Game On! The Age of Gamification

Could an iPad detect Alzheimer’s disease? A recent study intends to find out. Pharmaceutical giant Pfizer has partnered with therapeutic game developer Akili Interactive Labs to test whether a gaming platform used on iPhones and iPads can discern cognitive differences in healthy older adults at risk of developing Alzheimer’s. Researchers at the Gazzaley Lab at the University of California, San Francisco, first developed the game’s underlying mechanics that require players to steer around a track while shooting down road signs. The Pfizer study will build on the results of a previous study published in 2013¹ that found gaming techniques helped older people improve their capacity to multitask. The 2013 study also showed how patterns of brain activity changed as cognitive skills improved. “A tool that enables cognitive monitoring for the selection and assessment of clinical trial patients has the potential to be an important advance in Alzheimer’s research and beyond,” says Michael Ehlers, senior vice president and chief scientific officer in Pfizer’s Neuroscience Research Unit.²

Gamification is a hot topic within the healthcare industry today, and by definition, it refers to the application of game-style mechanics and communication techniques that are used to motivate and engage audiences (in this case patients), while offering to solve problems in a fun way. Worldwide, an average of three billion hours is spent per week playing online games, and those numbers are rising. For pharma companies, gamification has tremendous potential, especially when it comes to encouraging adherence to treatment plans and patient education.

In the case of the Gazzaley study, researchers recruited 30 participants for each of six decades of life, from the 20s to the 70s, and confirmed that multitasking skills as measured by the game deteriorated linearly with age. They then recruited 46 participants aged 60 to 85 and put them through a four-week training period with a version of a game called NeuroRacer that increased in difficulty as the player improved. The results were encouraging; after training, subjects had improved so much that they achieved higher scores than untrained 20-year-olds, and the skill remained six months later without practice. Certain cognitive abilities such as working memory and sustained attention that were not specifically targeted by the game also improved and remained improved. Both skills are important for daily tasks — from reading a newspaper to cooking a meal.

Under the agreement with Akili Labs, Pfizer’s clinical trial will assess healthy elderly patients whose brains show the presence or absence of amyloid (which may be an early marker of Alzheimer’s) as determined by Positron Emission Tomography (PET) imaging. The trial will measure cognitive abilities at baseline and over the course of one month’s game play with the NeuroRacer platform, renamed Project EVO. The objective is to evaluate Akili’s platform as a biomarker or clinical endpoint for potential use in future Alzheimer’s trials. Project EVO for the Alzheimer’s trial lends itself to the challenges faced by Alzheimer’s patients, since the ability to pay attention, plan or make decisions are common symptoms of a number of degenerative diseases such as Alzheimer’s, as well as psychiatric conditions like attention deficit hyperactivity disorder (ADHD), autism and depression.

Gamification and Education

For patients and providers alike, “learning by doing” is one of the most effective ways to absorb new or complex concepts. Syandus, a small experimental learning agency in Exton, Pa., recently pioneered a project for two large pharma companies to co-promote a drug for chronic obstructive pulmonary disease (COPD). The program features a simulation tool that lets physicians interact with a virtual patient and examine the consequences of certain behaviors. The virtual patient can mirror an actual patient through the insertion of specific medical records, and the physician can tweak environmental variables and measure patient response and reaction. For example, a physician might introduce a drug therapy or adjust the number of cigarettes a patient smokes per day. This kind of engagement can help physicians better understand a disease while also creating valuable interactive exchanges between doctors and patients.³ While not a game, per se, the COPD simulation program employs game technology by allowing physicians to make choices and see the results of those choices. “It’s hard for a patient to really understand what’s going on in their lungs, but when you go into the [simulation environment] and see a cross-section of what’s happening when you breathe — here’s the constriction that occurs — it helps to create a very vivid image of, ‘this is where you are, and if you keep smoking it will get worse, so let me show you where it’s going.’ Being able to demonstrate disease progression visually is very important,” says Doug Seifert, CEO at Syandus.³

Another pharma game billed as a cross between Pokemon and Facebook’s FarmVille has also been garnering attention. Launched in 2013 by Boehringer Ingelheim, Syrum (a play on words for “serum”) challenges players to discover new cures for diseases, create stable drug treatments and set up clinical trials in order to launch the drugs into the marketplace. Intended as a social game, Syrum combines elements of trading cards with Facebook functionality. Players use the social network’s platform to earn in-game rewards and connect with their Facebook friends to collaborate on molecule development. Boehringer hopes to attract as broad an audience as possible, including players from industry, healthcare, patient groups, medical schools and beyond. “We built Syrum with a view to creating an ecosystem through which we could engage with people around education,” explains John Pugh, director at Boehringer. Pugh says other goals include reputation management, market research and talent recruitment. “If FarmVille can reach 96 million people, and I can reach half of a percent of that, then I’ll be really, really happy,” he adds.⁴

Ward Round, a student-developed, problem-based learning application effectively pairs medical education tools with gamification principles. The app offers a medical learning experience in which the user is placed in the role of the doctor to solve clinical medical mysteries against the clock, adding gamification elements such as rewards and positive reinforcement. Medical specialties in the platform include cardiology, endocrinology, neurology and infectious disease. The question bank used in the Ward Round app was authored by Adrian Raudaschl, a graduate from Glasgow Medical School of Glasgow University, and case scenarios were verified by senior consultants in the relevant fields.⁵

