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These days, anyone with a smartphone can download a variety of games designed to make them healthier, whether that means helping them stick to an exercise routine, lose weight or manage a chronic illness. The games, invented by health insurers and a host of technology startups, are marketed directly to consumers, who use them to track their progress and record key health metrics such as blood sugar and pounds shed. Players of these games can win rewards, perhaps even cash, if they hit their health goals.
Experts have dubbed this trend "the gamification of healthcare". It means "applying elements and design concepts from games to other contexts that are not themselves games," says Kevin Werbach, Wharton professor of legal studies and business ethics.
"Using motivational techniques from games is part of it, as is creating engaging experiences for people." Werbach is co-author of For the Win: How Game Thinking Can Revolutionize Your Business, which argues that companies should think like game designers when they are devising new ways to motivate employees and customers.
In healthcare, however, gamification presents a distinctive set of challenges. Healthcare providers that want to offer games to their customers must do so without violating federal patient privacy regulations – a requirement that can make it difficult to target games to the patients who will benefit most from them. Even companies that are not subject to those regulations are finding themselves under pressure to protect players' most personal data.
Then there is the problem of the games themselves: how can companies make them engaging enough to keep customers interested? "It's sometimes hard to build a game that's sufficiently serious and on topic, but also fun," Werbach says.
Health insurance providers were among the first to dip their toes into gamification. UnitedHealth Group, for example, launched OptumizeMe, an app that allows people to participate in fitness-related contests with their friends, and the company is pilot testing Join For Me, a program that encourages adolescents who are obese and at risk of developing diabetes to play video games that require dancing or other physical activities. Healthways has a Boston subsidiary called MeYou Health, which has developed a rewards program for people who complete one health-related task per day.
Several technology startups have burst onto the scene as well, many of them focused on fitness. GymPact uses GPS to track its users to the gym. Members who meet their workout goals win cash, much of it from GymPact members who pay penalties for failing to exercise as promised.
Fitbit, based in San Francisco, markets wireless tracking devices that sync to smartphones and computers so that users can track their fitness activities. Then there is New York's Fitocracy, which is more of a Facebook-like social network, where people can track their workouts, challenge friends to exercise contests and earn recognition for meeting goals.
Werbach notes that there has also been a plethora of smaller companies inventing games for people with challenging health issues, such as SuperBetter Labs, a San Francisco company that is beta testing an online social game designed to help people coping with illnesses, injuries or depression. The company collaborated with scientists and doctors to develop the game.
Encouraging patient activation
Bonnie Henry is CEO of GameMetrix Solutions, which draws inspiration from classic games like Jeopardy and Solitaire to invent fun platforms for managing chronic illnesses, particularly diabetes.
"We're primarily based on a belief system that games and game mechanics are really going to be the motivating factor for chronic conditions that people struggle with on a daily basis," Henry says. "In the healthcare arena, there's a lot of discussion around patient activation, meaning getting people going [with games] and looking at the change in their engagement levels." GameMetrix provides platforms for companies, such as insurers, to create games for their customers tailored to specific health parameters.
GameMetrix's developers knew that pulling patients into the games would be a challenge, Henry says, which is why they decided to model their products on known properties. "One of the challenges companies face is they're trying to build new kinds of games and game mechanics. We focus on classic games where customers already know the game mechanics. They are games that have already been proven and tested."
When GameMetrix started in 2007, its founders tested their model by developing a game for people with diabetes that was based on classic trivia games like Trivial Pursuit. The company was stunned, Henry says, when 3,200 people started playing the game regularly, with very little marketing. "It's still live, and people are still playing. We recognise the motivations going on with these patients: They have a difficult time living with their condition. We are giving them a relaxed and therefore receptive environment for dealing with it."
According to Henry, one of the most valuable warnings in Werbach's book is to be wary of "pointification" or the awarding of points and badges to people who play games. She sees the healthcare community "rapidly embracing what I would say are simply loyalty programs, where if you participate, you get points or rewards. But it's really the deep elements of games and what makes them motivating that I think is missing. You may get a spike in participation, but it's not sustaining."
Werbach echoes that sentiment, adding that most of the unsuccessful games that have been tried in the business world failed because they relied too heavily on pointification. "The points aren't going to be effective unless they're embedded in a well-designed structure that uses them in a way people will find engaging," he says.
