The current state of health gaming
By Jonah Comstock
As Games for Health organizer and DigitalMill cofounder Ben Sawyer pointed out at the 2014 Games for Health conference, health gaming had some big milestones in the past year -- events that may not represent a breakthrough for the category but show it steadily building in importance. Health games made the cover of Nature when a study showed that a game called NeuroRacer could improve neuroplasticity in older adults, leading to a potential therapy for ADHD, depression, and autism spectrum disorders. A spin-off company, called Akili Labs, has since partnered with Pfizer to develop a game for Alzheimer's. And Facebook made two acquisitions with potential gaming consequences -- Oculus Rift, whose CEO keynoted last year's Games for Health conference and Moves, an app that puts the company into the increasingly gamified activity tracking space.
Health games are a subcategory of "serious games," a growing movement to use games and gamification in areas like education, healthcare, science or defense. It's an area of mobile health that has grown up right along side other kinds of health apps. One of the largest areas where gaming, or at least gamification, is being used is in corporate wellness, where game mechanics like points, rewards and competitions are used to motivate employees to move more or eat better, often in combination with an activity tracker. Similar efforts have been employed to get kids moving more, through game platforms like Zamzee or GeoPalz.
There are also plenty of exergames (or exercise games) in the direct to consumer market, including console platforms like Wii Fit and apps like Zombies, Run! This is a space that Sawyer and others think will explode as tracking and wearables become more and more ubiquitous over the next few years.
Games can also be used in the treatment of diseases, like the aforementioned Akili Labs. A study is underway right now at The Ohio State University testing Jane McGonigal's SuperBetter game on populations recovering from traumatic brain injuries. Many startups are working on using motion sensing game platforms like the Microsoft Kinect to treat patients who need physical therapy, as well as children on the autism spectrum. A game by HopeLab called Re-Mission helps educate kids with cancer about their disease and treatment, and has even been shown to improve their prognosis by giving them a sense of agency in their care.
Simulation games have a lot of potential in various areas of healthcare, whether as training games for mental health professionals and counselors (the province of Kognito), simulations for surgeons in training, or even public health education, such as dating simulations for teenagers that promote good sexual health or other positive health choices. One such game, PlayForward, recently completed a randomized control trial. Large-scale simulation games can be used to educate people about health risks in their environment in an effort to decrease their pollution or other kinds of waste.
Games certainly have a lot of healthcare potential. But does healthcare need full-fledged games, or is it better to add innovations from the gaming world on top of existing systems? Currently one of the big debates in the industry is around the term "gamification" -- what it means, what it should mean, and how it differs from full-fledged games.
Games vs gamification
Over the last few years, gamification has been used to refer to taking elements of games -- especially rewards, points, leaderboards, and social competitions -- and inserting them into apps geared at behavior change for fitness, wellness, or medication adherence. Gamification is increasingly popular among groups like payers and corporate wellness program vendors. But prominent voices in the gaming community have decried it, saying it uses game elements in an out-of-context and ultimately ineffective way.
"Bribery is not a game,” Ayogo CEO Michael Fergussen 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’.”
The concern is that those sorts of game mechanics work only so long as they are novel, and won't produce long term, sustainable behavior change the way an immersive game experience does. Additionally, at the 2014 Games for Health conference, attendees talked about gamification as primarily a way to sell games to enterprise buyers that might be shy about incorporating them.
"I think much of the attraction to gamification comes from the acknowledgement that games are very significant right now," John Ferrara, Creative Director of Megazoid Games said at the event. "But there’s a timidity about their professional legitimacy. People are nervous to say 'I’m working on a game.' Gamification is comforting in that way."
Another speaker at the conference, FIX CEO Mike Tinney said that his corporate wellness game company uses the term "gamification" in its sales copy, but "it’s a door opener and we immediately start to reposition when we get them on board."
What is it about games that works so much better than gamification? Well, Ferrara has a theory that effective games are constructed in layers, and that a successful game will address each layer before moving onto the next one up. At the base of that tower is motivation -- making sure that the player will want to play the game. Players play games for different reasons: for fun or recreation, as a channel for social interaction with friends, to establish and prove their skill, because it gives them a chance to be creative, or because it provides catharsis of some kind. Because the makers of health games have another goal, like getting people to move more or eat better, they can fall into a trap if they neglect to build a game users will be intrinsically motivated to play.
