C. Stephanidis and M. Antona (Eds.): UAHCI/HCII 2014, Part III, LNCS 8515, pp. 228–237, 2014. © Springer International Publishing Switzerland 2014

Training and Learning in e-Health Using the Gamification Approach: The Trainer Interaction

Pierpaolo Di Bitonto, Nicola Corriero, Enrica Pesare, Veronica Rossano, and Teresa Roselli

Department of Computer Science, University of Bari via Orabona, 4 – 70125 Bari - Italy {veronica.rossano,teresa.roselli,enrica.pesare}@uniba.it,

{nicolacorriero,pierpaolodibitonto}@gmail.com

Abstract. One of the basic conditions to learn is motivation. Thus it is essential for learning environments to motivate the students to proceed into the learning process. Several researches propose the inclusion of new technological trends, such as the Gamification, to engage the users. In this paper the solution adopted in UBICARE system, where the Gamification approach has been used for training and learning purposes, is presented. The Gamification was used in the simulation of clinical cases aimed to both empower the patients to adopt healthy life-style and train the medical and paramedical staff about diagnostic procedures, therapeutic interventions and follow-up of patients. In particular, the paper presents the trainer interaction that is useful in order to keep the system up to date over time and to allow the definition of clinical cases tailored on the basis of users’ needs.

Keywords: e-health, gamification, game based learning, learning by doing.

1 Introduction

The effectiveness of the learning by doing and the game based learning approaches has been largely documented in the literature [9, 15, 16, 17, 18]. In the latest years, the Gamification approach has revealed the value of game-based mechanics to create meaningful learning experiences in non-gaming contexts. “Gamification” is an informal umbrella term for the use of video game elements in non-gaming systems to improve user experience and user engagement. In other words, the Gamification can be defined as the use of game mechanics, dynamics, and frameworks to promote desired behaviours into domains like marketing, politics, health and fitness [1].

The mechanisms and dynamics of the game increase user’s engagement and stimulate their active participation enhancing the learning outcomes. This is one of the crucial issues in e-learning: the learning experience will be more effective the more the participants will be involved and active in it and not merely passive users of a content.

In this perspective, the Gamification in learning processes can be a solution to achieve excellent training goals. Moreover, the use of gamification approach in e-learning environments addressed to e-health domain is not new. The entertainment

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and fun that the game adds to the learning process is essential to engage the patients in learning how to manage and preserve their health status. This is particularly successful when the users are young, but it has been proved that also adults can be attracted to the games [10, 11, 12, 13, 14]. In Pain Squad [6], for example, the gamification approach is used to keep kids and teens with cancer engaged and motivated to complete their pain surveys twice a day. In Septris [7], instead, it is used to provide a practical approach to train medical and paramedical staff to manage daily activities of the patient, the therapy and the critical events.

In order to understand the role of gamification in education it is necessary to study in depth how the elements of the game can support the three dimensions of learning: cognitive, emotional and social [2, 8].

In the cognitive area the gamification can provide challenges perfectly tailored to the player’s skills, in fact, the difficulty of the challenges increases as the skills of the player. Moreover, to propose specific problems and to encourage the students to set attainable sub goals for themselves that are proximal and specific are features that motivate the players. Those properties represent the basis of the game experiences and the gamification approach that are particularly useful to support students during the learning process.

In the emotional area the game involves a wide range of user’s emotions: curiosity, frustration, and joy. The game often provides positive emotional experiences, and in case of negative ones, it encourages the players to use and transform them. One of the standard examples of negative emotional experience in a game is the defeat. Usually, the game implies repeated failures and often the only way to learn how to play is to repeat the game several times, each time the player learns something. In order to maintain a positive relationship between the player and his/her failures, the game provides rapid feedbacks to encourage the player to try until s/he succeeds. In traditional learning, instead, the feedbacks are not immediate and the students have few opportunities to try the exercises and when they can, the risks are high since the failures are monitored. The result of this process is anxiety and desire to escape. On the contrary, the gamification approach creates a learning environment in which any attempt is rewarded, in fact, when a failure occurs the player can correct her/his mistakes over and over again. Thus, the defeat becomes a necessary part of the learning process and students can see the failure as an opportunity, rather than being overwhelmed or become helpless and fearful.

In the social area the game experience allows players to experience new identities and roles, asking them to take decisions according to different points of view. For example, in most of video games players can take on roles that are imaginary, but sometimes they involve the players in real situations and environments. Moreover, the gamification allows to publish and share the achievements, which otherwise might remain invisible. In traditional learning, teacher traditionally provides the recognition, but in the gamified environments players can reward each other encouraging them to participate to the class/community.

On the basis of those premises it is possible to assert that a well-designed learning system that uses gamification approach can help students to assume meaningful and productive roles for learning [2].