Keeping customers engaged, referred to in the gamification realm as "stickiness", is one of the biggest challenges for companies that are trying to encourage healthy behaviours, says Katherine Milkman, professor of operations and information management at Wharton. Milkman recently co-authored a study designed to test whether allowing people to listen to exciting books-on-tape when they are at the gym – and only at the gym – would cause them to become addicted to exercise.
The researchers found that the tactic worked well at first, but then weakened over time. "We were able to increase exercise frequency because we tied something to the gym that was instantly gratifying and attractive," Milkman says. "It worked quite well for seven weeks, but then the kids in our study went home for Thanksgiving break. They came back, and they had forgotten about it. What I think that means is we have to be constantly evolving. You can't build one Super Mario game that people can only play while exercising and expect it to do the trick forever."
UnitedHealth is experimenting with several gamification models, including one that uses financial incentives to keep its members engaged over the long run. The game, called Baby Blocks, is offered to 50,000 pregnant members in seven states and is designed to encourage women on Medicaid to attend all their prenatal checkups. The women can unlock "blocks" in the game by going to those appointments. After they attend key checkups, they can receive rewards, such as gift cards for maternity and baby clothing. In 2012, the company says, 2,296 members actively used Baby Blocks pilot, logging 7,098 prenatal appointments and unlocking an average of 3.1 prenatal blocks per member. "We do think financial incentives are important," says Arrianne Hoyland, game producer for innovation and R&D at United. "We felt using extrinsic rewards could increase engagement."
Werbach says that paying people to get healthy may be effective, but only to a point. "Tangible rewards are potentially very effective, but also potentially very dangerous," he says. "If it signals that this is really not about improving your life, but this is about getting some financial payment, then people will tend to only do the thing to the extent that they get the payment. The totality of the game experience must be sufficiently engaging."
Protecting patient privacy
Any company that applies gamification to healthcare faces the added challenge of protecting patient privacy. Insurers, hospitals and other health providers are bound by the Health Insurance Portability and Accountability Act (HIPAA), which requires them to conceal personal health information related to all patients in their care.
But the rules for technology startups and other companies that don't provide direct patient care are considerably fuzzier, says Andrea Matwyshyn, professor of legal studies and business ethics at Wharton. "These kinds of innovative health gamification ventures are primarily governed by contract law and not existing privacy law," Matwyshyn says. "So a host of problems arise because of the way that digital contracts in particular have developed."
For example, when consumers sign up for most health apps or web programs, they are generally asked to agree to a lengthy contract, which they may not bother to read, particularly if it is written in a very small font and they are viewing it on a cell phone. "We know that the reality is the consumers don't read these contracts, or they do, but they have tremendous difficulty understanding them because they're written by lawyers for lawyers," Matwyshyn says.
Some consumers have complained that health-app companies release too much information about their personal habits. For example, Fitbit came under fire in 2011 when the sexual habits of several hundred of its customers started showing up in Google search results. The company had been making all of the physical activities of its members public to encourage exercise and competitive interactions. After the outcry, Fitbit flipped the default setting for its members’ activities from public to private.
Matwyshyn suggests that most technology startups working in health care need to place more emphasis on privacy concerns. "The legal consequences of losing consumer data are not aggressive enough to encourage companies to plan optimal levels of data security budgeting into their bottom lines," she says.
"In that sense, you have internal culture wars between the data security champions and the bean counters, who are more concerned with quickly visible profits quarter to quarter. Yet it does have real ramifications when a company is perceived by its consumers to have behaved in a way that violates their trust. The risk is that consumers will leave you." Matwyshyn says there's an "active debate" in the legal community about how best to tighten up the laws governing tech startups working in the health arena.
In the meantime, startups and established healthcare players alike continue to add elements to their games that will improve their stickiness. Most recently, health-related games have taken on more of a social feel, with features that allow users to challenge other users to fitness or weight-loss contests, for example, and to announce their results on Facebook and Twitter.
"Community and social experiences are very commonly connected to games. We want to play with and against others, and to share that experience with others," Werbach says. "So having a social dimension is typically a significant and valuable part of gamification."
But adding that social element isn't enough, Werbach warns. "As with everything else, it has to be done effectively. It's not enough to say, 'Do you want to announce to your Facebook friends that you hit this milestone in a game?' It has to be a real community."