Water Cooler Games - Games for Health, day 1

Games for Health, day 1
September 16, 2004 - by Ian Bogost

Keeping with my tradition of blogging conferences for those who can't make it across the state or across the pond, I'm here at Games for Health in Madison, Wisconsin. It's a two-day conference and unfortunately I have to leave ~~before the end of today, missing the last two sessions so I can catch my plane... wish me luck, I'm flying right into Ivan.~~ Update: Ivan clobbered my flight. So, I'm here for another day. Stay tuned tomorrow for an update.

There will also be an hour-long summary of the Games for Health conference at the Serious Games Summit DC next month.

One final reminder about this coverage. I've attempted to notetake accurately based on the presentations, but I do not purport to representing the speakers fully in these summaries.

You can read day 2's coverage here. Here's day 1's coverage.

Session 1: What is the Possibility Space?
Kay Howell (Moderator), Virtual Reality Medical Center
Brenda Wiederhold, Virtual Reality Medical Center
James Rosser, Beth Israel Medical Center
Debra Lieberman, UC Santa Barbara
Chinwe Onyekere, Robert Wood Johnson Foundation

Kay Howell
The principle question Howell asked of the panel was, what is unique about games for health. Panelists were then asked to discuss what more is needed in the field, or what possibilities have not yet been realized. Panelists were also encouraged to discuss best practices for research and development.

Brenda Wiederhold
Putiting the patient in the loop at the beginning is an important design strategy. Having multidisciplinary teams -- with subject matter experts and production experts -- are necessary to design effective specific game environments that work. This is true on both sides, the subject-matter side and the game development side.

The ethics of simulations in healthcare are important -- is it appropriate to put this content online, or should it be controlled in the home or the clinic? Wiederhold takes a conservative approach to this, suggesting great care in practice across state and national lines.

Using COTS games or modded games are a great way to gain flexibility and get test products to market. You can also use headtracking or mouse/joystick tracking in games, drawing them closer to the more expensive, less useful VR apps.

More research is needed, especially in controlled clinical trials and long-term follow-ups. How do we know there isn't relapse -- we have to prove that we're better than pamphlets.

The cost of game engines are holding health games back. Wiederhold used the example of the Unreal Engine, which still requires a massive license fee for distribution, often in the hundred or thousands of dollars. This means these games can't be sold -- they have to be given away. And giving games away means its harder to get money into new research. This situation is less of a problem in Europe and Asia. The military in the US has recognized the value of game-based training, but the National Institute of Health or National Institute of Metal Health have not yet contributed to research.

Wiederhold argued that we need unified platforms that avoid the balkanization of software and hardware support.

James "Butch" Rosser
Rosser encouraged us to look at the severity in the landscape of health -- 98,000 people die every year because a healthcare provider or system made a mistake. Battling this challenge means taking multiple fronts.

Rosser argued that the way we teach is outdated -- if students fail, it is because we are teaching them wrong. We need new innovation in education, and we need medical educators to rise to the occasion, to come out of the closet and to take responsibility for a new kind of teaching. We need a new kind of training that doesn't take place in a lecture hall. We need to surround these new students with interactive, fun environments to learn in, that build a thirst to learn.

We need validation for the activity we create, but we must also avoid waiting for innumerable studies before putting new game-based systems in practice.

Rosser argued that the solution comes in surrounding the patient with a ring of accountability for their own health. Healthcare access is getting worse. Our system of dealing with this problem is not working. The solution is in empowering individuals to become a front-line healthcare worker for their own well being. We can't send them all to medical school. We can't send them all to paramedics training. But we can design games, we may be able to empower individuals to become (more) responsible for their own health.

Debra Lieberman
Lieberman discussed the transition from game playing to improved outcomes, and how games can help health consumers to change their behaviors. Lieberman was responsible for demonstrating how games produce health outcomes. She presented a model for how a game can produce health outcomes.

What makes these games good enough to be played during leisure time, so that people wanted to play them? Lieberman encouraged designers to start with a goal, and offered four goal concepts for health games.

