Modern Healthcare Reports on Pioneer's Work on Games

Recently, Modern Healthcare highlighted Health Games Research, Games for Health and Pioneer's overall interest in exploring games as a health care innovation. The magazine described the work of our grantees and reported on recent research into the interaction of games and health. We thought you'd like to see what they had to say:

The Games Patients Play

Whether it's for treatment, prevention or even provider education, health care is becoming more and more interactive. An article by Modern Healthcare.

By Jessica Zigmond

Improving 21st century healthcare is, unquestionably, an expensive, complex and vital endeavor for the U.S. But can it also be fun?

Researchers, hospitals and insurers think so, which is why they’re investing time and money to develop interactive games that could change behavior—and perhaps help cut costs—in healthcare.

The Robert Wood Johnson Foundation, a not-for-profit philanthropy that focuses on the country’s most pressing healthcare needs, is leading these efforts through Health Games Research, an $8.25 million project funded through the foundation’s Pioneer Portfolio. Established about five years ago, the Pioneer Portfolio considers innovative ideas that could “break the current paradigms of healthcare,” says Chinwe Onyekere, a program officer at the foundation who works with the Pioneer team. In May, the foundation awarded more than $2 million to help bolster the evidence base that supports the development and use of interactive games for health purposes. A dozen institutions were granted up to $200,000 each to lead one- to-two-year studies of games that engage players who range in age from 8 to 98.

“We’re gaining insight into how people learn,” says Debra Lieberman, director of Health Games Research and a lecturer in the department of communication at the University of California at Santa Barbara, which is the program’s headquarters. “What I love is that people do this willingly. These games are so well-received,” she says, adding that it’s fun to watch how hard people try when playing a game.

Lieberman says she conducted a study of children ages 6 to 11 and asked if they preferred learning from a book, a video or a video game. She found that 49 of the 50 kids said they preferred a video game because it “lets you try things out.” She’s now trying to pull the over-30 generation into this world. “People say this will sugar-coat learning,” she says. “Learning is fun. Everyone loves to learn, but they need a reason to learn.”

The article continues after the jump.

Helping people stay healthy

Lieberman’s work has produced results that support her theory that games can be effective tools in improving healthcare. A 1997 study published in Medical Informatics evaluated the effects of Packy and Marlon, an interactive adventure video game that uses experiential learning to improve self-management of diabetic children and adolescents. Participants in both the treatment group and control group played their game for an average of about 34 hours over six months, or about 1½ hours per week, during their leisure time. After six months, the treatment group, but not the control group, experienced higher perceived self-efficacy—or people’s belief that they can achieve certain goals—for diabetes self-management, which includes increased communication with their parents about diabetes and improved daily self-management behaviors, such as monitoring blood-glucose levels, taking insulin as needed and eating the right foods. Also, the treatment group had a 77% decrease in diabetes-related emergency and urgent-care clinical visits, the study showed.

“The Internet pales in comparison in terms of interactivity,” says Lieberman, who received training in media and learning from instructors who helped create “Sesame Street,” the children’s educational program. “The Internet is incredible, but not as fast or interactive as a video game,” she says, adding that video games are also powerful learning environments because players receive feedback on their performance.

Lieberman oversees the Health Games Research program that funds studies in topics ranging from how motion-based games may help stroke patients progress faster in physical therapy to how people in substance-abuse treatment programs can practice skills and behaviors in a virtual world of a game to prevent relapses in the real world. Lieberman said the program received 118 applications, and this year’s grant recipients excelled in three areas: feasibility of the study, research design and team experience.

One 2008 grantee was the Communication Department at Cornell University in Ithaca, N.Y. Researchers there will explore how strategies of persuasion in a game can promote healthy behaviors in life through the “Mindless Eating Challenge.” In this “virtual pet game,” children between the ages of 10 and 14 choose from about a dozen pets and then must follow various tips in order to care for their pet of choice. The tips encourage kids to eat a hot breakfast, pause five seconds between bites, and avoid eating directly from a bag or container, according to J.P. Pollak, a Ph.D. student in information science at Cornell. The game is a cell phone application that kids can download.

“We’re designing game play that leads to higher motivation,” Pollak says. “The full study next year will last one full month, and we hope to see compliance with dietary tips.”

For older students, there is “BloomingLife: The Skeleton Chase,” an interactive game designed to promote physical activity and healthy lifestyles among college freshmen at Indiana University in Bloomington. The School of Health, Physical Education and Recreation received $185,000 for this study, which involves a mystery on campus that takes eight weeks to solve as it unfolds in a variety of media: e-mail, Web sites, phone calls from fictional characters and physiological monitoring. Two groups of 45 college freshmen—one collaborative, one competitive—will use this game as their laboratory component of their “Foundations of Fitness and Wellness” course. Jeanne Johnston, an assistant professor of kinesiology who is working on the study, says the project will develop a metric to evaluate the psychological aspect of the “game play” experience.

“I see a tremendous amount of applications in a variety of settings,” Johnston says. “One area where this would work well: the work-site setting. People are naturally competitive, and they enjoy being able to track what they’re doing and working as a team. So I think all of those components of health games you can apply to a variety of populations.”

