Guest Article: Why Games Matter in Healthcare

The Fifth Annual Games for Health Conference will be held June 11–12 in Boston, MA. The conference will focus on the many intersections between videogames, health and healthcare. I’ve written quite a few times recently about games in healthcare and how the IT around games in health is important to us. The conference is very affordable and there’s a 15% discount by entering bos09 during registration but the early bird pricing expires today. As the conference approaches I asked Games for Health co-founder Ben Sawyer to provide an update on where things stand in this emerging but important area of health IT. Here’s what Ben had to say:

The fifth annual Games for Health Conference takes place on June 11–12. The conference was started by the Games for Health Project in 2004 to gather together researchers, developers, health professionals and related stakeholders to share ideas, demos, and research concerning the use of videogames and their related technologies for use in health and healthcare. Since its single-track, 120 person origin in Madison, Wisconsin in 2004, the conference has grown to nearly 350 people and five simultaneous tracks. This year also sees the return of the event’s pre-conference workshops concerning games’ accessibility and virtual worlds for health, which were added last year and take place this year on June 10. The conference has mostly been held in Baltimore, MD but this year made the leap to its new home in Boston, MA—a city with a burgeoning game development scene whose reputation in health and life sciences goes without saying.

As the conference date approaches it seems a good time to take a mini-assessment of the field of games for health. When I started working on this area as an offshoot to the Serious Games Initiative (an effort that looks at many different sectors videogames can play a role in), the most significant work was the adoption of game engine technologies applied to the existing field of Virtual Reality (VR) medicine and cyberpsychology. VR medicine and cyberpsychology go back to the dawn of basic 3D graphics and have a rich if somewhat secluded history. Lots of great work has been done looking at both the therapeutic applications of VR and its ability to help with (mostly) surgical training. But an interesting thing happened on the way to the office. The technologies underlying much of VR medicine simply didn’t keep up with what the games industry was producing. This leads to two distinct things that the VR world is still grappling with: first, VR health researchers began using off-the-shelf game engines to pursue their work. They were cheaper and better. Second, a new generation of game developers, game publishers, researchers, and developers began exploring health opportunities with games (as a form of media) and game technologies that was in some respects not entirely connected to the VR health field. This group was arguably more interested large-scale opportunities that dealt with ideas such as aerobic exercise, nutrition, disease management, and more. They were also more interested in the intersection of games with the audience of gamers and what that represented for new health opportunities. From my vantage point I don’t view this as a point of friction for the VR health field, but it was a point of change.

Today the VR health and games for health fields co-exist. They have much to share with each other—and do. VR health supplies the games for health field with a much needed research base and ethic to uphold, while the games for health space bring many elements of scale, business case, innovation and creativity to the overall idea of media base behavior change, 3D graphics psychology and more. To understand the state of games for health today you must understand the evolution points games for health draws from and the VR health field is a critical touch point because it offers a heritage many people don’t realize exists.

A second heritage for games for health lies in the fact that there have been many different games for health and games about health throughout the history of videogames. Georgia Tech researcher Ian Bogost (with whom I’ve collaborated frequently) produced an entire chapter for his book Persuasive Games on the history of exergaming, which goes back to the days of the Atari 2600 Video Console System. You can read that article here. I myself have frequently presented on a series of videogames that have, throughout their history, been about health or contained significant health aspects in their game designs. These products are not as plentiful compared to how health themes frequent other media (especially TV), but there is a substantive history of games including Microsurgeon (Figure 1.1) by Imagic and developer Richard Levine, which was produced in 1982 for the Mattel Intellivision and later for the TRS-80 computer system.

When the conference first opened in 2004, the current state of games for health was clearly still emergent. Despite history to draw from, good related fields of work and several noted startups, the field’s biggest “hit” was the addition of a calorie counting workout mode to DanceDanceRevolution from Konami. Shortly thereafter, a few new exergames began to enter the market including responDesign’s Yourself!Fitness and Sony’s EyeToy: Kinetic—perhaps exergaming’s most underrated title to date.