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For these reasons in the UBICARE (UBIquitous knowledge-oriented HealthCARE) project, aimed at creating a social network to share clinical data and knowledge in order to favour the de-hospitalization of patients suffering from peritoneal dialysis and chronic heart failure, the Gamification approach has been used to both empower the patients to adopt healthy life-style and train the medical and paramedical staff about diagnostic procedures, therapeutic interventions and follow-up of patients [3, 4]. In particular, the paper describes the UbiGame component that support the acquisition of skills related to the treatment protocols and diagnostic procedure. The main innovation introduced in the UbiGame component of the UBICARE project with respect to the available solutions in the literature, is the trainer profile, which allows users to create new games according to specific users’ learning needs. The paper describes the trainer interaction, which allows new simulations to be built in order to keep the system up to date.

The paper is organized as follows: the next section describes the whole UBICARE system, section 3 describes the Simulation of clinical cases component, section 4 supplies an example of the trainer interaction and finally, some conclusions and future works are proposed.

2 The UBICARE System

In order to meet the final aim of the project, to allow the communication and information sharing between different figures involved in the patient management, the UBICARE system has been developed according to the social network paradigm. In particular, the missions of the system are to empower patients and caregiver in the disease management and to support and train medical and paramedical staff on specific procedures and guidelines. From a technological point of view, the offered services have been implemented using hybrid architecture, based both on plug-in and SOA (Service Oriented Architecture), to ensure the scalability of the whole system, as detailed in [4].

The Health Care Network (1) (Fig. 1) is the core of the system: it is a social network based on the open source framework ELGG (www.elgg.org). The use of an open source framework has allowed the developers to focus on design and development of the services to be offered by the system to better meet the functional requirements of the application scenarios.

The Data Acquisition plug-in (2) allows the collection of basic data useful for patient’s management and monitoring. It uses both automatic acquisition, using medical devices, and manual acquisition of parameters monitored daily by the patient/doctor/paramedic. The Patient Monitoring plug-in (3) allows doctors and caregivers to be continuously informed about the health conditions of the patient. In particular, on the basis of the data collected using the Data Acquisition plug-in could be sent both automatic alerts, to regularly remind of controls and to point out critical events, and manual alerts, to aware the patients of some events that can be critical for their health. The Knowledge Management Service plug-in (4) is the e-learning component devoted to the e-learning activities and allows the sharing of educational

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Fig. 1. The UBICARE system architecture [3]

resources among the community of users. In particular, the services available are the suggestion of personalized learning resources, simulations of clinical cases to train learners to deal with the main problems of their diseases, and the management of experience to share information about both official guidelines and medical protocols.

The Decision Support Service (5) is a web service that aims at supporting the medical and paramedical staff in managing the patient. In particular, it is able to suggest alternative therapies, to send automatic alerts based on patient monitoring, and to select interesting case studies to be used in learning and training processes. The Data Service Gateway (6) is a service infrastructure that allows the integration and interoperability of data in the whole system. The component ensures the extensibility of the system, the decoupling between distributed components, the transparency of the communication model, and the integration of the system with all different management systems of existing patient records (SSN DB in the figure).

3 The Simulations of Clinical Cases: UbiGame Component

The simulation component, named UbiGame, is part of the Knowledge Management Service. Starting from real medical records it builds a realistic problem, in order to allow specific skills about treatment protocols and diagnostic procedure to be acquired. In order to improve usability and maintainability of the component, the user interface and the decisional engine were split. A web service was built to retrieve all useful information for the simulation experience and to provide real patient data to help users to learn best practices in real case studies.

From the user perspective, the game consists of a web environment where a clinical case is defined according to a detailed patient clinical record, his/her actual

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Fig. 2. The simulation component architecture

Fig. 3. The simulation game

monitoring parameters and the user profile and learning needs. The simulation of clinical cases is mainly addressed to general practitioners and paramedical staff, which have to be empowered to take care of patients according to standard protocols and to manage any critical state of health of the patient [5].

The simulated patient asks to the expert (the player) what to do in order to improve her/his health status. The possible alternatives proposed to the player are: therapies, actions and examinations. The player has to respond to the patient within 90 seconds to prevent the patient from getting worse. The time is visualized by means of a counter and an avatar indicates the worsening of the patient by images (Fig. 3). The player’s answer could be completely wrong, correct or partially correct. In the first

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two cases, the game ends, while in the latter case a bonus of 5 seconds is given to allow the player to provide the correct answer.

When the simulation ends, a summary supplies detailed information about the game just ended. In particular, a detailed feedback is supplied for and against each possible answer.

UbiGame offers different scenarios to the different players according to the specific knowledge and skills that they should acquire. In particular, in the system have been defined the: caregivers, patients, nurse, general and specialist physicians. The professional figures involved in the patient’s management are organized in a pyramidal hierarchy.