That includes patient populations as well. In Redwood City, Calif., HopeLab was established in 2001 to develop a game that would give young people with cancer a sense of power and control over their disease, says Richard Tate, HopeLab’s director of communications and marketing.

“We engaged doctors, nurses, oncologists, game developers, game designers, patients and cell biologists to design a game that was accurate in a scientific perspective and also fun and entertaining,” Tate says.

The result was “Re-Mission,” a video game introduced in May 2006. HopeLab conducted a randomized, controlled trial to test the effect of the game on adolescents and young adults with cancer. The study included 375 male and female cancer patients between the ages of 13 and 29 at 34 medical centers in Australia, Canada and the U.S. Preliminary findings showed that playing Re-Mission produced increases in quality of life, self-efficacy and cancer-related knowledge for adolescents and young adults with the disease.

Behavior modification

“I think the research demonstrates the potential impact of games—to engage customers and positively influence the way they behave in the course of their treatment,” Tate says. “One of the things we know generally: (They’re) really compelling forms of entertainment. We also know that healthcare companies who are responsible for the well-being of millions of people are very interested in new, effective ways to reach their customers, but there is not always a bridge between the folks who design games and the healthcare industry (that is) into scientific evidence,” he says, adding that he hopes the HopeLab study in the journal Pediatrics will contribute to this evidence base.

While researchers are developing games and gathering research, Banner Health has already started using health games as a rehabilitation tool at its Good Samaritan Rehabilitation Institute in Phoenix. Rehabilitation services for patients have not changed much in 30 years and tend to be boring, says Mark Smith, system director of simulation and innovation at Banner. In addition, there is generally an 80% drop-off rate in exercise after patients are discharged to the outpatient setting.

“Gamers are very shrewd,” Smith says. “They know how to build games that engage your attention. Instead of sitting by yourself, you can play bowling or golf with your daughter or husband.”

Smith says Nintendo’s Wii game console—which sells for about $300—is “revolutionary” because it makes people get up and move, and also because it has created new opportunities in science, such as training clinicians. Smith oversees Banner’s Simulation Education and Training Center, which chose the Wii to train surgeons about two years ago.

“The purpose is to train clinicians of any kind,” Smith says, adding that games can help train practitioners to insert an IV tube or intubate a patient. “We’ve trained them on mannequins, but this trains teams like in an operating room.”

Whether they’re helping patients or training clinicians, interactive games have the power to change behavior, which, in turn, could eventually lower the cost of healthcare, says Ben Sawyer, president of Digitalmill, a Portland, Maine-based consulting firm. Sawyer is also co-founder of Games for Health, a project produced by the Serious Games Initiative to develop a community of stakeholders as well as a best-practices platform for games being built for healthcare applications. According to Sawyer, Games for Health has received nearly $1 million from the Robert Wood Johnson Foundation for the next four years. The funding will help sustain the program and allow Games for Health to continue hosting yearly conferences that he says add legitimacy to the idea of healthcare games.

“Bottom line is they reduce the cost of providing care because people are fit,” Sawyer says of interactive games. “Or it helps people to manage a chronic illness or condition better, such that they don’t make trips to the emergency rooms,” he says. “The other thing would be to improve training and quality of care, which leads to less medical errors, lower lawsuits.”

Insurers get in the game

Sawyer says that Games for Health continues to raise awareness about the issue, and the concept caught the attention of certain insurers. One of those is Louisville, Ky.-based Humana, which helped sponsor the fourth annual Games for Health conference in Baltimore in May. Humana also introduced a new Web site as part of its strategy to affect consumers through games and the health benefits of game technology, and it launched a game called the “HorsePower Challenge” for 100 students at five middle schools in Louisville. The students wore pedometers for four weeks to measure and record their activity levels. By the end of the challenge, the students had walked a total of 6,364 miles, a 10% increase over the previous four weeks.

“In the Games for Health space, we have a large initiative; we are looking at the whole space of electronic games,” says Miguel Encarnacao, director of emerging technology applications at Humana’s Innovation Center. “You have certain games that make you physically move more. You have games of an educational nature. You have other games that are more entertaining but bring a certain point across in an ironic way. There is a huge variety of games—what platform, what genre, what audience. We’re trying to look at this old space and find out which game applies to which audience.”

One such audience is the elderly, which was the subject of a pilot project between Humana and the University of Pittsburgh. Seniors in an assisted-living facility played a dance-mat game that was tailored to their needs, as it included a rail around the mat and used music from their generation. Encarnação says the game has helped the seniors become more active, which can reduce depression. Left untreated, depression can lead to rapid health decline and higher costs for treatment, he says.

Given that health games research has taken off in the past three to four years, there are not yet enough developers to create different platforms for the wide range of diseases that exist, according to Encarnacao, who says that Humana has received more requests from vendors and developers in the past year.

Meanwhile, the Robert Wood Johnson Foundation continues to support additional research in this area and will issue its second call for applications in January 2009.

“We’re hoping to connect the evidence that we’re building and connecting that to practitioners in the field,” says the foundation’s Onyekere.

Used with permission of Modern Healthcare Copyright© 2008. All rights reserved.