How to build health video games with a purpose?


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This is the ground study I made for the project. This is an inquiry into the history of health-themed video games.

The conclusion : wide-audience health games lack ambition. Research has shown games with a purpose can have a broad appeal for population AND bring a real benefit by teaching medical content and actually allowing for diagnosis of particular diseases to happen.

From this study, we know that a game teaching players the basis of diagnosis while being fun is possible. And trying to turn this game into a crowd-diagnosis platform is the ultimate goal to reach.

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How to build health video games with a purpose?

  1. 1. Cliinic.meA ground study : building a fun health game with which players can teach diagnosis to each other.Mathieu Goudot!!Majeure Management et Nouvelles Technologoies!
  2. 2. Abstract: How to build health games with a purpose? This is a tough challenge.! ! On our research we focused our research on the potential of building a health game with a purpose. We worked on how to build a health-themed game that would become a crowd-diagnosis platform. This project is called Cliinic.! ! This study regroups in a short presentation all the elements that serve as a preliminary study for our gamified crowd- diagnosis project.! ! We start with a qualitative analysis of the Health 2.0 trend in Part I. ! ! In Part II, we discuss the definition and the limits of today’s health games, a name that gets slapped onto anything that is even remotely good for your well-being.! ! We then analyze two very different games, yet equally important for our research on gamified crowd-diangosis.! ! Part III presents a research project on a proof-of-concept game to establish a crowd-diagnosis platform, for the binary diagnosis of Malaria-infected red blood cells. The methodology and the results are going to lay the basis for the actual research on crowd-diagnosis.! ! Part IV is a widely popular and recent Facebook game, from the House M.D. franchise. This genuinely fun game has a small yet present educational part to it. Its gameplay mechanics and storytelling are going to be the inspiration for our game.! ! Finally we will present the progress in our research and development effort on the Cliinic project, with the team of experts it mobilized.!
  3. 3. “We can rebuild [it]. We have the technology.”1! HEALTH 2.01:  The  Six  Million  Dollar  Man,  intro  scene.  
  4. 4. Digital health as a value propositionIn the US, there are structural reasons for the Patient-to-Patient and ePatientmovements to rise.!•  The cost of healthcare amounts to 20% of a typical household income1.!•  The US is the only industrialized nation with no universal healthcare system.!•  A consultation lasts on average 7 minutes. Time before first interruption: 18 seconds2.!•  90% of patients want to self-manage their healthcare through technology (accessing information, refilling prescriptions, booking appointments)3.! Figure  1:     Dave  deBronkart,  aka  epaEent  dave,  cured  his  kidney  cancer  because  he  parEcipated  in  ! a  online  community  and  learned  of  a  treatment  his  doctors  didn’t  know.  He  became  a   naEonal  spokesman  to  liberate  paEent  access  to  their  own  medical  data,  thanks  to   online  technology.     The PatientsLikeMe community constitutes great research grounds for assessing the effects of P2P healthcare:! •  91% of patients were diagnosed before joining the site! •  72% of patients found it helpful for better understanding their symptoms! •  42% found out what it was like to take a particular treatment thanks to patients like them.! •  37% take the decision to start a new medication thanks to the site.! •  12% of patients changed their physician after using the site4.! Figure  2:     PaEentsLikeMe,  is  a  data-­‐driven  website  building  a  community  of  paEents  based  on  the  sharing  of  all  the   Digital  health  brings  a  true  value  proposi.on  to   medical  data  paEents  generate.  Filling  in  their  data,  they  can  find  similar  paEents  to  share  medicaEon   advice,and  moral  support.     online  pa.ents  and  helps  with  big  picture   problems  such  as  public  healthcare  spending.  1:  Hidden  Cost  of  Health  Care  for  Consumers  Deloi)e  2012,  2:  John  Hopkins  2004,  3:  Connected  Health  Pulse  Survey  Accenture  2012,  4:  Sharing  Health  Data  for  BeAer  Outcomes  on  PaCentsLikeMe,  Smith  and  Wicks,  Journal  of  Medical  Internet  Research  
