The Gamification of Healthcare
Gamification can play a role in healthcare, especially in the management of certain chronic diseases. Let’s take a deeper dive into what all this could mean.
What is gamification?
My iPhone buzzed. I looked down and turned my left wrist towards me. On the display a green line appeared. The line sparkled as it navigated around the face of my watch and formed a ring. Using the watch’s vernacular, I had “closed my exercise ring”, meaning that I had exercised for at least 30 minutes that day. My watch was congratulating me for the accomplishment. It was a digital pat on the back.
There are three different types of health goals on my watch – a Move goal, an Exercise goal, and a Stand goal. An individual can set these goals and the watch measures your progress each day. Along the way, it encourages you with reminders and congratulates you with haptic cues and fancy visual displays. Exercise for 30 minutes, seven days in a row and you get a badge. The watch even issues challenges each month. For the month of May, my watch has challenged me to “close my exercise ring” at least 18 times. There are even “limited edition” badges throughout the course of the year, making the conquest of those challenges seem even more special. You can also track your friends’ progress and compete with them if you choose. All of this is intended to get me to engage in activity that promotes health. This is gamification – incorporating the components of a game to an activity in order to encourage engagement, drive adherence and, ultimately, modify behavior.
Does gamification work?
The short answer is that unfortunately large empirical studies on whether gamification actually works are scant. Perhaps not surprisingly you can also look on-line and find conflicting data and opinions on the matter. So, to start, I will share some personal observations.
A Personal Case Study
My personal case study on the matter involves a sample size of exactly two – me and my wife.
As part of her nightly routine, before bed each night, my wife checks her phone. If she is short on any of her fitness goals, it is obvious. If she spontaneously starts doing jumping jacks or walking repeatedly up and down the stairs, it’s a clear signal that she hasn’t yet achieved her daily goals. For her, “closing her rings” matters. As for me, I am exactly the same. My watch recently issued a particularly hard challenge in the month of February. It challenged me to burn my targeted daily “active” calories 26 times in the month. Active calories are the calories you burn from exercise. I thought this was a particularly difficult request since February was only a 29-day month and I have set my active calorie target very high, at 1,200 per day. It meant exercising vigorously with only 3 days of rest the entire month. It wasn’t easy, but I was able to complete the challenge – all to obtain a digital badge that has neither tangible relevance nor monetary significance. Now, I fully realize all the flaws associated with relying on our two-person example to draw any conclusions, but it is still a data point. So, let’s move beyond the personal, small sample level and into some examples from the professional domain.
Gamification in the Business World
Once upon a time, I used to lead a service organization. One of our challenges was to engage the product sales team to sell a service contract. Not surprisingly, the product sales team was motivated by one thing – selling products. Asking them to sell a service agreement for the product was an uphill battle. If they could give away the service in order to sell the product, they happily would. To try to motivate them, we offered commissions on service contract sales. This received very little traction because they viewed it only as ancillary income, and relative to their product-based sales commissions the amounts weren’t that exciting. We were struggling to capture their attention. Our team member responsible for the commissions program decided to modify it. She created a new program were the sales team wouldn’t earn money for selling a service contract, they would earn “reward points”. The reward points could be redeemed for different items inside a marketplace that she established. The items in the marketplace were things like golf clubs, TVs, washer and dryers, etc. Once the product sales team became aware of this program, service sales took off! Interestingly, the individual items listed on the marketplace were of less financial value than the cash-based incentives the sales team was getting under the original program. In other words, a set of $1,200 golf clubs was somehow worth more to the reps than receiving a $2,500 commission check.
A second example from the professional world comes from another business I led where we had leaderboards in a call center. In this particular case, we would track transactional Net Promoter Scores (NPS) for our call center representatives. After each call, the callers were surveyed about their experience with our representatives. These ratings were accumulated and the scores for the top performers and each of the various call center teams (our teams were split by geography) were displayed. Each representative also had visibility into their own score and knew how they stacked up against the top performers. We didn’t feel it was appropriate to display the scores of our bottom performers. We also would provide coaching and case studies of good calls and bad calls for the entire team. The goal was fantastic customer service and we created a visible environment where our team members would compete for the title of best service provider. In this case, it worked marginally well – where we definitely saw improvements in NPS scores – but it wasn’t a switch that instantly created consistent, exemplary performance throughout. I don’t believe it was motivational enough to turn a bad call center representative into a great representative, but I do believe it allowed us to accomplish a few things. First, it helped us reinforce the importance of providing exemplary service, which is critical when you are trying to build a culture. Second, we were able to link the scores to behaviors, emphasizing what “great service looks like”, as well as emphasizing what could go wrong on a call.
If I take my personal and professional experiences, I have concluded that gamification can work if it’s done properly. The qualifier of “if” is obviously critical.
What Makes Gamification Successful?
Based on personal observations there are a few key success factors:
Keep it simple … the rules of the game need to be easy. I know what it takes to close a ring on my watch. Our product sales teams also knew exactly how the sale of a service contract translated to a specific number of points. However, the transfer function between a representative’s actions on a call and a good NPS score from a customer is less clear. The more complicated the game, the less successful you will be.
