October 2016 | Issue 26
Games set to blast off in healthcare

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By Sean Firoz, Senior Executive, Communications & External Relations


The much anticipated augmented reality mobile game, Pokémon Go, took the world by storm, with “trainers” emerging from the comfort of their homes into the streets to catch virtual monsters. Within days, the game made headlines across the world on crowds stampeding across dangerous roads to players walking into rivers.

But at the same time, observers with an interest in healthcare noticed positive effects too. The game encourages players to step out of their homes and get that much needed Vitamin D and exercise to a degree that has not been achieved previously. Besides improving physical health, the game also helps players deal with depression and anxiety by allowing them to interact with other players in real life.

While this was an unanticipated effect of Pokémon Go, using gaming technologies to improve healthcare delivery, treatment adherence and the teaching of clinical skills is not new.

The gamification of healthcare, which is the application of gaming elements to a healthcare context, can be traced back to the 70s and 80s, in the form of video games with an educational objective. Games like the eight-bit video game Oregon Trail require players to manage the overall health and wellness of the characters to reach their goal, imparting key concepts about healthy living along the way.

It wasn’t until 2003 with the introduction of exercise-oriented gaming innovations by Microsoft at that year’s Consumer Electronic Show that the field finally exploded onto the scene. Then came the Nintendo Wii, which offered a variety of fitness games that encouraged players to be more active in the comfort of their homes.

However since 2014, interest from big multinationals in further developing healthcare games has waned and many people thought this novel idea would not grow further.

Today, clinicians and game developers are stepping into this void by leveraging newer technology such as augmented and virtual reality and mobile platforms, to improve the quality of these games and tailor them to the needs of the target audience.

To support this growing sector, the Games for Health Innovations Centre (ALIVE) was launched at the recent Singapore Health & Biomedical Congress. Announcing the centre, which is jointly set up by LKCMedicine and the National Healthcare Group, Guest-of-Honour at the event Minister of State for Health Mr Chee Hong Tat said, “In healthcare, games can motivate users to take greater ownership of their health by making the pursuit of wellness fun…Games are also a way to empower patients to be active participants in their care, and help them to make lifestyle changes such as diet modification, or follow an exercise regime.”

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NHG Group CEO Professor Philip Choo (left) shaking hands with LKCMedicine Executive Vice-Dean Professor Lionel Lee (right) after signing the Memoranda of Understanding (MOU) for ALIVE.

ALIVE will develop itself into a collaborative centre of excellence and international research centre for healthcare and medical education games in Asia. It aims to establish itself as a project consultation centre and grant evaluation agency by providing expert opinion on viability and scalability of innovative game solutions.

Vice-Dean for Education Associate Professor Naomi Low-Beer said, “ALIVE will enable gamification of healthcare and medical education to fulfil its potential by revolutionising the way we think about gaming technology and its uses. Work done by the centre will be standard-bearing for the region.

“The School’s strong commitment to this sector will also benefit our students. By exposing them early to a technology-enhanced learning environment, we aim to nurture doctors who are not only comfortable in using such technologies but who are able to see the potential of new gaming technologies and their possible uses in healthcare and education,” added Assoc Prof Low-Beer.

It’s more than just button-mashing

The applications of games to healthcare have the potential to fill many gaps – from alleviating manpower shortage to increasing adherence to treatment plans. Dr Loh Yong Joo, a consultant from the Department of Rehabilitation Medicine at Tan Tock Seng Hospital (TTSH), said, “Technological advances have allowed new models of care to be developed. These can enhance healthcare services in a myriad ways - increased productivity, heightened efficiency and reduced costs.”

One area of particular interest to healthcare professionals such as Dr Loh is the use of gaming technology in rehabilitative therapy or teaching patients to self-manage their chronic conditions.

Together with colleagues at TTSH, Dr Loh spearheaded research projects that use commercialised video game consoles, such as Playstation and Microsoft Kinect, for patients undergoing rehabilitation. Using motion-based technology and quality designs, these games aim to ease the patients into rehabilitation, and making the exercises both fun and engaging.

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An elderly patient trying out a prototype game for rehabilitation

LKCMedicine Class of 2018 student Joel Wong, who was involved in one of Dr Loh’s projects, said, “As the systems develop, there may also be room for allowing these patients to play the games at home, allowing them to do their rehabilitation without the need for a healthcare professional present.”

Besides TTSH, other hospitals such as the Singapore General Hospital (SGH) and KK’s Women and Children Hospital (KKH) have also produced prototypes for rehabilitative purposes, focusing on the elderly and children. These games were specifically curated to help patients feel more at ease with their rehabilitation sessions, spurring patients on to complete their therapy.

Games are also used to help patients self-manage their chronic conditions, such as depression, diabetes and even cancer. Having to survive and fight these illnesses is tough, and games can help lift these patients’ spirits and boost their morale during difficult times.

LKCMedicine Visiting Associate Professor and Acting Director of Medical Education Research and Scholarship Unit (MERSU) Nabil Zary, who also oversees ALIVE, said, “Studies have shown that when a cancer patient plays games which involve the player battling a tumour, it actually strengthens their morale and their willingness to fight.”

Fun, exciting and built with a specific objective in mind, these games increase patient engagement and help them on the road to recovery.

