for multi-disciplinary projects that, in addition to providing proof-of-concept of pharma-nutrition combination approaches address the major innovation hurdles perceived by industry. This was aimed for with the TNO-coordinated NutriPhaCT project that unfortunately failed to get granted in the H2020 process. Based on the insights gathered, we embarked on the ICOON project aiming to initiate a Shared Innovation Program in field of technology development to enable to innovate healthcare approaches to Diabetes prevention and treatment. For this, we aim to bring together partners from the different industry sectors as well as clinical and academic partners to jointly develop technology applicable for Pharma, Nutrition and Diagnostics companies and address both their joint and specific needs in view of development of better patient-centered interventions. Main results: • Based on all internal and external interactions a landscape of potential partners for a

Shared Innovation Program “NL Diabetes Vrij” has been drawn showing the ideal


positioning of TNO to orchestrate joint development of innovative technologies that will enable industry and society to innovate healthcare in the field of Diabetes (Figure below).

• Five small kick-start projects were initiated based on identified industrial interests within the indicated ecosystem, in which industrial partners participated by in cash or in kind contributions. The projects have a strong liver health and pathology focus.

Application: This project has resulted in the attraction of multiple partners for focus areas identified. This will contribute to the development of innovative and more efficacious approaches for the prevention, management and treatment of Diabetes based on pharma and nutrition products, and combinations thereof.

Ecosystem landscape of TNO technologies, (potential) industrial partners from Pharma, Nutrition and Diagnostics, and

key clinical and academic partners showing the perfect positioning of TNO to enable development of better patient-

centered preventive and therapeutic interventions in the T2 Diabetes arena.

6.2.3.2 Highlight WP 2: Stresscoach: multi-domain algorithms and feedback for individual stress prevention. In 2011 burn-out and strain were responsible for 1,3% of all absenteeism in the Netherlands. This concerns 75.603 employees (ArobNed, 2013). The length of absence in case of strain and burn-out is high; in 2012 this was on average 185 days. Besides the consequences for well-being, stress has a large societal and economic impact as a result of decreased productivity and health-care costs. In case of early detection of stress, worsening of the situation can be prevented through intervening at an earlier stage. Stress management thus has a large potential for companies as well as employees. Therefore, in this project a unique application for signaling and preventing stress was developed.

Results The resulting Stresscoach, which can be accessed via an online personal platform, calculates an individual stress score based on a heart rate variability measurement and mood questionnaire. The stress scores are thus based on variables from multiple domains (physical, mental and potentially in a later stage also endocrine).


Also, a decision tree for providing employees with relevant feedback and interventions based on their current stress level, was generated. This decision tree can be implemented as a feedback module in the online Stresscoach application.

Online platform Stresscoach

Application The Stresscoach can be applied in multiple ways by companies and service providers interested in decreasing stress of employees:

- As a part of PMOs, Health checks or PAGOs; - In supporting people with stress complaints in coach trajectories; - Use by individual employees, to increase insight in the course of their own stress

levels and its causes (e.g. by making the Stresscoach part of vitality programs); - Use by managers to generate insight in stress levels in their organization on group

level; for this purpose personal data will be anonymized. The current version of the Stresscoach is a starting point to come to smarter and more elaborate algorithms. It can be assessed through the link below. Companies and service providers can contribute to the ‘innovation-lab’ Stresscoach, by supporting further development in for instance collection of data, implementation of a feedback module and integration of point-of-care HRV and corticosteroid measurement. https://www.stresscoachonline.nl/portal/page/portal/STRESSCOACH/K/STRESSCOACH/PUBLIEK/INTRO/

6.2.3.3 Highlight WP3: My own health Changing behavior and lifestyle is not easy. Advice on physical activity, more healthy food intake, enough sleep and less stress are not (always) acquainted in individuals. This is mainly because behavior effects our health mainly in the long run. Moreover, the effect is uncertain. It is far more easy to change your lifestyle if the goals are more easy to achieve and to be seen. For instance, “I would like to wear that dress to my brother’s wedding, so I need to loose ten pounds in 6 months”.


