The goal of SimStay was to prototype a game that utilized new media and mobile technology to improve the patient experience and health communication between healthcare providers and patients. Throughout the research phase of the project it became apparent that there is evidence that the use of gameplay within health communication shows great promise, but there has not been a game developed that was not focused on a specific condition or disease. The case studies used in the research were some of the best examples of health games, but SimStay was unique in a number of ways. SimStay was developed to address a wider variety of needs than simply patient education or behavioral modification. The main features of SimStay addressed healthcare communication by breaking it into components that were identified throughout the research as having the largest impact. These key components included patient feedback, patient empowerment, accessibility, and patient education. SimStay is a virtual hospital environment that allows patients to explore their hospital to improve the relationship between patients and providers, while promoting patients to take an active role in their treatments and care.
Throughout the game, patients are encouraged to participate in their care by engaging with their care providers. This encouragement is communicated through the use of friendly avatars that use conversational messaging to prime the patients to ask questions about their care. The messages used throughout the game are heavily influenced by health communication theories and the concept of “Interactive health communication” as outlined by Renata Schiavo in Health Communication: From Theory to Practice. Schiavo defines “Interactive health communication” as “the interaction of an individual-consumer, patient, caregiver, or professional – with or through an electronic device or communication technology to access or transmit health information or to receive guidance and support on a health-related issue” (Schiavo, 2007). Throughout the development of SimStay, the use of interactive health communication was based on Schiavo’s observation that “interactivity is considered more likely to influence a group to take action” (Schiavo, 2007). The challenge with effectively implementing these ideas in SimStay is that the game was not simply intended to address one specific condition or treatment, as is the goal of most health games. The success found in games such as “Re-mission,” which was created for adolescents and young adults battling cancer, is partially due to the fact that they were developed for a very specific patient population. SimStay is intended to appeal to the whole of a hospital’s patient population. This is the reason for the inclusion of the many different features of the game, which includes in-game virtual support groups, casual gameplay, interactive elements, hospital information, and patient education materials to name a few. Other health games are based on storylines in which the player is a character within the story of the game. SimStay does not use story in the traditional sense, but allows patients to create avatars within a virtual environment that act as a simulation for the patient.
The simulation of a hospital environment uses the approach of “gamification” to allow a patient to explore their hospital regardless of their medical condition. In a white paper published by Ayogo Health Inc., it was noted that there is “concrete evidence” that playful design will improve patient engagement and health outcomes (Fergusson, 2015). This idea of playful design is in essence the crux of SimStay. As opposed to using traditional forms of health communication, such as health information communicated through medical websites or patient focused literature, SimStay provides access to this information through a video game environment. The information is based on traditional patient educational resources, but allows a patient to explore the information through a fun interface.
In an effort to empower patients to play an active role in their care, elements such as support groups, hospital staff avatars, and easily accessible means of providing feedback within the game environment are presented. These features are based on approaches that are commonly found throughout a hospital, but are in most cases not accessible digitally, or through a singular platform. They are also developed so that they can be presented in a manner that is familiar to a patient. Where a patient might find a physical suggestion box on the wall of a hospital or on the desk of nursing station, these can be found throughout the SimStay environment. Patients can leave feedback through the virtual suggestion boxes, which are then routed via email to the appropriate hospital contact. The use of avatars serves as a source of information to patients by the use of visual identifiers and messaging that is specific to that hospital. As noted in The HCAHPS Handbook: Hardwire Your Hospital for Pay-for-Performance Success, the most patients make a mental assumption that a hospital employee wearing scrubs is either a nurse or doctor (Studer, Robinson, & Cook, 2010). By patients interacting with friendly avatars within the game, there is an opportunity for hospitals to help patients better understand the roles of different hospital employees. This simple form of communication is meant to provide patients with a better understanding that their care is provided by a team of medical specialists, and will encourage them to discuss the various aspects of their care with these specialists. The avatars communicate that all of the healthcare professionals are approachable and available to answer questions a patient might have. These elements address the problems that most hospitals have in that they are often unaware of the lack of communication until after the patient has been discharged, and find out through discharge phone calls or patient satisfaction surveys. By the time patients provide this feedback, it is too late for hospitals to respond and improve communication. Providing this information in an easily accessible and interactive environment will allow hospitals the ability to address these issues while the patient is still in the hospital, improving the patient experience.
Another means of empowering the patient is through the inclusion of online patient support groups. Research indicates that patients feel better prepared for medical consultations, more informed about their specific symptoms, treatments, and overall illness when they participate in online support groups (Bartlett, & Coulson, 2011). Research has also shown that online support groups provide enhanced social well being, improved confidence in their treatments, enhanced self-esteem, improved confidence in the relationship with their physician, and a slight increase in optimism and control over the future (Bartlett, & Coulson, 2011). Additional research notes that participants in online support groups can strengthen relationships, and that online support groups can increase the social interest and empathy of a participant (Hammond, 2015). Empathy and social interest are not just for the benefit of the patient, but are also highly important for healthcare providers. The importance of providers showing empathy to patients, and patients having confidence and trusting their providers is undeniable.