Feedback on progress should be immediate … outcomes are important, but equally important is progress. Along these lines, if I take an action and don’t see progress instantaneously, it will be a deterrent. The opposite is also true. This was one of the challenges with our NPS scores. Our call center reps are taking dozens of calls a day. Over the course of a year, this translates to thousands of calls for each individual representative. A single good or bad score on a call isn’t enough to move the needle in a meaningful way so the opportunities for real-time positive or negative reinforcement are challenging. The more challenging real-time reinforcement becomes, the more difficult it becomes to successfully engage the participant.
The reward needs to be personally meaningful … when I would ask the product sales reps why they liked the rewards points program, they told me that a check is impersonal. Not only that, they would look at the after-tax amount and, relative to their product commissions, it just wasn’t that exciting. When I would ask them how they valued the rewards points, they told me that those represented something else. They didn’t see a flat screen TV as $1,500. They saw it as a Christmas gift for a family member. It had a different personal and emotional value. It’s why I believe airline loyalty programs work. They create a sense of exclusivity, and exclusivity has emotional value.
Gamification in Healthcare
As I mentioned at the outset, I believe gamification can play a role in healthcare and especially in the management of certain chronic diseases. Obviously, with chronic disease, clinical outcomes are of vital importance. Maybe it’s your weight, your blood sugar levels, your blood pressure, your lung function or, your heartbeat. In several chronic diseases, because of the explosion of sensor technology, outcomes can be measured and tracked easily and regularly – a digital scale, a glucose sensor, a non-invasive blood pressure cuff, a spirometer or even your phone to measure the electrical activity of the heart. In addition, managing these outcomes is tied to some basic concepts – medication management, nutrition, exercise and sleep. These things can also be tracked and measured regularly. Because of this, all the elements to gamify the management of certain diseases exist. I will offer an illustrative example.
Chronic Obstructive Pulmonary Disorder (COPD) refers to a group of disease that cause airflow blockages and breathing difficulties. COPD is a chronic disease and, left untreated, can cause an individual’s lung function to deteriorate over time. You can measure lung function every day through a spirometer or a peak-flow meter. These devices can be obtained for the home and range from less sophisticated manual devices to digital, Bluetooth enabled products that connect directly to your smartphone. There is no cure for COPD, but it can be treated. The goal with COPD management is to ensure that lung function does not deteriorate. This is where a potential gamification opportunity could exist. By measuring the lung function regularly, it is possible to assign points for the daily FEV1 (the measure of how much air a person can force from their lungs in one second) values or peak flow scores. The higher the values, the more points a person would accumulate. As the patient uses the device more regularly, data could be accumulated to perhaps provide actionable insights to help a person understand what actions could further improve lung function. Predictive analytics could alert a patient on whether lung function – based on trends – is moving in the right direction or not. Accumulated points could then be redeemed in an on-line store for any products that promote a healthy lifestyle. Partnerships could be considered with health insurance companies so that the points could be used in health savings accounts, to lower deductibles or off-set co-pays. Alliances could be established with local pharmacies so that additional points are earned if a patient gets a flu shot, to help prevent a potential respiratory issue. Communities could be created so that patients could connect, share strategies on how to manage their disease, etc. In addition, routine challenges could be established that promote healthy behavior – for example, a 30-day challenge to encourage a patient to walk, engage in other physical activity, or perform therapeutic breathing exercises.
What I have laid out is intended to be illustrative only. Is it for everyone? No. Will it ensure someone with COPD quits smoking or takes their prescribed medication? Of course not. It also requires broad engagement from multiple stakeholders. In addition, a program like this would need to engage clinicians and behavioral psychologists, at a minimum, to ensure it was structured properly and effectively. However, despite these challenges a well-structured program may provide the incentives required to motivate certain patients to act on behalf of their own health. Gamification is not a silver bullet, rather another arrow in the quiver to help combat chronic disease. COPD may not even be the best place to start, but hopefully this example provides at least a mental model as to how gamification for chronic disease management could potentially work.
Gamification can play a very interesting role in the management of certain chronic diseases. If structured properly, it could help motivate a patient to better understand their disease, how to effectively treat it and, most importantly, empower them to take proactive steps to drive better outcomes. When coupled with topics we’ve discussed in previous articles namely, decision support and predictive analytics, gamification has the potential to become another weapon in the healthcare system’s arsenal to improve outcomes, lower cost and promote patient satisfaction.
Afterword:
Please do not confuse the gamification concepts presented here with your company’s employee wellness program. There are a number of fundamental differences between an employee wellness program and gamification. First, what wellness programs intend to solve for is the company’s healthcare costs and health related absenteeism. Gamification puts the patient at the center and in control. Also, since employee wellness programs are a corporate program, they typically need to be offered to all employees, therefore the elements of the program are often generic. Gamification in healthcare needs to be disease specific. In addition, the “incentives” within a wellness program can vary. They may include “carrots”, such as reimbursing an individual for a health club membership. This is well-intended, but there is no guarantee this is how an individual wants to go about improving their health. In other cases, they may include “sticks”, such as penalties for non-participation, which is a terrible way to create emotional buy-in.
