Gamification to improve healthcare outcomes

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Talking about gamification has gotten me into a whole lot of “heated discussions” over the past couple of years. Sometimes it’s with the sort of ahead-of-the-curve professionals who talk at length about the intricate game-play of Call of Duty versus the simple pleasures of Angry Birds; sometimes it’s with more sceptical types who balk at buzzwords and think digital culture is an oxymoron; sometimes it’s with both at the same time.

Dubious name, solid credentials

Gamification is certainly not the most elegantly invented word in digital technology; hearing it is enough to make some people roll their eyes. It’s the “game” part that turns off people who aren’t familiar with the principles behind it. It invokes aged stereotypes of hard-core shoot-‘em-up gamers, immersed in online mayhem – or perhaps newer stereotypes of cute cats on smart phones.

The uninformed see games as a category of activity that’s all about fun and entertainment and has nothing to do with serious things in life, such as business and healthcare. That’s way off. Some of the smartest, most serious people study games. In fact over the past decades games and the principles underlying them have revolutionized our understanding of how people think and behave.

The first milestone was the publication of the classic 1944 work Theory of Games and Economic Behavior by mathematician John von Neumann and economist Oskar Morgenstern. Building on their work, 8 game theorists have since won the Nobel Prize in Economics. Game Theory has been applied to many other fields including philosophy, biology, artificial intelligence, military strategy, epidemiology and politics. It all gets very complicated but at heart Game Theory is about people making decisions.

Popular culture got another challenging take on games from the 1964 best-seller by psychiatrist Eric Berne: “Games People Play: The Psychology of Human Relationships”. Berne’s notion of games is a series of interactions that follow a predictable pattern in which one person obtains a “payoff” or “goal”. In most cases, participants are not aware that they are “playing.”

At first blush, gamification itself may seem closer to those prejudices about games being trivial; its raw material is the likes of Super Mario, Sonic the Hedgehog and Lara Croft. But dig a little deeper and here too the issues of interactions, decisions and motivations come into play. Anyone interested in those issues must be interested in a key question behind gamification: What is it about computer games that gets more than half a billion (that’s over 500,000,000) people round the world voluntarily playing at least an hour a day – often so deeply engrossed that they forget to eat or sleep?

The success of computer gaming and its recent offspring social gaming is based on the industry’s rapidly-evolving understanding of game design and game mechanics. The gaming industry has more expertise than any other in attracting people’s interest, holding attention and getting them to engage in specific behaviours e.g. look for this, click on that. Gamification is about taking the underlying principles of gaming and applying them to virtually any non-game activity, including health care.

Essential elements of gamification

Games typically feel like play but that doesn’t mean there’s no work involved. The crucial difference is perception. For most people, work is when they have to put time and effort into an activity they feel obliged to do for money or duty; play is putting time and effort into something they want to do because it’s enjoyable.

Games must have rules that spell out what you can and can’t do: what you must and must not do. Rules provide an essential sense of order and logic to a game.

To drive motivation games must have clear in-game small-scale tasks, such as finding hidden tokens, and the tasks must lead towards an overall longer-term goal, such as finding all the tokens within a certain time.

A sense of competition helps to fuel participation, whether it’s playing against another individual, against a leader board or against a personal best.

Smart games give players a constant stream of carefully calibrated rewards as feedback and encouragement to progress: extra points, higher status, badges. These reinforce the brain’s own reward system that releases dopamine on completion of a task or goal.

Games must offer scope for improving a player’s level of skill, and for raising the level of challenge to match it. When skill and challenge levels are matched, the player feels a state of flow as described by Professor Mihaly Csikszentmihalyi in his highly influential work Flow: The Psychology of Optimal Experience.

Gamifying healthcare

When people engage in anything that normally counts as a game (e.g. baseball, rock-paper-scissors, World of Warcraft) they take it for granted there’s no practical purpose to the game beyond playing the game and enjoying it; any benefit is a bonus.

When people engage in gamified activities, they understand there’s a meaningful purpose beyond playing the game. They engage because they value the purpose but may not have the willpower or presence of mind to achieve it easily; gamifying the activity helps people to remember and motivates them to stick at it. For healthcare there’s plenty of scope: losing weight, sleeping more, making healthier food choices, improving fitness, monitoring health metrics and medication compliance are all obvious candidates for gamification. Children and young people are the most likely to feel comfortable playing games, and to demand fun from things they have to do.

