Level Ex's latest mobile game challenges cardiologists' skills for CME credits

The free Cardio Ex game features more than 35 levels that test the player's vascular knowledge, spatial reasoning and decision making.
By Dave Muoio
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Over the past few years, video game development studio Level Ex has put out a small handful of educational mobile games designed to simulate complex patient cases and procedures for doctors. So far, these games have been designed for physicians practicing pulmonology, airway intubation, anesthesia and gastroenterology, leaving some of the company’s biggest fans itching for a game focused on their own medical specialty.

“Generally, cardiologists are very tech-oriented. We actually have one in four interventional cardiologists [in the US] already playing one of our other games,” Sam Glassenberg, CEO and founder of Level Ex, told MobiHealthNews. “The demand is ridiculous [among] the doctors, we can’t build it fast enough to meet the demand. That’s one of the reasons we built Cardio Ex to begin with — we have thousands of cardiologists that are playing our other games. Like, they’re playing [Gastro Ex] and [Pulm Ex] waiting for us to release cardiology. It’s crazy, like, you’ve got interventional cardiologists removing polyps from the colon.”

For these players, Glassenberg’s company has launched its fourth standalone app, Cardio Ex. Now free to download on the App Store (and coming soon to Google Play), the game offers interventional cardiologists with more than 35 levels designed to challenge their knowledge, spatial reasoning and fast-paced decision making. And, if the player completes each puzzle quickly and receives a high rating, they can earn continuing medical education (CME) credits directly through the app.

“Every specialty has its really interesting, challenging cases. It has an array of skills that you need to deploy, that you need to develop over time to become an expert. What we do is we capture those challenges and build out gameplay that really pushes those skills to their limits,” Glassenberg said. “In Cardio Ex for example, we start with real cases submitted by doctors and extend into some really interesting, plausible cases that really sort of push your spatial reasoning and decision making. ... These are skills you’ll employ as a practicing physician.”

While the aim and broader methods of Cardio Ex are similar to the other games built by Level Ex’s game development team (the members of whom Glassenberg noted have a resumé ranging from Mortal Kombat to Call of Duty to Diner Dash), the new game does have some key differences in its design.

Chief among these are the visuals — whereas the procedures simulated in prior games are primarily visualized through an optical scope, interventional cardiology instead relies on fluoroscopy, a type of continuous X-ray imaging. Cardio Ex amplifies this difference by taking some graphical liberties, presenting some cases in traditional black and white and others with a range of colors and other visual effects designed to engage players and provide immediate visual feedback for their in-game actions.

“The entire game is played under X-ray. You need to inject contrast dye in order to even see the vasculature, to see the maze that you’re playing in,” Glassenberg said. “You’ll see there’s a range, there’s some cases that are visualized under black and white fluoroscopy. But over time, as the cases get more and more difficult and extend from the real to the plausible, that’s where we start reimagining fluoroscopy and amping up. So, all of a sudden, you perforate, so that means you start visualizing, you see the blood pouring into the surrounding tissue, and we amplify that with visual and audio effects.”

This unique component also plays a key role in the game’s challenge, since players can’t inject the dyes required to view their subject while handling their stents, balloons, catheters, drills and other tools. Successful players — and practitioners — need to rely on their knowledge of the case and the blood vessels to work their way through the puzzles with as little downtime between actions as possible.

“There’s a lot more decision making, a lot more spatial reasoning involved in this game than anything we’ve ever done, and those are the skills that let you advance and get a higher score,” Glassenberg said. “The skills that our games reward are the skills that you need to be successful and effective as an interventional cardiologist.

“And this is the hardest game for me to play," he added. "When I played this on stage, debuting it at the American Heart Association’s Innovation Forum keynote, I had to bring a cardiologist on stage to demo because I couldn’t talk and demo at the same time. Like, I’m injecting way more dye than a seasoned cardiologist would because I don’t know my way around the vasculature that well.”

Alongside player leaderboards, achievements and other social engagement features still in the pipeline, Cardio Ex will be continuously updated with new levels over time. This kind of strategy is vital to the mobile games market, Glassenberg said, and has so far provided Level Ex’s prior games with re-engagement rates “way higher than we would ever have in a [mainstream] video game.”

Equally important for the company is the fact that this new content is the pillar of its broader commercialization strategy. For each of its apps, Glassenberg explained that Level Ex cuts deals with pharmas and device manufacturers that allow these customers to feature their specific devices or treatments within a level of the game. It’s a strategy that’s more interesting to the player than a banner ad or video interruption, he said, and gives the player an idea of how these products are intended to be used during a procedure.

“Our current partners … are Pfizer, Merck, Baxter, Medtronic and several other top 10 pharma and med device partners that we haven’t announced yet,” he said. “You’re going and playing all these game levels, and there’s also game levels sponsored by Medtronic or by Baxter that either showcase the benefits of the product, or help you understand how to better use that product, as a video game. So we have partners that are going to be doing that in Cardio Ex, and you’ll be able to try out cool cardiology products, pharmaceutical and med device, on virtual patients in our games.”

Level Ex isn’t alone in designing skill-based video games for doctors — both Osso VR and Fundamental VR have built virtual reality apps that help surgeons learn and practice their procedures. On the patient side, mobile games have been used to educate patients about their conditions or promote physical activity and healthy lifestyles. And of course, Akili Interactive Labs is seeking FDA clearance for their cognitive, video game-based pediatric ADHD treatment.