  5. 5. Digital health as a business opportunity B2B The key is targetting incumbents in the health sector such as big pharma and insurance companies. At a 2011 Games for Health meeting in Palo Alto, Epocrates and Doximity’s founder Jeff Tangney insisted on insurance companies being the best B2B customers for digital health services, because of their focus on innovations reducing health spending of their customers. ! ! PatientsLikeMe for instance employed the same business model Facebook is embracing : leveraging and monetizing user data selling it to third parties.! ! With a move toward pay-for-performance for US hospitals, those are incentivized to adopt new technologies.! ! Figure  1:     B2C ! The  amount  of  funding  that  went  to  digital  health  startups  help  assess  the  opportuniEes   in  this  nascent  field.  More  than  $500M  only  for  US  health  startups  in  2011,  with  a  clear   ! preference  for  B2B  models.   According to the Health 2.0 startup incubator Rock Health, the consumer ! market for digital health amounts to 14 billion dollars, among wich 4 ! billion for health-related video games alone.! ! ! ! ! ! ! ! ! ! ! Figure  2:     The  tradeoffs  are  the  same  in  digital  health  than  in  any  other  B2B/B2C  sector  or   industry.  Digital  Health  White  Paper  Rock  Health  2012  
  6. 6. The legacy of the 1.0 digital health players Long before the Internet 2.0, the new mobile innovations and the social networks, there were health 1.0 startups that focused on building Patient communities like WebMD or on providing new services for physicians like PracticeFusion or the later CurveDental.! ! Building on their experience now new startups can bring about new business models. Here is a non-extensive, ingenuous list of new niches, made by the Rock Health incubator, with an example of a player in each of these niches.! For  the  kids   For  the  old  Emers   For  the  ladies   Figure  1:     “Old  school”  programs  such  as  WeigthWatchers  found  a  second  wind  and  even  greater  success  thanks  to  the  online   Sensing  stuff   turn,  allowing  for  be)er  community  interacEons.  InnovaEons  are  not  always  at  the  core  of  all  those  companies,  but  they   all  are  digital  in  some  sense  and  hence  provide  inspiraEon  to  following  health  2.0  startups.  QuanEfy  yourself   The  new  EMR   Be)er  doc-­‐paEent  relaEonship   Diagnose  or  treat  it   Mental  Health   Enhanced  care  delivery   Health  Q&A   Get  yo’  ass  in  shape   Food  &  nutriEon   In  the  cloud   Find-­‐book-­‐rate  a  doctor   Bill  payment,  cost  transparency   Clinical  trial  modernizaEon  Digital  Health  White  Paper  Rock  Health  2012  
  7. 7. Not your Mom and Pop’s Doctor Mario.!HEALTH IN THE VIDEO GAMES
  8. 8. How do you mix health and games? What is a game? ! ! Games are the most interactive media available to us today. Games are designed to give feedback to the player, to inform them on their “game state”. ! This is the first basis of fun : the feedback loop1. It’s the atom of an interactions known as gameplay mechanic. Those gameplay mechanics then get dressed up with other elements of fun, such as storytelling, graphical elements, multiplayer and/or competition aspects, character customization and progression.! The second and most important element of fun is the goal. A game is a rule-based activity that involves challenge to reach a goal, and that gives feedback about progress towards that goal. It’s the challenge that brings about the fun, because of the effort , it’s where the payoff is. It can be Figure  1:     A  typical  feedback  loop  in  Doom  2  :  punch  enemy  >    get   boiled down to : trying, learning, winning.! visual  reward  +  increase  score.  