Event Wrap Up: Games for Health 2005

The Games for Health 2005 conference, produced by the Serious Games Initiative, was held last week on Sept. 22 and 23 in Baltimore, Maryland. The conference's content focuses on serious games as used specifically in health and health sciences, including games used for training students in healthcare-related studies as well as games used for treating patients.

Ian Bogost, a researcher and professor and speaker at the event (the session that he presented was titled Advergaming of Prescription Medicine), attended several sessions, which he summarizes here.

Games for Health 2005, Day 1

Introduction Speech

Stephen J. Downs, senior program officer, Robert Wood Johnson Foundation, asked in his talk, “Why did the [Robert Wood Johnson] Foundation invest in video games?” Their “pioneer portfolio” looks for innovative projects that might be influential five or 10 years hence. Robert Wood Johnson research has shown that it takes 17 years for a new finding to make its way into widespread practice, and we have to start now to accelerate that progression.

Welcome Address

Dr. Bruce Jarrell, dean of the University of Maryland School of Medicine welcomed attendees. He said research is the primary focus of the medical school and mentioned that the process of teaching medicine is done by lecture and apprenticeship. The electronic age in medicine is limited: PowerPoint, web pages, and a few simple simulations are about as in depth as it gets. The effect of the digital revolution has not yet touched medical curricula in a meaningful way. The problem solving in medical school needs to be improved.

Jarrell spends his time with surgical residents and tries to dig into problems with his students, helping them "repair the holes" in their knowledge. This learning requires customization based on the students, a wide range of common sense and technical knowledge, and an engaged, interactive address of the students. In general, the practice of medicine currently does not include techniques of this nature.

Natural language processing and computational linguistics are one technical obstacle that must be hurdled in order to change this situation. Funding for improvements remains hard to find, and it needs to be improved. Content is king at medical school, not just process.

The Future of Games for Health

Ben Sawyer of the Serious Games Initiative, which organizes the Games for Health conference, says there are two sides to games for health: personal treatment and professional practice. The former includes treatment, disease management, physical therapy, exer-gaming (or gaming that promotes exercise), mental health treatment (VR/psychotherapy), cognitive learning (Brain Training for the Nintendo DS is an example), and other applications that people personally purchase. The latter includes health messaging, modeling, simulation, and training.

The future of games for health includes virtual reality medicine, commercial games, and technology. Sawyer articulated a concept he called the Personal Health Record, which takes personal information, doctor visits, data recording from various devices, and produces output that could be tied into or bound to games. One use for this is recording and measurement information.

Sawyer described a whitepaper the initiative is working on to help individuals evangelize the use of games for health. They will also be taking the initiative on the road, and launching a game contest for games for health, akin to a kind of specific Independent Games Festival.

He then described the "plague" now afflicting World of Warcraft, an infectious blood disease that has ravaged the game. Sawyer showed a video of the epidemic at work, which created calls to "quarantine the server." It is the first such "outbreak" on record in a game. So, now we need "health for games" in addition to "games for health."

Sawyer also showed the Brain Training games and a slide from Nintendo president Satoru Iwata's Tokyo Game Show keynote that demonstrated how Brain Training has a very different sales pattern than other games. Most games have a big launch but a steep drop off shortly thereafter, but Brain Training has seen consistent sales over the first four months of sales. Brain Training is above the other DS games, including Nintendogs, as a driver of DS hardware adoption. Brain Training's demographics are very different as well, with at least 25 percent of players age 45 or older.

He also showed a video of the new Revolution controller, demonstrating that the method of play in these games also includes a health game: a dental surgery game using the new controller. Finally, Sawyer argued that there's no dividing line between commercial game innovation and games for health, and health games can be healthy for the games industry.

Ben's Game: Visualizing Cancer Treatment for Children

Eric Johnston of Lucas Arts and now affiliated with the Make-a-Wish Foundation, met Ben Duskin, a young boy who was diagnosed with leukemia at age 5. At age 8, Duskin submitted a wish to Make-a-Wish to make a game about fighting cancer.

