PRO Powered Game Mechanics

Hypothesis: Patient engagement can be improved utilizing game mechanics to improve Patient Reported Outcomes (PRO) response rates.

It has been well established that we are in an era pushing towards an emphasis on quality, not quantity, care.  Defining what constitutes quality care remains a target we continue to define.  Patient reported outcomes (PRO’s) were developed in an effort to bring another element to research, but have become an effective tool for measuring both diagnosis specific and procedure specific outcomes.

There are a few methods currently being used for acquiring patient data for quality analysis . First, direct paper questionnaires that must be handed out, retrieved, then manually entered into the system. Second, digital questionnaires that are typically emailed to patients that must be filled out electronically then lighter uploaded or manually entered into the system. The first system cannot be carried out without a team of assistants to gather and enter data.  It can be successful if carried out by a by a charismatic resourceful team.  The second method is analogous to junk mail and is only successful if the medical team can repeatedly follow up and keep trap of patients and response rates.

Historically, response rates for the above methods range from 24% to 99%.  Successful teams typically are found in the research setting utilizing the paper method. These teams showed the best response rates, but are also the least efficient. The numbers for most studies using paper methods are in smaller sample size studies ranging in the 100’s to 1000’s at most.  The digital method is much less costly and much more efficient.  However, the response rates outside of academic institutions are rarely above 50% and in our most recent effort using secure messaging to reach patients having rotator cuff surgery fewer then 70% of the patients opened the secure message and we were never able to achieve a response rate greater then 40% during the six months that we utilized this method.

The group that was tested for rotator cuff surgery was a group that was consented for surgery, that was well established by the index surgeon and were counseled that they would be receiving these PRO questionnaires.  In addition, to the preoperative information, patients who did not fill out the questionaries were sent them again and reminded at their first postoperative visit.  Despite this, the program was abandoned after six months after the response rate fell below 30%.

This experience begged the question, how do you get patients engaged enough in their own health care to obtain usable data to improve the quality of the care they are receiving?  Patient engagement is the key.  To that end their is no other entity that is better at engaging people in a task then the digital gaming industry.

Digital gaming was a 61 billion dollar industry in 2015.  The digital gaming industry was able to convince people to attend to task for sometimes hours at a time and willingly spend 61 billion dollars for the privilege of doing so.  Game Mechanics, defined as constructs or methods designed for interaction with the game state, thus providing gameplay, are powerful psychologic tools. We theorized that we can use game mechanics to improve patient engagement to build a tool that is not only effective but also inexpensive and efficient.

Ratchet health partnered with Proliance Surgeons, a forward thinking surgical subspecialty group located in Seattle Washington to pilot game mechanics as it applies to PRO capture. A cross platform tool was developed for their spine surgery department to collect PRO specific to the index procedure.

The spine surgical pilot took place in 2015  with 317 patients as part of the proof of concept phase.  At the completion of the pilot 297 of 317 patients had completed the PRO with a response rate of 94% postoperatively. Proliance was able to perform the pilot with no additional resources.  No clinical or research staff were added and no clinical staff were diverted to the maintenance of the pilot.  There was no change in the clinic flow for the scheduling process which is a crucial element for the clinical care team.

The importance of using Game Mechanics is not limited to improving how we measure quality in accordance with new regulations.  Most of the current research utilizing vetted outcome tools are small sample size academic center prospective or retrospective trials typically measuring in the 100’s or 1000’s.  Most of the larger data sets are from registries that are based on complications, return to surgery and readmissions and not outpatient long term assessments. More then a million hip and knee arthroplasties are performed in this country each year.  Using game mechanics we have to ability to capture a greater percentage of the outcomes from the interventions we perform then ever thought possible.  This can only be said if it works, does not require additional clinical/research staff, and is affordable.  As physicians and scientists we could have the sample size to truly grade the care we provide on a level that will impact the next generation of medical innovation.

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