BMJ 2014;349:g5615 doi: 10.1136/bmj.g5615 (Published 15 September 2014)

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Feature

FEATURE HEALTHCARE AND TECHNOLOGY

Video games on prescription Computer games are being designed as healthcare tools because of their power to engage, motivate, and inspire. Stephen Armstrong considers the potential and the dangers of using games to inform or treat patients Stephen Armstrong journalist, London, UK Is this the future of medicine? Little Artie has been left at the doorstep of his grandma’s house—a spooky mansion filled with shadows. His grandma has been taken, and only he can save her. As he moves through corridors and darkened rooms, terrifying shapes loom above him. His only friend is Teru the Magical Hat, who shines more brightly the calmer Artie becomes. If Artie panics, however, Teru dims and the darkness grows. This is MindLight, a haunted house computer game aimed at teaching relaxation techniques to anxious children. Currently undergoing trials with Dutch primary school children, it’s the result of a collaboration between Isabela Granic and Rutger Engels, professors at Radboud University psychopathology department, and Dutch computer games studio Gain Play. Kids wear an electroencephalogram monitoring headset and as brain activity slows, the player’s light shines brighter. Granic hopes the game will train anxious children to conquer their fears.

“We know when people are anxious that they’re very absorbed by threats and they can’t focus on their own goals,” she explains. “So you train the cognitive control system to focus on positive things—using puzzles that they have focus on—and ignore threats. They learn by practice over and over.”

MindLight is at the leading edge of the so called gamification of healthcare—Silicon Valley’s attempt to join the medical profession. The theory of gamification—using game mechanics to help people solve real world problems—is gaining credence as a motivation tool for everything from financial services to terror groups such as Hamas. The potential is obvious: in 2011, people spent roughly three billion hours a week gaming, and the number of hours that gamers worldwide have spent playing the online sword and sorcery game World of Warcraft since its launch in 2004 adds up to over six million years.1 The possibility of using this immense amount of engaged time in a productive way has been exciting academics researching so called serious gaming for almost two decades. There are already more than 300 health related games available as well as some 13 000 apps professing to give medical advice, according to the NHS Commissioning Board.2

There are games designed to help cancer patients stick with drug therapy, games aimed at allowing patients to receive physiotherapy at home, and games that claim to treat Alzheimer’s.

Yet this is a market in its infancy and as yet not formally regulated. “We think healthcare games are currently at between 5% and 15% of their total potential market,” says Brian Burke, research vice president at leading US tech consultancy Gartner. “These games are still strongest in the US, although there’s a strong presence in the UK, Holland, Spain, and India.”

So far, although some evidence suggests games could be hugely useful in certain areas of healthcare, few scientific studies have been published. So should patients be using them?

Huge potential

For advocates like Olivier Oullier, professor of behavioural and brain sciences at Aix-Marseille University and adviser to the World Economic Forum on neuroscience and behaviour, the benefits are clear. “When kids don’t concentrate in school we tend to rely on pharmacology,” he argues. “But pills are not the only solution—cognitive brain therapy is as effective. The games industry is as big as the pharma industry and it can develop new games in months rather than the years it takes to develop new drugs. Developing new ways for kids to learn through gamification has to be better for society than another prescription for Ritalin.” Certainly the industry flagship games Re-Mission and Re-Mission 2, both from HopeLabs in California, have delivered impressive results. The game, launched in 2006 with the Teen Cancer Trust, pits players against cancer cells in the blood, firing drugs at the mutating cells to keep them in check. “The biggest problem in adolescent and teen cancer patients is getting them to stick to their chemo treatment,” explains HopeLabs head of communications and marketing, Richard Tate. “The drugs make them feel awful and look awful.” After the game’s release, HopeLabs tested its efficacy on 375 patients with cancer aged 13-29 at hospitals in the US, Canada, and Australia. Patients received either an off the shelf computer

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BMJ 2014;349:g5615 doi: 10.1136/bmj.g5615 (Published 15 September 2014)