Enhance Self-Concepts
For example, diabetes, asthma in kids -- for example, a main character in a game with one of these conditions to promote a role model, or a signature character),

Self-Efficacy
For Lieberman, this implies a link between knowledge and behavior -- knowledge games like quizes in and of themselves do not guarantee behavior change. How do we get from that knowledge to behavior? Lieberman argued that having a sense that of I can do this leads to more behavior change. Games are great environments for challenging skills and showing outcomes. In a diabetes game, blood glucose was the measured element. In an asthma game, it was peak flow. She found that the games improved players' sense of self-efficacy.

Knowledge and Skills
This is the typical idea of communicating specific knowledge in games and measuring outcomes, whether inside or outside of the game.

Communication and Social Support
Cooperative, two-player versions of games enable players to increase communication inside and outside the game about self-care and their feelings about their condition. Children demonstrated a deeper understanding, for example in a smoking game.

Lieberman pointed to a clinical trial from one of her games, Pecky & Marlon, that teaches about diabetes. Compared to a control group playing an entertainment game at home over 6 months, players of Pecky & Marlon reduced urgent care and ER visits related to diabetes by 77%.

Lieberman's Important Points to Think About:

Knowledge is a good thing. But we need to affect attitudes, and ultimately behavior. We need to design games to encourage better health behavior not just better health knowledge.
Theory-based design is a promising way to build these games. How can we leverage what we know about how people play and learn.
Research evidence is desperately needed in health care to promote adoption. Control trial evidence that shows that the games work is necessary -- despite the fact that the industry may have lower standards for other medical products. The health community is still resistant to adoption of games, but that condition is improving.
We need games that avoid undesirable effects -- e.g. violence, racism, sexism, and some of the other bad imagery in commercial games.
Learning is fun, and we don't need to sugarcoat it with the idea of "stealth learning" or trickery. Put the learning on the table in the game.

Chinwe Onyekere
Onyekere talked about the funding goals of the Robert Wood Johnson foundation. She described what they are looking for in opportunities: Products that have a major impact on healthcare, high risk and high return. Breakthroughs, not incremental change, in two categories, Community Building and Products. Games fall into the latter category.

Onyekere outlined some of the RWJ's ideas about ways to accomplish such products.

High-Level Simulations -- policy questions, scenario planning, and work-force strategies
Training -- teaching skills through training for medical and nursing students, or how medical schools use simulated patients
Increasing Interest -- using games as a way to highlight the health profession as a career option, for example addressing the nurisng shortage
Health Messaging -- putting health messaging into COTS game to take advantage of the massive game audience. Taking lessons from TV and movies, Onykere drew an analogy with screenwriters to use games as a communications platform

Note: when challenged by Marc Prensky in Q&A that most of these issues have been attempted in games, Onyekere argued that her goal is to build a marketplace that is not disjointed. Rosser added that those trials clearly didn't get the job done -- now we have a greater critical mass to accomplish such activities.

Community building in Onyekere's conception means creating a marriage between the people who know games and those who know health care. She feels that PBS is a good analogy -- it used television, with foundation involvement, to increase communication.

Session 2: 1000 Abstracts Later, What's Been Done, Why, and How?
Michael Erard, University of Texas School of Nursing

Erard evaluated over 1000 medical journal abstracts on games or game-like artifacts used in health, and he presented the trends and categories of materials he found.

Approach: search journal archives for "video game" and "computer game." With the results, ask these questions: What's out there? Who worked and works in the area? How much has been done? What can be adapted? What resources can we draw on.

Some Treasures:

modifying juvenile behavior using a computer game (1988)

dopamine release in video games

videogames as training for powered wheelchair

Erard found work done or reported in 20 countries, among many types of populations (children, schizophrenics, seventh day adventists, pilots, MBAs), but interestingly no Asians or Hispanics. (IB: Erard presented a full list which I couldn't possibly reproduce on sight).

Most of the studies are looking at the effects of games on people when they play them, seeking information about the integration of the medium into the daily lives of their players.

