As well as being at the forefront of the entertainment industry, games are a rewarding form of personal expression and communication for millions of people around the world. Games also represent the most powerful ingredient in the human interaction with technology; fuelling development of the interface tools people take for granted in their relationships with computers and driving technical development.
Games could be the most important digital health tool of the 21st century and have a highly influential impact on the engagement pharmaceutical companies foster with health care professionals, patients and the public. Yet it is tempting for people to separate them from the 'serious' business of work, education and health.
So what defines a 'game'? Jane McGonigal, director of Games Research and Development at The Institute for the Future, Palo Alto, California, believes that games share four key defining traits:
Although competition, collaboration and connectivity are also key to most games in the 21st century, it is worth bearing these defining principles in mind when looking at applications in healthcare.
Motivating by design
Motivational design refers to the process of arranging resources to bring about changes in motivation and, consequently, behaviour. It is here that the defining principles of games can be utilised outside the gaming environment.
Over the last four to five years this complex integration of users' needs and motivations has been shorthanded with the term 'gamification'.
Gamification is the integration of game mechanics and game design thinking into non-game applications. It is often referenced as one of the most important trends in technology with the promise that it can turn 'users' into 'players', dramatically increasing the capacity to influence behaviour.
It is this power to influence that has excited people within healthcare. The need to engage people in activities that impact adherence to medication, disease management and prevention and engagement with public health are obvious.
It is a concern that poorly executed gamification misunderstands the nuanced psychological interaction players have with games. For example, it has been observed that many iterations mistake incidental properties such as points and tables with primary features, such as interactions with behavioural complexity. In simple terms, focusing on the feedback system before aligning the goal with the person's needs and desires.
When this is done correctly it is powerful for the very reason that it strikes nobody as a 'game'. YouTube is a highly effective gamified environment, motivating users through a sophisticated system that encompasses: collecting with the 'favourites' feature; points, a crucial motivator with the now staggering importance of 'YouTube views'; feedback, delivered with comments posted by other users, and exchange encouraged by enabling viewers to post video replies. Finally, personalisation as a whole suite of options enables users to customise what they present to the world.
Already there is a growing research to support this approach in nutrition, weight management and obesity, disease prevention, self-management, adherence, cognitive behaviour and mental and emotional health, to name but a few.
When games specifically designed to improve patients' health clinically are included too, impressive results can be attained. Games on consoles or mobile devices have been proven to improve conditions ranging from depression to Parkinson's disease and recovery from stroke. In a post-PC world, dominated by tablet and mobile devices, directly improving health through game design is a real and tremendous opportunity for pharmaceutical companies.
Medicine seems especially well suited to the genre of simulation games. This form of game attempts to replicate various activities in 'real life' for various purposes: training, analysis, or prediction. The possibilities for training doctors, informing medical professionals about complex changes to a care pathway or a new medicine or redefining the old fashioned but well-loved 'case study' are extremely exciting.
Already there are companies such as TruSim, a division of Blitz Games Studios, developing interactive 3D worlds that enable training of medical staff through simulations of situations that are not possible in the real world.
TruSim states that 'Patient Rescue is a proof of concept for a game that supports health professionals to recognise the signs of patient deterioration, use set protocols to assess a patient's condition and intervene effectively'. It has been developed in partnership with County Durham and Darlington NHS Foundation Trust in the UK.
The company has also developed a game called Triage Trainer that 'develops accurate decision making in the life-saving skill of triage. The game is set at the scene of an explosion in a busy high street and the player's job is to prioritise the multiple casualties for treatment'.
Imagine the possibilities for narrative-based simulation and immersive gaming in redefining the communication of a new medication or health technology intervention in a complex disease or therapy area. Could this form of virtual simulation, collaboration and competition be the future of the 'self-directed' detail? It would certainly be more exciting.
The virtual world
Massively multiplayer online role-playing games (MMORPGs) are a genre of role-playing video games in which a very large number of players interact with one another within a virtual game environment online. The most famous of these is World of Warcraft (WoW), first released in 2004. As with other MMORPGs, players control a character within a game world, exploring the landscape, fighting various monsters, completing quests and interacting with other players.
As at December 2011, 10.2m people were subscribed to play WoW. If the collective time people have spent playing the game is added together it comes to an amazing 50bn collective hours, or 5.93m years. By that measure, people have spent as much time playing the game as they have spent evolving as a species.
The possibilities these virtual world environments have for health are truly fascinating. Only one year after WoW's launch in 2005 the event which has become known as the 'Corrupted Blood plague incident' took place in WoW.
It began when a deadly blood disease generated by the particularly unpleasant monster Hakkar the Soulflayer, a blood god lodged at the heart of the Zul'Gurub dungeon, was transmitted to players outside the confines of the dungeon through the efforts of malicious players. Within hours it had spread beyond the confines of the dungeon and tens of thousands of players' characters succumbed. Eventually the game manufacturer had to step in to contain the infection.
The reaction of players to the plague closely resembled previously hard-to-model aspects of human behaviour that may allow researchers to predict more accurately how diseases and outbreaks spread among a population.
Indeed, a paper in the American Journal Epidemiology by Ran D Balicer argued strongly that 'virtual environments could serve as a platform for studying dissemination of infectious diseases'. More interestingly for pharma they might 'prove a testing ground for novel interventions to control emerging communicable diseases'.
Harnessing gamers for science
Another aspect to consider is the possibility to crowd-source the gamers themselves to solve problems for businesses and for science. Gamers tend to be persistent and creative problem solvers and positively welcome a challenge.
This valuable resource was spotted by a team of medical and computer scientists, engineers and professional developers in 2008, when they announced a revolutionary new computer game enabling players to contribute to important scientific research.
This experimental project was developed by the University of Washington's Center for Game Science and Department of Biochemistry. The objective of the game is to 'fold' the structure of selected proteins using various tools provided.
When announced in 2008 at the 'Games for Health' conference in Boston, Zoran Popovic, a professor of computer science at the University of Washington, boldly stated: “Our ultimate aim is to have ordinary people play the game and eventually be candidates for winning the Nobel Prize in biology, chemistry or medicine.”
They are not quite there yet, but an impressive list of achievements can be attributed. In 2011, players helped to decipher the crystal structure of a retroviral protease, an AIDS-causing monkey virus. The puzzle was available to play for only three weeks, but an accurate 3D model of the enzyme was produced in just ten days. The problem had baffled scientists for 15 years.
The power of games within healthcare will come from a deep understanding of motivational design, through getting under the skins of the people we want to communicate with. It can also come from unleashing the possibilities of gaming in the 21st century, including applications that go way beyond what was possible in the past. Finally though, if we let people help us solve problems together, just as in social communications, we can achieve more than we could ever dream of achieving by ourselves.
Alex Butler is founder of the healthcare digital marketing agency The Social Moon