The rise of gamification in healthcare

When I entered medical college, 57 years ago, we had pharmacy classes where we learnt to make mixtures, and stick properly-cut dose markers on medicine bottles. Over the next few decades, as practicing doctors, we learnt that medication could be delivered orally, under the skin, into a muscle, vein, artery, tumour, through all the orifices in the body and through sustained release and implanted depot preparations. Soon, perhaps, there may be smart digital pills with inbuilt sensors that will improve compliance and adherence.

Though interested in advances in healthcare, I had never anticipated that apps would become part of the therapeutic armamentarium. There are thousands of healthcare-related apps out there, with a rapid proliferation in apps prescribed for specific health conditions, similar to a specific medication.

Digital therapeutics

Digital therapeutics (DTx) is the term given to use of apps as a supplement or even replacement of conventional medications. The Digital Therapeutics Alliance (DTA), a global non-profit trade association, defines and manages DTx software programmes to prevent, manage and treat specific medical conditions. Apps are approved following evidence-based therapeutic interventions. Specific apps are used for the management of various NCDs, several neuropsychiatric conditions including anxiety disorder, depression, substance use, insomnia, Attention-deficit/hyperactivity disorder (ADHD) and others.

Apps address individual needs. DTx requires only consumer mobile devices such as smartphones and tablets. Most fall outside the ambit of the Food and Drug Administration (FDA), as FDA-regulated hardware is not required, and are commercially available. The European Union, Korea, Japan, and China are now introducing regulations to control and approve healthcare related apps.

DTx products are not medical devices: wellness apps do not need to meet Good Manufacturing Practices (GMP) criteria or provide evidence of safety and efficacy. The DTA has elaborated on how products should be made available to patients: direct-to-consumer, DTC; over the counter, OTC; or prescription. The medical requirements of DTx are (1) treating a disease (prescription), (2) management of a disease (OTC or prescription), and (3) improving health function (DTC, OTC, or prescription).

A clinician prescribing an app expects evidence that its use has bettered healthcare outcomes, even if the mechanism of action is totally different to that of a medicine. Apps may provide patients with new treatment options for unmet medical needs. They may work independently, complement other treatments, improve currently available treatments or reduce dependence on certain drugs or specific treatments. DTx can be customised and personalised, taking into consideration individual lifestyles. This could advance the ability to deliver the right therapy at the right time in the right amount directly to patients.

Gamification of medicine

The gamification business in the medical field is expected to grow exponentially. A scoping meta-analysis of published papers revealed that 80% of studies confirmed that improved patient engagement and motivation bettered health outcomes. Engagement, motivation, reminders, compliance and adherence improved with the offer of challenges and rewards. This led to better, more cost-effective health outcomes.

Improved self-management was demonstrated in diabetes, hypertension, obesity, cancer, stroke and coronary heart disease. Gamification promoted dietary changes, physical activity, medication adherence, symptom management and improvement in cognitive functions. Motivation was due to the availability of instant feedback, progress tracking, rewards for healthy behaviours and making prescribed activities more enjoyable, Games led to better understanding of one’s condition and treatment, leading to better decision-making and empowerment in disease management.Connecting to online communities with others having similar problems helped. Aligning goals with patient motivations and ensuring autonomy in achieving tailored goals is critical. Designing games to maintain long-term motivation without causing frustration or disengagement is a key challenge.

The use of apps

EndeavorOTC is the first FDA-authorised digital therapeutic app for ADHD. In a clinical study 73% of participants reported quality of life improvements, including completing projects on time, increased productivity and paying attention when interacting with others. This was after playing with the app, mobile video game, for six weeks, 70+ minutes a week. Paediatric patients with ADHD played the game at home for four weeks. This is the first prescription-required therapeutic app.

The MySugr app transforms diabetes tracking into a game, assigning challenges and rewards for logging data and managing blood sugar. It is particularly useful for young patients with Type 1 diabetes. Packy and Marlon is a game used in managing juvenile diabetes. A review found a 77% reduction in diabetes-associated emergency visits compared to non-players. The Re-Mission video game series allows children and young adults with cancer to control a nanobot fighting cancer cells. This let to better understanding and acceptance of the disease in children. Gamified interfaces like GameWheels turn wheelchairs into joysticks to video games. This motivates patients with serious injuries to achieve higher activity levels during rehabilitation. SuperBetter is an app helping users achieve self-improvement goals including weight loss and building resilience. Zamzee, an activity tracker uses quests and challenges to encourage movement.

The hackneyed phrase “ an apple a day keeps the doctor away” will perhaps eventually be replaced with “an app a day keeps the hospital away.”

(Dr. K. Ganapathy is a distinguished professor at The Tamil Nadu Dr. MGR Medical University and past president of the Neurological Society of India and the Telemedicine Society of India. drkganapathy@gmail.com)