Above motivation is meaningful choice -- an engaging game has to give the player some agency in the outcome, which allows for tactics and strategy to exist in the game. Other layers go on top of that, like balance and usability. Aesthetics, the superficial design elements of the UI, are at the top of Ferrara's pyramid.
In his talk at Games For Health, Ferrara looked at a number of health games he felt failed at their intended purpose. Some of them fail because they are meant to be educational games, but the game elements muddle the educational message. For instance, Ferrara talked about a financial planning game by Charles Schwabb wherein the highest score is attained by choosing to not start a family, to prioritize work over everything else, and to "die alone with lots of money and no one to leave it to."
In a less extreme example, a toothbrushing tablet game for the Leap Frog system imposes a 30-second time limit for kids to clean all the virtual plaque off a set of teeth. Not only is it very hard to win, but the message is not aligned with healthy habits -- most dentists recommend brushing your teeth for two minutes, and that's by no means a maximum someone should be punished for exceeding.
The takeaway from these examples is that there's a dual challenge in healthcare: Games for health have to be worthwhile in themselves, with an intrinsic motivation for people to play, but that motivation cannot conflict with the health messages and lessons the game is meant to convey.
Who will pay for health games?
As health gaming looks to move forward, the industry faces challenges when it comes to monetizing their products. When companies sell directly to consumers, the money can be very good -- for instance, many people credit Wii Fit with saving the Wii platform by bringing in a wider demographic than most other games. The problem, according to Ferrara and Stephen Yang, a physical education professor at SUNY-Cortland who also spoke at Games For Health 2014, is that mass appeal direct-to-consumer games don't really need to be concerned with increasing movement -- only with convincing people they increase movement to sell some games. But a 2012 study in Pediatrics suggested that those games didn't really contribute to increased activity among players.
Game developers working on things like physical therapy games find themselves selling to clinics and providers rather than directly to patients or consumers. This has its own problems, of course, as getting games approved for reimbursement is a slow process, and game developers aren't used to the strenuous level of efficacy data insurers are looking for. Getting providers to pay for something that isn't covered by reimbursement is often a challenge as well.
Pharma is a space with some interest in games, which could be used to improve medication adherence or educate patients about things like proper inhaler use. But the large pharma companies are so risk-averse and have so many regulations, they're often not nimble enough to work with game companies, according to Sawyer and Steffen Walz, a professor at RMIT University in Melbourne, Australia. Correction: A previous version of this article identified Walz as a professor atthe University of Melbourne.
"Pharma, and we're talking about big pharma, are large organizations, they have core products they want to keep selling, and they’re very very conservative," Walz said. "That means you have to educate them. ... The real problem we’ve been facing is we have to explain to them what the use is and can be. Behavior change? They can’t use that in a certification process. They have to have a biometric marker."
The saving grace has been the increase of pharma companies like Merck, Roche, and Pfizer adding innovation groups that can pilot things the larger arm of the company won't touch. "This will become the only model by which pharma plays a role in games and apps," Sawyer said.
What's next in games for health?
Just as Apple, Google, and Samsung have now shaken up the tracking space with their near-simultaneous entrances, the niche, startup-filled field of health gaming is also waiting to be shaken up by big entrances. As those plays bring health tracking to a larger group of people, it opens the way for games built around health tracking to have a wider appeal, and a more well-established base of standards for developers.
Sawyer mentioned that Apple's mysterious iWatch product could prove to be a new platform for game designers, with a lot of potential for health gaming. Google Glass also offers potential for augmented reality health games, that could reward users for the healthy choices they make in day to day life while wearing glass.
One large company that has been involved in health gaming for a long time is Nintendo, and they announced a major shift into health in January, though the company has been very quiet about the details. All we know right now is the launch date is April 2015 and CEO Satoru Iwata told the Wall Street Journal that “the new product wouldn’t be wearable, that it wasn’t an extension or version of the Wii Balance Board — which players can use to measure their weight or posture while playing on a Nintendo exercise game — and that it wouldn’t be used in the living room.”
