Susanna Pollack: We are seeing that after the last 5 years to a decade of researchers, scientists, and universities, that have been conducting clinical trials and longitudinal studies, about the efficacy of games as digital therapies are now being released. The industry is now in a position to present games to clinicians and the public as viable treatments to address real healthcare concerns. 

Jeffrey Freedman: Welcome to the RP HealthCast. Science, Innovation, Life. One story at a time. And I am your host, Jeffrey Freedman. On this episode of the RP HealthCast, digital therapeutics, and how gaming and digital applications are becoming prescriptive therapy. The term digital therapy, it sounds like a very new age or holistic self-help way to make you feel better, but this could not be further from the truth. We have been easing into this world of digital therapy for many years now, and it has slowly become part of our everyday lives. We have been wearing fit bits or apple watches for several years, and these devices that originally told us how many steps we are taking,now can actually track our sleep patterns and our heart rates. We have been using apps to track what we eat and measure our calories, but during this pandemic, we have been using apps to even visit our physicians without leaving our couches. And also, this past year, the FDA approved the first ever digital application or game to be given by prescription from a physician to a patient. And new technologies like virtual and augmented reality, allow us to simulate real-world situations in safe environments, to explore things like teaching surgeries at a medical school, or even to better understand climate change or social injustice. Digital technology is certainly coming of age. And companies in this space are looking to solve some of the world’s largest healthcare issues, such as diabetes, congestive heart failure, obesity, and Alzheimer’s disease. To help us better understand this complex technology, I spoke with 3 experts in the field: Susanna Polack, the President of Games for Change. They are a nonprofit that empowers game creators and social innovators, to drive real world impact through games and immersive media. Dr. Walter Greenleaf, a behavioral neurologist and a visiting scholar at the Stanford University Virtual Human Interaction Lab. And Noah Falstein, a gaming industry executive and previously, Google’s chief game designer. Susannah, thank you so much for joining us today. Can you tell us a little bit about Games for Change, about what your corporate mission and your goals are? 

Susanna Polack: So Games for Change is a non-profit that has actually been around for quite a while. We have been around for 18 years, and have more or less grown up with a growing understanding that games can have a power beyond entertainment. And as an organization for the past, almost 2 decades now, we have been advancing this concept that games can be used as drivers for social impact, and across different sectors. So whether games can be used in education, in classrooms, to teach for math games, for young people, to games that are used to create build awareness around global issues, or in other contexts about how games can be used to help ensure wellness, and in some cases, address illnesses and conditions in the health industry. So one of our flagship programs is The Games for Change Festival, which we have been running for 18 years. So at the festival which this year will be virtual, for the second time, and offered free for the second time, will be held from July 12th to the 14th, and it’s 3 days of packed programming, where you can sample talks, panels, workshops, around one of the topic areas you might be interested in. 

Jeffrey Freedman: Now in terms of health care, and the way games can change the way we view ourselves, and the way games can be used to actually monitor our health, there has been a lot of development in this area. Now, there are both prescribed games, and then there are health care application type games. Now, I noticed on your website, you had a game that you are highlighting, and it is called Gris. Can you tell us a little bit about that? 

Susanna Polack: So Gris is a beautiful game that was made by an independent studio. It has won some terrific awards, including The Game with the Most Impact by The Game Awards, which is like the Oscars of the video game industry. The game itself follows a girl whose name is Gris, who wakes up in the palm of a crumbling statue of a woman. It is a beautifully designed game, which is one of the areas that kind of just draws you in, but the fact that it also deals with issues about revisiting childhood about memories, about relationships with your family, it deals with mental health issues, and it kind of pushes your imagination in a way that one, is just joyful, but also reflective. It stands apart from just an entertainment based game, to a place where you can actually explore grief, emotional well-being, and a lot of self-reflection, which is not necessarily what you would expect from a video game, but still find it incredibly rewarding to play, right? Like you feel like you have gone through an experience, you have enjoyed yourself, and you come out of it with a unique kind of perspective. 

