Talk about serious games and game-like simulations design given at the Laboratory of Computer Science of the Massachusetts General Hospital (Boston, USA). The Educational Game development approach used for developping different games in the medical domain is presented. This is exemplified with the first-aid game, the educ@ONT project with the National Transplant Organization in Spain (ONT) and the Surgical Checklist game. Some final ideas about Learning Analytics and how this can be used for evaluation and for integrating heterogeneus information in a Learning Record Store are presented.

1. Educational Game Development
in Healthcare
Baltasar Fernandez-Manjon
balta@fdi.ucm.es @BaltaFM
e-UCM research group
Visiting Scientist MGH-LCS
MGH – Laboratory of Computer
Science, Boston, 13/08/2013

2. e-UCM Research Group
• CS Professor at Complutense U.
– Director of e-UCM
• e-UCM research group about
Learning technologies
– 15 researcher
– Serious games
• Application to the medical domain
– European projects
– www.e-ucm.es
• Collab. with C. Blesius MGH
2

3. Can be the games used as a didactic
tools in Healthcare?
• What is the potential of videogames in education
and healthcare?
• Other questions
– How to use videogames?
– What can be teach using videogames?
– When to use videogames?
– Where videogames will be played?
• Videogames are very expensive. It is cost-
effective the use of educational videogames?
• Is there any methodology that simplify the
creation of games in healthcare?

4. Serious games and gamification
• Serious game is “any meaningful use of computerized game/game
industry resources whose chief mission is not entertainment”
• Sawyer, B. (2007). The "Serious Games" Landscape. Presented at the
Instructional & Research Technology Symposium for Arts, Humanities and
Social Sciences, Camden, USA.
• “The word “gamification” has emerged in recent years as a way to
describe interactive online design that plays on people’s
competitive instincts and often incorporates the use of rewards to
drive action—these include virtual rewards such as
points, payments, badges, discounts, and “free” gifts; and status
indicators such as friend counts, retweets, leader
boards, achievement data, progress bars, and the ability to “level
up.”
• Anderson J. , Rainie L. (2012) The Future of Gamification, Pew Internet.

5. Videogames as educational tools
• Video games can be instrumental in acquiring abilities
and skills like
– Spatial perception and recognition
– Development of visual discernment and separation of
visual attention
– Development of inductive logic
– Cognitive development in scientific/technical aspects
– Development of complex skills
– Spatial representation
– Inductive discovery
– Iconic code construction
– Gender construction
Aguilera M de, Mendiz A. Video games and education. Computers in Entertainment. 2003;1(1):10

6. Who is playing games?
• Pew Internet report. Adults and Video Games 2008
• 53% of American adults (>= 18) play video games
• 97% of teens play video games
• men (55%) are slightly more likely than women (50%)
to play any kind of digital game
• 76% of students report playing games, compared with
49% of non-students
• computers are the most popular gaming device, but
young adults prefer gaming consoles
• Virtual worlds only draw a small crowd
http://www.pewinternet.org/~/media//Files/Reports/2008/PIP_Adult_gaming_memo.pdf.pdf

7. Use of games in residency programs in
USA (2010)
Akl EA, Gunukula S, Mustafa R, et al. Support for and aspects of use of educational games in family medicine
and internal medicine residency programs in the US: a survey. BMC medical education. 2010;10:26.

8. Alinier G. A typology of educationally focused medical simulation tools. Medical teacher. 2007;29(8):e243–50.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/18236268.

9. Effects of different types of simulations
Arnold, J. J., Johnson, L. M., Tucker, S. J., Chesak, S. S., & Dierkhising, R. A.
(2013). Comparison of Three Simulation-Based Teaching Methodologies for
Emergency Response. Clinical Simulation in Nursing, 9(3), e85–e93.
“to compare the effects of 3 simulation methodologies (low-
fidelity, computer-based, and full-scale) on the outcomes of
emergency response knowledge, confidence, satisfaction and self-
confidence with learning, and performance.”
“the statistical findings did not support the hypothesis that RNs who
receive full-scale simulation training will score higher in knowledge,
confidence, and performance than those receiving computer-based
simulation or low-fidelity simulation”
Note: only 28 participants

10. Trainer SGI Coventry (de Freitas) Resuscitation 81 (2010) 1175–1179

11. Educational videogames challenges
• Identification of more large success cases
• including scientific and formal evaluation
• Scalability and maintainability
• reducing initial cost and TCO
• Taking into account curriculum and involving
educators
• Including student evaluation into games
• Learning analytics
• Actual application in educational settings
• Taking into account current technical infrastructure

12. Games characteristics
• Basically, a game is an abstract world where
some goals should be obtained following
some rules
• Fun elements
– Conflict and challenge
– Fantasy and curiosity
– Perception of the advance
– Progressive difficulty
– Feedback

13. MGH – Laboratory of Computer Science,
Boston, 13/08/2013
Flow in games
Chen J. Flow in games (and everything else).
Communications of the ACM. 2007;50(4):31.

