The first line of my bio reads, "I am a medical doctor specializing in games for health." A punchy opener for sure, but what does it mean? In this series of blog posts, I'll be breaking down what I mean by "games for health", and the many different ways that I believe videogames - yes, videogames - can be utilized in healthcare.
In this first blog post, we will examine the issue of patient adherence, and how certain game design principles that serve to make games so compelling to play can be employed to engage patients in their own treatment plans, therapy, and care. It is the bucket of games for health that I call, games for engagement.
(Prefer to watch instead of read? Check out the topic explored on my games for health YouTube channel...or continue reading on!)
Games For Engagement
1. The Patient Journey: Healthcare's Uncharted Territory
Healthcare has a major compliance problem. It turns out, while doctors are experts at telling patients what they need to do to improve their health, getting patients to actually follow through is a different story. Healthcare providers are masters of the initial stage of the patient journey, we are ready to tell you what test to get, what medication to take, or regimen to undergo to cure what ails you. But as healthcare providers, we have not given enough attention to the back-end of the patient journey - what happens after the patient leaves the hospital or clinic, what the patient actually does once they receive their prescription from the pharmacy, or better yet, why they never even bothered to pick it up.
I once heard a healthcare commentator say - healthcare does not take place in the doctor's office, it's what happens in-between office visits. Yet, we fail to utilize the tools to set patients up for success for growth in-between visits.
This blind spot in medicine leads to a phenomenon called "clinical inertia," where treatment options fail to address a patient's needs because of barriers that are not addressed by the patient, provider, or healthcare system. This is a problem because doctors are not trained to understand this blind spot and often lack the tools and time to address it. As a result, patients fall through the cracks and do not get the care they need.
2. The Patient Experience is the User Experience
The patient experience is a specific example of the discipline of user experience (UX). UX design and research are typically associated with software or app development. UX researchers are the link between a company and its users, ensuring that a company's products fit the needs of end-users. UX designers, on the other hand, focus on how a product looks and feels to use. In short, UX teams are dedicated to understanding the user experience.
Imagine if the same level of care was given to understanding the patient experience. This would be a major step forward in achieving personalized care. We can learn a lot from the design world, in terms of processes, to improve the way we deliver care as healthcare providers. But understanding the patient experience is only the first step. We can do more to engage patients in their own care by looking at another specific example of the user experience - the player experience.
3. The Player Experience: Taking UX One Step Further
Like software and app developers, game developers also live and breathe the user experience - but in videogames, we call it the player experience. The player experience in videogames is similar to the user experience in software and app development, but with an added focus on engagement. Everything a game developer does, in some way, is intended to keep the player engaged in the experience - to keep players playing. At the core of this principle is a bible of game design principles - a fine-tuned set of rules and game components that have evolved from the first-ever videogame, Tennis for Two, into the over 220 billion dollar industry where videogames sit today - a staggering number that on its own proves the power of engagement.
By borrowing from these principles, the healthcare industry can improve the patient experience and increase adherence and compliance. Just as game designers use tools to keep players engaged, health designers can use the same tools to keep patients engaged in their treatments - to keep treatments treating.
4. Tools of the Trade
The most crucial part of any game is what is known as the core gameplay loop (CGL). The CGL is the primary mechanic, or activity, that players engage in and is the heart of the player experience. If a CGL is not properly defined or executed, a game will likely fail. This often appears as a jumble of ideas (even if they are good ideas) that lack a connective tissue binding them all together. The result is there is no driving force that motivates players to progress through the game. It is crucial that the CGL is compelling, or engagement will suffer.
CGLs can vary between games, but each game genre often share similar CGLs. For example, the CGL in the classic videogame Super Mario Bros is: run to the right of the screen, avoid or jump on enemies to defeat them, rescue the hostage (Princess Peach). On top of this CGL are accessory loops that further drive the CGL, such as breaking blocks to receive power-ups, collecting coins to earn extra lives, or reaching flag poles at the end of each level to unlock the next level where you can start the loops all over again.
(Image Source: Ethan Stanaway, Super Mario Bros: Core Game Loops and Reward Structures)
Central to the CGL, is a driving force that serves to keep players feeling attached, engaged, or accomplished - all factors that drive motivation. A CGL can incorporate one, or all, of these factors, to create a positive feedback loop, where players are encouraged to continue engaging in the cycle because the reward is worth it. While accessory loops, graphics, and other game features can enhance the overall game experience, if the CGL is not strong, the overall product will fail. When all is said and done, the player must feel compelled to rescue the princess.
5. Defining Core Loops In Healthcare
Core loops do not only exist in games though. In fact, if you pay attention, you'll see core loops everywhere. Traditional sports like soccer or baseball are driven by core loops (progress through innings, score points, win the game, win the series). Education is full of core loops (acquire knowledge, take tests, receive a good grade, unlock further education & career opportunities). Certainly, in healthcare core loops should be a no-brainer: take this medication each morning, cure what ails you, live a longer and healthier life.