Slowly over 2005–2006 the field began to expand through a combination of new projects that started up and existing projects that became better known. The most important of the new projects was Hopelab’s Re-Mission title (figure 1.2)—a videogame where the player stars as a nanobot fighter named Roxxi, a cross between the lead character in Sega’s Space Harrier and Laura Croft from Eidos’ Tomb Raider. This meticulously produced title interwove information about cancer and its treatment regimen with gameplay involving a well-depicted 3D battle against cancerous cells inside the body of various types of cancer patients. The game mixed narrative about cancer with specific procedural rhetoric involving fighting until every cancer cell is eradicated to create a new form of media based behavior change. Research conducted by HopeLab, published recently in medical journals, showed that there was a significant effect on various aspects of cancer patients who played the game including higher levels of chemo in their bloodstream vs. the control group—who were given a different videogame to play. While companies like Raya Systems had previously shown similar effects with games like Packy & Marlen, Hopelab reestablished, in a more recent timeframe and with a higher-end product, that media-based behavior change techniques could be enabled through videogames.

Then the Wii came out.

If you were to move ahead twenty years and then ask the casual bystander when the idea of games for health started, most uninformed but interested observers would pinpoint the release of Nintendo’s Wii platform as the time when the world noticed games could contribute significantly to personal health. The Wii turned many ideas upside down in the videogame industry, but most of all, its focus on more universal movement to drive gameplay in all its games has ushered in a much bigger focus on how active videogame play can have great potential in aerobic exercise and physical therapy.

The combination of the launches of Wii Fit and more recently Electronic Arts’ EA Sports Active title, it’s fairly easy to say in a general sense that the idea of games for health is no longer embryonic. Taken at the worldwide retail level the trailing 18 month sales of WiiFit ($90/unit) results in total revenues over $1.6B. That is revenue any pharma, medical device, medical service, or exercise equipment company must be envious of. EA Active, I suspect if reviews are good, will have total global sales (at retail) close to $120M-$250M in the next 12-18 months, which if it were a standalone company, would make EA one of the top fitness product companies in the world. Already the CEO of game publisher Ubisoft has singled out exergaming as a genre that will contribute to top-line revenue growth as the current prices of home videogame console prices drop over the next two years.

What this explosion of new off-the-shelf technologies has done is prove not only that there is a market for games for health (or at least exercise), but it has also quickly broadened experimentation inside the health sector. The Games for Health Conference 2009 features more then a few talks about how the Wii in particular is being used in various physical therapy settings, such as for burn victims and people with Parkinson’s disease.

EMERGING ISSUES WITH ACTIVE GAMES

The issue with such uses from what I’ve learned, however, is that they represent the will to use such technologies but not in their ultimate forms. With the Wii, many adventurous therapists are essentially bending the system and games to their will. They’re finding it useful, novel, and invigorating—but they’re having to adapt things to fit the situations they use it in. For example, one therapist puts tape over the areas of the screen displaying scores because scoring provides improper or even negative feedback to the people he is working with. A group fitness instructor we spoke with last summer showed how they use shadow play of DDR on the Wii to get first-time users up to speed with the game before they play it for real, because it is difficult to dump them right into the game without the possibility of getting discouraging results when they start.

Many videogame companies would be the first to point out they’re not building technology for physical therapy or anything with even a tinge of medical treatment (least of all because of perceived liability or regulatory issues)—but ironically, what most researchers who are trying to adapt these titles to their needs will tell you is that the changes developers would need to make and the small things they could add, would make a major difference not only to researchers and patients but to all players of such games. As someone who designs games for a substantial portion of my work life, I absolutely agree with them. The ideas I’ve seen from the grassroots and professional research communities about how to improve off-the-shelf games for use in fitness and therapeutic settings would make most games better overall. This is why the Games for Health Project exists: to help foster these communications so all games get better, whether they are consumer titles or specially targeted efforts and implementations.

The dichotomy of the recent explosion in fitness titles isn’t just within their specific designs either. The biggest question hanging over the recent headlines of Wii Fit, EA Active, Gillian Michael’s game from Majesco, etc., is this: as consumer fitness titles with significant sales, are they having any real or especially novel health impact? Our opinion is yes and no. Yes, because as we’ve seen with some research, and anecdotally, there are people who have previously shunned other opportunities for exercise that are turned on by these new products and as a result do get into shape and often even move on to more traditional forms of exercise such as bike-riding, playing sports, etc. However, it’s also a no because like many fitness products, there is also good evidence that sustained usage is a fraction of sales.

