One of the great things about living near a “destination city” such as Washington DC is that friends and relatives often come to visit. This past Fourth of July week was a perfect example, as my sister-in-law and niece came to visit and to celebrate our country’s birthday in it's capital city.

My niece had also recently just turned 21, and was celebrating her birthday too. One thing that they both wanted to do was to go to a casino. Luckily about an hour or so north was Arundel Mills, an outlet shopping destination and (non-smoking) casino.

I’m much more a student of human behavior than a gambler, so I went to the casino with them mostly to observe the behavior of those that were gambling. I was amazed at the amount of engagement that the people had with their slot machines. They pressed and pressed buttons, watched wheels spin, lights flash, listened to buzzers and bells ring, all in the hopes of maybe winning it big.

I wondered if somehow this heightened engagement could somehow be channeled to Health IT and to meeting the new higher thresholds of patient engagement required to comply with Meaningful Use Stage 3.

Gamification has been a fairly hot topic for a few years now, and many industries are scrambling to understand it, and to find ways that they can use gamification to improve client engagement in their product(s).

Wikipedia defines Gamification as the use of game thinking and game mechanics in non-game contexts to engage users in solving problems and increase users' self contributions.

I’m sure that I am not the first person to think about the gamification of a patient portal as a way to increase patient engagement. I’m sure that I will not be the last. I do, however have a unique perspective on gamification and an understanding as to why so many gamification projects often fail.

I was involved in a study on gamafication back in 80's when I was a graduate student at UCLA. Toward a Procedure for Minimizing and Detecting False Positive Diagnoses of Learning Disability was probably one of the first published scientific studies (1989) promoting the benefits of Gamification. In that study we developed a test that was based upon performance on an interactive video game for the Apple IIe platform called "Arty The Aardvark."

The results illustrated the key role motivation plays in determining the validity of diagnostic assessment and demonstrated the potential value of similar tasks for use in differentiating, from among individuals diagnosed as LD, those who do not have impaired learning processes.

Although this study was conducted a long time ago, and that computers have made significant improvements, the fact remains that providing highly interactive and motivating tasks can provide significant positive performance enhancements.

While at the casino, I couldn’t stop thinking about why were the people so engaged with the slot machines and how can it be applied to Health IT? What was their motivation?

• Was it the chance that everyone has to win?
• Was it the huge expected value?
• Was it the variable-ratio reinforcement schedule?
• What about the immediate feedback?
• What about the multi-sensory experience of being in a casino?

Many gamification projects fail because they are not fully integrated into the needs and the motivations of the users. Some companies try to create a simple contest, where the winner receives some form of financial incentive. The problem with these simplistic games as that as soon as there is a clear leader, most of the others realize that they will not win, and they will no longer engage.

At the casino, when someone wins the big jackpot we are happy for them, but we will likely play our game more in the hopes of also winning a similar jackpot. When we see someone near us win, we feel that we can win too. Perhaps gamification in a patient portal might take the shape of a online weight-loss contest for diabetics. In this scenario, everyone wins because losing weight will help improve the quality of life for the patients.

Providing small rewards for short-term gains are fine, but what about the big jackpot? People at a casino bet against themselves in the hopes of somehow winning big. Gamification of healthcare needs to be able to show patients that by engaging with the system, by doing what they need to do to be healthy, that they can experience BIG positive changes in their lifestyle and quality of life. The gamified weight-loss program needs to clearly identify a big reward that every participant would strive to receive.

One thing that is highly motivating at the casino is the variable ratio reinforcement schedule. Imagine a rat pressing a lever in a "Skinner box" to receive food. In this classic psychological scenario, a response is reinforced after an unpredictable number of responses. Numerous studies have shown that this creates a high steady rate of responding. You never know when the machine is going to pay off, and you continue and continue to respond (or engage). This is much more motivating than a number of fixed rate reinforcement schedule. Knowing that the machine is not going to pay off anytime soon would obviously reduce your level of engagement.

Patient portals can use the variable ratio reinforcement to provide additional incentives for the patient to engage. Randomly rewarding positive healthy behavior with online coupons could be one way, I’m sure there are many more.

When playing a slot machine, you know right away whether you have won, or if you have lost. One of the most annoying things about many web-based applications is that they do not give the information that users need when they need it. Did my action “take?” Did I “do it right?” In the 21st century “real-time” world users expect information presented to them that is timely, updated and accurate. In our multitasking, impatient, twitterverse, instant gratification culture not immediately providing the most up-to-date information could give a false indication that everything is fine, or even a false indication that something is wrong.

Make sure your patient portal provides real-time updated information.

The sights, sounds, smell and touch in a casino can provide a multi-sensory experience that is highly motivating. Given that many casinos also give free drinks to their patrons, we can probably add taste to the list and say that casinos actively engage all five of our senses.

It is likely that the human brain has evolved to develop, learn and operate optimally in multi-sensory environments. Research suggests that training protocols that employ uni-sensory stimulus regimes that do not engage multi-sensory learning mechanisms are not optimal for learning and engagement. However, multi-sensory protocols can better approximate natural settings and are more effective for learning and increasing overall engagement.

Creating a patient portal that can provide multi-sensory stimulation to the patients will be much more effective, more motivating, and lead to more engagement with those interacting with it.

These are just a few examples of how engagement with patient portals can be enhanced. The benefits of Gamification, much like interface design, can be further enhanced when organized by someone with a background and experience in understanding the key psychological principles that are at work. Working with a user experience team, such as The Usability People, is the best way to ensure that your patient portal users will be highly engaged on a system that is efficient, effective and satisfying!