As videogames have become mainstream and emerged from the dimly-lit arcade rooms of years past, gaming technology has found increasing application in medical training, pain management, rehab, and digital therapeutics.
On Justin Barad’s office desk in San Francisco sits an old floppy disk copy of Life and Death. It was a 1988 computer game that put players in the role of an abdominal surgeon tasked with diagnosing and treating a variety of conditions ranging from kidney stones to appendicitis.
The primitive pixel-based graphics are a far cry from the top tier videogames of today. But the disk acts as both a reminder of his previous career aspirations of being a game developer, as well as his current passion of merging the seemingly disparate fields of gaming and healthcare.
Barad himself found his own way into the medical field as an orthopedic surgeon and eventually as an entrepreneur and co-founder of his own startup. As CEO of Osso VR, Barad and his team (many from the videogame industry) have developed a virtual reality-based training tool for surgeons. The company has raised around $3 million in funding and works with top medical schools like Vanderbilt University, Harvard University, and UCLA.
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Osso VR is part a new generation of companies that aim to apply the visually appealing and immersive qualities of the gaming industry into the very serious business of healthcare.
“If we want to change the perception of healthcare past something that’s old-fashioned and archaic, we should take the best technology in other fields and use it to push the limits of what’s possible in healthcare,” said Barad in a recent interview.
For example, the multimillion-dollar Auris Health Monarch surgical platform utilizes controllers that wouldn’t feel out of place in front of an Xbox or Playstation.
Medical videogame company Level Ex has built a mobile-based gaming platform meant to act as an engaging training tool for physicians. The Chicago company has developed educational gaming modules across different specialties like pulmonology, anesthesiology and cardiology.
Dr. Atman Shah, an interventional cardiologist at the University of Chicago, served as technical advisor to Level Ex for the development of their cardiology application, which challenges players to perform procedures like securing dissociated stents and treating cardiac perforations.
“There’s already plenty of simulations out there to show people how to put an IV in, but what I think a lot of people want to do with these games is actually challenge themselves,” Shah said. “We can’t take certain risks with patients, but intrinsic to a game is the ability to push ourselves outside of a comfort zone and break our own internal barriers.”
Eventually, Shah said he sees the potential of medical gaming technology to become even more realistic through the incorporation of additional patient information and context.
“Fun is underrated in medicine,” Shah said, pointing to the ability of videogames to build social interactions and encourage friendly competition and knowledge sharing among specialists.
There is no straight line connecting advancement of gaming technology and its growing role in healthcare. But as videogames themselves have become mainstream and emerged from the dimly–lit arcade rooms of years past, gaming technology has found increasing application in medical training, pain management, rehab, and digital therapeutics.
One person who has witnessed this evolution is Noah Falstein.
Now the owner of his own design and consulting firm — The Inspiracy — Falstein was an early employee at legendary game development firms like LucasArts Entertainment and Dreamworks Interactive.
A throughline in his career — from the doldrums of the 1990s to the present-day enthusiasm around video games as a potential neuro-therapeutic — has been working in the “serious games” category.
During his tenure as Google’s chief game designer from 2013 to 2017, Falstein started to see a renewed interest and funding in the games for health field and determined it was the right time to jump back in.
“People working in this field were basically working off grants or research projects which were only up to a few hundred thousand dollars,” Falstein said. “Suddenly, just in the last three or four years, I started to see tens of millions, even hundreds of millions of dollars being invested. And that was a signal to me that the rest of the world had finally kind of caught up.”
Falstein currently serves as an advisor to Mindmaze and Akili Interactive — two companies at the forefront of applying gaming technology in the clinical space. The companies have raised $110 million and $140 million, respectively.
Back to the beginnings
In order to trace where video games in healthcare may be going, it may be useful to examine some of the initial challenges faced in merging the two disciplines.
Many of the early experiments focused on interactive gaming experiences to improve nutrition and fitness. Falstein recalls an NIH-funded game he worked on called Hungry Red Planet that put players in the role of the leader of a Mars expedition to teach them about proper eating and creating a self-sustaining community.
The game failed to gain commercial traction partly because there was not enough money to effectively market and distribute the game. Additionally, the food pyramid government standards around nutrition were changed soon after the game’s release.
This issue of finding an effective route for commercialization mirrored the experience of Richard Buday. Buday is the founder of Houston, Texas-based design firm Archimage, which developed games for health for two decades.
He recalled that in his early days in the industry the term “videogames” was explicitly avoided.
“They didn’t call them videogames back then because it was not politically correct and would have problems getting funded,” Buday said. “The name we used for them were computer-based interventions.”
Those perception issues were compounded by the cultural disconnect between developers and healthcare professionals.
“You’ve got the research community which is very science and evidence-based and you’ve got the development community which is heavy into fiction and interactive storytelling,” Buday said. “It was hard to get everyone on the same page. I remember one child psychiatrist saying ‘If we have to lock kids in a room and make them play the game, then that’s what we’ll do.’”
While the stigma around videogaming terminology subsequently started to wear off, developers like Archimage still faced significant hurdles in actually building a profitable commercial sales strategy. One major issue was the delay in going to market because of the grant application and allocation process, which was lengthened by the time it took to perform clinical validation experiments and publish results.
“For about seven years you’re frozen out of the commercial market and by the time you’re ready to go to market you have technology that’s eight years old and outdated,” Buday said. “That length of time was just a market killer.”