Jeffrey Freedman: It is fascinating, that there is a whole ecosystem and infrastructure preparing us for the future of this health technology. It is a future where technology can have such a social impact and bring about real change. So, to further explore the convergence of technology and our well-being, I spoke with Dr. Walter Greenleaf. Dr. Greenleaf is a behavioral neuroscientist and a professor at Stanford University, and a visiting scholar at Stanford’s Virtual Human Interaction Lab. Walter, why don’t you tell me a little bit about your work at Stanford University first? I mean, what is the Virtual Human Interaction Lab? 

Dr. Walter Greenleaf: It is a research group at Stanford, founded by my colleague, Jeremy Bailenson. And the focus of the lab is to look at how immersive technologies, augmented reality, virtual reality technology, and mixed reality technologies and others, how our behavior is affected by the use of these environments, and also how these very engaging environments can be used to both measure attitudes, and moods, and cognitive states, and also influence attitudes and moves in cognitive states. So some of the example projects are how we can use virtual reality to measure, and perhaps increase empathy for people who are in a different social status situation that we are in, or from a different age or ethnic background. Other examples might be how we can increase understanding and awareness of the effects of carbon dioxide in our atmosphere, on ocean acidification. Essentially, the power of virtual environments is that we can create an experience, and through those experiences, people learn, and people change their attitudes, and that is what we study at the lab. 

Jeffrey Freedman: Walter, why don’t you set the table for us about what the topic is today, which is digital therapy? Can you define that for us? What is digital therapy? And are these devices, or are they apps and games? And are they supposed to replace a healthcare provider, or actually heal somebody? 

Dr. Walter Greenleaf: Well, we are entering into an era where, I would like to say that the continents are colliding, that the advent of some of the technology titans to get into health care, such as Apple with their Apple watch for cardiac monitoring. What used to be some hard lines of division, there was a big Pharma industry, and the medical device industry, and now, it is getting mixed up with so many other players coming in to improve the way we provide health care, and that line between consumers interest in health and wellness, and clinician’s interest in seeing and working to help a patient improve, it is sort of blurring. Consumers are now becoming more engaged and interactive with their healthcare journey. And through the advent of some really powerful technologies such as wearable sensors, machine learning, to make sense of all the data, the use of the heuristics from the entertainment and gaming industry, to help make some of the applications that are used in healthcare, promote adherence, so people will stay with the often difficult thing they need to do. It is really evolving quite fast, and we are seeing the advent of combination therapy, where a medication might be used in combination with a digital app. We are seeing the combination of medical devices, with platforms that are used to collect information both before, during and after the use of the medical device. So what used to be separate zones are merging in a very powerful and meaningful way, and it is also happening very fast. 

Jeffrey Freedman: So as a consumer, as a patient, as somebody that is in need of healthcare assistance, how do I know what is right for me? I mean, there are so many different options and choices. 

Dr. Walter Greenleaf: That is such an excellent question, it is a bit of the Wild West. One can go to different websites and sign up for different programs, one can download apps through the Apple App Store for example. There are some really amazing products on their way that can make a big difference in some difficult problems, like multiple sclerosis, or stroke rehabilitation, or addressing anxiety and depression. It is fantastic that there are such powerful, innovative solutions out there right now, and on their way to come out in either another stronger format, but it is hard to identify which ones are the best. And because digital healthcare apps are not always in the zone that is regulated by the FDA, because they are more often in the health and wellness arena, it is hard to see which ones are the best, which ones have been vetted and accepted. I think there will be eventually an evolution of curated platforms, where clinical societies or groups that are looking out for the benefit of the user, will sort out, and score, and evaluate some of the existing systems that are out there. But right now, it is very difficult to identify those that are the best. 

