mHealth games and gaming technology have the potential to improve patient engagement and boost clinical outcomes – if only people would take them seriously.
“The word ‘game’ has always been a serious barrier,” says Beth Bryant, of Games for Health, a Portland, Me.-based group acquired by the Personal Connected Health Alliance and HIMSS in 2014. “For a long, long time, people have tried to call it ‘serious play’ or used other words to get around it.”
Yet it is serious business. Several payers and pharma companies have invested in games and gaming platforms to push the needle on patient engagement efforts like medication adherence. Even Express Scripts, the nation’s largest pharmacy benefit management organization, recently turned to Mango Health’s gaming platform in an effort to boost compliance.
"Our experience has taught us that when patients are active participants in their health, they achieve better health outcomes,” Glen Stettin, Express Scripts’ senior vice president and chief innovation officer, said in a press release. “Mango Health's success in keeping patients engaged in their care through fun, user-friendly mobile applications is a natural extension of the care our pharmacists provide to our members. We look forward to bringing together our unique capabilities to motivate patients and encourage positive and healthy behaviors.”
But “fun” and “friendly” aren’t words typically associated with healthcare. And those within the mHealth and digital health gaming ecosystem say that’s what’s keeping the industry down.
Bryant, who has seen the once-sizeable Games for Health pavilion dwindle away at each year’s mHealth Summit, says the market is struggling to find an, ahem, game plan.
“There are lots of smart, bright people” in the industry, she says. “It’s a very competitive market, but they haven’t been able to get it going.”
PASSION VS. REASON
To be clear, mHealth games and gaming technology are two separate concepts.
The first deals with games that promote health and wellness or seek to improve care management or clinical outcomes.
The second – also called gamification - refers to technology that promotes engagement by feeding that natural human desire to play a game, compete with others and receive rewards.
And that, experts say, can be tricky. You have to know your target audience, your goals and – most importantly – what engages your audience. It’s very easy to do this wrong.
"Bribery is not a game,” Michael Fergusson, CEO of the mHealth gaming company Ayogo, famously said at the 2012 mHealth Summit. “It’s not enough just to give people rewards for doing the right thing. Points and badges are to games what page heading and chapter numbers are to books. I can put page numbers and chapter headings on my VCR manual, but that doesn’t make it War and Peace.”
Some see mHealth gaming as an effort to appeal to emotion over reason. To compel true patient engagement, they say, one has to play to the passions.
“We in healthcare have for too long been overly targeting the rational mind,” says Tryggvi Thorgeirsson, MD, MPH, a physician at the National University Hospital of Iceland and a researcher of behavioral economics at the Harvard School of Public Health. “Most digital health solutions are reason-based,” whereas efforts to change patients’ behaviors should focus more on “finding meaningful ways of giving you instant gratification and rewards.”
Last year, Thorgeirsson – also called “Thor” - and Saemundur “Sam” Oddsson, MD, launched SideKickHealth, a Silicon Valley-based company that uses gamified services and apps to target behavior change for lifestyle-related conditions. The company’s first product is targeted at vulnerable populations at increased risk of developing Type 2 diabetes.
“We collaborated with SidekickHealth because it makes our program scalable, allowing us to provide more diabetes prevention programs to those in need,” says Marlayna Bollinger, founder and executive director of the Skinny Gene Project, a San Diego-based non-profit organization whose Diabetes Prevention Program has been recognized by the Centers for Disease Control and Prevention (CDC) with helping to prevent or delay type 2 diabetes.
“With SidekickHealth, we can maintain the high-touch relationships that are especially important to low-income participants,” she said in a press release issued by SideKickHealth. “We can modify the program to make it culturally relevant and ensure information is not just received; it's understood. In groups that are at high risk for diabetes, like Hispanics and Native Americans, SidekickHealth has been especially effective in helping people lower their risk for diabetes.”
Thorgeirsson says games and gaming technology appeal to the “reptile brain,” or the part of the brain focused on emotion. It ties together emotional triggers – rewards, social gratification, the thrill of winning a contest – with decision-making skills, targeting the idea that people are far more apt to change their behaviors and adopt a healthier lifestyle if they’re emotionally invested in it.
Thorgeirsson knows he’s dealing with serious issues – some 68 percent of deaths worldwide can actually be traced back to lifestyle diseases – but that doesn’t mean games should be cast aside for more weighty concepts.
“I prefer that my users don’t take it overly seriously,” he says. “I don’t want them to feel that this is a clinical solution. I want them to enjoy playing it every day.”