The  goal  of  the  game?   ! Finish  it  with  the  highest  score.  “ Games can change people’s attitude, ! Health games tend to align game goals with health goals. Fitness games align physical exercises with progression and in-game scoring and rewards. Therapeutic games align health knowledge and skills with factual information needed to win the game. This is one of the first improve their skills and benefits of health games, and why they are quite often targetted at children (see next slides).! ! their confidence. They The problem is most game developers stop there. They remain factual and at the can bring behavioral knowledge level. ! ! changes. ! Games are about behavioral change, not just knowledge. And this is interesting for health Figure  2:     games. Because in most cases people know what they need to do in order to get in shape or Quote  of  Debra  Lieberman,  PhD,  director  of  the  Health   Games  Research  naEonal  program.   manage their health. What lacks is the behavioral change. Games can instill new habits thanks to their game mechanics. Game developers can break the barriers that refrain us from adopting healthy behaviors.!Can  playing  digital  games  improve  our  health?    Debra  Lieberman  TEDxAmericanRiviera  
  9. 9. Health games, what are those?The idea of linking health and video games is not new and has been time for practically as long as video gamesexist. The first commercial fitness video game was Athletic World on the NES and designed to be used withthe Power Pad. The game featured olympic-styled challenges, where the player run and jumped on the pad inthe same fashion as a modern dancepad, but also had a personalization mechanic: is asked the player for thedate and the player’s name, gender and age to adapt the challenges accordingly. Since then, the Figure  1:    commercial success of the Wii Fit, a fitness pad for the Nintendo Wii, helped install fitness video games as The  Bandai  Power  Pad  (1986),  a  beneficial for the health and well-being of player through interactive physical exertion.! precursor  of  all  fitness  games.  !!!On the other hand, educational games are often focusing on conveying knowledge and education, and tend to sacrifice gameplaymechanics to that end. Those are then closer to serious games, that we are excluding from our research scope today. Even the best!among those games, such as Bronkie or ReMISSION, both targeting kids, sometimes fall short of being fun, because they mainly!target a particular disease or condition, cutting down the universal and general aspect medicine and health have: everyone isconcerned by health problems, why not try to tackle its whole complexity?!!A third type of health games are too often ignored. A hospital-simulation game, Theme Hospital was completely health-themed, but witha cartoony twist and without rigorous real-life medical content. Those few health-themed games, like Dr. Mario or the more recentTrauma Center, made the player play in a medical environment, but without any educational part to it. The goal of the game waspure fun. The health theme is just there to bring relevant gameplay mechanics. Those games were far better commercial successesthan educational games.!! Fitness  games   EducaEonal  games   Health-­‐themed  games   Figure  2:     Figure  4:     Figure  3:     The  Wii  Fit  commercial  success  is   Bronkie  (1997)  was  a  game  (developed  by   Theme  hospital  (2002)  was  a  game  where   key  to  showing  fitness  video  games   Debra  Lieberman)    where  the  player  was  a   the  player  was  a  hospital  manager  and  had   is  fun  and  engaging.  A  lot  of   dinosaur  with  asthma  that  had  to  clear  the   to  cure  crazy  and  cheeky  diseases,  it’s   research  has  been  made  on  the   planet  of  dust  and  cold  flu.  ReMISSION  (2009)   become  a  classic  of  the  genre.  Trauma   subject.   had  the  player  navigate  in  3D  in  the  body  of   Center  on  the  Wii  was  a  surgeon  simulaEon   cancer  paEent  to  destroy  tumors.   game  using  the  Wii  stylus.  