Jeffrey Freedman: Now, you mentioned that a lot of these applications are not regulated. I know there are some apps that are FDA approved, and I believe Akili has an app called EndeavorRX, and that certainly crosses the line from a wellness app or a medication reminder. Now, what is the difference? I mean, why do they need to be FDA approved? And what are they trying to do, versus the app you could download from the App Store? 

Dr. Walter Greenleaf: The difference is validated clinical claims. If a product, like the one that you just mentioned by Akili, wants to make a claim that it can be effective as a treatment for a particular clinical problem, then they do need to go through the FDA review process. On the other hand, if a product wants to say that it improves your mood or it helps you reduce feelings of worry, that is very different than saying it cures depression or it treats anxiety. In order to be able to make those stronger claims, you need to have taken the trouble to do the hard work of validating through research. What I think will make a difference though, is that now that many of the pharmaceutical and medical device companies are getting involved in this arena, they have both the resources, financial resources, but also the expertise on how to conduct clinical trials, how to validate an intervention. We are in a better position now to create a dynamic healthcare system that extends beyond the clinic, and allows the clinicians to check in with patients and see how they are doing, that’s not every 3 weeks. Information flows in when people elect to provide it, to use a metaphor from the gaming arena, it can be a quest, with people assisting you along the way. So instead of having these very punctate experiences that are limited in time and space, it becomes something that the patient or user can participate in an active, engaged way to take agency over their healthcare journey, and have a more dynamic interaction with the healthcare system. I think that is going to really change things quite a bit, to be able to have the user or patient have more information, to have more points of contact, and more powerful tools to help them along their way.

Jeffrey Freedman: Walter and the Virtual Human Interactive Lab are doing some amazing work in bridging the gap between the real world and the virtual world, to potentially solve some of the planet’s biggest issues from social inequity, to climate change, to curing disease. To better understand how gaming, in particular, can affect our health, I spoke with one of the world’s leading game design executives and thought leader, Noah Falstein. Noah, aside from being a game developer himself for over 20 years, recently left Google as their chief game designer, to focus his time solely on health related projects using gaming or gaming technology. Noah, thank you so much for joining me today. Now I spoke with Dr. Greenleaf earlier about his work at Stanford University, and he kind of set the table for us about what digital therapeutics are all about. Now you, among many other things, are a lifelong game developer, and you approach things a little bit differently than him. Technology has obviously changed dramatically over the 20 plus years that you have been programming and being part of game design. So, the question is, are we having that tipping point of being able to meld serious medical therapy at home, at your fingers, on our phone, or phone devices? 

Noah Falstein: Absolutely, I think the technology has been advancing so rapidly on a lot of different fronts, and they all are complementary to each other. So certainly, computers in general, and what I do with video games, is worlds apart from what I did at the beginning of my career. It is just mind-boggling to me how many orders of magnitude, faster, and more memory, and all the other things we have. At the same time, medical imaging, a lot of medical science devices, particularly things like EEG and FMRI have also been advancing. And it feels to me like we definitely have hit, not necessarily a tipping point, but certainly a minimum level of quality on all those things together, that we were able to do some amazing things, and if it is anything like the games industry that is just going to continue to accelerate and get better, over the next few decades. 

Jeffrey Freedman: As you say, things have been advancing. Now, what are some examples? What are some innovative examples that you have seen? I mean, you are there day-to-day. So what are some great examples of digital therapeutics or gaming that helps the healthcare of individuals? 

Noah Falstein: Well, there are so many now, the one that I have been most directly, and I would say, long-term involved with Akili Interactive. They are currently cleared by the FDA, for doctors to prescribe their video game that they make to treat teens with ADHD. It’s very exciting for me to see that because I started working with Dr. Adam Gazzaley on this. Actually, on our predecessor, that moved into this about 12 years ago, and it has been a very long slog, the FDA clearance just came in last year, and even now they are still scaling up, because getting doctors to prescribe a video game as treatment is a big deal. But that is a great reflection of what I was just saying because Dr. Gazzaley, he was head of brain imaging at UCSF, and the kind of work he was doing, seeing what is happening in brains as people are multitasking, was really at the foundation of him turning to video games as a way to do testing, and then treatment for exactly those kinds of disorders. 

