#GottaCureEmAll – Pokemon GO teaches healthcare a big lesson
August 1, 2016 § 18 Comments
If we can believe what we are seeing, Pokemon GO is the world’s most effective, and most widespread, population weight loss intervention. Already, its users spend more time on the game than on other wildly popular mainstream social media platforms like Facebook, Snapchat and Twitter. Over the space of a few weeks, it has prompted millions of children and teens to get off the couch, turn off Netflix, leave the laptop in their bedroom, and walk out into the world to breath the fresh air. More than a few adults have done the same.
Healthcare should pay attention. While healthcare researchers are slowly coming to grips with ‘new’ ideas like gamification and social media to defeat obesity, the game industry has jumped the queue and may have already done it. Silicon valley has drawn down on its deep well of expertise in building large and complex software systems, and in embedding such systems into the real world. They have drawn on their deep experience with and understanding of the psychology of online social media, of what makes games ‘fun’, and what makes them ‘sticky’.
I doubt if Niantic, the Pokemon company, looked to randomized clinical trials to design and implement their system. The world of software moves too fast for that. It has an engineering culture of fail early, fail often. And because of that, it has as much right as scientists to claim that it is driven by experimentation and data, or as the philosopher Karl Popper would have said, conjecture and refutation.
For those who have not been drawn in to the world of Pokemon Go, it may be hard to understand what the fuss is all about. It is just another time-wasting, obsession inducing computer game. Yes it is interesting that it uses augmented reality and your physical location as part of the gameplay, but so what? People just walk around collecting different characters, oblivious to what is happening around them. The end result is a different kind of walking screen-time zombie, with the added risk of walking into the traffic or driving into a wall as you play the game.
There is another way to look at it. Firstly, irrespective of the game ‘medium’, the real world ‘message’ is that people are more than happy to exercise, and to engage with others in the real world, with the right motivation. For younger generations who have grown up in a world that is digitally augmented, the digital-social complex is the way to access their lives. Jogging with a fitbit is probably compelling for those who already run or are motivated to exercise. Pokemon GO does something more miraculous. It causes the Lazarus generation to rise up, and to move.
Pokemon GO makes walking the basic currency of the game. If you chance upon the eggs of Pokemon creatures, the only way to make them hatch is to walk a prescribed distance. Some eggs require 10k of nurturing before they crack. If you want to catch different Pokemon (and if you are a player, you #gottaacatchemall), then you will find spawning grounds in parks and open spaces. If you want to top up the items you need to catch Pokemon, then you have to walk from one Pokestop to another.
One of things that appears to make gambling ‘sticky’ is the uncertainty of reward. Each rare win reinforces the desire to keep trying for a bigger future reward. Pokemon GO has an interesting strategy of combining certainty in reward (eggs hatch after a defined distance is walked) with uncertainty (creatures appear unpredictably, and their behavior and value is unpredictable). As you progress in the game the rewards increase along with your status. Our brains are washed in an addictive dopamine broth with every reward, every step forward.
Pokemon GO also strives for social equity. When a creature appears in a given location, anyone who is there can see it and catch their copy of it. This means that there is real value in finding stronger players than yourself, because they will trigger the arrival of rarer creatures. These stronger players are also likely to have set lures to attract creatures, and the benefit of these lures is also socialized. Stronger players will have obtained their status by walking great distances, and so a sort of social modeling probably takes place influencing the behavior of newer players, further reinforcing the culture of movement.
Mass and spontaneous social congregation is an unexpected side-effect. Reports of many thousands of people all rapidly congregating in parks as rare creatures appear have been repeatedly reported. It is a sociologically fascinating emergent property of the game. It can also drive the locals crazy, blocking roads, and keeping people awake, as crowds chase the different creatures that appear at night. How wonderful if healthcare could trigger the same mass interest, with thousands queuing when Zika vaccination becomes available? Indeed, how can we mobilize such mass response for all sorts of health prevention activities?
The early uses of Pokemon GO in healthcare are examples of simple adoption. Placing Pokestops in the wards and surrounds of a children’s ward provides distraction and joy to hospitalized children who may be in dire need of fun. There are also of course the usual reactionary demands that the game be banned from clinical spaces .
