*6.3. Implementation Challenges of Serious Gaming and Virtual Coaching in Healthcare*

There are various challenges on the way to the implementation of a pervasive integrated system such as the PERGAMON gamification platform into the practice of hospitals in their care for chronic diseases. It is essential that the technology used to enhance self-management, is integrated in the daily routine of the patients in a non-obtrusive way [10–12]. Every step that requires extra actions on top of all obligatory procedures for the user has to be avoided. During the past years some progress has been made in simplifying blood glucose monitoring [5], but these systems are expensive and not-reimbursed. Simplification, unobtrusiveness, safety, reliablity and robustness are prerequisites for introducing new techniques such as the PERGAMON platform.

Prejudice and stigmatization play important roles in the acceptance of tools and devices that support disease management [70,71]. This is not only the case for medical devices, but also when the game, or platform components like an activity tracker, or a sensor look clumsy or childish, they may become objects of mockery [72]. We learned from the user evaluations how essential a good balance is between flawless and non-obtrusive technology, challenging but not to difficult gameplay, and excellent fine-tuning to the age group.

In health care a rather conservative attitude often exists toward new developments. An important reason is that, because of safety precautions, proven technology is preferred above new techniques. So far, proof of the effectiveness of serious gaming is considered insufficient, and privacy issues or cyber-crime are increasingly considered to be a risk. Furthermore, the ICT departments in health care

institutions are fully focused on medical systems and do not have the knowledge, the experience or the willingness to deal with other applications before their added value is demonstrated. Research has shown that the perception of facilitators, i.e., the degree to which an individual believes that an organizational and technical infrastructure exists to support the use of the system, is one of the most important variables to consider for increasing doctors' and nurses' intention to use the new technology for telemedicine [73].

A second factor that impedes the introduction of complex digital platforms may be a financial one. Hospitals and other healthcare systems are non-profit organisations and the return on investments for serious gaming and virtual coaching is still very uncertain. Patients on the other hand are used to the fact that the costs of healthcare are largely reimbursed by health insurance companies. Before they are willing to pay for the apps and wearables, they have to be convinced that playing, learning and being coached by a gaming platform offers them great benefits. Health insurance companies will only reimburse the costs of these platforms when there is proof of savings or an explicit and measurable increase in the quality of health care, which is hardly ever the case. Finally, many patients with chronic diseases have long-standing habits of performing their repetitive actions in a certain way and with a particular device. Technology acceptance studies in health care showed that changing to new devices (e.g., blood glucose meters) will only be accepted by the patients if the benefits that they experience are very clear [73].