This downside to exergaming is partially built into the structure of consumer fitness products (be they from the videogame industry or otherwise) because at “Big Videogame Publisher X,” if I lead the team that built Fitness Game 2009 for $10,000,000 and subsequently sold four million copies at retail, I’d be well rewarded. Meanwhile, if I reported to the Robert Wood Johnson Foundation (who is the funder of the Games for Health Project) that for $10,000,000 I got 4,000,000 people to exercise, 95% of whom quit after four weeks or were already were in good shape and were fitness fans now using videogames, it’d be seen as not nearly the same success. This is what I call the “exergame impact gap” and the goal we’re now working toward is to see if the gap between sales impact and vulnerable population health impact can be closed with a decent level of significance through a combination of better design and, most importantly, post-game support by the health and fitness community.

Perhaps the most controversial thing I can add here is that the videogame industry has an opportunity to differentiate itself from many other consumer fitness fads by truly diving deep into the health and fitness community to build games that really help improve their ability to reach and create sustained usage with people who are not exercising properly or enough. So far, the industry hasn’t quite done this—but if the game industry draws more significantly on its competitive instincts and growing science-based design practices, we may see that emerge. This is important because the opportunity games have over many other fitness interventions are quite significant and if you follow the flat lined revenues of many game publishers, they absolutely need to begin growing and invading new consumer markets such as fitness and wellness.

RECAP

To summarize thus far, games for health have existed in several forms for quite some time. Many pioneers have achieved some success points to date, and the current generation of games and game consoles has seen an explosion in active games now used for fitness and some innovative efforts in physical therapy. I’ve not spent much time on it here, but the field of cognitive fitness and therapy with games is also booming. Many new pieces of science, startup activity and new products are now entering the market to address developments in cognitive fitness and therapy. However, like the physical exergame field, the field of cognitive fitness is also having to sort out its science, impact gaps and sustainability. Still, the notion of brain fitness with videogames, like exergames, is no longer embyonic.

The largest difference between 2007–2008 and today, for me, is that I no longer feel the need to describe the general concept of videogames playing an active role in health and healthcare as nascent. It has arrived.

THE FUTURE

As table 1.1 shows, the field of games for health goes way beyond just exergames, physical therapy, and cognitive fitness. While any broad field has its first movers that become (for better or worse) its poster children, the single most important thing I can communicate to those of you reading this far is that the opportunities for games for health are broad. This year’s conference features a multitude of talks on (potentially) related uses of games for epidemiology, multiple sclerosis, training, public health messaging, nutrition, child development and more.

Health touches many parts of life. Videogames are a medium we’re just beginning to understand as being very broad based. To think that this combination would only touch on a few small points would be tragic.

We’re clearly in a period of transition for games for health. The field is moving from an emergent status to a state where its validity will now be based as much on its business scale, scale of health impact specifically, and its overall sustainability than the logic of the initial concept. As such, we are working this year to transition the Games for Health Project as well—to one less concerned with merely promoting the concept than to activities designed to see its impact as both a mile wide and a mile deep.

Games are Health 3.0—where the idea of information therapy moves beyond textual based relationships housed on thin clients dominated by textual content. One of the things that will make games different is already being seen in the first movers within the space. It’s the notion that the mere act of playing creates the behavior change so many other forms seek to create as a byproduct of their consumption. A large segment of the health impact of videogames is based on a formula that the delta between consumption and change is zero. Even when this is not the case, games bring traits to Health 2.0, that while symbiotic, take things to the next level by potentially improving motivation, enabling deeper emotional impact, and providing visualization and social experiences that are considerable. To merge the worlds of Health 2.0 and games is non-trivial. It can’t just be embedding the odd flash application on Facebook or PatientsLikeMe.

This year at Games for Health 2009 we’re going to be exploring many of the themes I’ve laid out here. We’re going to cover four key themes:

1. The heritage of games for health with talks from early pioneers in games for health, and prior art in games that covered health themes.
2. The current impact and research behind the two biggest first movers in games for health: exergaming, and cognitive health, with tracks devoted to each segment.
3. The impact gap between the potential reach of games for health and the actual impact it is or is not having due to the current structure of the field and the games themselves.
4. The future of the field at its broadest horizons and what can be done to see success in as many areas as possible.

In five short years, the change has been quite amazing—but despite much being done, things are clearly just getting started. Ben Sawyer co-founder Games for Health Project Games for Health Conference www.gamesforhealth.org