Social media has already taught us a lot about how to deliver health services in new ways. The great potential for augmented reality in healthcare is yet to be tapped . Pokemon GO can teach us even more. We must learn to be more nimble and agile in the way we develop interventions to change behavior and deliver health services. The engineering worldview has much to offer, and it shares the same DNA of scientific reasoning so embedded in modern healthcare research. We are entering a time when more and more of the population will be embedded in an online social web, and that will be the universe in which we must engage with them, and where healthcare is delivered. And we must embrace that future, because in the end, we #GottaCureEmAll.
The Guide to Health Informatics 3rd Edition 
Enrico, what a great posting and I love this comment. “One of things that appears to make gambling ‘sticky’ is the uncertainty of reward. Each rare win reinforces the desire to keep trying for a bigger future reward”.
Enrico, Your wonderful post ignored the advantages of current EHRs on physicians’ heart health. Where ever physicians are obliged to use EHRs they benefit from significant increases in heart beats and cortisol production. Clearly this has important health effects.
Enrico, I think you are grossly mistaken about the randomized controlled trials. All of the most powerful websites use RCTs all the time. They call it A/B testing. They’ve gotten so advanced that they use all sorts of sophisticated statistical inference tools. You can literally purchase tools that will help you with ‘conversion rate optimization’. Check it out. Shocking.
Hi Karim.
You are exactly describing what the blog talks about. Industry indeed is using both rapid testing to evolve design, as well as harnessing data from users to conduct mini trials. I would argue that you perhaps are using the term ‘RCT’ too loosely when you included A/B testing under that category.
Many of us are actively looking at the use of observational data (what you call A/B testing) for clinical decision support, but this is quite controversial amongst the ‘pure’ RCT community. They would say that there are too many uncontrolled confounders in such studies, and that even though you can statistically correct for the confounders that affect A/B comparisons, you cannot avoid all the risks of bias that are associated with subject recruitment and randomisation methods.
Here are some papers from my team that explore these issues in more depth:
http://www.futuremedicine.com/doi/full/10.2217/cer.15.12
http://www.futuremedicine.com/doi/abs/10.2217/cer.13.65?journalCode=cer
Thanks Enrico,
A/B testing, done correctly, is not an observational design. It is an experimental design in an analytic study. The purpose of A/B testing is to create a predictive model, not a statistical model.
https://www.amazon.com/Quality-Improvement-Through-Planned-Experimentation/dp/0071759662
Karim
Karim Keshavjee MD, MBA, CCFP, CPHIMS CEO, InfoClin Inc
C: 647-405-9756 E: karim@infoclin.ca W: http://www.infoclin.ca
On Tue, Aug 2, 2016 at 12:18 AM, The Guide to Health Informatics 3rd Editi
We may have to agree to disagree on this particular point. With observational data over time, its easy to use one period for training and the following for test purposes, and build predictive models. Indeed that’s the point of the Green Button paper I mentioned in the previous post.
I’m pretty sure that if they’d provide 30 million to develop is behavior change intervention (http://gamerant.com/pokemon-go-30-million-dollar-investment/), we’d build smth better, simply because we have different goals; physical activity is currently a side-product, the app doesn’t aim to optimize physical activity. Also, the physical activity people are getting isn’t very ‘moderately vigorous’; given the evidence, this is one of the issues we’d grapple with a behavior change scientists (i.e. is it ethically acceptable to settle for sub-optimal behaviors?).
In that respecty: unlike Niantic, we’d also not accept money from McDonalds to lure users into a McDonalds 🙂
The problem isn’t that we don’t use gamification; I was already developing a gamification intervention 10 years ago (and this wasn’t anything special even back then). The problem is that back then, because we barely have funds, we had to make do with two students as developers, instead of a million-dollar studio. And this is still the case. It’s hard to even get one million for a behavior change project; and then you still have to do your determinant studies etc to figure out the dynamics of the behavior to influence.
So I think this is mainly the problem; not a differential focus or a negative effect of scientific rigour, but simple funding.
