I want to discuss something interesting that's making waves in healthcare – gamification. But let's not just view it as a trendy new tool for patient engagement. Instead, let's see it as a rich source of clinical information, transforming how we approach healthcare.

Let's begin with a bit of background. In healthcare, gamification means using game design principles in non-game situations to drive patient engagement, behavior change, and learning. Why? Because gamification isn't just about making healthcare fun, it's about making it effective. And, to tell the truth, it’s a huge market, valued approximately 5 billion $ only this year globally.

Take, for example, a healthcare app, where patients get rewards just for taking their meds on time. Besides the basics like tracking meds and getting reminders, users also earn points for sticking to their medication schedule. Additionally, they can earn badges for various achievements, such as adhering to the schedule for a consecutive month or sharing their progress with friends.

In the context of gamification I personally also like to discuss immersive experiences, telehealth and augmented reality. These technologies have the potential not only to enhance patient outcomes but also to transform the entire healthcare experience. For example:

In virtual environments people can connect for sessions, regardless of their location. They provide a private and secure space for participants to openly discuss their feelings and support each other. Good use cases are groups for:
- Chronic Illness Support
- Addiction Recovery
- Weight Loss
- Therapy for Trauma Survivors
- Etc.

Medical students can use augmented reality to explore and interact with detailed 3D models of the human body. Medical professionals locate veins for procedures like blood draws and IV insertions.

Incorporating Wellness Data

Now we need to connect the wellness data from your gamified and virtual experiences with your regular health records, like what your doctors and insurance companies keep. Why is this important? Well, patients want to have their wellness data as a part of their healthcare profile for a fuller picture of their health. It helps track how much they are involved in different activities and how it affects their health.

But it's not just for patients. Doctors and insurance companies also benefit. They can see how the coaching and group activities impact your overall wellness, which might mean you need less medication.

Let's imagine you've been feeling really down lately. You visit the hospital, and the doctor tells you that you have early stage diabetes. They give you medicine and say you have to eat only healthy food - no steaks, no alcohol, and no sugary snacks and drinks - for the rest of your life. But you're not ready to give up everything. You know you need to make some changes to your body, improve it, but you don't want to take medicine and follow this strict diet forever.

So, you search for a wellness app that suggests a different way. It offers personalised meal plans, helps you keep track of nutrients, reminds you to take your medicine, gives tips on staying active, provides useful information, and has a supportive community.

Fast forward six months, and you go back to your doctor. Tests show big improvements. Now, instead of taking medicine every day, it's just once a week. And finally, you can enjoy a nice steak. The doctor asks you what you did to get these results so they can give advice to others. You are showing them the app, scrolling through your historical data there, pointing to meal plans, physical activities, educational resources and so on. That's why linking your wellness data directly to clinical data is helpful. It means the doctor can use this information in many ways to improve your life and the lives of others.

Technical Challenges

I don't want to get too technical in this article especially without making sure there is enough background provided. So let's start by talking about one of the products we developed for our customer earlier this year. It'll help illustrate a common issue and give a good reason for the challenges we had to deal with.

The product was all about using gamification technologies and virtual worlds to serve a specific group - ethnic minority women aged 70 and older with diabetes. Studies have shown that group therapy, even when done online instead of in person, significantly improved the health of group members and reduced their dependence on medication to manage their condition.

The product essentially offered professional coaches for diabetes patients in a virtual world environment. It went beyond traditional coaching and group sessions to include activities like virtual aerobics and assessments. A key part of the process was the ability for individuals to adjust their avatars in the virtual world. Users could create avatars based on their physical appearance using our software or design avatars that reflected how they saw themselves. This allowed them to change their avatars based on their self-perception over time and share this with others.

Within the virtual world, there were video players, whiteboards and other interactive objects. The platform also supported video conferencing, including private one-on-one calls between participants and the option to ask the coach private questions in the same virtual room. A spatial audio feature provided a powerful 360-degree virtual audio experience.

All session details, such as timing, session type or invited participants were managed through a care plan in the healthcare provider system and put together by the coach specializing in treating this demographic. A periodic questionnaire provided feedback on how individuals felt about the results, becoming part of an encounter and their clinical data.

The technical challenge of the product was to place required triggers throughout the virtual world to track when someone entered a specific virtual room, sat down in a particular chair, clicked on something to watch a video, or read something on a screen while standing. All these events were captured and sent back to the healthcare provider, becoming part of the results of their care plan and the encounters linked to the care plan for that individual patient.

Another component involved pushing all that data out, deidentifying it, and running a machine learning AI algorithm for various analytics. A data analyst produced reports, which were then sent back to the payer funding this exercise. The reports revealed that nearly 70% of the attendees in the test case experienced a significant reduction in needed medications, resulting in overall better mental and physical health due to these group sessions.

That's the use case we worked on.

So let’s finally get to the challenges, how we handled them, and some of the other options that could take place.