Besides clear short-term goals, personalized information is a crucial factor in behavioral change. Focusing on your own health and wellbeing is more easy knowing how to influence your own health. And moreover if you know what factors are (currently) influencing your health. Our personal data is continuously being gathered in different settings: (health) care, the financial sector and all sorts of authorities. And of course you collect your own information. In order to realize effective behavioral change, all these data need to be combined and the information need to be given back to you in a secured way.

• Setting short-term goals is needed. • Your own (medical) behavioral information is needed. • The options to prevent you from getting or worsen a disease is needed.

Different factors influencing behavioral change of individuals.


6.2.3.4 Highlight WP4: Type-2 diabetes e-coach Focusing on maintenance (prevention) and regain (preventive medicine) of optimal health, e-coaches can play an important role in personalization of health care and will allow implementation of better and more cost-effective prevention strategies. Type-2 diabetes (T2D) is an important application area. A T2D e-coach should have the following functionalities: 1. Monitoring (body weight, physical activity, food intake, plasma glucose concentration,

mood, appetite, and energy) 2. Prediction 3. Feedback 4. Goal setting 5. Social support 6. Problem Solving 7. Reminding An existing e-coaching tool, PatientCoach, developed at the LUMC Leiden, provides an excellent platform for a T2D e-coach. The Patient Coach project is an existing public-private partnership of the following organisations and sponsors: LUMC, ROH WN, Radboud MC, Glaxo SmithKline, AstraZeneca, Boehringer Ingelheim, Fonds NutsOhra. LongFonds, The development of the diabetes module was carried out with the contribution of LUMC and ROH WN medical care organisations. Contacts have started with additional partners in order to develop the patient coach into a prevention coach platform, targeting more specifically the high risk groups of the big 5 chronic diseases. Examples are: Cooperatie Zelfzorg Ondersteund, AstraZeneca, Novo Nordisk, RijnmondNet, VitaLinq, DIEP.nl, Apple, Microsoft, Medvision. Part of the work has been carried out in a European context with contributions of: Fraunhofer (DE), European Society on Lifestyle Medicine (FR), ICCS (GR), Brainstorm Multimedia (ES), German Research Center for Artifical Intelligence (DE), University of Bath (UK), Servicio Aragones de Salud (ES), LUMC (NL), Centre d’Investigation Clinique (FR), Bath University (UK). Main results: • A prototype new application of PatientCoach for Type-2 diabetes, developed in

collaboration with the ETSB program • A prediction module for body mass index, plasma fasting glucose and insulin sensitivity

integrated in PatientCoach.


PatientCoach profile chart with the different modules predicting for example BMI, glucose and insulin sensitivity based on food intake and calorie expenditure.


This Flagship has been in operation for two years. In its first year (2013) the conceptual frameworks were developed. A clear vision was articulated and laid down in a publication that was well received in the community. This vision formed the basis for various projects that were executed from end 2013 until 2014, either under the direction of the Flagship or in one of the Innovation Areas of the Theme Healthy Living. In the coming years we will work on a series of projects that are fully based on the vision developed within the Flagship and that have been acquired under the supervision of the Flagship. These include H2020 projects, projects that were funded with TKI toeslag and b2b projects from food and pharma companies. More importantly, the vision developed in the Flagship formed the guiding principle for the technology Roadmaps within the Theme Healthy Living that were developed throughout 2014 for the TNO strategic plan 2015-2018, especially in the area of field labs. In retrospect the Roadmaps Food and Nutrition, Personal Health Technologies and Health Work and Employment would have lacked the coherence and vision they currently express without the founding work of the Flagship. Now it is up to these roadmaps to capitalize on the work of the Flagship to develop and implement real innovations in health and healthcare.

TNOreport 47/47

7 Signatures

The Hague, 3 March 2015

Drs.H’Drop( Dr. K.E WapenaarHead of Stategy department (a.i.) Editor

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