Video Games x Healthcare

Video games: Fun, visually breathtaking, easy to learn, doesn’t tell me I should reduce my salt intake because of familial risk for hypertension.

Healthcare: Inconvenient, visually sterile, complicated, does tell me I should reduce my salt intake because of familial risk for hypertension.

Which one am I more likely to engage with?

I used to play games way more video games back in the day, but now that I’m stuck in the house I’ve been slowly getting back into them.

Here’s a scratchpad of observations.

Video Games Have Figured Out Social Mechanics

One player games are fun, don’t get me wrong. But playing with friends and other people online is what keeps me coming back.

Our healthcare journeys have been treated as one-player games. We’re basically doing it alone, and that can get tired very quickly. As healthcare becomes more de-stigmatized, we should think about what a more social version of healthcare looks like.

Key components gaming has figured out on the social front:

• Ranking and Matchmaking Systems - It sucks when you start a game and you’re playing with people 10x better than you. Finding people at approximately the same skill level going through the same issues as you makes it way more inviting. Healthcare companies can think about better matching patients in similar parts of their healthcare journeys and similar types of journeys (e.g. by disease, similar end goals, etc.) Diabetes management companies with cohorts for their programs, Alcoholics Anonymous, etc. have some components of this that I think are quite effective.
• Guilds/Teams + Competition - Games have done a good job of letting people organize their own teams, groups, etc. and set up their own hierarchies (e.g. guild leader). One beneficial thing this does is outsource organizing the group to a player, who does it for social currency (aka the cheapest form of labor). The second thing it does is that it creates competition between groups, where the group AS A WHOLE has aggregated goals to complete as part of the competition (e.g. your team is relying on you to help them win). Not wanting to let your team down is a huge motivator, and healthcare companies should think about ways to create these group dynamics that create some intrinsic motivation for people to improve their health.

• Modding and Remixing - A key component of gaming today is allowing players and the community to easily alter the game to create new versions. This is called “modding”. Sometimes players will create new skins or characters for a game, create new maps, or sometimes they’ll create totally new games using components from the original game (e.g. Dota is originally a mod of Warcraft 3). Modding is important because it allows players to generate new, interesting versions of a game they like that others may like as well. This creates a powerful modding community where people can request features, modders are incentivized to keep tweaking and improving a game, and totally new forks to mods can appear. I’d like to see more this in healthcare, where patients or physicians can more easily create “mods” and remixes off of treatments, lifestyle changes, etc. that are low-risk and others can test, improve upon, and share themselves. There are some examples of this already in healthcare (some which are less regulated/safe) like communities around DIY automated insulin pumps or research that builds on someone else’s findings/data. But I think there’s more ways to apply the modding concept in healthcare, starting with tools to make it easier for people to create and share mods.

Training And Leveling Up In Games Is Fun

Video games are experts at teaching you the rules of a game and building mastery. If your goal is to relay complex information about how to do some set of tasks for an end goal (aka. all of healthcare), then there are lots of lessons to learn from games.

Learning and leveling up are a very key part of games - if people get bored they’ll quickly abandon a game. Because of this, games have figured out ways to make training fun and leveling up not seem like a totally repetitive grind.

Some key components here:

• Goal setting - In games, you level up very quickly when you just start out to really get the dopamine rushing. As you become more advanced, the fun of the game becomes challenging yourself and spending more time to get to higher levels for some tangible purpose (defeating a boss, gaining a skill, etc.). Right now in healthcare we’re asked to do healthy things to POTENTIALLY avoid getting sick down the line, but maybe we need to find more ways to DEFINITIVELY gain things for hitting key milestones, spaced out so it feels like we’re working for it. This could be money, recognition within a community, more responsibilities/freedoms, or access to certain events, etc.

• Stat Tracking and Fast Feedback Loops - When you can actually SEE your stats in a game and how they change due to different actions, it pushes you to improve certain stats you might be weak on or double down on strengths (e.g. my agility is bad, I should do more to improve it). One of healthcare’s big issues is the lack of direct feedback loop between action and how it impacts the different “stats” of our bodies. What if we could actually see more immediately how our stats changed; would that push us to make healthier decisions on a daily basis vs. right after we see a doctor? Or we could we better compare our stats today vs. different snapshots of those same stats in the past (aka benchmark against ourselves instead a “generally healthy person”)? For example, a company like Levels shows healthy people how their blood glucose changes in response to different activities. Maybe that pushes people to eat less sugary stuff if they can directly see how it impacts them today instead of 10 years from now.
  
