More than twice that many logged in to play Future of the Hospital last week.

For a 24-hour period starting at 9 a.m. Tuesday in California, 637 people from around the world convened online to compete and share ideas about what hospitals might look like in the future.

As the game moved through time zones and across datelines, players in California and other United States were joined by players in India, New Zealand, the United Arab Emirates and other parts of the world.

Rachel Maguire, research director at the Institute for the Future and principal "game guide" for the event, said the response has been positive, and she predicted her organization may pursue more health care crowdsourcing events.

"This was our first foray into health care as a topic for the general public," Maguire said. "We really didn't know what to expect. When you're using these kinds of platforms, you're always going to get a certain number of techies who are involved because of the online gaming aspect, but beyond that we weren't sure. We thought may 200 or even as many as 300 might get involved," Maguire said.

"But in the middle of the night it became clear that we had a lot of global interest when people in India and other parts of the world began to log in," Maguire said.

The California HealthCare Foundation, which publishes California Healthline, provided funding for the game.

Hospitals Serve as Centerpiece for Changing Industry

The hospital game is one of several "collaborative forecasting" games designed for the Institute for the Future's online Foresight Engine. The goal is to tap into collective multidisciplinary expertise to encourage and steer change. Besides health care professionals, players in the hospital game included architects, planners and sociologists.

Community hospitals were picked as the centerpiece for the institute's first foray into health care for a couple of reasons -- their central role in community health and as a symbol of an industry undergoing profound change.

"Community hospitals are rarely seen as a public resource," Maguire said. "If we run a game about public education, everybody feels comfortable about expressing an opinion about the neighborhood elementary school or the high school. But some people don't think they have the right to talk about what happens to hospitals in their town. Financing and delivering health care is so complex that it can be daunting to people, but the public does have some ownership over what happens to their community hospitals. That was part of the impetus behind this game," Maguire said.

In explaining the premise and rules of the game, institute officials wrote:

"For over 100 years, the hospital has been the core of our health care system and a pillar of every community -- the central hub where people enter and leave this world, and where scientific discoveries become life-saving procedures. But in the last couple decades, technological, social and economic forces have chipped away at this model. As these trends continue -- making traditional clinical environments punishingly expensive to run, and increasingly less necessary for many health care needs -- the future of the community hospital is uncertain."

Too Soon for Winners, But Themes Emerged

Although it's too early to tally up specific results -- or award winners in several categories -- some themes clearly emerged, officials said.

"The idea that the hospital should be seen as a center of community wellness rather than a place you go when you're sick seemed to resonate throughout the game," Maguire said. "That kind of language and those kinds of ideas percolated long before we launched that challenge in the game. It seemed people had very strong opinions about that -- especially around how do you change the culture? Do you add athletic fields or stage cooking classes?"

Maguire said some players countered with "maybe hospitals should be where we go for high-specialty care and maybe we should take more of the routine things that happen at hospitals elsewhere."

A changing workforce and new occupations also were recurring themes, Maguire said.

Players answered a series of challenges and played cards presented in the game. Questions and tasks in the game included:

Construct a 21st century safety net system that is fair, economically sustainable and delivers high-quality emergency care services to all in need.

How will new technologies like telehealth help hospitals provide relevant care in a world where fewer services require stepping foot inside a clinical environment?

In the next decade, can the community hospital compete with specialty hospitals or with highly personalized consumer technology?

Winners and "micro-forecasts" will be announced next week, officials said

'Vehicle for New Ideas'

The competition was engaging and perhaps a key part of the experience for some, but for Kristi Miller, senior strategist for the American Heart Association and one of the game's six judges, the game was mostly about ideas.

"For me, the experience represents a wealth of information and new ideas. The game was the vehicle for that," Miller said.

"The top people on the leader board were very into the game mechanics, but I'd say for 80% to 85% of us, it was all about the content."

Miller, who participated as a player and now will judge her fellow players' entries, said crowdsourcing can produce both a general sense of a community's opinion on a broad topic, as well as "nuggets you might not get anywhere else."

"Anytime you have that very public forum you get a kind of 'crowdspeak' -- a sort of collectivism -- but you also get some specific nuggets," Miller said a day after gameday.

"I haven't been through many of the cards yet but already I've seen some ideas around re-purposing the nature of hospitals -- co-locating with libraries, symphony hall, retirement communities -- to make them more of a community hub. There were suggestions about dropping the word 'hospital.'"

Brendon Shank -- associate vice president for communications at the Society of Hospital Medicine -- said the sharing of ideas in the game was similar to what's going on in his organization's online community.

"Very smart people in health care are having conversations similar to the game, but not in this kind of free-form but facilitated format. It was great to see people contribute, build, challenge and support ideas," Shank said. "It actually reminds me a lot of the conversations that our members -- hospitalists -- are having on our brand-new online collaboration tool," Shank said.

"I found (the game) immensely valuable. There were lots of very good ideas -- some very big, some very granular. It also gave a sense of perspective for the challenges hospitals face ... and the opportunities ahead of them.

"The success of the game and HMX, the society's new collaboration tool, both point to a very deep need for innovative conversations about these challenges and opportunities," Shank said.