While support groups and education materials are large components of patient empowerment, they are not enough to ensure the participation of patients. This is the reason for the inclusion of features in SimStay that require less commitment from the patient. These features are simply meant to encourage patients to play the game. Casual games are included within the game environment, but require that the patient login to the game to access. Research has shown there are a number of health benefits to playing video games, which suggests that even if patients only use SimStay to access the casual video games, they will be exposed to these benefits (Fergusson, 2015).
While SimStay is intended to serve as a benefit to both patients and providers, it is developed with an awareness of the changing landscape of healthcare in the United States. As identified by Ivan Illich in his book Medical Nemesis: The Expropriation of Health, there have been a number of issues that have surfaced due to the “medicalization” of our society (Illich, 1975). This is to say that there is a public perception that the individual has been removed from the treatment process. Illich claimed, “better health care will depend, not on some new therapeutic standard, but on the level of willingness and competence to engage in self-care” (Illich, 1975). Illich’s work suggests that the improvement of healthcare will come through the empowerment of the individual. SimStay provides a simulated environment that places the control into the hands of the patient. While a patient may not feel comfortable questioning their provider during their treatment, SimStay encourages that a patient actively participate in their care. The question is whether this encouragement will have a strong enough impact on the patient that will change this perception.
Accessibility and privacy were also identified as playing an important role in the development of SimStay. Accessibility is an issue that is difficult to address due to a number of layers that limit accessibility to both quality resources and care. SimStay is able to address two of the issues regarding accessibility, one in that not all patients speak English as a first language. This is addressed through the inclusion of the top four languages spoken in the United States as a setting option within the game. It is proposed that if SimStay were implemented in a hospital, an evaluation of the patient population would be evaluated to determine if additional languages were necessary to best serve that facility’s patients. The second issue is related to the gap in communication due to providers often using medical jargon and clinical terminology when speaking with a patient. This is an issue, because as noted by Illich, individuals have been conditioned to view the physician or medical professional as those with the ability to heal. SimStay uses character messaging to encourage that a patient becomes involved, but also provides layered communication to provide patient education. The top layer of information is provided through layman’s terms and allows for a general overview of the healthcare system. For example, the employee avatars can explain their roles and responsibilities in the hospital. As a player begins to further explore the game, they are able to access information that is more technical and clinical if they are interested. They are also provided with a way to access their electronic health record and more detailed and clinical health information if they want to learn more about their condition or treatment. While it is not expected that they understand the clinical elements, they will be encouraged to ask their provider for further explanation regarding areas of their care that they do not understand. This benefits the patient in accessing information, but will also identify areas that a provider can improve their communication. This is a component that would need to be evaluated throughout the implementation of SimStay to determine its effectiveness, and would likely need to be refined over time. In regards to privacy, SimStay would only be accessible on the hospital’s closed network, and would not store patient information. Appropriate hospital employees would be able to see which elements of SimStay are most used, but they would not be able to see which patients were using the features. They would also not be given a patient’s information when a patient submits feedback, unless the patient willingly provides this information. Hopefully this would encourage patients to leave honest feedback, whether positive or negative. Hospitals have significant incentive to improve the quality of care they provide to patients, and honest feedback and suggestions are the best opportunity to improve their policies and procedures.
Fully developing this game would require significant work, and the end result would not only need to be aesthetically pleasing, but would require detailed user testing on both the patient facing side and also the back end content management system. The goal of the game is to be intuitive and simple for a patient to play without complicated instruction. For providers, the back end of the game would need to be easily updated to ensure that information is current and accessible. The suggestion for this is that each feature would be modular and accessible to trained hospital employees with a stake in quality improvement and operations. While the features and game mechanics would require a development team, it would be necessary that inline text editors be used to update in game content. This project provided a conceptual prototype for a product that has well researched potential benefits for both patients and healthcare providers. A fully functioning prototype would be difficult to develop, but I have strong confidence in the possibility that SimStay could be developed and effectively implemented.
Bartlett, Y. K., & Coulson, N. S. (2011). An investigation into the empowerment effects of using online support groups and his this affects health professional/patient communication. Patient Education and Counseling, 83, 113-119.
Fergusson, M. (2015). Designing Digital Tools for Patient Engagement (White paper). Ayogo Health Inc.
Hammond, H. (2015). Social Interest, Empathy, and Online Support Groups. The Journal of Individual Psychology, 71(2), 174-185.
Illich, I. (1975). Medical nemesis: The expropriation of health. New York: Pantheon Books.
Schiavo, R. (2007). Health communication: From theory to practice. San Francisco: Jossey-Bass.
Studer, Q., & Robinson, B. (2010). The HCAHPS handbook: Hardwire your hospital for pay-for-performance success. Gulf Breeze, FL: Fire Starter Pub.