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FEATURE

game or the same game plus Re-Mission. The results were published in Pediatrics in August 2008.3 “We found that playing Re-Mission led to more consistent treatment adherence, faster rate of increase in cancer knowledge, and faster rate of increase in self efficacy in young cancer patients,” Tate says. “A carefully designed video game can have a positive impact on health behavior in young people with chronic illness.” Its follow-up, Re-Mission 2 Nanobots Revenge, launched last year, is based on Cat God vs Sun King, a non-healthcare game in which players rain fireballs on the Sun King’s attempts to build a tower. Nanobot, conversely, sees players raining drugs down on a mass of cancer cells as they grow towards a patient’s blood stream. The graphics are more sophisticated than in the first Re-Mission, but the key difference is in distribution. Re-Mission came on a DVD and shipped to 250 000 patients worldwide. Re-Mission 2 is downloadable as an app.

Lack of evidence There is, so far, no available research on the efficacy of the new version. Indeed, this could be said for the entire healthcare games industry.

“Healthcare games have been around for a long time, but they’re still in their infancy, which is unusual in technology,” says Christos Gatzidis, who works in the creative technology department at Bournemouth University devising therapeutic uses for game techniques such as “first person shoot-’em-ups”—games where the player is inside a character’s head and shares their point of view. “I think the pervasive presence of smartphones and tablets is going to change that. What’s lacking is a proper evidence base for the outcomes—we need some serious and expensive academic research to understand the effects of these interventions.” Without an evidence base, the idea that games could help people manage their illness—or even treat it—is facing some resistance. Controversy abounds over a possible relation between video game addiction and attention deficit hyperactivity disorder, and there is general concern that computer games encourage a sedentary lifestyle and bad eating habits. Early healthcare games pioneer Willem-Jan Renger, head of applied game design at the University of Arts in the Netherlands, points to an early game designed to help diabetic children understand their condition.

“The game had a diabetic avatar whose blood sugar you had to control,” Renger explains. “Kids were great at keeping their avatar healthy. What we found, though, was that while playing the game they were sitting on their sofa eating chocolate—which did their own diabetes no good at all.”

Some fear drug companies might use games to manipulate patients into buying their products. There are also concerns over healthcare games and data security following recent attacks on sites like iCloud.4 And with controversy over computer guided disability checks for welfare claimants in the UK still rumbling,5 there is reluctance to allow games—and technology in general—to replace face to face contact between patients and doctors. The Wellcome Trust is already supporting several game based therapy projects with the aim to gather some scientific evidence.

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It has given a £1.3m translation award to King’s College London Institute of Psychiatry to follow up on a small project that allowed patients with schizophrenia to create avatars for the voices in their heads and effectively battle them. In a pilot study with six patients, almost all reported a reduction in the frequency and severity of the voices.6 Three patients stopped hearing voices completely after experiencing them for 16, 13, and 3.5 years, respectively. The Trust’s Centre for Neuroimaging at UCL has been running the Great Brain Experiment based on a freely available game app that investigates memory, impulsivity, risk taking, and happiness in a bid to understand if mobile games can be reliable tools for conducting psychology experiments. More than 60 000 people have taken part so far, and the study’s first results were published in July—successfully reproducing well known findings from laboratory studies and demonstrating, says Dodgeon, “that mobile games can be used to reliably conduct research in psychology and neuroscience. We can now investigate how factors such as age and education affect cognitive functions.”