1. Capture data

In our use case this included capturing of all the patient activities within the virtual world, when the patient logged in, which avatar was used, how the patient communicated with others. We literally injected Javascript event listeners everywhere based on user input, actions, activity within the virtual world, video call initiations, etc.

Also, using machine learning, we extracted key insights from clinical conversations if this was allowed by the patient, and stored that internally too. These insights provide a foundation of the clinical documentation workflow

This does not mean we are going to send all the data to the healthcare provider system right away, but we have to make sure we are capturing the raw data internally to boil some useful insights in the end that can be shared. Some of the conversions will require complex algorithms, machine learning, third party tools and services, but this is worth it

2. Integrate with the Healthcare Provider

If you want to add a patient's health and wellness data to their clinical record, you must communicate with systems that store these records. This might involve using an EMR (electronic medical records) system if the patient's medical history is electronically maintained by a single provider, an EHR (electronic health records) system if managed by multiple providers, or other options depending on the specific use case.

There are various ways to communicate with other healthcare provider systems and start reading/writing patient clinical data:

Call proprietary APIs. Although proprietary APIs may grant access to features unavailable through standard protocols and are often optimized for performance within the EMR system, they may lead to vendor lock-in. This makes switching to a different EMR system or connecting to multiple EMR systems at once challenging without significant development effort.

Direct database access. This is another option that provides granular data access and full flexibility in querying data. However, it poses security risks, potentially bypassing data validation and integrity checks implemented by the EMR system, resulting in data inconsistencies.

Leverage standard protocols. HL7 standards are increasingly favored in the healthcare industry to promote interoperability and data exchange among multiple healthcare systems. It's like a common language that helps different systems communicate uniformly. This includes HL7v2 messaging, CDA (Clinical Document Architecture), and the latest FHIR standard (Fast Health Interoperability Resources). HL7 standards have a growing community and industry support, with ongoing development and enhancements, ensuring they stay current with evolving healthcare needs.

For example, your system could generate a FHIR MedicationAdministration resource, which describes the event of a patient consuming a medication, and send it to a FHIR-Compliant API of the EMR.

Use gateway services. Another approach is to employ a gateway, a specialized integration platform that captures information from your system, transforms it (including delegating the transformation logic to other third-party services), validates, and sends it to any other target system, addressing all interoperability and security concerns. It can utilize some of the connectivity methods mentioned above after evaluating all pros and cons, but the risks are decreased as a reputable gateway provider has extensive experience and a wealth of knowledge similar to your use cases.

When you connect to healthcare providers, make sure to focus on keeping things safe. Using well-known standards like OAuth2, OpenID Connect, and Smart on FHIR gives you a strong and widely accepted base for keeping user access secure. Typically, clinical information systems will already have these authentication and authorization mechanisms in place, making it easier to integrate securely.

To make sure the information goes back and forth safely, use SSL/TLS protocols. This extra layer of security stops anyone from accessing or changing the data during its journey.

When you have good security in place, your gamified apps follow the rules set by healthcare standards, making sure data handling is safe and authorized. In general, this is a complex issue that goes way beyond this topic. However, for someone looking to begin integrating with healthcare providers securely, the mentioned standards, protocols, and frameworks should serve as a solid starting point.

3. Handle data privacy concerns

Gamification elements often involve personal and sensitive data. We are talking about utilization of personal health information (PHI) and personally identifiable information (PII). Integrating these elements with clinical data in the healthcare domain is a complex process that involves careful consideration of various factors.

This includes adherence to the Health Insurance Portability and Accountability Act (HIPAA) in the USA or General Data Protection Regulation (GDPR) in the EU, which sets the standards for safeguarding PHI and PII, ensuring an ethical and responsible foundation for their use in healthcare initiatives. Healthcare providers, as well as any organizations involved in the processing of healthcare data, must comply with these principles, including obtaining explicit consent for processing sensitive personal data, implementing appropriate security measures, and ensuring the rights of data subjects are respected.

In some situations, it's not necessary for your gamified app to share personal information with other systems, especially for things like analytics. Instead, you can use a process called de-identification with clinical data. This means removing or changing personal details in the data, making it hard to connect the information to specific people. By doing this, those systems can learn important things from combined and anonymous data without revealing individual patients' private details.

De-identification methods may involve taking out direct identifiers, like names and addresses, and tweaking certain details to make it unlikely for someone to figure out who the information belongs to. Using de-identification helps healthcare projects find a balance between getting useful insights from data and following the rules to protect sensitive information. Organizations should carefully think about whether sharing personal information is really necessary and, when possible, use de-identified clinical data to follow privacy rules and meet legal requirements.

Conclusion

In conclusion, the intersection of gamification and clinical data represents a transformative frontier in healthcare. It provides valuable clinical insights and promotes positive behavior changes. However, the integration of gamification into healthcare systems presents technical challenges, from capturing those insights to safeguarding privacy.