14. Laws of Learning For Games’ Linked to
‘Game Design’ (Murphy 2011)
Law of Learning Idea Game Design Techniques
Motivation Motivated students learn Flow is the fundamental attraction of games. Games are
(Law of Readiness) more fun and require moment-by-moment choices. This leads
to extremely motivating experiences.
Feedback Feedback is how Feedback is an essential part of games and a
(Law of Exercise) learners correlate actions requirement for flow. The simplicity of games helps the
with outcomes learner correlate actions to outcomes.
Practice Practice is necessary for Games use practice to promote mastery. They use
(Law of Exercise) learning and mastery increasing difficulty to keep players in flow and promote
the learning of virtual or real skills needed to progress.
Positive Feelings Learning is increased Games are supposed to be fun - defined as the positive
(Law of Effect) when associated with feelings associated with compelling flow experiences.
positive feelings The simplicity and involvement of games encourages
feelings of accomplishment and mastery.
Intensity Intense experiences A person in flow is intensely focused on an activity. The
(Law of Intensity) increase learning, feedback loop intensifies the relationship between action
interest, and retention and outcome. Games use a combination of immersion
and engagement to create intense experiences.
Choice/Involvement Involvement and decision Games simplify the world to a series of interesting and
(Laws of Intensity, making can increase meaningful decisions. From moment to moment, players
Readiness, Effect) motivation, intensity, and are actively engaged in the process of learning through
positive feelings experience.

15. Evaluation Questions
for “Serious Games” (in Medicine)
• Does it work? (beta-testing)
• Is the content accurate and appropriate for target
audience? (content review)
• Is it easy to use and easy to learn to use? (usability-
navigation)
• Is it compelling/engaging for the target audience?
(realism, satisfaction)
• What are the learning goals? (learning)
• How well do the learners achieve those goals? (learning)
• What else are they learning? (learning)
• Does it track the learner’s performance? (learning
management system)
http://simworkshops.stanford.edu/06_0626/pdf/Evaluating_serious_games.pdf

16. Educational Game Development
Approach in Healthcare (EGDA)

17. EGDA Methodology
• Teaching procedural knowledge in healthcare
• game-like simulations created from
– description of medical procedures
– representative teaching cases
• Close collaboration with of game designer
with medical experts
– Minimal requirement for medical experts
• Rapid prototyping using eAdventure
– Early validation by experts

18. eAdventure: creating videogames
without programming
• Environment to create point and click adventure
games
• Open code (java)
• Multilingual
• Games as Learning Objects (for LMS)
• Support for Learning Analytics
Now working on …
Support for tablets, multidevice (HTML5)
• http://e-adventure.e-ucm.es
eAdventure,

19. eAdventure game platform
Authoring environment for the production of point-and-click
adventure games & immersive learning simulations

20. e-Adventure game platform

21. eAdventure: main characteristics
• Reduce the development and maintenance costs
• Involve the instructors in the design and development
• Focus on adventure videogames
– Story is more important than action
• First person and third person games
• Games are packed as a Learning Objects using the “de facto”
e-learning standards
– IMS Content Packaging & IEEE Learning Object Metadata
• Videogames can be automatically deployed in an e-learning
platform (e.g. Moodle, LAMS, BlackBoard)
• Easy to include support for Learning Analytics

22. eAdventure educational features
• User tracking and assessment
– the relevant situations can be detected and included
in a report that can be used for auto evaluation or
assessment purposes
• Adaptive games
– The designer can include an adaptation profile for
changing the behaviour of the game (e.g. initial state)
• Produced games can be stored in a repository of
educational contents
– AGREGA Spanish Ministry of Education central
repository for learning contents
• Very simple to include Learning Analytics with eA
games

23. eAdventure in Medical Education
• CPR game – First-aid game
– Centro de Tecnologias Educativas de Aragon
(Spain)
– Identify a cardiac arrest and teach how to do a
cardiopulmonary resuscitation
– Oriented to middle and high school students
– Includes how to use a automatic defribilator
– Tested in schools with 340 students
Marchiori EJ, Ferrer G, Fernández-Manjón B, Povar Marco J, Suberviola González JF, Giménez
Valverde A. Video-game instruction in basic life support maneuvers. Emergencias. 2012;24:433-7.
Available at http://first-aid-game.e-ucm.es