Also, aren’t you a bit optimistic about how users do it all by /walking/. Don’t a lot of people simply drive around or use public transport and get out when they get close?
All good points.
My no of 1 experiment shows that driving does not register as walking. (Maybe driving very slowly would).
As to funding you are completely right. Industry can quickly amass lots of $ to develop a product, whilst we researchers must patiently and often futilely await grant funding.
It is also the case in my experience that new ideas that would quickly excite a software house or venture capitalist, are considered radical and unfundable by conservative grant panels.
I think my point, especially with the many lifestyle/behaviour change RCTs I read, is that we would do well to spend some of the very expensive RCT money on more iterative design and testing of interventions, which might be a faster and cheaper way to get to a place where an RCT might make sense. Some research group completely get the design/engineering paradigm (especially I must say In Europe), but many others see the build as a bit of user feedback, a prototype, and then the RCT.
If I can summarise what I want to say it is
1/ Pokemon GO is an example of a class of very engaging, population wide intervention, and we have not seen its like before (in terms of uptake and engagement – I agree that the game elements individually are not new, but they are surely finely honed). We would be unwise to dismiss any lessons that it can teach us. It all gets even more interesting when we ditch the phones and start wearing mass market AR head gear like Google Glass.
2/ Not everything about Pokemon GO is great (McDonalds sponsorship etc), and it surely in time will be replaced by a geolocated AR Harry Potter world, or something else. It is a mistake to dismiss the entire general class lesson because of specific concerns about the first exemplar.
I would love for the scientific world to take back the technology innovation lead. How we do that is an open question for health behaviour change, at least in my view. But I’m clearly controversial with this one.
Very right. Science is moving too slow, and funding is always an issue. My feeling is that when the game industry develops an intervention, it is more likely to exist for a longer period than an intervention developed by scientists. For starters because they have more money, but secondly because industry wants to *make money* so they’ll be sure that it’ll be a success! Also, if science wants to keep up with the industry they have to change this “if it’s not an RCT it’s not good enough” attitude. Before we know if funders might fund the game industry instead because it yields faster and better results!
This is a wonderful discussion keep it going
From the naivety of a clinician and minor academic I garnered these thoughts from the Pokémon discussions yesterday.
They solved and interoperability and presumably the standardisation problems
They solved a UI adaptability problem
They obviously solved many of the “if it is not (clinically) useful it will not be used” problems
I had reservations about sustainability -limited domain
Here is a terrific commentary from public health folks at Johns Hopkins covering similar territory to this blog. Well worth a read
http://www.globalhealthnow.org/news/pok-mon-go-pandemic-or-prescription-the-public-health-perspective
Great to see that Enroico’s post has generated such interest. From my perspective there must be something in the the use of interactive digital experiences, games if you like, for health. We have after all a new(ish) journal, Games for Health, that is exploring the topic.
Such technologies integrate a number of fundamental elements that humans find engaging over the long term for both entertainment and education: narrative and storytelling, art and creativity, playful exploration of the world, the rules that we wrap around play gives us games and competition wrapped around play gives us sport. All of these elements are deeply engaging yet so rarely used in health behaviour change interventions. Integrating all of these elements via interactive digital technologies (like Ingress/Pokemon GO) that we carry with us on a regular basis, may be a mechanism by which we will be able to ‘disrupt’ (in the Christensen sense) health research.
Our standard approach to health and medical research; expensive, short-term RCTs where pre-defined interventions are rolled out to relatively small numbers of participants, has been a wonderful way of trying to understand health and wellbeing from a systematic, well controlled perspective.
However, we now have at our disposal digital tools which could enable us to deliver and acquire vastly more informative datasets about population health and wellbeing. Think about the opportunities of Apple’s Health and Research Kits for data acquisition in the pockets of hundreds of millions of people. Already we are seeing initiatives like the UCSF health eHeart, and now health ePeople, studies which are leveraging these kinds of technologies.
From my perspective, the evidence base around the impact of exercise and good nutrition is screamingly clear. We’ve known the benefits of both for decades yet engaging the population in large scale, sustainable healthy behaviours/health behaviour change seems elusive. Games, and the kinds of technologies we carry with us, or which are unobtrusive in the environments through which we walk, run and play, might just be a vehicle for making significant inroads into our ability to translate the evidence base.
