Note: In 2013, Health Games Research completed its work. This web site is now an archive and will not be updated. Please visit the web site of the Center for Digital Games Research at UC Santa Barbara to find current information about health games and the broader field of digital games, and to use the Health Games Research online searchable database.

David Warhol

By Kate Metropolis and Maria Chesley Fisk

Anyone who wants to improve health and health care by making a new serious game relies on several kinds of expertise involving, for instance, in-depth knowledge of (1) the health issue and how to prevent, treat, or manage it; (2) the needs, interests, and abilities of the target population; (3) the instructional design principles and behavioral health strategies to integrate into the game; (4) research methods for usability testing and play testing during game development and for conducting outcome studies such as beta tests and clinical trials after game development; and (5) the design, art production, and programming of immersive, entertaining games.  All of these specialty areas are integral to the creation of a health game that will be both engaging and effective – so that players will love to play it and will emerge with strong gains in knowledge, skills, attitudes, self concepts, and/or motivations that can lead to improved health behaviors and outcomes. 

Game developer David Warhol brings technical and creative expertise to the table.  He has amassed decades of experience with a wide range of game genres, and he draws on this background to achieve his clients’ goals.   Warhol is president of Realtime Associates, Inc., a full-service video game development studio in El Segundo, California, which he founded in 1986. Realtime Associates has developed successful commercial games by the score for franchises such as Star Wars, Sesame Street, NBA Live, and Leapfrog. The company’s first major effort directly aimed at health behavior change began in 2003 when HopeLab, a non-profit organization dedicated to creating cutting-edge health interventions for young people, asked Warhol to develop a commercial-quality PC action health game about cancer, called Re-Mission.   An extensive clinical trial found that Re-Mission increased adolescent and young adult cancer patients’ knowledge about cancer, self confidence in their ability to adhere to their treatment plan, and their actual adherence to their treatment plan, such as carrying out their maintenance chemotherapy. The studio has also worked on serious games involving street safety and conflict resolution for younger children (Ace’s Adventure and Cool School), and on training simulations for the U.S. Army (Elect BiLat, Joint Fires and Effects Training System). As musicians like to say, Warhol’s got the chops.

What insights does Warhol have about getting all the experts to work together well? Difficulties are most likely to arise, he says, when team members are not familiar with each others’ processes, practices, and principles. For example, in his experience, clinicians and academics seem less driven by deadlines, budgets, and tight production interdependencies than are game developers.
This difference in perspective is, Warhol says, “a much greater concern than one might imagine.” He estimates that he’s spent as much as a quarter to a third of his time on a project to bridge the gap between his development team and the scientific and content experts—time that he would otherwise have been able to spend working on the game itself.

To mitigate the impact of this cultural divide, Warhol finds it helpful to reach an understanding early in the collaboration about the roles and responsibilities among the different participants, and to work out a protocol for the back-and-forth evaluation of ideas. “It’s not the areas that are obviously different that need definition,” he points out, “but rather the areas of overlap.”

The role of the game development team, as Warhol sees it, should be “to coax out all of the salient information from the experts, to sort through it, to map it onto possible game constructs, and offer it back to them to make sure that the intended message is coming through.  “In other words,” he continues, “we take the approach that the game development team is responsible for incorporating the client’s content, not that the content team is responsible for designing the game.”

When Warhol talks about people who want to publish serious games and what he wishes they grasped about his line of work, he isn’t being critical of any of his past or present clients; he just has the advantage of having seen how a client’s lack of production experience can affect a project. Here are key points he would like his clients to bear in mind:

“Game development is more costly than you probably think.

“The cost is nothing more than how many people work on it over what period of time.

“The secret is to find a development partner you can trust.

“In the design of your game, do fewer things better rather than trying to be expansive in scope but thin in quality. The target audience is sophisticated and can tell whether an experience has quality or not.

“Even though the goal of a health game is to convey the message and the interactive experience to the player, production values are just as important, if not more important. If a game isn’t compelling and fun to play, the message will be lost or the user base won’t be driven to complete the game.

“In some cases, the most elegant serious games hide the message in the game equivalent of a Trojan horse.” 

Of the role of research in serious game development, says Warhol, “During the design phase of a serious game, we need to identify the research goals and get them wound into the game design, to consider them just as we would other factors in an entertainment game design cycle.  Then we can build in the metrics that will deliver the data the researchers need to give us legitimate feedback about how well the intervention is functioning and delivering on the design.”

Warhol offers some practical insights to developers interested in working on serious games:

“You may think serious game development is trivial; it isn’t. If game development is a polynomial, serious game development adds another significant term to that polynomial.”

“If there are differences of opinion, the entity holding the purse strings gets to make the final call. It may or may not be the right call for the maximum efficacy of the game, but that’s how things work.”

In the final analysis, “a great collaboration on a serious game,” Warhol says, “is like the old Reese’s Peanut Butter Cup commercial where two people bump against each other and one says, ‘Hey, you got chocolate in my peanut butter!’ and the other says, ‘Hey, you got peanut butter in my chocolate!’ That being said, I don’t tell you how to make your peanut butter, so don’t tell me how to make my chocolate!”

Warhol finds working on serious games to be simultaneously demanding and rewarding—just as the most engaging games are, in fact. “Coming up with the best possible way to convey non-entertainment content in an entertaining way, often with tight budget constraints, may be the biggest challenge,” he says, “but pulling that off is actually the greatest satisfaction.”

How does Warhol view the future of health games? For the long term, he’s optimistic. But in the short term, Realtime Associates hasn’t yet seen the market reach the size where it makes sense to devote resources to grow that part of the business. For now, the company develops serious games when a client approaches them needing work for hire. However, Warhol thinks the market will grow.  “Currently the people and organizations with enough resources to commission a health game are hesitant to invest in this kind of health intervention because they don’t understand how engaging and impactful a good game can be.   But, give it twenty years,” he points out, “and the people making those decisions will have grown up with Halo and Grand Theft Auto. They’ll be less put off by the apparently non-serious stigma of the genre, and they’ll know from experience how well games can reach people.”