MAKING A GAME OF HEALTH AND WELLNESS
Aside from medication management, mHealth gaming is a popular tool with payers and self-insured businesses looking to boost participation in health and wellness programs.
Mike Tinney, CEO of FIX Health, which designs mHealth engagement platforms for health plans and employers, calls the market “health entertainment,” rather than gamified health. He sees the process as taking “the experience of a game” and using that to create better health products.
“We’re an interactive, story-based experience that is built from the ground up as a game,” he says.
Tinney, a longtime patron of the Games for Health pavilion at the mHealth Summit and a strategic partner of HIMSS who’s developed that organization’s health challenge run for the past three years, says the healthcare industry has been slow to embrace games because it has trouble equating entertainment with healthcare. But with payers and corporate health plans, the focus is on participation and sustainability.
The idea here is to inspire, rather than incentivize, he says. You’re not changing opinions or making radical adjustments in lifestyle, just compelling people through an entertaining platform to make better choices and live a healthier lifestyle.
“No one’s eating a doughnut and thinking it’s healthy,” Tinney says. “They know it’s not good. What we need to do is raise the priority level of healthy behaviors.”
KILLING CANCER WITH A GAME
mHealth games have been around in the clinical environment for decades, with little fanfare. In 2011, a commentary in the Journal of the American Medical Association by Leighton Read, of Alloy Ventures and Seriosity, and Stephen M. Shortell, MD, of the School of Public Health at UC Berkeley, argued that healthcare should pay more attention to the gaming industry.
The two noted advances in GPS, accelerometers, wireless sensors and mobile hotspots, saying the technology could revolutionize healthy gaming through location-based activity tracking, movement monitoring and even vital sign recording.
By far the most popular and well-known mHealth game is Re-Mission, developed in 2005 by HopeLab, a California-based non-profit, with backing from Genentech and Cigna.
HopeLab’s goal was to help children and young adults understand their cancer and improve treatment adherence. In Re-Mission, players use "Nano-Bots" and weapons like chemotherapy and radiation to kill cancer cells - think "Space Invaders" mashed up with “Fantastic Voyage.” It was well-received in a field in which "fun" and "cancer" are rarely found in the same sentence.
"For kids in particular, games are a great way of communicating," Richard Tate, HopeLab's vice president of communications and marketing, said during a Games for Health Conference in 2013 in Boston. "Kids see this as a something they could use to fight their disease, as opposed to something that is just happening to them."
Tate said children with cancer often have problems complying with treatment. They're not motivated to take drugs or undergo radiation therapy, and are affected both physically and psychologically.
In 2008, HopeLab brought in 275 teens and young adults from 34 medical centers in the United States, Canada and Australia to test the efficacy of Re-Mission. The study, Tate said, proved not only that children use the game to increase their knowledge of the disease, but that "it got them to take their treatments more consistently."
HopeLab – which now has six games on the market - uses children as consultants during the design process. Austin Harley, one of HopeLab's game designers, said the children were asked to describe what cancer looks like, and what they'd like to do to it. The answers, he said, were often visceral, but they helped designers shape each game so that it appeals to children.
"If it's not fun, they simply won't play it," he said.
Likewise, he said, kids won't play a game just to learn more about cancer. Tate pointed out that simply knowing more about cancer didn't improve the outcomes in the study, and that those outcomes had to be tied to a shift in attitude.
"It's not about knowing everything," Harley said. "It's about feeling empowerment."
The games – Nanobot's Revenge, Stem Cell Defender, Nano Dropbot, Leukemia, Feeding Frenzy and Special Ops – are available free online at www.re-mission2.org.
THE GAME AS A CLINICAL TOOL
Some companies see mHealth gaming as a form of digital therapeutic, and as such can be used as a substitute for traditional narcotics or pharmaco-therapy.
Just last year, Boston-based Akili Interactive Labs, a six-year-old company that has developed a video-based gaming platform for cognitive conditions like ADHD, Alzheimer’s, autism spectrum disorder and depression, raised more than $42 million in venture capital funding, boosting its total equity to more than $51 million.
The company’s platform, Project:EVO, is based on research done more than a decade ago at the University of California at San Francisco by company co-founder Adam Gazzaley. Akili’s flagship game requires users to navigate an alien avatar through an obstacle course. The user’s actions and complex decision-making behaviors as the game changes course are recorded and analyzed.