Health insurance company Humana has been actively innovating to make fun things healthy and healthy things fun with Humana Games for Health (HG4H). In its Horsepower Challenge (HPC) targeted at school students, players wear a pedometer in their shoe; the device stores up to two weeks of data and uploads remotely via a remote access point to a website. Individuals can track how many steps they and their team have taken; the steps convert to points that can go towards purchasing accessories. The company reckons the challenge prompts a 35% increase in physical activities.

Bayer’s Didget blood glucose meter has been developed specifically for young diabetes patients aged 5-15 with the aim of getting them into consistent testing habits through play with a purpose. It connects directly to Nintendo DS and DS Lite platforms and gives them access to Didget World, an online password-protected secure community where users can interact with each other and compete. The meter includes the game Knock ‘Em Down World’s Fair that encourages young users to upload their readings; health behaviour is rewarded with tickets for prizes such as mini games, special power-ups, snacks and clothes for the user’s online avatar. The main question mark hanging over this sort of approach for youngsters is whether it risks encouraging them to stay indoors to play computer games.

Canada-based Hospital for Sick Children has created the Pain Squad app for the iPhone. Its purpose is to help children and teens with cancer to track how intense their pain is, how long it lasts, where it’s located and what helps to treat it. The app enrolls users as rookie crime-fighting characters as progresses them up through the ranks as they complete surveys.

The newly-launched Games for Health Journal features extracts of a roundtable discussion with experts who flagged up positive outcomes for games used in managing diet, physical activity, asthma, pediatric cancer, diabetes, cystic fibrosis, pain, phobias, addiction and stroke rehabilitation, as well as cognitive functioning of older adults, social perceptual skills of autistic children, and improvements in physical activity and nutrition across a wide range of age groups.

Insurers Aetna Inc. enlisted gaming and team-based competition to promote employee health goals with its Get Active! Program. The online system gets users to set goals (e.g. weight loss), track progress, compare results, team up with supporters and take part in challenges. Aetna reports that employees that participated in Get Active! Program had a body mass index (BMI) reduction of 7.8 points compared with those who did not.

On a much shorter time span (mere minutes), Cambridge Consultants has created a gamified system called T-Haler to train people to use their asthma inhaler correctly; according to the American Academy of Allergy Asthma and Immunology, around 8% of the US population suffered an asthma attack in 2009 and globally an estimated 300 million people suffer from the condition. The T-Haler system uses as wireless training inhaler that monitors how a patient uses their device and provides them with real-time feedback via an interactive video game. In just a few minutes of training, correct usage went from the low 20% range up to 6%, and was still at 55% a week later.

Gamification for health isn’t just for patients.

Stanford University has developed a game called Septris designed to educate healthcare professionals about sepsis and to gamify management of the condition. The idea is to heal all of the patients who are progressively deteriorating. If their condition gets worse, patients move toward the bottom of the screen whereas if their condition improves they move up the screen. Reaching either screen limit will either result in death or discharge.

A popular app called Ward Round puts the user in the role of doctor to solve clinical medical mysteries against the clock. Using a quiz format, the game is to answer questions fast and correctly to progress through levels of expertise from High School Student. The game is open to anybody but is apparently an advantage to aspiring medical professionals needing to sharpen up their knowledge.

As in other high-skill areas (e.g. flying) a lot of game-designers’ expertise is focused on creating compelling simulations. The US Defense Advanced Research Projects Agency, spiritual home of the Internet, has put out an RFP for apps that are engaging and challenging to the user to train medical first responders.

All the signs indicate there is virtually unlimited scope for gamification to help all stakeholders to improve health outcomes across the board. That’s certainly the view of Tom Baranowski, Professor of Pediatrics specialising in Behavioral Nutrition: “There are probably no limits to where we could take video games, as long as there is a behavior or psychological component to what is being done”. For a company such as mine working at the nexus of digital, marketing, and healthcare, gamification is one of the most exciting tools we have for helping our clients get to the future first.