But in many ways, games for health are still waiting to take off. The killer health game Sawyer was searching for at 2013's conference has still not emerged. What's changed is that the Games for Health project isn't sitting around waiting for that game, but instead taking steps to bring it about. Sawyer announced a new toolkit for prototyping games about nutrition, because the existing ones on the market leave so much to be desired.
When Sawyer was brainstorming ideas for a nutrition game kit he was building, his friend told him something that resonated — “I don’t think about nutrition, I think about food. Make stuff about food.” So Sawyer developed a kit to help inspire other game developers to come up with meaningful games that help kids learn about healthy food. Some of the ideas Sawyer brainstormed when creating the kit included how to simplify the ideas behind nutrition yet add diversity of topics, such as exploring beyond calories and binary choices like fruit versus pizza. He also wanted to figure out how to engage developers and non-developers, keep the goals set on good outcomes, identify issues around food that improves health and health outcomes, and identify areas where games could offer deeper content.
In addition, DigitalMill is working on an open-source gaming platform called Meili, named after the Norse god of travel. The system would help facilitate the creation of games that used the smartphone's built in activity tracker or other sensors in combination with an interface that is either audio-based or requires only glancing at the screen. These would be games that, in Sawyer's words, "turn people into human joysticks" who can control the game just by moving.
A timeline of health gaming
By Aditi Pai
Digital health games have been gaining popularity in recent years and some bigger players are even starting to get involved, but six years ago far fewer digital health games were making headlines. MobiHealthNews has compiled a timeline that starts in 2009 when Corventis and the University of Southern California created an iPhone app game called Beating Heart and leads us all the way to just a few months ago when the Journal of the American Medical Association (JAMA) Pediatrics published an article that found overweight and obese children lost weight and demonstrated a significant increase in physical activity after using a 16-week weight management program that incorporates active video gaming.
Along the way, other researchers published studies showing the efficacy of gaming and more startups began creating their own apps, instead of just bigger companies. This is not a comprehensive list of events in digital health gaming, but rather a splash of some of the biggest health gaming headlines over the last five years.
October 2009: Corventis, USC create concept Beating Heart mobile game
Wireless health company Corventis demoed a concept iPhone app called Beating Heart. The app is a game that leverages Corventis’ wireless “band-aid” sensor to transmit the player's heart rate to the iPhone, which then can broadcast the heart rate over Twitter and Facebook or via text message or email. By using Bluetooth, the concept app also demonstrates that players can get a snapshot of nearby players’ heart rates in real-time. The concept app aimed to demonstrate the ability for mobile health to become interactive and fun through a social game, and could create social incentives to becoming healthier. Read More
April 2010: Bayer, Nintendo bring blood glucose meter integration to US
Bayer brought the Nintendo DS enabled blood glucose meter, Didget, to the US. Inventor and entrepreneur Paul Wessel wanted his diabetic 4-year-old son, Luke, to stop hiding his glucose meter, so he found a way to pair one of Luke’s treasured possessions, his Nintendo DS, with his least favorite. German healthcare company Bayer purchased Wessel’s idea for a Nintendo DS game paired with a glucose meter and branded it Didget back in 2009. Read More
June 2010: Humana launches mobile games for health
Humana, a US health insurance company with more than 10 million members, announced that its games for health team had launched the first of several iPhone apps that use gaming to help people engage in healthy activities. According to Humana, Colorfall offers customers an amusing way to exercise their brains and bodies as they interact with the game as players must arrange cascading colored tokens in the order of the colors of the rainbow. In order to get the colors, the player needs to take a picture of something that has that color on it. Read More
July 2010: Mobile apps for Obama’s Apps for Healthy Kids
First Lady Michelle Obama’s Apps for Healthy Kids competition website posted 95 apps that aim to encourage kids (or encourage their parents) to make healthier decisions and help curb childhood obesity. The competition, which is part of the First Lady’s Let’s Move campaign, aims to drive the country closer to achieving Obama’s stated goal of eliminating childhood obesity within one generation. Of the 95 entrants, half-dozen or so were specifically created for mobile platforms (iPhone and Android mostly). Some mobile apps included Rhythmatics Kids, a Guitar Hero for running, and Work It Off!, an app that teaches children the correlation between the calories they eat and the calories they burn. Read More