Some non-human popularions were taught to play games: 2 macaques, 11 rhesus monkeys, and 4 pigs.

Health conditions included Asthma, Dental health, hearing loss, cancer, cerebral palsy, traumatic brain injury, erb's palsy, stroke, ADD/ADHD, Rett Syndrome, Schozopphrenia, phobias, learning impairments, language impairments. In some cases the games probe the nature of these conditions, in other cases there are outcome-based studies, all of which seemed to suggest positive uses of games.

Erard noted significant sophistication even in research done 20 years ago. Many researchers never returned to the video game space, however.

Erard produced the following categories from his analysis:

Demographics -- who are game players, and what are their habits
Education -- formal educational topics inside games
Effects -- dependence, addition, obesity, violence, and other possible results of playing games. Violence was most researched, skill, problem solving, moral development, and obesity were least researched. Samples were typically small and not multiethnic. They were focused primarily in sociobehavioral therapies and aging. Outcomes were more comparative than expected.
Game Design -- a small area, but primarily about interface design and its effects on physical engagement and use.
Health -- games on improving specific health medical conditions, such as asthma, drug use, hearing, sex, etc. Many articles focused on aging, including therapeutic uses in nursing home populations. At least 20 articles focused on effects of gameplay on well-being in general. Some articles suggested strategies for games for the elderly ("Eldergaming," Erard nicely termed it), that don't depend on speed and quick hand movement. Health promotion was also covered, but interestingly there was little in pregnancy prevention, HIV/AIDS prevention, and so forth. Some examples include a self-management skills game for asthma, Health Hero, antismoking, diabetes, asthma, Kiosks to teach teens HIV/AIDS prevention (the only HIV item)
Research -- not just the use of games in healthcare, but also how games had been used in other ways in health research. Many were used as environments and stimuli, including assessment, communcation, descriptions, parapsychology. In the most cases, the game was a setting for an activity that the researcher was more interested (e.g. speed of learning). Many were also used to study physical or cognitive outcomes, or response measurements. Few games were made by academics specifically for an experiment; most were COTS. Few were mods.
Therapy -- games used for therapy, including both COTS and researcher-developed games. Includes task management for ADD, affiliative behavior for kids with cerebral palsy. Many were used in adaptive environments. These are more Games for Rehab or Games for Remediation than Games for Health. These understood the user in a broader environment, not just in the context of the condition. Examples included Busted, a game for troubled youth, Funny Face, a cartooning computer game for play therapy, Fast ForWord, a language intervention program to treat language learning impairments.
Training -- games used specifically to change or improve behavior in specific horizontal situations, including games about general decision making, nurse training, health care system simulation, competitive situations, decision-making, etc.

In summary:

Much Research was aimed at measuring the impact of games in everyday life.

Games as therapies seemed to be developed as therapies of last resport for resistent populations. They are infrequently discussed as a component of a larger therapy process.

Simulated worlds for other research

Erard outlined several research opportunities based on his findings:

Comparative outcomes (old vs. new, new vs. new)

Game outcomes with diverse populations

How do you use games with other therapies / interventions

Game outcomes & costs of health care

Erard will complete further analysis and make these resources available to the games for health and serious games communities.

Session 3: Games which Help with Phobia Treatment
Brenda Wiederhold, Virtual Reality Medical Center

Wiederhold presented videogames for training therapeutic interventions. She uses videogames as an adjust to traditional therapies. Patients are taught coping skills in the context of visualizing or experiencing the situations they are afraid of. VR or games are not as overwhelming as in vivo experiences, so they are a good starting point.

Her team does physiological monitoring to provide an objective measure of the effects of the treatment. This helps correlate the desensitization. They started in 1997 treating fear of flying (aviophobia) and fear of driving. For these, they use COTS games, which are very effective at simulating the environment. Wiederhold cited a 95.5% completion rate, which is much lower than other therapies. Midtown Madness is especially useful because it offers both real environments (Chicago, London) and different driving conditions, as are Need for Speed (for mountainous terrain, agoraphobia). From a hardware perspective, they use regular machines, multiple screens, head-mounted displays, and full car installations.