Akili, which markets itself as an “electronic medicine” company, hopes to have the game cleared as a medical device with the U.S. Food and Drug Administration by the end of 2017, after which it would be marketed as an mHealth product to healthcare providers. It’s also planning to expand the platform to help treat neurodegenerative disorders like Parkinson’s and multiple sclerosis.
“Both drugs and behavioral therapy leave an opportunity for something that can engage a much broader set of patients in a very safe and still effective way at their homes,” Eddie Martucci, the company’s CEO, told Medtech Boston in 2016.
One of the more active players in the market now is OfferCraft, a Las Vegas-based company launched by former Advisory Board executive and longtime healthcare consultant Aron Ezra. The company recently partnered with The Hospitals of Providence in El Paso, Texas, to launch an online trivia game to educate the local Hispanic population about liver disease, which kills twice as many residents in that county as in any other county in the state.
“The hardest thing for a healthcare provider to accomplish is to motivate changes in behavior to get people to take a more active role in their own health,” Kurt Gross, the hospital’s director of marketing and communications, said in a press release. “That’s what this campaign is all about, and it has the potential to save lives. Liver disease is preventable, and it’s taking a disproportionate toll on people in our community. We hope to change that.”
Ezra, OfferCraft’s CEO, sees gaming in healthcare as a “very new market,” with an across-the-board potential of helping people do things they need to do but aren’t comfortable or compelled to do. That might mean learning about health risks, taking medications or living a healthier lifestyle. For clinicians, it can be used to help children express their feelings or explain their discomfort, to measure acuity in people with behavioral or neurological problems, or to measure dexterity and motion in people with motor function challenges.
“Healthcare is inherently scary,” he says. “It can be intimidating to people. It’s expensive. It’s painful at times. How do you make things like that fun?”
Ezra says many of the earlier games “were not well thought out,” and fell by the wayside because they offered rewards like virtual badges or points – prizes that really don’t appeal to game-players. Today’s games, he says, offer prizes as rewards, or create social platforms so that players can compare themselves with friends and other players.
“One of the biggest mistakes is if they don’t make it fun,” he adds. “If playing the game actually seems like work, you won’t get people to play it.”
GAMES FOR PROVIDERS
Another big market, Ezra says, is in games designed for clinicians or hospital staff. They can be used to reinforce hospital protocols, such as infection prevention, emergency procedures and sepsis detection, or provider education or information, such as an update on a virus outbreak or new guidelines for treatment.
“A vast majority of providers are unaware of the value” of games, he says.
Qstream, a Harvard medical school startup, has been developing mHealth games for years that help healthcare providers and other companies improve knowledge retention and proficiency.
The premise is simple. Design a quiz around a pressing issue – hygiene, sepsis, patient engagement, cardiac care guidelines, fire safety protocols – and push it out to targeted staff members, be they residents, doctors, nurses or other care providers. The quiz is administered several times over the course of a week or two, and questions are only retired if they’re answered correctly several times in a row.
“It’s simple, effective and fun,” says Mary Hallice, Qstream’s healthcare practice lead, who’s worked with dozens of health systems to create specific quizzes. Recently, she says, they’re been used to tackle issues like unnecessary cancer screenings, high blood pressure and patient pain ratings.
“Interval reinforcement is a proven way to increase knowledge retention,” she says. “In the medical field where (clinicians) must take in and retain a lot of information, a reinforcement method that’s engaging and conveniently available has tremendous benefits to both learning and on-the-job performance.”
In all aspects of mHealth games and gamification, it’s important to remember that each program has to be designed with specific audiences and objectives in mind. No two programs are alike, and one that’s redesigned for another population will, more often than not, fail.
OfferCraft’s Aron Ezra says each of his company’s projects is different – a game designed for patients having their gall bladder removed might be used once or twice and then discarded, which one dealing with a chronic issue would be long-term and would need to be updated or refreshed on a regular basis. That includes monitoring feedback, watching for trends and making sure the rewards remain valuable.
The biggest challenge in getting healthcare providers to embrace games, he says, lies in finding the right place in the budget.
“There are new situations all the time, new challenges,” he says, noting he’s developed games recently for a hospital wanting publicity for a new remote clinic, for a healthcare provider targeting depression patients, and for another provider looking to improve housekeeping protocols after a patient is discharged from a room.
“It’s almost impossible not to get too super-excited every day,” he says. “You really are helping people every day with this.”
And that’s no game. Or maybe it is.