So far, HopeLabs and Wellcome are the only major backers of healthcare games research to publish in reputable journals. In some cases, game designers are experimenting with apps and games designed to affect the player’s brain without publishing any academic work supporting their intervention. The benefits of gamification might be immense, if HopeLabs and Wellcome’s research is replicated. Unless well conducted studies are forthcoming, however, the risk is of a new market in unlicensed digital supplements installed on the two billion smartphones already in circulation. It’s in everyone’s interests that Artie gets out of the mansion safely. Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6 7 8 9

McGonigal J. Be a gamer, save the world. Wall Street Journal 2011 Jan 22. http://online. wsj.com/articles/SB10001424052748704590704576092460302990884. NHS England. NHS Commissioning Board launches library of NHS-reviewed phone apps to help keep people healthy. Press release, 12 March 2013. www.england.nhs.uk/2013/ 03/12/nhs-apps/. Kato PM, Cole SW, Bradlyn AS, Pollock BH. A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial. Pediatrics 2008;122:e305-17. Dutta N. iPhone 6 Apple launch—after iCloud hack, is your data safe on HealthKit? HealthSite 2014 Sep 10. www.thehealthsite.com/news/iphone-6-apple-launch-after-icloudhack-is-your-data-safe-on-healthkit/. Jee C. DWP awards Atos £10 million IT contract for healthcare assessments. Computerworld UK 2014 Jul 14. http://dellkv.computerworlduk.com/news/public-sector/ 3530443/dwp-awards-atos-10-million-it-contract-for-healthcare-assessments/. Wellcome Trust. Avatar therapy helps silence voices in schizophrenia. Press release, 29 March 2013. www.wellcome.ac.uk/News/Media-office/Press-releases/2013/WTP052694. htm. Gunning E, Richards E. Should patients be able to email their general practitioner? www. bmj.com/content/349/bmj.g5338. Brody E, Doyle E, Radhakrishnan J, Shaw D. Combat obesity with the internet. GP 2013 Aug. www.gponline.com/combat-obesity-internet/health-promotion/exercise/article/1193591. Thompson BM, Brodsky I. Should the FDA regulate mobile medical apps? BMJ 2013;347:f5211.

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BMJ 2014;349:g5615 doi: 10.1136/bmj.g5615 (Published 15 September 2014)

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FEATURE

Should doctors be prescribing games to patients? In 2013, NHS Choices launched its health apps library—essentially a list of health related smartphone and tablet apps that have been reviewed by clinicians to ensure they are clinically safe (http://apps.nhs.uk ). For Charles Lowe, director of the Digital Health and Care Alliance, part of the government’s delivering assisted lifestyles at scale programme, this doesn’t go far enough. Lowe is lobbying for NICE to assess the safety and effectiveness of medical apps and games to give general practitioners a list of options to prescribe to patients. “Right now, serious games aren’t generally used by GPs,” explains Maureen Baker, chair of council at the Royal College of General Practitioners. “We have a health informatics working group that’s aimed at addressing the arrival of new technology but it’s only just coming to terms with the arrival of email.”7 Some GPs are already experimenting with the use of gaming tricks to help change patient behaviour. In 2013 a group of west Oxfordshire GPs, led by David Brodie, Emma Doyle, Jey Radhakrishnan, and David Shaw, offered obese patients access to information from diet to exercise based around an anonymous online league table where patients reported weight changes.8 One of the most striking outcomes, the GPs found, was that almost 90% of the male patients lost weight—with men typically the most reluctant to join a weight loss programme. Although there are games and apps with similar possibilities, Baker suggests the UK’s regulatory system makes it difficult for GPs to use them with confidence. And there is a growing need to distinguish between healthcare games for keeping people well and healthcare games for serious medical conditions. Debate is ongoing in the US over the need to regulate mobile medical apps for serious conditions.9 “There are standards for patient safety and IT, and rules for software suppliers to the NHS,” she explains, “but something like Fitbit [a game to encourage fitness] or an obesity game falls between all of these stools. The whole process of regulation needs to be overhauled. Double blind randomly controlled trials work very well for drugs but they’re seen by many as the gold standard for any aspect of clinical care, and many of these wellbeing boosting games and apps simply don’t require that level of scrutiny.”

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Video games on prescription

professing to give medical advice, according to the NHS. Commissioning Board.2. There are games designed to help cancer patients stick with drug therapy, games aimed at allowing patients to receive physiotherapy at home, and games that claim to treat. Alzheimer's. Yet this is a market in its infancy and as yet not formally.

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