For arachnophobia, her team used a modified version of Half-Life, in which they created environments with spiders starting in glass cages, then on the floor, and Max Payne, which offers spider situations the player probably won't encounter in the real world.

They have also started creating their own environments, such as the San Diego airport, to help treat anticipatory anxiety for fear of flying. For example, they created a jetway to allow players to experience a safe environment where many have panic attacks. EyeToy and DDR are also used for rehabilitation.

Of the controlled studies of videogam therapy, Wiederhold demonstrated a significant reduction in distress and avoidance.

Session 4: Yourself Fitness (Fitness Game for Xbox and PC)
Phineas Barnes, responDESIGN

Barnes showed Yourself Fitness, which comes out next week for XBox and in the coming months for PC. It's a personal trainer game. He told an anecdote about his brother-in-law opening all his Xbox games on Christmas morning -- all given by women. What games, he wondered, could be made for women, since they seem to be doing all the shopping?

Maya, the character in the game, walks you through an exercise regimen. She helps the player take a number of standardized tests, and then creates a plan to remedy the player's deficiencies, including a calendar and an eating plan. Each workout day is different, and Maya's vocal instructions adjust to learn with you, and you can choose different environments for her so you don't get bored.

From focus groups, Barnes found that personalization was the missing link in fitness. Workout videos don't help you figure out what you need to do, or track your progress and goals.

The game took 18 months, 20 people, and $5 million, raised from angel investors. Barnes argued that the money is out there as long as you can demonstrate a business model. For Yourself Fitness, health and fitness is a high growth area. Fitness memberships and purchasing are growing, but the expense of memberships is prohobitive. Women also have time limits -- day care issues and demanding schedules. Home fitness is a solution, but the DVD and VHS market don't allow customization.

At the same time, the game industry is huge, but growth has slowed. It's time for a broader audience in gaming, and women should get something out of the $150 investment in the Xbox they buy for their kids. Female consumers dominate both the home fitness space and the videogame retail space -- they make (or "approve") 75% of consumer electronics purchases. They should benefit from some content. Barnes's suggestion for funding is simple: don't wait for grants, get to retail. With that funding, you can do research and development for more products.

Interactivity in Yourself Fitness comes from Maya interrogating you about how you feel and how you respond to different workout elements. In the future, they are looking to make Yourself Fitness Xbox-Live equipped, and to add real-world device integration like wrist-heart monitors and GPS.

Session 5: BioFeedback Game Design (Journey Through Wild Divine for the PC)
Corwin Bell, Wild Divine

Wild Divine uses fingertip biofeedback controls in a retail game for stress reduction and meditation. The idea is to put people in charge of their own health condition. They based their idea on three principles:

(1) Effective on an individual level -- "I feel better"
(2) Low cost -- the product is $160 including the biofeedback device
(3) Entertaining -- something someone will want to spend time playing

The game is a 10-hour adventure/journey (not played all at once). The peripheral uses skin conductivity to detect your stress level, heart rate, and other factors. The game rewards players for responding to different physiological goals, which is bound to the fantasy-style story. The game creates visual metaphors for changing breathing, heartrate, and other stress conditions.

Games for Health provide a contrast to the violent games and adrenaline-intensive games. Bell told a funny story about watching overwhelmed E3 attendees stumbling out of the exhibit floor into their booth, eager to get over their overstimulation.

The product took 3 1/2 years, 5 people, and $3 million to develop.

Session 6: Cardiac Arrest Training Game (PC)
Craig Bannon, Legacy Interactive

Legacy converted their popular consumer market games when real doctors and lawyers started calling them asking if they could produce games for real-life scenarios. Their consumer market games had stopped selling, and they started making games based on on the Law & Order and ER licenses. As requests for training games increased, they began working on more situation-specific games, including one for Honda to train salespeople.

