Playing Games: Adopting Game-Based Strategies Can Improve Engagement and Outcomes

Games aren't just for fun anymore—research has shown that incorporating game-based strategies into patient outreach or physician training and education cannot only improve engagement, it can also lead to better outcomes.

"I see games and gamification being adopted more widely than ever before on both the patient side and the health care worker side," says Karl Kapp, EdD, professor of instructional technology at Bloomsburg University and the author of The Gamification of Learning and Instruction. 

On the health care professional side of the equation, Dr Kapp says he's seen more medical schools adopting game-based strategies to improve education and retention of knowledge, even if it's something as simple as digital flashcards where students get points for correct answers. There's also been a "big explosion" in the use of serious games in health care that operate similarly to simulations; however, participants may be timed or get points for successfully completing aspects of the game that are designed to mimic real-world situations.

There has also been an increase in the use of games or game-based strategies aimed at patients themselves, whether it's to improve patient engagement or to promote behavior change.

"One of the hardest things with patients of course is to incentivize them to stay on the medical protocol," Dr Kapp says. "So, one of the things that some organizations have starting doing is gamify the medical protocol, so we've seen things like gamified inhalers to teach people how to properly align the inhaler. There's a game to teach kids about cancer called ReMission." 

But while game-based strategies have been found to improve outcomes for both patients and health care providers alike, success isn't guaranteed just because there's a game involved. There are several key components to consider as payers and providers decide whether adopting game-based learning is the best strategy for them.

“Gamification” vs Just “a Game”

“Gamification” is a term that has garnered a lot of attention in health care, but just what does it mean and how does it differ from a game itself? 

Dr Kapp describes gamification as something that takes game elements and incorporates them into something else. For example, maybe patients are sent a reminder to take their medication each day and, if they record that they've taken it, they get points or badges.

"So, it's a continual use of game elements to influence behavior," he says. 

He believes there can be 2 types of gamification: structural or content. Structural gamification is simply putting a game structure around regular instruction or recommendations—possibly logging into a diabetes website and tracking food to earn points. 

With content gamification, the content is changed to be more game-like. So, for instance, a fitness challenge may be presented as a mission to run 3 blocks in an attempt to escape zombies.

A game, however, is a self-contained entity that you play for a very defined period of time. 

"It's designed to be a game, so you know it's a game environment, it's not masking as something else," Dr Kapp says.

Both gamification and game strategies are used in health care.

Why Use Games?

One of the most significant reasons to incorporate games into teaching and education strategies is that they've been shown to produce results. 

A comprehensive review published in 2014 by Francesco Ricciardi and Lucio Tommaso De Paolis in International Journal of Computer Games Technology examined the role serious games have had on the health care industry and concluded that games can act as a useful tool in education and skill development. 

"Studies demonstrate that users who practiced a serious game training have better results than users experiencing traditional learning processes," the authors wrote. 

In addition, a recent study into the use of a mobile game designed to reinforce dermoscopy proficiency among clinicians at the University of Lyon 1 in France found that using the mobile game improved dermoscopy proficiency from a baseline of 66% to 94% among clinicians in a few weeks.

The mobile game was based on a medical education platform designed by Qstream to improve clinical skills among clinicians by using knowledge and data. 

Under the platform, participants receive specially designed questions or scenarios on their mobile devices that they can answer at their convenience, whether it's between rounds or in line at the coffee shop.

"They can take it in just minutes a day," says Mary Hallice, the health care practice lead at Qstream. 

Customers are able to design their own content and customize how frequently clinicians receive questions, how many times they need to answer a question correctly to signal mastery, or when they should receive questions that were answered incorrectly again. 

The game-like design of the platform, which Hallice describes as game-based learning rather than gamification, has produced high levels of engagement, often over 90%.

"We're seeing very high levels of engagement come from game mechanics, but behavior change comes from the methodology of scenario-based challenge repetition," Hallice says.

Alpesh Amin, MD, MBA, MACP, SFHM, FACC, the Thomas and Mary Cesario Endowed Chair of the Department of Medicine at the University of California, Irvine, says the university is using Qstream for its residents and medical students as a way to improve learning in the area of quality improvement.

He says the platform has allowed staff to test students’ and residents’ knowledge and reinforce principles. One benefit is that it can be done at the participant's convenience. 

Dr Amin, who also serves as executive director of the hospitalist program at University of California, Irvine, says he is also able to easily assess who has answered the questions and who has gotten the correct answers. The platform even offers a way to compare individual results against one another to increase competition and engagement among staff.

"It's a different methodology than sitting in a classroom and having to learn and then taking a quiz or a test," he says.

Dr Kapp says other advantages to game-based strategies are that they can allow people to explore consequences in a safe environment. 

"People learn a lot from failures. We learn more from our failures than we do from our successes, so a game lets us fail safely, learn from that, and then correct our mistakes," he says.

Games also typically give corrective feedback during the process and may offer a visual form of mastery. 

They also offer clinicians an opportunity to replay a scenario over and over until he or she gets it right. 

Gamification, specifically, doles out information slowly over time, which can help reinforce knowledge or behaviors. 

Obstacles to Success

Games or game-based strategies can help improve engagement and may also lead to a higher level of mastery of clinical skills, but a game in itself doesn't guarantee a positive outcome. 

Dr Kapp says while many people want to create games where the participant doesn't realize he or she is learning while playing the game, it isn't the most effective way to achieve success. 

"The research is pretty clear that is not a good way to use game for instruction," he says. "In fact, the best way to use a game for instruction is to tell the learners the content they are going to be learning or experiencing in the game, have them play the game, and then debrief the game." 

He says a common mistake is failing to debrief participants after the game.

"Without that reflection people are really just playing a game, so you really need to have them reflect on it," he says.

Another obstacle, particularly for gamification, is too heavy of a reliance on external rewards and a failure to tie the intrinsic rewards in real life with the extrinsic rewards received in a game. 

"The reason why we are gamifying the drug protocol is not so that you get on the leader board, it's maybe to give you a better quality of life or save your life. That link needs to be explicitly clear," Dr Kapp says.

He says if that link isn't made clear, eventually the external motivation will expire and participants will lose interest and motivation. 

In gamification, he also says the novelty can wear off if aspects of the activity or platform aren't changed about every 90 days. 

Finally, he says that games should be designed to address specific goals and should focus on fostering engagement, rather than simply being fun. 

"The reasons why we are using elements of games is not because they are fun, but because those elements are engaging and we know that engaged people learn more, they have a higher likelihood of changing behavior," he says. "We have a higher likelihood of influencing them if we use engaging techniques." 

Dr Amin also says while he's found that using mobile games to quiz residents and medical students on their knowledge improves efficiency from an educational standpoint, adding convenience, and improving engagement, it still requires time in a student’s or resident's day, which is often already scarce. 

He says that while the methodology is an advantage from an educator’s standpoint, it could just signal an added responsibility to some who are already overworked.

"From the user's standpoint, it really depends on all the other stuff that's going on in his or her environment," he says.