Yet, adherence and compliance remain major issues in medicine. One reason for this is that the rewards in healthcare are often invisible or delayed, making it difficult for patients to stay engaged in their treatment. For example, high blood pressure is usually not a symptom you can feel, so you aren't rewarded by symptomatic relief after improving your blood pressure. In essence, the human body, and medicine, has failed to create a compelling core loop.
Take physical therapy (PT), for example. PT is a well-studied discipline that is known to have real impact on recovery, whether it be from a musculoskeletal issue, neurocognitive, or otherwise. Yet, only 35% of patients, on average, fully adhere to their PT care plans. The other 65%? That's what we call an unmet need.
All hope is not lost though. Healthcare providers can incorporate feedback loops into their practice to keep patients engaged. For example, regular check-ins and status updates can provide patients with positive reinforcement. However, instituting consistent feedback loops takes time and discipline, the former which is often in short supply among healthcare providers. Digital interventions can help fill this gap and improve patient engagement. Overall, incorporating core loops and feedback loops into healthcare can improve patient outcomes and make the patient experience more compelling.
6. Game Loops in Healthcare
In order to improve adherence and compliance in healthcare, we need to create compelling core loops that motivate patients to follow their care plans. If the motivation to get better, or to be healthier, is not enough to drive patients to adhere to their care plans, we must determine what will. But, we don't have to recreate the wheel - we only have to look at the 220 billion dollar behemoth of an industry that has already mastered the art of engagement.
By incorporating the principles of game design, such as CGLs, into healthcare, we can create engaging solutions that motivate patients to get better because the process of doing so (the core loop) is compelling. Automated feedback loops can also provide patients with regular updates and positive reinforcement. These solutions may look like reward based systems, where the act of engaging in your treatment regimen progresses you towards a meaningful goal.
Fr example, a patient with diabetes could have a CGL that involves checking blood sugar levels and earning skill points for in-range values. These skill points can then be used to defeat enemies and rescue the princess. Sound familiar? Perhaps our avatar is even a plump little Italian plumber. Notice the CGL remains the same as in Super Mario Brothers - the only thing that has changed is the input we are using to interact with the game. Instead of running and jumping, the patient interfaces with the game by entering blood sugar values. The CGL, though, remains the same - compelling as ever.
7. Find the Fun: The Role of Gamification
There is a potential issue with our proposed diabetes game: the input method of entering blood glucose data is not as engaging as the input method in Super Mario Bros (precise timing of button presses), which is an active way to interact with the game that also requires a skill-set that contributes to what makes the overall experience "fun" and engaging. However, as long as the CGL is intact, we can improve on the "fun" in other ways, by utilizing gamification techniques.
Gamification involves using game design principles to motivate and engage users, beyond the groundwork established by the CGL. This can look like the inclusion of features such as leaderboards, "leveling-up" systems, challenges to complete, or rewards, like customization options to personalize your avatar or play experience. Gamification can also include introducing high-fidelity graphics, an eye catching art-style, or even the inclusion of a compelling overarching narrative to the game.
Gamification has the potential to improve patient engagement, but it should not be used as a substitute for a compelling CGL. Health designers should be cautious of relying on game-like elements alone to increase user-engagement, as the novelty can wear off quickly without a solid CGL in place. This is a common issue seen in wellness apps, which often add game-like elements such as leaderboards and reward systems to their platforms to boost user-engagement, but this approach is often short-lived. Like a mentor of mine in the space once said to me, "chocolate covered broccoli is still broccoli." To create a truly effective health product, gamification should be implemented only in conjunction with a CGL to address the issues of patient adherence and compliance.
8. Wrap-Up
Healthcare has a major compliance problem. Healthcare providers struggle with patient adherence and compliance, often due to a lack of attention to the patient journey beyond initial treatment. By taking inspiration from user-experience design, and specifically, game design principles, we can improve the patient experience and increase adherence to treatment plans. Gamification, the use of game design principles to motivate and engage users, can be a powerful tool in this process, but it must be implemented in conjunction with a compelling core gameplay loop to be effective. By focusing on engagement and utilizing gamification techniques, health designers can create meaningful change in patient outcomes and illuminate the patient journey and experience.
About The Author:
Dr. Amiad Fredman is a leading expert in the field of games for health and the medical design of digital health products. With his experience in both healthcare and design, he has a deep understanding of how to design and develop engaging and effective health solutions that improve patient outcomes and experiences. As the co-founder and Chief Product Officer of Aegis Digital Health, Amiad is leading the charge in revolutionizing the remote patient monitoring space for diabetes patients and their healthcare providers. In addition to his work at Aegis, Amiad is an active speaker and opinion leader on the topics of health design and games for health. He hosts his own YouTube channel, Digital Doc Games, and writes a health design blog where he shares his insights and expertise with a wider audience. Amiad is passionate about using his skills and knowledge to create effective and engaging health solutions that improve patient outcomes and experiences, and is always looking individuals and companies to meet and collaborate with in the games for health and digital health space.
Follow Dr. Amiad Fredman on social media:
Twitter: https://twitter.com/DigitalDocMD
Website: https://www.amiadfredman.com/
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