In this session, Johnston showed Ben's Game in which the player controls a child on a board. The player's goal is to combat cancer by fighting cancer cells.

The game took six months to make, with Johnston and Duskin working one evening per week and Duskin also on weekends. The game has been downloaded 172,000 times. Traffic on Make-a-Wish Foundation's web site increased from 100 visitors to 60,000 visitors per day after the game launched.

Ben's Game was hard to take on as a company, says Johnston, because of the time required. The first step was to acquire funding, a step they skipped. When Johnston made his first game, he accomplished it alone and in only 10 weeks (Pipe Dream, a classic puzzle game). Since then, the scale of gaming has increased considerably, so Johnston used this new opportunity as an excuse to get back to his short, independent approach. The project budget included a USB flash drive to allow Duskin to take the game home after every meeting, and 16 liters of limeade. Johnston was surprised and impressed by the child's involvement and guidance, he said.

The second step was to ask permission of LucasArts to make the game, which Johnston says he also skipped. He just started making the game, realizing that in the worst case, he could simply make it at home. After getting some traction, LucasArts allowed him after-hours access to the office, including the sound studio, which was a huge help in the development process. The company's Legal and PR departments allowed the game to be released for free; the company also facilitated a tour of Skywalker Ranch and the archives for Duskin, places that Johnston has never been himself.

One question Johnston found himself bound to ask was: “How can we design a game about cancer?” Clearly the player can't lose or die. The two decided to focus on distraction and entertainment for kids undergoing cancer treatment. Distraction is a big part of pediatric medicine, and there's very little you can do in treatment.

Every Tuesday, Johnston and the young Duskin worked on the game (except one week when Duskin was grounded). In the lecture, Johnston showed photos of the two working on the game, demonstrating the child's detailed involvement in the design as a primary driver. He shared his experience watching Duskin play the game, which he cited as a tremendous help in the iterative design process.

The game's development started with the concept of a field of cells, but an abstract and stylized game too. The field has mutating cells that grow, similar to John Conway's game Life. Ben's Game uses a shield (to protect against side effects), health, ammo, and attitude as markers of the player's health level. But when attitude runs out, you keep fighting, living beyond what the level says you can.

Mutating cells aren't very understandable, and kids don't see those; they see the nasty side effects of treatment. So in the game, you fight monsters which are manifestations of seven side effects: fire represents fever, q-balls are hair loss, “ro-barf” is vomit, vampires represent bleeding, the tornado stands of rashes, snow monster are colds, and the evil chicken represents chicken pox. The game allows players to choose from a number of playable characters or create their own.

Next-Generation Healthcare Learning Platform

The speakers on this panel were Dr. Claudia Johnston of Texas A&M Corpus Christi, Douglas Whatley of BreakAway Games, a serious game developer, and Timothy Holt of Oregon State University.

Dr. Johnston first described Pulse, a virtual learning space project in which a healthcare learning system models dynamic changes in care environments. The idea is that an immersive and persistent environment for responsive medical training alongside high-fidelity graphics would make for a valuable adaptive learning environment.

Pulse is conceived as a "virtual clinical learning lab," the panelists said, that provides a persistent healthcare world with patient simulation. Challenges include the technical and programmatic representation of medical treatment.

The game will be used by the military healthcare team, the healthcare delivery system (nursing and medicine, certification, and the like), and higher education degree programs. Games allow rehearsals for life and offer the promise of improved learning.