  This also comes down how we get people to take these measurements regularly if it’s not passive. Companies like StateSpace use games to measure reflexes and cognition for gamers, and Lumosity, et. al use brain games and puzzles. Both of are conceivably neurocognitive assessments disguised as games.
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• Skill Trees - How you present “stats” to the end user matters. If it’s too complicated it’s not useful. Games with good explanations of how upgrades work, skill trees, etc. (aka. NOT YOU FINAL FANTASY X WITH YOUR STUPID SPHERE SYSTEM) have figured out ways to start with simple visualizations and get more complex as players feel comfortable. An analogy might be a company like Whoop, which presents a lot of data as composite scores for Recovery and Strain. These are easy to understand on their surface, and for advanced players they get more granular.
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• Flexing - Getting to higher levels becomes old very quickly unless you can show off all the cool things you have because of your high level (which also motivates lower level people to grind it out). This might be cool items, abilities, badges, etc. but being able to show off the amount of hours or skill you have pushes people to reach those goals. How do we let healthcare people brag a bit about what they’re doing? Fitness apps have incorporated some of these components, how would Strava stay afloat if people couldn’t casually announce they biked 100 miles in the shape of the American flag?
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There’s an interesting second order effect that video games have - by making training fun, they can turn people into experts within a specific game fairly quickly. From the Shopify CEO:

“I’m a card-carrying member of the “video games are actually good” club. I’ve learned so many things in my life through video games. The only reason I learned programming is because I wanted to make changes to the video games I was playing. And obviously not all games are created equal; I tend to point out a few I think are extremely valuable. Factorio is one of those. It’s the one game that anyone at Shopify can expense. Because it’s just bound to be good for Shopify if people play Factorio for a little while. We’re building supply chains for our customers; logistics networks; and Factorio makes a game out of that kind of thinking. And you know what, it’s actually not surprising, cause that kind of thinking is super fun. - Tobi Lutke, CEO fo Shopify

I have asked my employers to expense Resident Evil, but apparently a GaMe aBOuT a zOMbIe ViRUS iSn’T hEalTHcAre.

Video games can turn average citizens into hyper-local experts of a specific set of rules. There are already some interesting healthcare examples of this. One paper aimed to teach players how to identify malaria infected red blood cells through a video game. FoldIt creates puzzles that people try to figure out to help predict how proteins will fold. Borderlands 3 recently introduced a minigame WITHIN the game where players help organize nucleotides to help sequence stool samples (which then gives in-game currency to spend in the main game).

Healthcare companies should identify about problems they have which require a ton of manual labor, think about the rules of that problem and if someone could be quickly trained on it, and then develop a game that makes the task interesting itself. Massive online crowdsourcing is still underutilized in healthcare.

Games Have Strong Engagement Mechanisms

Video games have become masters of engagement, to the point where there are serious questions about potential addiction issues. Healthcare giants have become whatever the opposite of a master is at engagement. A newborn of engagement? Idk that doesn’t sound right.

Here are some mechanisms beyond just giving someone badges or scoreboards and traditional low-effort gamification attempts.