I take the point of one commentator that games are $$ to develop but counter with the fact that the Australian Government is looking to universities and research institutes to innovate in the way that they think about translating fundamental and pure research into policy and practice and to partner up with industry. I think there is significant opportunity to not only build the evidence base around the impact of games on health, but also to develop a knowledge economy industry on the topic. It is certainly something those of us in the Games for Health community in Australia are working towards.
Am open to continuing the discussion on how we might access funding to run the research projects. Also want to give a heads up that I’m looking to build the games for health development capability in Australia, in particular looking to kick start this in regional areas like Coffs Harbour where I am now based at Southern Cross University.
Contact details below if you are interested
Stuart Smith, PhD, MSc
Professor & Business Development Coordinator
Coffs Harbour Campus
Southern Cross University
Hogbin Drive, Coffs Harbour N.S.W. 2450
T: +61 2 6659 3352 | M: 0437 470 256 | E: Stuart.Smith@scu.edu.au | W: scu.edu.au
Twitter: @StuSmith2454
Stuart, this is my response to your comment, “From my perspective, the evidence base around the impact of exercise and good nutrition is screamingly clear”.
There are many positive impacts of exercise most of which have been documented by Coiera and Labrique and they also note exercise programs have very little benefit on weight reduction (BMI).
For those trying to lose weight.
Exercise as a weight loss strategy – directly associated with education and inversely associated with age and body mass index.
55% used exercise as a weight loss strategy alone
58% of these eat fewer calories.
Those using exercise as a weight loss strategy,
57% met minimal 1998 N I Health recommendation of ≥150 min•wk-1
46% met lower end of the 2001 Am. Coll. of Sports Medicine of 200 min•wk-1
30% met the upper end for 300 min•wk-1.
19% met the 2002 Institute of Medicine recommendation of 420 min•wk
Conclusions: Despite the importance of physical activity in a weight loss program, only about half of the persons trying to lose weight reported using exercise. Even among those, only slightly more than half met the minimal recommendations for physical activity.
Exercise/ physical work as a human activity makes us hungry! So what dietary options are available? I think Schlosser documents this well.
“The Golden Arches,” Schlosser says, “are now more widely recognized than the Christian cross.” Of course, McDonald’s isn’t alone. “The whole experience of buying fast food,” he writes, “has become so routine, so thoroughly unexceptional and mundane, that it is now taken for granted, like brushing your teeth or stopping for a red light.”
At the very least, Schlosser makes it hard to go on eating fast food in blissful ignorance. But in a larger sense, what “Fast Food Nation” criticizes is the very free-market enthusiasm that has made heroes of the burger fans Bill Gates and Warren Buffett, the latter of whom has famously been a major McDonald’s shareholder. Here is another side of the unfettered money culture that has been celebrated as an exciting orgy of entrepreneurialism and opportunity. At one point, Schlosser quotes a scientist who specializes in food safety. This man is discussing the meat industry’s reluctance to perform certain tests on its products, but he could be talking about almost any of the questions Schlosser raises about the fast-food business — or, come to think of it, about the culture that takes that business for granted. “If you don’t know about a problem,” the man observes, “then you don’t have to deal with it.”
Fast Food Nation: The Dark Side of the All-American Meal
By Eric Schlosser (Houghton Mifflin) NYT Book Review 21 Jan 2001
Is there a consent process for PokemonGo? It will need to address benefits of the procedure (eg. walking, vitamin D etc) and the risks (walking in front of cars and off cliffs, being verbally abused for not watching where you are going). I look forward to the first class action from a group of lawyers for failure to advise….
Actually, being a US company, Niantic seems to have that covered. You are explicitly warned ever time you log on to not drive, not trespass, not go out to dangerous locations alone, pay attention to your surroundings etc. I think they have lawyers …
[…] Coiera, esperto in informatica medica, parla sul suo sito di Pokemon Go e delle implicazioni per chi si occupa di sanità elettronica: mentre un crescente numero di ricercatori si occupano di introdurre elementi di gioco in app per […]
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