Substance Abuse Treatment with Game Technologies

Ro Nemeth of the National Institute on Drug Abuse (NIDA), and Darion Rapoza of Entertainment Science, spoke during this session. The gaming community has a perception that the National Institute of Health (NIH) doesn't have an interest in serious games because few grants seem to be awarded. However, virtual reality was once in the same situation, and now it's a major funding outlet for NIH and NIDA. Gaming will eventually grow into a similar funding outlet. Small Business Innovation Research (SBIR) solicitations are common and opportunities will become more plentiful even in the near-term. Nemeth encouraged people to talk to her to find the right NIDA or NIH contact for their ideas to help make them fundable.

Rapoza, however, used her portion of the presentation to show and discuss a game, which promises to offer more preventative intervention for drug abuse than any other related materials could afford.

Created using the Unreal Engine, the game is an action/adventure role-playing game, akin to Deus Ex. Action/adventure games typically have a high proportion of both male and female players, and they are the best platform for the translation of evidence-based approaches to drug intervention, according the Rapoza.

Feedback suggested that more advanced technology was needed to engage players. Rapoza showed an Unreal 3 screenshot and argued that this was the target to meet.

Games are an especially good medium for reaching the poor. According the a study Nemeth cited, 100 percent of urban and rural poor people play games daily, have internet access, and (as a projection) 100 percent of the fathers of urban and rural poor would play games with their kids once a week or more. Games are thus demographically appropriate for the problem of drug addiction education, and video games are cost effective compared to other preventative interventions.

In developing the game, Rapoza mapped the effects of drug abuse—short- and long-term memory loss, emotional problems, difficulties focusing and problem solving, and so forth—and mapped them to gameplay attributes; so in the game, the effects of drug abuse alter whether your player identifies a person as a friend or foe, the conversation you have, dialogue trees, impulsivity, aim, movement, and skill. Skill enhancement is based on a hierarchy of achievements.

Power-ups in the game come in the form of coffee and amphetamines, which players can use to study for exams in the game and do better. Cravings are represented as pop-ups during gameplay, and can be dismissed with "auto" responders (that is, auto-smoke), which models the actual addiction process. During severe addiction, the player may lose control of the character, who will use the drugs without the player's permission. Some players experimented with saving the game in a "pure" drug free state , then experimenting with drugs, then going back to the saved game, said Rapoza.

Video Games: Just What the Doctor Ordered

Dr. Anuradha Patel of the University of Medicine and Dentistry of New Jersey (N.J. Medical School) discussed using existing games to treat pre-operative anxiety in children. Most children experience anxiety before surgical procedures, and they experience the most severe distress when anesthesia is introduced. Research shows that children tend to exhibit certain maladaptive behaviors after surgery, even up to a year afterward: bad dreams, disobedience, separation anxiety, tantrums, and bed-wetting. These behaviors would not have manifested before the operation. The cumulative effect of these exposures is unknown.

Behavioral preparation programs, including coping skills training, have traditionally been used, but are time consuming, expensive, and not necessarily successful (more information can lead to more anxiety). Behavioral therapy such as distraction with toys, storytelling, hypnosis, and so forth has also been used. Other researchers have tried environmental modification. Medications also produce delayed recovery and more agitation, and parents are concerned about "drugging" their children.

Games, said Dr. Patel, can help focus attention. Games are known to increase dopamine neurotransmission and absorption. In the study, Dr. Patel's group used a Game Boy to active distraction. Because the device is portable, the child can play it while anesthetics are administered.

Based on a Yale Prop Anxiety Scale (a standard measurement method in the field), the group determined that the anxiety of children playing games was lower than those with parents present but no additional anxiety drugs, and parents present with the introduction of anxiety reducing drugs. Seventy-one percent of the participants in the Game Boy group had no change in anxiety during the study. Interestingly, parental presence alone is associated with the most increase in anxiety. Moreover, the study suggested a possible improvement in post-surgery behavior, rather than an introduction of new negative behaviors.

Taking Games for Health Mobile

Charles P. Schultz of Motorola presented this session, whose premise was that games can provide players with a sense of mastery over their condition. Schultz used the example of YuGiOh as evidence that kids can learn large bodies of information about arcane topics, and this can be applied to health instead of fantasy. Motorola tried to realize this by extending existing internal products and initiatives. At the same time, the company wanted to avoid using mobile technology as a nag, said Schultz.