• Lotteries - Nothing like a daily draw for a 1/1,000,000 chance of getting a rare item to make me come back to a game every. single. day. There’s quite a bit of research in behavioral economics that suggest that variable award amounts work, and you see it work in certain parts of healthcare like contingency management therapy (which offers patients suffering from addiction to draw form a bowl of different types of prizes if they stay clean). Mango Health also has a weekly raffle if you’re healthy. How come I don’t get anything cool and fun when I see my PCP??? Also money is great, but everyone has different priorities so the gifts in the lottery should be more tailored to the end recipient.
• Voting - American Idol really hooked viewers in by getting them to vote and showing the results the following week. Fortnite has many contests where players submit ideas and the community votes on what they want to see included in the game (e.g. send us your dance, and we’ll include it as a dance in the game if people vote for it). You sort of see some versions of this in healthcare - input from physician and patient panels gets incorporated in areas like clinical trial design and some regulations, etc. but it’s not quite the same submit and vote that games use. I think incorporating contests and voting for way lower-risk and fun stuff is something healthcare companies should think about.
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• Timeboxed events - Games will frequently have an event that lasts between specific dates (e.g. get this rare card by competing in the tournament on 10/15). When the flu shot used to come to my office for a day, I made sure to get it. I think if we timeboxed specific things in healthcare where you HAD to go get it or there was a heavy incentive to go on a specific day - people would be more likely to plan in advance vs. continuously putting off (like screenings, checkups, etc.).
• Visuals - Based on every presentation I’ve seen from researchers/physicians, they’ll be jailed if they have good visuals. But it’s amazing how much good aesthetics and animations can make even simple games become addicting. That’s basically how Candy Crush became a household name while being a super simple game. Companies like Level Ex are bringing these same design principles and modern gaming engines like Unreal are being experimented with to make medical education more fun and interesting. Applying similar visual appeal to fitness games and chronic disease programs might actually get people to use them more. The bar is pretty low - this is what we’re currently working with from an aesthetics perspective.
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Implement a few of these engagement mechanics, and healthcare companies might start measuring things in daily active users instead of decade active users.

When Healthcare Comes To Games

An interesting thing to think about is how the worlds of healthcare and gaming have begun to blur already. We’ve begun seeing it with digital therapeutics - Akili Therapeutics is quite literally a video game to treat ADHD.

But I think there’s more to it. A running theme of this newsletter has been “healthcare is coming to places you already are” - your grocery store, employer, home, etc. But as we spend more time in games and care becomes virtual, maybe healthcare should come there too.
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Games are simulations, you can run massive real-world experiments in a game to see how its participants react. In the past I wrote about how World of Warcraft accidentally created a real pandemic and it ended up mimicking a lot of aspects of the current COVID pandemic. What if we ran other simulations within games?

What if virtual care and diagnostics came into the game itself? Borderlands introduced the sequencing mini-game within the larger game to gain Borderlands currency. EVE online has (non-medical) grief counselors for new players. Video games could work much more closely with healthcare companies to potentially detect mental/behavioral health issues early, or do a quick asynchronous health screen while waiting for a match. Embedding healthcare natively to these games could get people to engage more with the healthcare reducing the friction, and games could make that attractive by giving away in-game rewards to incentivize uptake.

What if the games themselves became more active? Wii boxing is probably the most I’ve ever sweat from a game, and Ring Fit looks like a super fun and accessible way to turn the Nintendo Switch into a game workout.

What if our everyday choices were turned into healthcare games? Turning our daily habits into small nudges for incrementally healthy choices probably has the least friction. Pokemon Go got so many people to actually walk around and get exercise in a fun way. Russia ran an experiment where you could do squats to get train tickets. One of the larger scale deployments seems to be LumiHealth which is working with Apple, Evidation Health, and the Singapore government to build an entire healthcare universe that combines different sensors + maps+ actions (like getting screenings, vaccinations, etc.) to make a personalized healthcare video game.

I think this is doubly important because good healthcare habits need to start much younger and our current public health system is not investing enough money that far upstream. Games are such an integral part of teenagers and young adult lives; they can transition from a force that makes the more sedentary and unhealthy to one that can better build these more active behaviors.

I’m not going to pretend like video games are paragons of ethical design either. All of the above taken to the extreme leads to design choices intentionally meant to get people hooked. But the reality is that healthcare companies are competing with video games when it comes to attention, lifestyle choices, and allocation of time. Healthcare companies can incorporate some of the above to make their offerings easier to use and more fun so it doesn’t feel like as big of a dopamine drop.

Thinkboi out,

Nikhil aka. “I’m not an actual gamer I just play Smash Bros Ultimate online and get absolutely destroyed”

Twitter: @nikillinit

IG: @outofpockethealth

Thanks to Malay Gandhi for feedback + brainstorming this post

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