  10. 10. Health Games today are disinspirational Our hypothesis is that health games today lack the reach we see video games could have. Healthg games are either fitness games that are a fun and interactive way to adopt a healthy behavior, or they are educational games for kids or a targeted segment of patients.! ! But games can truly have a more important impact. Biologists tapped into a vast computational ressource, the ability of the human brain to recognize patterns and to reason spatially with a multiplayer online puzzle game called Foldit. It had deep gamification elements, and turned out to be a major success, achieving computations on a much broader scale than what would have been possible using conventional ressources1.! ! Jane McGonigal, PhD and UC Berkelery ! researcher, became an advocate on how gaming can have a purpose and impact the greater Figure  1:     good, through four positive elements : ! FoldIt  (iniEal  release  in  2008)  is  a  massively  mulEplayer  puzzle   game  harnessing  human  players  appeal  for  compeEEon  to   •  blissful productivity: gamers have goals find  the  best  stable  folding  pa)erns  for  proteins.     and objective, the feedback loop inform them constantly on the impact they have2! •  urgent optimism gamers spend 80% of their time failing in game worlds, yet they stick to the challenge through resilience2! •  stronger social bonds playing a game boosts trust among players2! •  epic meaning playing as a hero in a Figure  2:     fantasy generates awe and wonder, Jane  MCGonigal  giving  her  2010  TED  speech  on  how  gaming   positive feelings that according to research can  help  bring  the  best  in  people.   Figure  3:     SuperBeAer,  for  which  Jane  McGonigal  is  a  CreaEve  Director,   make people more likely to collaborate on a is  a  way  to  leverage  the  posiEve  elements  of  gaming  to  reach   self-­‐development  goals  for  players.   larger scale2! We suggest that health games can and should leverage the empowering mechanics researchers have unveiled, because of the universal appeal the health theme has. We are going to study how those mechanics can be applied and our applied research progress in that direction.! !1:  PredicCng  protein  structures  with  a  mulCplayer  online  game,  Cooper,  KhaEb  et  al.  and  >  57,000  FoldIt  players,  Nature  2010,  2  :  Be  a  Gamer,  Save  the  World,  Jane  McGonigal  The  Wall  Street  Journal  2011  
  11. 11. Malaria detection through crowd-sourced games.!THE MALARIA EXPERIMENT
  12. 12. A health crowd-sourced game on Malaria Inspired by the TapIt experiment, researchers have been driven to try to port the same kind of experiments to the medical field, to tap crowd-sourcing’s vast resources for health.! ! How? Combining machine learning and gamification, UCLA researchers built a telepathology platform to see if they could approach the accuracy in diagnosis of medical professionals with gamers that are non-medical experts, to make remote diagnostics decisions without the need of a local medical expert. ! ! The target field of study was the analysis of microscopic analysis of biomedical specimens, and the target disease was malaria, because of its effects on red blood cells (RBCs) and the fact infected RBCs are recognizable with a light microscope. Malaria is still the major health problem Figure  1:     for scores of tropical and sub-tropical countries (cause of 20% of all childhood deaths in the The  Malaria  Diagnosis  Game  interface:  the  gamer  uses  the   region). ! syringe  to  select  infected  red  blood  cells  and  the  bucket  to   collect  the  healthy  ones.   ! ! ! ! Interestingly enough, computer vision has been tried as a means to automate malaria detection ! in RBCs. However the extreme variations in blood smear preparations (used to photograph ! RBCs), cell density, illumination and optical material made the task an inconclusive one. Human vision however can abstract those variations and recognize the sane or infected patterns.! ! The game platform was primarily meant to be the web, but was accessible through any Android- enabled device (tablet or phone). ! ! The game validated the skill of players by providing a training phase where they were submitted to 261 RBCs known images of which 20 were infected and identified as such in the database, but of course not for the player. Players had to attain a 99% level of accuracy to be allowed to Figure  2:   participate in the actual game. Then during the game roughly 20% of the RBCs were control The  hybrid  (machine+human)  diagnosis  plaoorm.  A  computer   cells, used at the end of a game as a means to score the player’s performance.! vision  algorithm  first  assesses  if  images  are  difficult  or  not  to   diagnose  (with  T  as  the  difficulty  threshold),  difficult  images   ! are  fed  to  the  players,  and  then  merged  with  the  easy  ones  to   expand  the  training  database  and  reinforce  the  computer   vision  algorithm  through  machine  learning.  Distributed  Medical  Image  Analysis  and  Diagnosis  through  Crowd-­‐Sourced  Games:  A  Malaria  Case  Study,  Mavandadi,  Dimitrov  et  al.,  May  2012  Public  Library  of  Science  