April 2011: JAMA argues it's time to take mobile health games seriously
The Journal of the American Medical Association (JAMA) published a paper that argued health-focused video games, including those for mobile platforms, now deserve “serious attention.” Dr. Leighton Read of Alloy Ventures and Seriosity and Dr. Stephen M. Shortell said while people doing jumping jacks in front of their Xbox may prove entertaining, the real news is how Read and Shortell see mobile devices playing a big role in the healthy gaming world. Read More
July 2011: Diabetes Hands Foundation launches mobile game
HealthSeeker, a free mobile app that uses gamification for diabetes management and health improvement, launched for the iPhone and Android platforms. HealthSeeker was created by the Diabetes Hands Foundation (DHF) in collaboration with the Joslin Diabetes Center. It was developed by Ayogo Games. HealthSeeker began life as a Facebook application, where it currently has more than 8,000 users. The game allows players to complete specific “missions” that encourage exercise and healthy activities. Successful completion of the missions earns players points and “kudos” from fellow players and Facebook friends. Read More
July 2011: PHR provider Dossia adds games, incentives, social networking
Dossia unveiled the latest version of its Dossia Health Manager software. It will be available to existing customers in the third quarter of 2011. According to the non-profit consortium, the Health Manager now “integrates game and social dynamics, incentives and messaging to foster sustained user engagement and behavior change, thereby offering long-term value to employers, employees and their families.” Read More
July 2011: Humana developing game for students
Raja Rajamannar, SVP and Chief Innovation and Marketing Officer at Humana explained a project Humana was working on called the Humana Horsepower Challenge. The project involved giving pedometers to students in 60 different schools across the US. Humana developed an “aquarium” game where the students’ pedometer logged activity data was represented by fish avatars of various sizes. (Humana has its own branded pedometer device as part of its Humana Gear offerings.) Students who exercised more appeared in the “aquarium” as larger fish. Rajamannar said that the students in the program did six times as much physical activity as they did before the program started. He said activity levels for the group were still higher on average than they were before the program. Read More
March 2012: Medical device and design company develop asthma inhaler game
Medical device design and development consultancy Cambridge Consultants showed off its latest creation, an asthma inhaler training device called the T-Haler. According to the company the concept device “more than doubles patient compliance.” According to Cambridge Consultants, the device offers interactive software, linked to a wireless training inhaler that monitors how a patient uses the device and provides real-time feedback via an interactive video game. T-Haler provided visual feedback to the user on their performance and the areas that need improvement. Read More
March 2012: Cancer-fighting video game may positively impact behavior
HopeLab Vice President of Strategic Partnerships Ellen LaPointe wrote in the company's blog that a researcher at Stanford Business School found an hour of playing the company's cancer-fighting video game Re-Mission, created in 2006, could cause shifts in emotion, knowledge, and perceptions of chemotherapy that might potentially influence downstream behavioral impacts. Since then, HopeLab has launched a second version of Re-Mission that is a collection of online games. Read More
November 2012: Study finds virtual avatars improve fitness motivation
A study from the University of Missouri found social engagement with avatars can improve self-image and engagement in a health context. Elizabeth Behm-Morawitz, study author and Assistant Professor of Communication at U of M, looked at self-reported data from 279 users of the game Second Life, where players create virtual avatars and interact in an online, social context with other players. Behm-Morawitz found that in general, Second Life players used their avatars to test out new looks or styles in a low risk environment. She also believes the social nature of Second Life enhances the sense of identification users have with their avatar. She said the real market for this might be engaging a group of people, gamers, who often aren’t already invested in fitness. Read More
January 2013: UnitedHealthcare, Konami bring health games to schools
In partnership with UnitedHealthcare (a division of UnitedHealth Group), Konami, a Japanese company that is one of the pioneers of the video game industry, entered the field of public health. The company offered their DanceDanceRevolution Classroom Edition as a pilot in three schools in Florida, Georgia, and Texas. Read More
February 2013: SuperBetter graduated from Rock Health's fourth class
