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Current uses and future clinical applications

RESEARCH REPORT

Health Care IT Advisor

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IT leaders, strategy leaders, and innovation teams 25 min.

Virtual Reality in Health Care

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Executive summary and table of contents

Virtual reality (VR) allows users to interact with computer-generated, multi-sensory environments.

Fully immersive VR blocks out external stimuli and immerses the user in three-dimensional (3D)

interactive digital environments. In contrast, augmented reality (AR) supplements a view of the real

world with computer-generated images. A number of industries have adopted VR systems, but much

of its mainstream attention has come from the gaming industry, which has long embraced the

technology and has made it accessible to the general public. In addition, many large technology firms

have started to invest heavily in VR, including Facebook, Samsung, Google, and Sony.

Although VR is often labeled an emerging technology in health care, it has been evaluated for

decades for its ability to improve clinical training and education, interactive diagnostic imaging, pain

management, psychiatric and behavioral treatment, and general patient health and wellness. Despite

evidence that demonstrates the potential medical efficacy of VR, most of this past research has been

academic, and so this technology is not yet widely used in clinical settings.

Historically, the high cost of VR systems has been a significant barrier for adoption. However, the

ubiquity of personal computers (PCs) and smartphones has brought a rapid decline in cost, which has

made this technology accessible to more health care organizations. Further advancements in headset

portability, processing power, and computing graphics have led to increasingly vivid virtual

environments that can be customized to fit specific medical applications. While many stakeholders

remain skeptical about VR in clinical settings, others feel VR offers the potential to not only bolster

existing treatment methods, but also open up new avenues for patient care in the near future.

Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Market segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Examples from the field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

IT components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

VR opportunities and challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Market adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Action items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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Definitions and scope

Origins of virtual reality (VR) technology

Although VR is considered a modern technology, its origins can be traced back as far as the 1920s

and the development of the world’s first flight simulator. During the 1980s VR gained widespread

attention, as NASA, the US Air Force, and a company called VLP Research began creating new

applications for VR. Many credit the founder of VLP, Jaron Lanier, with coining the term “virtual reality”

during this time. The 1990s saw further advancements in VR headsets, controllers, and head-tracking

technology.

Complemented by the rise of the internet, the PC revolution led to further improvements in graphics,

processing speeds, video technology, film, gaming, and wireless connectivity. VR technology has also

benefited from less expensive hardware and the ubiquitous nature of mobile devices, such as

smartphones and tablets. And large investments by companies like Facebook pushed other big firms

to enter the VR space, such as Google, Microsoft, Samsung, and Sony.

Technology classifications

Computer-mediated reality occurs when technology modifies our perception of the real world, such as

through the use of wearables or handheld devices. Along the spectrum of mediated reality, there are

two main categories: augmented reality (AR) and VR. Although AR and VR can often overlap in terms

of their function, there are distinct differences and uses between these two types of technology.

• Augmented reality: This technology superimposes computer-generated images, holograms,

videos, and sounds over the user’s view of the real environment. AR can be used on mobile

devices, tablets, glasses, or head-mounted displays (HMDs), and uses sensors (e.g.,

accelerometers, gyroscopes, GPS), cameras, and projectors to create the illusion of digital objects

with the user’s sight unimpeded. AR provides real-time supplemental information in context with the

environment, and allows users to interact with and manipulate the digital information they see.

Google Glass and Microsoft HoloLens are examples of AR products.

• Virtual reality: This technology uses software to generate a three-dimensional (3D), computer-

generated environment that is completely immersive to the user. VR allows users to explore and

interact with a complete simulation of the real world, using an HMD and typically an input device,

such as a controller or data glove, to interact with objects in the virtual world. VR aims to remove

external stimuli, so it requires technology that can provide high-resolution images with seamless,

natural interaction to replicate reality through our sense of sight, touch, and sound. Oculus Rift and

HTC Vive are examples of VR products.

The primary difference between AR and VR is the level of immersion. VR applications combine

hardware, software, and sensory synchronicity in a way that achieves a sense of “presence” for the

user, so that the subject feels fully immersed in that digital environment. This is in contrast to AR, in

which the user also interacts with computer-generated images, but as a supplement to his or her real

environment. This report focuses primarily on VR applications.

Sources: Virtual Reality Society, https://www.vrs.org.uk/; Health Care IT Advisor research and analysis.

Overview

To explore augmented reality in more depth,

read our research report Augmented Reality in

Health Care: Here to Stay or a Passing Fad?

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VR has a wide range of applications

Medical professionals have studied VR for decades to analyze how virtual systems could enhance

clinician training and improve patient behavior and health. Historically, this occurred primarily in

research laboratories and academic clinics, with some private industry collaboration. Once VR

became more affordable and practical to use, it became easier to adopt this technology in new clinical

care settings. Today, health care is one of the most promising industries for VR applications.

Examples of different uses for VR across four categories are listed below.