  13. 13. The results : a successful experiment Within the framework described above, several experiments have been conducted to assess the efficacy of crowdsourcing over machine learning, and the hybridization of both.! ! The crowdsourcing experiment turned out to be a true success: “The combined accuracy of the gamer diagnoses was 99%, with sensitivity (SE) of 95.1% and specificity (SP) of 99.4%. The positive predictive value (PPV) and negative predictive value (NPV) were also quite high at 94.3% and 99.5% respectively”.! ! The computer-vision algorithm without the human crowd and on the same dataset achieved the following results : an overall accuracy of 96.3%, with SE-SP of 69.6%–99.0%, Figure  1:     and PPV-NPV of 87.7%–96.9%.! The  effecEve  crowdsourcing  “formula”,  quoEng  the  study  :  “The  images   ! are  treated  as  a  sequence  of  binary  values  that  are  broadcast  by  the   server.  The  gamers  are  effecEvely  noisy  repeaters  that  in  the  most  ideal   The hybrid experiment, with the algorithm described in figure 2 of the previous slide, case  output  the  correct  symbol  for  the  inputs  that  they  receive.  Each   allowed to increase SP and PPV by 20% and 7% respectively, but with only 10% of the repeater  transmits  its  own  noisy  version  of  the  same  input  symbol  to  a   decoder.  The  decoder  combines  all  the  received  repeater  outputs  and   RBCs sample being submitted to the crowd, the rest being analyzed by the computer vision decodes  a  final  output  zi,  which  ideally  will  be  the  correct  label/ algorithm. This helped make this game a really viable option for crowd diagnosis, reducing diagnosis  for  the  input  images.  The  repeaters  can  be  modelled  as  Binary   CommunicaEon  Channels  (top-­‐ler).  pij  corresponds  to  the  probability  of   the crowd required size while increasing its efficiency. ! receiving  symbol  j  when  in  fact  symbol  i  was  transmi)ed.”     ! The last experiment increased the RBCs sample size. This experiment yielded an SE of 97.8% and an SP of 99.1%. The PPV was 96.7% and the NPV was 99.4%. This experience boosted the PPV, which is important as the high-rate of false-positives in malaria diagnoses is one of the major challenges in sub-Saharan Africa, according to the study.! ! The major takeaway : the accuracy of the human crowd is within 1.25% of the diagnosis decision made by the infectious disease expert.! ! It’s interesting to notice this experiment was just a proof of concept, and calls for a broadening of the method for a larger platform with more players.! Figure  2:     ! SensiEvity  is  the  most  impacted  to  the  skill  of  the  players  for  crowd-­‐ For the Cliinic project, we aim at reproducing the same kind of framework for studying the diagnosis  plaoorms,  as  this  graph  shows.  Accuracy  seems  to  be  less   sensiEve.     impact of the crowd on diagnosis. However we aim at involving a greater chunk of what makes a game a game : storytelling, fun, & gameplay progression.!Distributed  Medical  Image  Analysis  and  Diagnosis  through  Crowd-­‐Sourced  Games:  A  Malaria  Case  Study,  Mavandadi,  Dimitrov  et  al.,  May  2012  Public  Library  of  Science  
  14. 14. What’s great? What’s wrong? Is it lupus? !THE HOUSE FACEBOOK GAME:A CASE STUDY
  15. 15. A lesson in gameplay InnerThis facebook game epitomizes one of the observation we made: solving medical loopmysteries can be fun. House M.D. made that clear to everyone, and even before that, TVshows like ER spurred the medical knowhow of the masses.!!Facebook games is a great medium for viral growth, enabling to attain a large audience Figure  1:    (we will study this in the next few slides), all the while engaging for a long duration casual Is  this  the  Malaria  mini-­‐game  spin-­‐off?  No,  it’s  just   the  way  player  can  make  blood  count  gamers, and incentivize repeat usage. The approach Ubisoft chose was to cradle the invesEgaEons:  a  Emed  mini-­‐game.  