The game is available online and on iOS app and helps people dealing with a range of challenges turn their life into a game in order to better face that challenge. In March, SuperBetter founder Jane McGonigal said the game has more than 250,000 users. She added the Ohio State University was conducting a clinical trial of 40 patients to test the efficacy of SuperBetter for helping patients recover from traumatic brain injuries. Read More
Cigna’s Director of IT Strategy and Innovation Willis Gee said that historically healthcare has not been leveraging games to engage customers, but it's ubiquitous. He added that something like 70 percent of mobile phone owners are playing games on them and a large percentage of households have game consoles in them. Gee pointed to Cigna’s longtime work on healthy gaming with HopeLab, where it has helped to develop games for people with cancer and the exergaming system Zamzee, which is fighting childhood obesity and inactivity. Read More
June 2013: Miami Children’s CIO interested in adding gaming feature to discharge process
While still a far off prospect, Miami Children’s Hospital Senior Vice President and Chief Information Officer Edward Martinez and his team are interested in adding a gaming feature to the discharge process to help obese kids stick to a healthy schedule and remember to exercise. The process would entail introducing the kids to a game that would include a fitness component so advancing in the game is a direct effect of getting exercise. With many products on the market that offer these kinds of services already, Martinez sees an opportunity to either purchase, partner or build it in-house. Read More
June 2013: Ayogo is building an adherence game for big pharma
Health gaming company Ayogo’s CEO Michael Fergusson hinted at the Games for Health conference in Boston that the company is working on a new game for a major pharmaceutical company. The game, which is played partly online and partly on a mobile device, is a social game designed to be played like an alternative reality game. It integrates a broad prescription compliance program along with a diet and exercise program. Read More
June 2013: Sparx game combats depression among youth
New Zealand-based Sparx is a video game to help youth cope with depression that was created by University of Auckland Associate Professor Sally Merry. The object of Sparx is for the player to rid him or herself of negative thoughts and aim to reach ‘hope’. Within the game, the avatars that a patient can play as have New Zealand accents, which Burt believes will add to the fantasy of the game for an American audience. Burt also sees this is a possible treatment option for the influx of patients that hospitals will receive after the Affordable Care Act fully takes effect. Read More
June 2013: Zombies, Run! makers to launch spy-themed walking app
London, UK-based Six to Start, the creators of runaway hit fitness game Zombies, Run! announced that they are creating a new game that will use the same gamified, story-centric approach as Zombies, Run! but without the zombies — or the running. The game, called The Walk, is a spy thriller and it will be focused on getting people to move more and generally be more active. It’s being sponsored by the British Department of Health and the National Health Service (NHS) in London. Six to Start launched the game in December 2013. Read More
August 2013: Mobile motion camera launches with fitness game
Israel-based Extreme Reality has developed a motion sensor technology using a 2D camera, allowing the motion sensor to be used with mobile devices like tablets and laptops. Indie Hero, a British game company, is launching the first fitness game for this platform. Indie Hero’s game, called Beatboxer+, is a music-based shadowboxing game that instructs users to use one of six different punching motions in time with the music. Players can use the $15.49 game on its own, or take advantage of a partnership with Shadowboxer, an Australian company that makes a resistance-producing waistband. Read More
September 2013: Study finds racing game can improve brain functions
A new study from the University of California, San Francisco shows that a specially designed mobile video game could improve neural plasticity in older adults, improving their ability to multitask and to filter out distractions. A spin-off company is currently testing a version of the game for the possible treatment of ADHD, depression, or autism spectrum disorders. The study, published in the September issue of Nature, included three different experiments with a car racing game, called Neuroracer, played on a laptop with a video game controller attached. Read More
September 2013: As Wii U sales flag, Nintendo sets sights on Fitbit crowd
Video game maker Nintendo seems to be putting its energies into fitness in an effort to save its floundering Wii U console, including launching an activity meter that could compete with the likes of the Misfit Shine or the Fitbit One. The company announced that Wii Fit U, the new version of the company’s successful fitness game Wii Fit, will finally launch November 1. It was no surprise that the company is turning to Wii Fit U to revitalize the struggling system, given that the original Wii Fit was one of the best-selling console games ever. The software will be bundled with a clip-on activity meter worn at the hip called the Fit Meter. Read More