WellWorld is an internal MMORPG built on Torque, started in October 2004, and funded through 2005. The goal of the game is to help players manage an acute lifestyle health condition like diabetes or heart disease. In the game, the player receives token rewards for the acting in ways that support his or her health condition. The purpose is to help kids (or adults) understand and feel more confident managing their own conditions.

Motorola has a project called "seamless mobility," which involves the ability to access what you want, when you want it, wherever you are. The new iTunes phone is an example of this initiative. Other kinds of mobility are content, experience, brands, information, social experience, device independence, and demographics. So, specific content can be transmitted based on the purposes of the game. Specific content from different domains could then be delivered to the game world. These additional materials could be pushed to a phone. The game world could also move between devices (PC to mobile), and demographically, the parent and child should both be able to engage the experience.

So far WellWorld has incorporated branded content from LifeScan and the American Heart Association. Motorola sees this as a viable method for distribution and funding. The videos in the game are accessible through the game or on a phone. In terms of demographics, parents want age-appropriate themes and Motorola wants a "happy, shiny look." With respect to device mobility, the phone clients are possible, but may have limited features.

The justification for an MMORPG was based on research that showed social support helps people engage in positive health behaviors, said Schultz. Higher values of the social contract index are associated with increased odds of health behaviors. Conceptual buy-in has been positive.

FreeDive

This session was presented by Brian Morrison of the Believe in Tomorrow Foundation and Lyn Dahlquist of the University of Maryland. FreeDive is a scuba diving simulation (created by BreakAway Games) that Dahlquist is using as a pain distraction tool for kids during particularly uncomfortable treatments. The idea behind the game is to distract kids from pain, which requires actual cognitive attention. In Dahlquist's studies, pain tolerance increased more than two-fold among kids in a controlled experiment using a hand submerged in ice as the pain stimulus.

Games for Health 2005, Day 2

The Future of Healthcare and Health Technologies at a State Level

Chris Foster, CSO of Baltimore Business and Economic Development, spoke about the opportunities and problems that the state of Maryland is funding or considering funding, and though specific industries are not targeted, currently 45 percent of the total falls under “life sciences.”

Traditionally, medical device technologies and products have been the targets. However, looking forward the savings from electronic health records (in terms of lives and costs) are suggesting a number of new opportunities. Foster argued that the rest of the world looks to the U.S. to solve healthcare problems.

Military Medicine, Modeling, & Simulation: How do Games Fit In?

The Telemedicine and Advanced Technology Research Center (TATRC) is a U.S. Army agency that applies physiological and medical knowledge and simulations for medical decision-making and training. They focus on medical research and development, specifically trying to create industrial opportunities in medical modeling and simulation.

J. Harvey McGee, presenting this session, explained that TATRC strives to improve trauma training and reduce medical errors through medical modeling and simulation. Out of gaming technology, TATRC hopes to help young army men and women perform their combat medicine jobs in the field around the world.

Magee showed a video that TATRC uses to introduce the very youngest and greenest soldiers to combat medicine and the challenges of providing acute care during live combat situations. The video claimed that simple procedures could help save up to 90 percent of people on the battlefield wounded in combat.

Simulated environments can affect trainees, and medical simulation is disruptive—but it can disrupt and revolutionize the medical profession. Simulation effectiveness is the biggest challenge in the area. Researchers are using digitally enhanced mannequins, PC training, and virtual reality training, environments that can provide case-based scenarios and courseware.

Personal Health Record: An Interactive Portal for Your Health

Omid Moghadam of the Personal Health Record Programs at Intel Digital Health Group spoke on this panel. The Intel Digital Health Group is an eight-month old initiative devoted to using silicon technology in diagnosis and software for healthcare. Moghadam talked about the idea of games for disease management.