24. http://first-aid-game.e-ucm.es

25. Evaluation of the first-aid game
• 342 high school students
• Control group with emergency medical
doctors

26. Experiment
• After a short introduction of the game
students play for 50 minutes

27. Control group
• Control group expend the same time with 2
emergency medical doctors and a medical
maniquin

28. CPR game Results
Pre-test and post-test for evaluating knowlege
game
Marchiori EJ, Ferrer G, Fernández-Manjón B, Povar Marco J, Suberviola González JF, Giménez
Valverde A. Video-game instruction in basic life support maneuvers. Emergencias. 2012;24:433-7.

29. eAdventure in Medical education: evaluation
• HazMat Training (Massachusetts General Hospital)
– Use of the game for evaluate students
– Staff certification for handling Hazardous Material
(HazMat) shipments
– Problem
• Moving face-to-face training to online training
• The training includes a game packing evaluation
– Deployed from 2009 to 2012
• Reduce certification time & cost
• The outcome of the game is part of the final grade
Done by Carl Blesius, Pablo Moreno

32. Educ@ONT : Evaluation, distribution and logistics of
transplants
– National Transplant Organization (Spain)
– Training new staff in the transplant suprahospital
procedures
– Problem: pre-existing situation
• Tacit knowledge, no fully represented in the existing
description of the procedures
• Not a predefined set of teaching cases
– Other outcomes of the game creation
• Better formalization of procedures that can be tested and
refined by the medical personnel
• Creation of 10 representative teaching cases
Done by Blanca Borro, Baltasar Fernandez, ONT

33. a) Main scene corresponding to a real picture of ONT central
office b) Action of evaluating the organs.
c) Documentation available for the player. The player is
opening the zone distribution document.
d) Character of the simulation representing the liver
transplant coordinator.

34. Now: Surgical Safety Checklist

35. Surgical Safety Checklist

36. Surgical Safety Checklist

37. Improving evaluation: eAdventure +
Learning Analytics (LA)
• eAdventure games can include a learning
analytic module without modifiying the game
• LA information can be used to improve
evaluation
Game Engine
Communication
API
LA Database

38. • Raw data can feed several systems
– A Learning Record Store (LRS using xAPI)
– A Learning Analytics System
eAdventure + Learning Analytics (xAPI)
Raw data
LRS
Learning
Analytics System
Statements
Analyzer
Statements
Analyzer
EXPERIENCE
API
EXPERIENCE
API

39. Other experiences with xAPI (MGH)
– Integration of different user information
• Heterogeneus systems
• Medical mannequin simulation data in LMS (The Hub)

40. Conclusions
• Many opportunities of serious games in the
medical domain
• Need to do more evaluation of the effect of
the serious game application in real settings
• Cost and integration in the learning flow are
identified issues
• New oportunities with Learning Analytics and
new e-learning specifications
– Experience API (xAPI)

41. References
•eAdventure. http://e-adventure.e-ucm.es/
•MGH Learning Lab. http://www.massgeneral.org/learninglab/
•First Aid Game. http://first-aid-game.e-ucm.es/
• Marchiori EJ, Ferrer G, Fernández-Manjón B, Povar Marco J, Suberviola González JF, Giménez
Valverde A. Video-game instruction in basic life support maneuvers. Emergencias. 2012;24:433-7
•Pablo Moreno-Ger, Javier Torrente, Julián Bustamante, Carmen Fernández-Galaz, Baltasar
Fernández-Manjón, María Dolores Comas-Rengifo (2010). Application of a low-cost web-based
simulation to improve students’ practical skills in medical education. International Journal of Medical
Informatics 79(6), 459-467 (doi:10.1016/j.ijmedinf.2010.01.017).
•Brian Johnston, Liz Boyle, Ewan MacArthur, Baltasar Fernández-Manjón (2013). The role of
technology and digital gaming in nurse education. Nursing Standard, Vol 27, No 28, pp 35-38, March
•Ángel del Blanco, Baltasar Fernández-Manjón, Pedro Ruiz, Manuel Giner (2013). Using
videogames facilitates the first visit to the operating theatre. Medical Education. Vol 47, Issue 5, pp.
519-520 (short contribution to the really good stuff section).
•Borro-Escribano B., Martínez-Alpuente I., del Blanco A., Torrente J., Fernández-Manjón B.,
Matesanz R. (in press) Application of Game-Like Simulations in the Spanish National Transplant
Organization. Transplantation Proceedings Journal.