Patient and caregiver profile is the lower profile within UbiGame. The game goal for caregivers is to point out only real problems and train them to call a doctor or a medical institute only when necessary. Nurse is a medium profile: s/he is able to identify simple problems, to check therapy and to support patients and caregivers by suggesting who can solve particular problems but they can not take decisions about therapy, and they have to redirect patients to general or specialist practitioner. General practitioner, instead, is asked to solve simple/medium problems according to their skills, such as change therapy or recognize critical events by suggesting the appropriate actions. In this way, the patient will refer to the specialist only if necessary. The specialist physician indeed handles problems with a high level of difficulty. His goal in UbiGame is to test the system and to suggest possible specialist advice.

The main problems in the gamification approach applied to learning contexts are the addiction to the system and the scalability of the didactic contents. In this view, it is important to involve the player in the game updating process. The main aim of the updating process is to extend the player experience, over the time, before s/he, as naturally happens, get bored and finds the game repetitive and monotonous.

To avoid the mentioned problem of addiction, a trainer, among the different users of the game, has been defined. The trainer can create new simulation sessions and modify an existing one. The updating actions can be required because players can send feedbacks about the quality of the simulation game and in order to suggest improvements.

4 The Trainer Interaction

As said before, the goal of the Trainer within UbiGame is to create and to manage the simulations of clinical cases. The Trainer profile is not necessary a specialist. As previously mentioned the profiles are organized in a pyramidal hierarchy, thus the trainer of each level can create a simulation game for the levels below him. For example, a nurse can create a game for patient, caregiver and other nurses. The main idea is to provide different kind of games with different difficulty levels and on the basis of the actual users’ learning needs (Fig. 4).

When a trainer starts the game interaction, the system selects a real patient profile within a specific trainer specialization context: cardiology or nephrology. For each specialization a set of real patient records are stored in the UBICARE database.

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Training and Learning in e-Health Using the Gamification Approach 235

service, the UbiGame generates a set of simulations of real clinical cases using clinical profiles and actions coherent with the knowledge base of the DSS. The second kind of simulation is generated starting from clinical profiles manually introduced by trainer. Using a simple interface (Fig. 5), in fact, the trainer can add and manage the monitoring data, their values and the possible problems related to them. Like in the previous case, the action engine of UbiGame will use those data in order to build a set of simulations on the basis of the data inserted by the trainer.

Fig. 5. UbiGame Web Server: A subset of health problems of the patient

When a user asks for a simulation of a clinical case in the system, both the sets defined as previously described are used to select the one that best fits the user’s learning needs.

5 Conclusions

The gamification approach can improve motivation and keep user engaged in order to make the learning process more effective. This is particularly useful in those contexts in which the learning is a necessity and, thus, often not pleasant. In the e-health field, for example, there are situations in which both patients and caregivers are forced to acquire knowledge and skills to improve their life-style. Moreover, the gamification approach could be helpful also to professional figures for acquiring new skills. These premises have led to the adoption of the gamification approach to design and build the simulation of clinical cases component, embedded in the Knowledge Management

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Service of the UBICARE system. In order to make realistic the interaction with the learning environment, real patient records are used to build the simulated clinical cases. In addition, in order to keep the system up to date over time and to allow the definition of clinical cases tailored on the basis of the users’ needs, a trainer profile has been added among the players. The trainer is a special profile that can easily add new simulations based on her/his own experience and update her/his game according to the feedbacks of the community. This is one of the strengths of UbiGame component, since allow the contents (the simulations) to be continuously renewed both automatically using the knowledge base of the DSS and manually using the trainers’ expertise. Moreover, the use of an external web service, in which the logic of the game is embedded, guarantees a high level of scalability and variability without problems for the user experience. Currently, an experiment is underway at the Polyclinic of Bari that involves patients and medical and paramedical staff to measure the usability of the UbiGame component and the effectiveness of the simulated clinical cases. At present, the appreciation of medical and paramedical staff have been collected, they state that the simulation of clinical cases could be useful to learn about treatment protocols and diagnostic procedure. Also some results about the usability have been collected trough an online questionnaire; the main problem pointed out was the difficulty of access to the patient record. In the long term, more results about the patients learning effectiveness and usability will be collected in order to improve the component.

Acknowledgments. This work was supported in part by the Project UBICARE (UBIquitous knowledge-oriented HealthCARE) - EU-FESR P.O. Puglia Region 2007-2013 Grant in Support of Regional Partnerships for Innovation - Investing in your future (UE-FESR P.O. Regione Puglia 2007-2013 – Asse I – Linea 1.2 - Azione 1.2.4 - Bando Aiuti a Sostegno dei Partenariati Regionali per l’Innovazione - Investiamo nel vostro futuro).

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