That was one major reason for Buday closing his design firm in 2016.
Outside of physical fitness and nutrition, one avenue explored by game developers was brain training applications to improve neurological and mental acuity. However, this field suffered from dubious scientific validation, even as brain training games like Brain Age sold millions of copies around the world.
In one infamous case, Lumos Labs – the company behind brain training program Lumosity – agreed to a $2 million settlement in 2016 with the FTC over unfounded claims that the game could help users perform better in their jobs and reduce or delay cognitive impairment associated with aging and Alzheimer’s disease.
A more positive milestone was the development of Re-Mission by the nonprofit Hope Lab Foundation. Known as the first multi-million dollar serious game, the Re-Mission put pediatric cancer patients in the role of a nanobot which could attack cancer cells.
A multi-center randomized trial found that the game led to more more consistent treatment adherence, faster rate of increase in cancer knowledge and faster rate of increase in self-efficacy in young cancer patients. Even so, the relative success of the game did not translate into a larger movement towards gaming in healthcare.
Forging another path
In recent years, the idea of gamification started to gain steam as digital health companies sought to introduce video game-esque reward systems and engagement tools in wellness and health products. Somewhat ironically the trend took off, even with scant research showing the effectiveness of purpose-built videogames as a lever for behavior change.
Falstein has decried the term “gamification” as “snake oil” and more marketing mumbo-jumbo than an actual effective introduction of gaming technology for health.
“There are some who feel that a quick fix like slapping on a high score table or giving people some reward badges means your product is gamified and will triple adherence,” Falstein said. “Not only will it not work long term, but the research shows that once you start to reward someone with external validation like that, as soon as you take the rewards away they stop doing it.”
To Falstein, the term acts as a catchall that covers up the difficulty of successfully merging the two fields of healthcare and gaming.
One clinically-validated company in the digital therapeutic gaming space taking that charge head on is Akili Interactive.
The Boston, Massachusetts-based startup is developing videogame-based digital therapeutics for neurological and behavioral disorders. The company’s lead product AKL-T01 is a videogame-based therapy for the treatment of pediatric ADHD and is currently under FDA review.
The company’s DNA appears to synthesize core characteristics of the two industries in equal measure.
“We are half medicine and half entertainment. So we made a strong choice and an explicit choice to bring an equal focus and resourcing and philosophy to the business from the gaming side,” Akili Interactive CEO Eddie Martucci said, in a recent phone interview.
In product decision meetings at Akili, research scientists sit alongside medical device executives and game designers in order to ensure that all divisions are duly represented. While Martucci built a company to respect and incorporate each discipline in the final product, he got scant credit for his efforts at first.
“In our initial conversations with investors or pharmaceutical companies we got laughs and we got used to people making really clever comments because it seemed like it was joke hour,” Martucci recalled.
However, a cultural shift has occurred lately.
“What has really changed for me is that the initial reaction bar has changed pretty dramatically to now where people think this can be a thing,” he said.
Martucci attributes it to changing attitudes of patient empowerment against status quo practices, as well as growing concern over issues of overprescription and side effects associated with traditional pharmacotherapy.
Gaming as medicine
Some of the foundational ideas around these therapies are not new. For instance, Falstein recalled his experience at East3, a short-lived company that tried to develop a consumer brainwave helmet before running headlong into an embezzling CFO and the dot-com crash.
What is new, however, is the approach of building clinical and regulatory validation of these neurotherapeutic claims as part of the existing healthcare system.
Companies successfully braving the scrutiny of the FDA approval process have attracted investors and traditional healthcare stakeholders by opening up a pathway towards commercialization, a barrier which stymied the industry in the past.
“Getting FDA clearance is a high end, very expensive process that takes years and millions of dollars. We’re just starting to see progress in the past couple years,” Falstein said. “Before that you couldn’t make claims and it was hard to get people excited when it just a kind of vague promise that the tool might be good for you.”
One company at the forefront of pushing this trendline forward has been Lausanne, Switzerland-based Mindmaze.
Mindmaze has earned FDA approval for its MindMotionPro and MindMotionGo products, which helps stroke patients though neurorehabilitation using VR and game-like training activities to rebuild neurological and motor function.
Understanding that the regulatory timelines shouldn’t hobble companies working in the digital health market where tech advances in leaps and bounds in the blink of an eye, FDA has has developed flexible and faster frameworks for clearance. In Akili’s case, while the company has kept its core algorithm consistent to ensure the same therapeutic effects for users, it has made sure to keep updating other features like graphics, rewards and challenges to keep the game in line with current trends and interests.
“It does no one any good if you develop a product that’s so stale it just sits on the shelf,” Martucci said. “I think you have to develop yourself, be adaptive, take market insights and listen to your patients. The worst thing we could do is slip into paternalistic medicine where we say ‘we built the thing five years ago but you know we know that’s what’s good for you.’”
Even with these early victories for the therapeutic gaming industry, there are many unanswered questions about how these sorts of digital medicine will be integrated into the healthcare system. And who will pay for them.
While readily admitting the challenges posed by those questions, Falstein remains optimistic about the industry’s ability to answer them, citing another another trait that videogames and healthcare have in common: continual evolution.
“One of the things I love as lifetime game developer is that the games industry is constantly reinventing itself and that’s part of what has kept me interested and attracted to it after all these years,” Falstein said. “The medical industry works much the same way and I love that aspect of medicine where you don’t stop learning and discovering.”
Date: May 29, 2019