Personal health records have a role in remedying the cost/quality disparity, unsustainable cost increases, and no reasonable consumer force in the market. Healthcare IT has some role in remedying this situation, but only in regional health information.

Personal health records (PHR) are patient-directed gathering and augmentation of consumers' own medical information, a method by which services can be delivered to consumers. The transaction systems for PHR include remote medical systems, patient data, pharmacies, primary care physicians, hospitals, and specialists. Right now, there is only patient-sourced data—information patients provide themselves. A new national infrastructure will manage hospitals, physicians, and labs.

Game Technologies and Future Healthcare Opportunities

Ariella Lehrer, Legacy Interactive, talked about a scripting language Legacy created to address character behavior.

There's a need for improved AI tools, including middleware and scripting languages, argued Lehrer. In response, Legacy created STORI, a scripting language used to create actor behavior in its ER game, which creates interactions between characters and their environments. Because STORI is a technology framework, it has cross-platform capabilities, and can be used with other higher-level game engines or graphics systems. STORI was designed to be a designer-scriptable tool to create interaction. While the language is still too technical for some designers, it increased the accessibility of the behavior authoring.

In ER, which released in June and contains STORI, you start as an intern and work your way through seven episodes of skills and missions. The AI language controls the diagnosis and treatment processes, interactions, and episodic content. You also have to keep track of hygiene, food, rest, and composure to manage patients effectively. The player selects attributes, and his or her skills are based on them. Each episode includes multiple plot lines, for example, assigning interns to new patients. If one of your interns kill a patient, you're fired.

The player is also affected by the attitudes of others. The characters are internally motivated but are managed by the STORI AI system. Your relationships can help or hinder your ability to treat patients.

STORI also controls patients in the waiting room, like waves of patients, totaling over 100 in the hospital, all interacting with one another. The game also adds perks and special abilities (such as kissing other doctors). A Sims-style affinity system allows players to build bonds with other in-game characters.

Though the game has no medical content, Lehrer suggested that the framework for the game could be extended with real medical information and problems to increase the depth of interaction for more formal training. Lehrer offered that while Legacy is not a tools company, it could license STORI to interested parties.

Interactive Entertainment Technologies for Healthcare Training

The ETC and University of Pittsburgh Medical Center are interested in textbook-to-real world training integration, of which gaming is a part. Simple initiatives can save lives in critical hospital situations as well as everyday situations.

Crisis Team Training, built in Panda3D, a low-cost 3D game engine, is a training program for seven people that teaches trainees how to respond to chaotic situations. They adapted NASCAR techniques: The pit crew has to work fast and accurately every time. Why can't doctors and nurses perform with this speed? The curriculum teaches this approach with traditional, real-life simulation, which is both time-consuming and expensive.

The groups developed a game in which players have to treat a patient while dealing with the softer issues related to managing the room and each other during crisis. For example, the simulation includes "blocking"—when doctors and nurses are in each other's way and the players need to contend with that immediate situation in the environment. The players communicate with each other in the same room to accomplish the healthcare tasks required.

The group demonstrated a three-minute "code" emergency. Amusingly, the game crashed, but while it lasted the demo effectively displayed the time-sensitive collaboration required in the game.

Evaluation of Virtual Learning Environments for Emergency Medicine

Patricia Youngblood of Stanford University collaborated with the university to create a sim-tech game, a virtual emergency education simulator. Together, they also created a first responder training system, both built in Forterra, owned by the company that used to run There.com (Forterra uses the There technology). Like the last demo, this is a multiplayer emergency medicine crisis resource-management training tool, adapted from standard research and training practices.

Because There is a virtual world with voice support, the scenario can be played out with users distributed around the world. Next, Youngblood and Stanford University hope to debrief first responders online to support both training and summary in the virtual world, since physically distributed teams can often benefit from training together remotely.

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