Jeffrey Freedman: Well, what are the limitations of these types of games? I mean obviously, you have to be under the prescription, under the guidance of a healthcare provider. But what does the game actually do for the individual? How does it make them better? 

Noah Falstein: Well, the majority of these games are treatment oriented, because a treatment is only one of the modalities that games and health are using, but when they are treatment oriented, tends to be for neurological issues, anything from ADD, ADHD, to PTSD, to depression. Just mood elevation in general, all sorts of things along those lines. I do not expect that we will see a game that will treat cancer directly. I did work on a game that helped teach teens why they need to stick with their chemotherapy regimen, when they have had cancer and are trying to recover. So it is that kind of thing. One of the major limitations is that it doesn’t no change your chemical makeup, except to the extent that your brain can do that itself. But neurology, things that the brain can do, are still pretty amazing, and so many things, the ones I mentioned and many more that can be treated that way. I am really excited that it will continue to expand and find new areas in all sorts of brain oriented areas that can be improved. 

Jeffrey Freedman: I guess with the advancement of virtual therapy, virtual reality, and augmented reality, the brain takes on a whole different approach. So where does it end? I mean, where does it begin? What is real? I guess from the study of psychology or psychiatric disorders, that could be quite helpful. 

Noah Falstein: Yeah, one of the earliest ways that VR was used, even back around 20 years ago, when the quality of VR was much lower, was for treating post-traumatic stress disorder or phobias by putting people into environments where they experienced a trauma, or something that they are scared of, and letting them gradually desensitize by starting with something very simple and scaling up from there. It is kind of one of the simplest ways of doing that. But virtual reality, because it takes the whole world away from you and presents you with a world completely under control of the clinician, it’s very powerful that way and it seems to affect people’s emotions more strongly than most other media that we have encountered. 

Jeffrey Freedman: Alright. So if you were to have a crystal ball, and to look out 3 years into the future, where do you see the industry going? 

Noah Falstein: Well, I think there are a lot of really exciting things that people miss when they think about digital therapeutics, or specifically, I will just talk about the combination of games and digital therapeutics that is my specialty. People hear that, and they think oh, this is something for kids, or this is something where the games can maybe make people feel a little calmer or distract them. But it goes so much beyond that, beyond, in the sense of treatment as I have already mentioned. But there are companies that are using games to train physicians and caregivers in really innovative ways. I would say, my totally informal and unscientific survey, has been that it seems that at least 90, if not 95 percent of recent graduates of med school were video game aficionados somewhere along the way. So it is really natural for a lot of them to continue their studies that way. An area that has just barely begun to be touched upon, that I think we are going to see a lot more of, is using games, possibly everyday entertainment games, with special modules that will measure how people are using them, and how their keystrokes on a keyboard or their use of game controller or joystick, is changing over time to diagnose the possible early onset of degenerative diseases, things like Alzheimer’s or Parkinson’s, but also just neurological things that hit people at any age that can be picked up by the different ways that people actually play those games, or the kinds of speed and accuracy of their keyboarding. So those are just some of the areas that I would not be surprised if it becomes a normal thing for many games to include that kind of diagnostic information, with people being able to opt in if they wish to be able to be told if they find some reason that they might want to check with the doctor about their conditions. 

Jeffrey Freedman: I would like to thank our guests today, Susanna Polack, Dr. Walter Greenleaf, and Noah Falstein, for giving us a well-rounded perspective of how technology and gaming is helping to lead us to better health outcomes. To learn more about them and the projects they are working on, please check out their bios and their links in our transcript. RP HealthCast. Science, Innovation, Life, one story at a time.

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