Bannon showed a game that taught Advanced Cardiovascular Lifesupport (ACLS) Skills for a major medical textbook publisher. With a budget under $200k, this game represents what Bannon characterized as a more realistic opportunity for healthcare games. The game included traditional elements like quizes, and scenarios where you have to treat a condition. The player uses medical tools to assess the patient, and includes a "PDA" that gives advice about what to do next. The game uses a combination of experimentation and direct challenges/questions to ask for precise settings (for example, for oxygen delivery). Each scenario is scored based on the player's performance. A summary review at the end helps the player understand what they did properly and what they missed.

Session 7: Development Guidelines for Health Games
Kurt Squire (Moderator), UW Madison
Barry Silverman, University of Pennsylvania
Doug Whatley, Breakaway Games
Mary Derby, pullUinSoftware
Noah Falstein, The Inspiracy

Barry Silverman
Silverman has built a few games on healthcare topics at the University of Pennsylvania.

Issues: this is an immature field that is project/deadline driven. We don't have design guidelines to turn to, or the information we do have is fractured. There is no reasonable software development environment for the health game marketplace, there are few standards for programmers, and there are no journals in the field. Interdisciplinary teams often don't talk well, even if they do collaborate on games. Areas of deep knowledge (silos) don't understand each other well.

Silverman also suggested that cartoon-like messages are more fungible for some players.

Doug Whatley
Watley's BreakAway Games makes both entertainment games and serious games. In serious games, though, real lives may be on the line. Moreover, the complex production processes for some large organizations are sometimes overwhelming and offputting for games. Game developers often iterate very, very quickly, creating a starting point very fast, but then changing things over time. Rather than spend 6 months making specifications, get a first iteration out as fast as possible and then iterate for 6 months.

Whatley related a lesson he learned from Sid Meier: the computer should not be the part having the fun. When you move into a realm when subject matter experts are in charge of content.

Budgets in healthcare -- for individual institutions or hospitals -- the numbers get broken down very significantly, and it is harder to fund them. Whatley used the example of creating budgets for "core games" that the DOJ would fund, and then each municipality might spend a small amount of money customizing it for their needs.

Mary Derby
Primary and practical goal of the program and proof in reaching that goal is the most important design consideration. Her company, pullUin software, has $2.5 million in government funding (e.g. NSF) to attempt to make this possible. Some of their projects are not games (a Palm-based ornithology game), others are, such as a game about complex body systems, and a USDA-funded project for nursing assistant training.

She characterized a basic need for "cheat codes" for the US Code -- how to understand the federal regulations. Regulations impact every aspect of the program, and therefore they impact every member of the development team.

Development challenges include content-tracking for open-ended experiences. She suggested scaffolding content so you can point to it if you need to, akin to using shortcuts, save points, or cheat codes in commercial games.

Derby suggested that tracking and reporting is also essential. A traditional test may still be required, so content must be developed to track against this.

Derby also recommended early prototyping and iteration.

Noah Falstein
Trying to make a game fun is hard enough, even with $30 million, but on a smaller budget game that has fun and another purpose is even harder. The main lesson Falstein related is that content in a game that motivates the player will contextualize or lay a groundwork for understanding. Kids don't realize that they're learning when the content facilitates their learning; all entertainment is about learning fundamentally.

Note: I had to miss the last two sessions to ~~catch~~ fail to catch my plane. Here are the titles; I'll try to get notes from other participants to post here.

Session 8: Why the Monkey Can't Do It: What the Medical Profession Can Teach Us about Game-based Medical Training
David Williamson Shaffer, UW Madison

Session 9: Improving Surgery Outcomes with Videogame Exercise
James Rosser, Beth Israel Medical Center

Comments (4) | Post a Comment | TrackBack (0)

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Comment from Susan R on January 30, 2006

I think in health care system there’s inequality among different groups of people, and it should be addressed in a different and more effective way.

Comment from Andrew Spark on February 3, 2006

I think devolution in the health care system is required because the health care system in every country also needs some major changes.

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