Support for Patients and Caregivers

Gamification presents a distinct set of challenges in the healthcare arena, especially since providers are dealing with diseases that are anything but fun and games. Designing a game that is sufficiently serious but also engaging is no easy feat; for example, how do you use gaming techniques to engage patients battling cancer? HopeLab, a gamification pioneer, developed a popular program that does just that. Re-Mission targets adolescents and young adults with cancer and is played on tablets, laptops or smartphones. The game allows players to pilot a nanobot named Roxxi as she travels through the bodies of fictional cancer patients, destroying cancer cells, battling bacterial infections and managing side effects associated with cancer and cancer treatment.⁶

To create the game, HopeLab researchers, led by Dr. Pamela Kato, worked with video game developers, cancer experts, psychologists and young people with cancer. Research has demonstrated that specially designed games like Re-Mission can help drive positive behavior and potentially improve biological health. One study on the effects of Re-Mission published in the medical journal Pediatrics showed improved behavioral and psychological factors during cancer treatment.⁶ According to the study, participants given Re-Mission maintained higher levels of chemotherapy in their blood and took their antibiotics more consistently than those in the control group, demonstrating the game’s impact at a biological level. Participants given Re-Mission also showed faster acquisition of cancer-related knowledge and faster increase in self-efficacy. These results indicate that a carefully designed video game can have a positive impact on health behavior in young people with chronic illness. The study was the largest randomized, controlled study of a video game intervention ever conducted, following 375 teens and young adults with cancer at 34 medical centers in the United States, Canada and Australia during three months of cancer treatment. Participants were randomly assigned to receive PCs pre-loaded with a popular video game only (control condition) or that same control video game plus Re-Mission.⁶

When it comes to children and diseases, the management of care outside of the hospital setting often falls on parents. In these situations, parents can feel ill equipped and intimidated when it comes to administering needed medications. Scott Randall, CEO at BrandGames, recently launched a gamification project aimed at helping parents learn to correctly administer injections to their children.⁷ “The risks involved in administering the medication are significant, and all patients get is this little box with a piece of rice paper in it, and it says, hold the syringe like this, put it together like this, do this, do that, and stick it in your kid’s leg,” says Randall. “They’ve never done this before, and now they have this hysterical child on their hands, and they’re supposed to be administering the medication.”

The idea for the game is built around the concept of a tutorial, where users match the different steps in the process, assemble an interactive syringe, and then receive coaching on whether or not they’ve done it correctly. Game developers say the key performance metric in this instance is based on a reduction of adverse events.⁷

BrandGames has also created healthcare training for a nursing program at Johnson & Johnson, and pharma rep training for Daiichi Sankyo. “The idea is, how do you engage the doctor and how do you engage patients? When you’re looking at patient outcomes, you have to give the patient the big picture of what the medication is doing. At the doctor’s office, you get a Xerox of a Xerox of a Xerox. You go home with no emotional engagement; you have no context around your treatment. Without that, patients don’t participate in their treatment, and outcomes are worse,” says Randall.⁷

Patients who struggle with symptoms of chronic illness take an average of seven years to receive an accurate diagnosis. A new gamification platform called CrowdMed is seeking to significantly shorten that timeline. CrowdMed targets two different audiences: patients who have bounced from doctor to doctor without success, and those who want to help them. Patients who want to participate simply fill out a questionnaire that details their symptoms and case history. They can then submit their case for free or offer a “reward” to the medical detective who eventually solves their case. The second audience on CrowdMed are the self-appointed “detectives,” an audience comprised of doctors, medical residents and laypeople who compete on a point system to try to come up with an accurate diagnosis.⁸

As far as incentives, CrowdMed provides cash rewards (keeping a 10 percent commission for the company) and the “feel-good factor” premise that by participating on the platform participants can make a difference in a stranger’s life. In fact, CrowdMed’s website recruits participants with this intriguing proposition: “As a Medical Detective, you can use your personal experience, intuition, and online research skills to help solve the world’s most difficult medical cases. You can not only win cash, prizes, and status, but also help save lives.”⁹

Getting in the Game

Pharma companies looking to gamify their brands might wonder where to start. Experts suggest making education and learning top priorities in any prospective gaming platform, and also encourage developers to spend ample time researching specific behaviors unique to their particular patient audience. One multimedia instruction guide to gamification produced by PMLiVE Publishers in association with Grey Healthcare Group, offers a helpful how-to manual for stakeholders interested in jumping on the gamification bandwagon. Authored by Dr. Kieran Walsh, clinical director at BMJ Learning, Andy Hastie, head of digital at Grey Healthcare Group, and Matthew Hunt, European head of planning at Grey Healthcare Group, the guide looks at how the pharmaceutical industry can utilize gamification theories and explores where the health benefits could lay. Structured as an easy-to-follow tutorial, topics include theories, dynamics, rules and practical applications for using gamification in healthcare. According to the study’s authors, “As with any emerging discipline, there are many ways that it could develop, but at the very heart of it are some basic truths: People like challenges, they love rewards and they certainly enjoy sharing their success.”¹⁰

Gamification can be a costly, time-consuming endeavor requiring a significant investment in research and design, coupled with a willingness to “think outside the box” when it comes to disease diagnosis and treatment. The Pfizer video game trial for Alzheimer’s, for example, marked the first time a large pharmaceutical company evaluated a mobile video game as a clinical tool to determine early signs of neurodegenerative disease pathology.²

In addition to the Pfizer study, Akili Labs is also running trials with Duke University in children with ADHD; kids with autism spectrum disorders; college students in Vermont with autism, ADHD and other cognitive deficits; and two studies in people with depression. By examining outcomes in these and other studies, pharma companies, providers and other healthcare industry stakeholders will have an opportunity to evaluate their own objectives and determine if gamification techniques are a viable option for encouraging compliance, managing disease symptoms and, in some cases, offering opportunities for early intervention and treatment.