October 2013: App to help children handle anxiety may add games
SmartCAT, an app to help children handle anxiety, supplements brief therapy, eight or fewer sessions, with a set of cues to remind young people of skills taught in the sessions. The team plans to add a gaming feature. The first game they have developed, called Thought Buster, has thoughts that people might think floating across the screen like though bubbles and the kids are instructed to pop the bubbles of thoughts that make them anxious. An example thought would be ‘People are going to laugh at me’ or ‘Somebody’s going to get hurt’ or ‘I’m not going to know how to do this.' Read More
November 2013: DanceDanceRevolution goes mobile with iOS app
Popular exercise videogame DanceDanceRevolution may find new life in an unlikely place: the smartphone. Developer Konami released DanceDanceRevolution: Pocket Edition, which allows iPhone, iPad, or iPod touch users to play the dancing game without the need for large hardware like external dance pads. Read More
December 2013: Guitar Hero inventors launch exergame Blue Goji
Blue Goji, co-founded by Guitar Hero inventors Charles Huang and Kai Huang, launched an exergame called Goji Play, available for $99 online. The game is meant to be played at the gym on exercise machines such as treadmills, elliptical machines and stationary bikes. Blue Goji has three components. The app, available only on iOS devices, a set of wireless controllers that can be attached to any fitness machine, and an activity tracker to wear while exercising. On the app, users can play a variety of games, 12 total, designed for Goji Play. When users play the games, an activity tracker on the user sends data to the app. Read More
January 2014: Video game maker partners with Pfizer for Alzheimer’s clinical trial
Boston-based Akili Interactive Labs partnered with Pfizer to conduct a study of Akili’s iOS-based game, Project Evo, in the hopes of using the game to detect indications of Alzheimer’s in healthy individuals. The month-long study of 100 participants includes a mix of some who have risk markers of potentially developing Alzheimer’s and some who do not. All participants will take the game home and play it daily while researchers test whether the algorithms within the game can distinguish the group with risk markers. Read More
January 2014: GlassesOff aims to eliminate reading glasses with brain training
Israeli neuroscience technology company GlassesOff has announced its first iPad app, just a month after the company launched its iOS app for iPhones and iPods. The apps help users eliminate dependency on reading glasses by “enhancing the image processing function in the visual cortex of the brain,” according to the company. Within the app, users can play intensive visual stimulation games comprised of the 12-minute game sessions and reading evaluations. Read More
February 2014: Virtual pet game targets kids asthma management
Boston-based LifeGuard Games is gearing up to launch a mobile game to teach children to manage their asthma. Wellapets, which is due to launch at the end of February, follows the mold of recently popular virtual pet games like Club Penguin or Moshi Monsters, but with an extra element of chronic disease management. In the Android and iOS game, kids in the game will adopt a virtual pet and take care of it, but in addition to feeding and playing with the virtual pet, they’ll also administer the pet’s inhaler, look out for and clean up potential asthma triggers, and play unlockable minigames. The game will cost about $4 and the company will primarily seek to distribute and market it via pediatricians and other business-to-consumer channels. Read More
March 2014: Researchers found playing certain mobile games for 25 minutes can reduce anxiety
After just 25 minutes of playing a game, which is based on a cognitive treatment for anxiety called attention-bias modification training (ABMT), researchers found a reduction of anxiety levels in stressed people, according to a study of 75 adults published in Clinical Psychological Science. In the game, which researchers have not given a name to, users try to avoid “threatening stimulus” such as an angry face, and instead focus on happy and neutral faces. Read More
March 2014: Study finds children exercise 7.5 minutes more per day with Kinect than without it
Overweight and obese children lost weight and demonstrated a significant increase in physical activity after using a 16-week weight management program that incorporates active video gaming, according to a study which will be published in the May issue of the Journal of the American Medical Association (JAMA) Pediatrics. Seventy five children, ages eight to 12, participated in the trial at their local YMCAs and schools in Massachusetts, Rhode Island, and Texas. Fifty five percent were female. The study used UnitedHealth Group’s pediatric weight-management program, Join for Me. Read More
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