House M.D. breath-taking storytelling inside the familiar Farmville-like isometric layout, withbuilding elements in your hospital, avatar customization, and less-pervasive-than-usual friendinvites. !!To realize diagnosis and investigations of patients, the gaming mechanics are really simple,and amount to copies of famous mini-games or puzzle games. A cardiac arrest triggers amouse-bashing action (clicking many times) or a rhythm mini game (clicking in cadence).Those mini-games are the inner feedback loop.!! Figure  2:     The  example  of  the  pharmacy  shows  the  The progression, aside from the storytelling, is also driven by two outer feedback loops: the appointment  mechanism:  to  cure  paEents  you  need  appointment mechanism and the widening of gameplay possibilities. By restricting the to  order  pills  wEh  cash,  if  those  are  not  in  stock,  you   need  to  wait  for  the  order  to  arrive.  At  later  levels  actions with a cost of energy for every actions, and having to order medications and wait for this  can  take  up  to  a  day.  Forcing  you  to  step  back  them to arrive, this generates an appointment loop. Unlocking investigation rooms and from  your  session  and  come  back  later,  forcing  levelling up generates a sunk-cost fallacy (I invested so much time, it would be a waste not to repeat  usage  unto  players.  continue) making the player want to continue. !!Part of the success of the game comes from it reproducing the kind of characterdynamics found in the TV series: the player is just a mute team member in the originalcast, with House making frequent comments and piques, in a fan-service fashion. This ispretty efficient and makes for an enjoyable gaming experience. The storytelling is really Figure  3:    good, with patient cases still inspired by Lisa Sanders (medical advisor on the show and well- The  classic  social  game  economy  and  reward  known writer of the bestseller book Every patient tells a story), creating a real will to pursue system:  energy,  experience  points,  credits  (real   currency),  cash  (in-­‐game  currency),.  You  can  also  the game and go forward.! noEce  an  invesEgaEon  room  that  is  currenly  locked.  ! Outer Only  by  playing  more  will  the  player  by  able  to   access  it  and  unlock  new  mini-­‐games.  To conclude, this game tightly wraps efficient game mechanics together and build a health- loopthemed game with more than usual, beyond just the game setting of a hospital. But didUbisoft succeed in conveying the !
  16. 16. How succesful is it in conveying medical knowledge? The game didn’t go for what was easier: they didn’t try to “cartoonize” or “dumb-down” the medical content of its game. The diseases are actual diseases, and not a funny representation of them. ! ! Rather than that, it focused on making the patient stories as compelling as it could, all the while being rigorously exact. ! Figure  1:     ! This  board  explains  the  basics  of  differenEal  diagnosis  to  players.   The first very interesting element, is by conveying the actual methodology of modern evidence- based medicine. The player must undertakeFigure  2:     research and investigations, to eliminate potentialAs  of  the  28th  of  August  2012,  House  M.D.:  CriEcal  Cases,  the  game  had  130,000  Daily  AcEve  Users  and  over  1,200,00   diagnoses (which are established in advance forMonthly  acEve  users.  Its  DAU/MAU  raEo  was  rather  good,   the user). This is very positive because it’s makingwithin  a  11  to  13%  window  according  to  this  AppData  Graph.   the inner workings of differential diagnosis to the user.!The second interesting element is an in-game disease database, indexing all the diseasesmet during play sessions, and through which House (a figure of authority) gives some factualinformation on the conditions to the player. !!The reaction on the forums is very positive. Some players are actually pausing game sessionsto check for the diseases they face on Wikipedia or Google. This is exactly the reaction ahealth game should strive for.!!As far as the Cliinic project is concerned, the House M.D.:Critical Cases game constitutes an Figure  3:    important inspiration. ! An  unheard-­‐of  feature  for  a  facebook  game:  an  actual  knowledge  ! base  giving  informaEon  on  all  the  in-­‐game  diseases,  their  causes,   symptoms  and  treatments.  Not only are the gaming mechanics really good and polished, but also the medicalcontent is relevant and improves the medical knowledge, in a relative way, of its millionof players.!
  17. 17. The conclusion!THE PROJECT
  18. 18. The dev team Wilson Mathieu Guillaume UBC Med student, Ariel reviews clinical cases and in charge of graphic design! The med team Havard CS VP of Marketing in IT graduate and CSundergrad, lead B2C big data startup, student, lead developer! co-founder and developer! product manager! Janny UBC Med student, drafts clinical cases, creates The advisors prototypes, co- founder! Gert Stan UBC Language and Literacy Laura Education PhD candidate, health literacy researcher! UCSD CS teacher, UBC Pharmacology crowdsourcing and teacher and Virtual machine learning Patient expert, reviews expert, honorary CTO! and proof-reads cases!