Benjamin Siow, an LKCMedicine Class of 2018 student who worked on understanding the elderly’s receptiveness of games in healthcare for his scholarly project, said, “Games in healthcare, if used appropriately, work on the principles of enjoyment to increase immersion in the activity. Participants can then learn and retain knowledge for longer periods of time.”

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LKCMedicine Student Benjamin Siow guiding a senior citizen on a game to gain feedback on the effectiveness of the game

But it is not just patients who can benefit from gaming technology. Healthcare professionals who have to master a combination of skills, such as time-management while performing clinical tasks well can also benefit from it.

Technology is no stranger to medical education, as seen in the use of technology-enhanced Team-Based Learning offered at LKCMedicine. In addition, a small group of students also got to pilot a new game that trains them in performing male catheterisation accurately and in a timely manner so that they are better skilled when they perform the procedure on patients.

Dr Adrian Tan, a consultant family physician at TTSH, who developed this male catheterisation simulation game, said, “To help them be more prepared or raise the level of pre-course knowledge to expedite learning and appreciation of the practical session, this game was born to help them learn in a fun way, as well as increase information retention on the subject.”

It is not just the pointing and clicking that helps students retain information through games, the act of performing the procedure in a virtual reality setting is key to learning complex procedures, and ensures players are engaged and retain information better.

Is the difficulty setting too high?

Creating video games for the purpose of healthcare and education can seem like a dream solution to keep patients and students engaged. But how long can this engagement be sustained? 

Pokémon Go may have been the biggest hit game, but mere months after its launch, participation rates are beginning to drop. Applied to a healthcare scenario, if patients get bored with the games that accompany their rehabilitation, the likelihood that they continue is slim.

This is just one of the myriad challenges that clinicians and game developers have to overcome for healthcare games to reach the mainstream.

“We constantly need to be creative and innovative to keep users engaged in these games,” said Assoc Prof Zary. “This is truly a test for the nation as to how innovative Singapore can be, because once games become a commodity, the risk is that there’s nothing special about it anymore.”

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Assoc Prof Nabil Zary giving a presentation on Games in Medical Education at the Singapore Health & Biomedical Congress last month

Certain groups of people, especially the elderly, may not be as receptive to games as well. As healthcare games get more technologically advanced, the less tech-savvy may fall behind, making it difficult for them to understand the advantages and uses of these games.

Benjamin said, “Many of them are worried that they won’t be able to utilise this new technology and wondered if they could actually use such games. Moving forward, these games need to be implemented in a positive, encouraging fashion.”

LKCMedicine Class of 2018 student Lavisha S Punjabi, who worked with Dr Tan on the catheterisation game, remains positive about the potential of gamification in healthcare. She said, “I am convinced that with the big advancements in healthcare and healthcare education that we will witness people who dare to venture beyond the healthcare sphere and collaborate with experts from other areas.”

As technology advances, it will be down to people like her to drive innovation and capitalise on the potential offered by gaming technology.

A new dawn is coming

With healthcare games in their infancy, there is still room for improvement before this field can take flight. For games with actual substance to be produced, there needs to be an ecosystem of developers, clinicians, trial testers and a thriving market to ensure that there is enough interest.

To date, many games are adaptations of commercially available technologies that transform an existing practice into a game. If gamification is to hit the mainstream, it will need to do more than that. Gaming experiences will have to be mapped to learning or clinical outcomes and be closely evaluated. Clinicians in particular will have to play a key role, working closely with developers to start looking at the unique ways in which different gaming technologies drive and sustain engagement.

Assoc Prof Zary said, “Currently, in particular to education, people have been trying to replicate existing ways of learning. But what you have to think about is what can a game do that nothing else can? So the whole field is moving towards engagement.”

There has been some groundswell in the last 10 years. The Serious Games Association (SGA) is one community that focuses on bringing both education and technology experts together to create prototypes and collaborate on games to educate society in different fields. “Serious games”, as they are commonly called, is a broader term for the gamification of healthcare.

Dr Loh, who is a member of the SGA, said, “We discuss new initiatives to bring potential serious gaming applications to the healthcare and education sectors. I also help raise awareness of serious gaming within public healthcare by coordinating and organsing various platforms.”

Gaming equipment has also grown beyond the computer screen, creating a more immersive environment. Video game big wigs such as Sony and Microsoft have revealed virtual reality technology as part of their push towards a more engaging way to play video games, advances that were welcomed by game developers; it will come to no surprise that these new technologies could be used for healthcare as well.

The possibilities are endless. From 2D side-scrolling games to creating educational virtual reality spaces, these games could very well play an important role in the future of healthcare.

To bring gaming into the mainstream requires large-scale interest. Assoc Prof Zary said, “If we don’t get enough people who can develop games and evaluate them, we would not have a commercial environment to produce and sustain these games in the future.”

Today, the gamification in healthcare has reached the stage where simply developing a game and disseminating it to the users is not enough. To ensure that players do not feel bored, clinicians and game developers have to find a way to increase engagement. Finding that balance between achieving the desired objective and retaining the users’ engagement will determine the lifespan of a game and how well it will do in the future.

Just like patches to a video game, the gamification in healthcare continues to grow, until the day perhaps when we see Xbox consoles as a commodity in our hospitals.