Sources: Valmaggia LR, et al., “Using Virtual Reality to Investigate Psychological Processes and Mechanisms

Associated with the Onset and Maintenance of Psychosis: A Systematic Review,” Social Psychiatry And Psychiatric Epidemiology, 51, no. 7 (2016): 921–36, https://www.ncbi.nlm.nih.gov/pubmed/27262562; Serino S, et al., “Virtual

Reality as a Potential Tool to Face Frailty Challenges,” Frontiers in Psychology, 8, no. 1541 (2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591852/ ; Jones T, et al., “A Pilot Study of the Impact of Repeated

Sessions of Virtual Reality on Chronic Neuropathic Pain,” The International Journal of Virtual Reality, 18, no. 1 (2018): 99-34; Lee HS, et al., “The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic

Review and Meta-Analysis,” BioMed Research International, 2019, https://doi.org/10.1155/2019/7595639; Williams LM, et al., “The ENGAGE Study: Integrating Neuroimaging, Virtual Reality and Smartphone Sensing to Understand Self -

Regulation for Managing Depression and Obesity in a Precision Medicine Model,” Behaviour Research and Therapy, 101 (2017): 58-70, https://doi.org/10.1016/j.brat.2017.09.012; Health Care IT Advisor research and analysis.

1) Categories are adapted from presentations by Dr. Walter Greenleaf,

Virtual Human Interaction Lab, Stanford University.

Market segmentation

Medical VR categories1

Education and training Medical interventions

• Surgical skills training and preoperative planning

• Clinical skills training

• Equipment and medical device training

• Imaging visualization

• Emergency response planning

• Telementoring

• Social skills training

• Patient education, virtual hospital tours

• Rehabilitation (stroke, brain injury, physical therapy)

• Vision therapy (amblyopia, strabismus)

• Pain management (acute, chronic)

• Telemedicine (virtual doctor or therapist)

• Phantom limb pain

• Assessments (neuropsychological, diagnostics, activities of daily living)

Behavioral and mental health Wellness

• Addictions (alcohol, drugs)

• Developmental and learning disabilities (autism, Asperger’s syndrome)

• Mental disorders (schizophrenia, attention deficit hyperactivity disorder, Alzheimer’s disease)

• Mood disorders (depression)

• Eating disorders

• Exposure therapy (post-traumatic stress disorder, anxiety, phobias)

• Meditation, mindfulness

• Fitness (diet modification, exercise)

• Treating isolation (3D avatar)

• Stress management

• Recreation

• Virtual travel for the disabled

• Counseling

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VR for pain and anxiety management

Pain management has been a common research focus for VR in health care, with numerous studies

showing marked improvement in patient pain scores associated with wound care, phantom limb pain,

dental care, chemotherapy, and other conditions and procedures. VR offers a virtual “escape” or

distraction for many patients during treatment and recovery, which can actually trick the body to block

pain signals from reaching the brain (in the same way an opioid would). Researchers argue that VR

can offer a potential alternative to using drugs to manage pain, distress, and anxiety.

Sources: Gold JI, Mahrer NE, “Is Virtual Reality Ready for Prime Time in the Medical Space? A Randomized Control Trial of

Pediatric Virtual Reality for Acute Procedural Pain Management,” Journal of Pediatric Psychology, 43, no. 3 (2018): 266–275, https://doi.org/10.1093/jpepsy/jsx 129; Spiegel B, et al., “Virtual Reality for Management of Pain in Hospitalized Patients:

A Randomized Comparative Effectiveness Trial,” PLoS ONE, 14, no. 8 (2019), https://doi.org/10.1371/journal.pone.0219115; Tashjian VC, et al., “Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial,” JMIR

Mental Health, 4, no. 1 (2017), https://mental.jmir.org/2017/1/e9/; Children’s Hospital Los Angeles, https://www.chla.org/; Cedars-Sinai, https://www.cedars-sinai.org/; Health Care IT Advisor research and analysis.

Examples from the field

Children's Hospital Los AngelesNonprofit pediatric academic medical center • Los Angeles, CA

CASEEXAMPLE

Researchers at Children’s Hospital Los Angeles conducted a randomized control trial to see whether

VR could help reduce pain and anxiety in children and adolescent patients receiving a routine blood

draw in an outpatient phlebotomy clinic. There were 143 participants. Roughly half used VR, while a

control group received their blood draw according to standard of care procedures. Based on pre-

procedure and post-procedure surveys, the study showed that VR significantly reduced acute

procedural pain and anxiety compared to the control group, and VR patients and their caregivers

reported high levels of satisfaction with the procedure.

Cedars-Sinai Medical CenterNonprofit academic medical center • Los Angeles, CA

CASEEXAMPLE

Researchers at Cedars-Sinai conducted a randomized comparative-effectiveness trial on 120 adults

presenting with a variety of ailments in the inpatient setting. Half of the patients were given VR

headsets (showing meditative content) and told to use them three times a day for 10 minutes per

session (and as needed for ongoing pain) over three days. A control group was shown guided health

and wellness television programming during the same period. Throughout the study, all patients were

asked to rate their pain levels on a scale of 0 to 10.

The results showed that the VR group had noticeable decreases in pain scores post-intervention

(-1.72 points) compared to the control group (-0.46 points). Those patients with the most severe

baseline pain levels saw the most significant improvement, averaging roughly 3.04 points lower on the

pain scale compared to an average drop of 0.93 points in the control group. Patients in the VR group

also showed significantly higher levels of satisfaction with their experience compared to the control

group.

In a separate 2017 study, the same researchers found that patients using short-term VR therapy

reported a 24% drop in pain scores, compared to a control group that saw a 13.2% drop in pain scores

using a two-dimensional distraction video.

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VR for mental health treatment

Mental health is a crucial, but often overlooked, aspect of patient care. VR allows therapists and other

mental health professionals to immerse patients in safe digital environments to help treat a variety of

anxiety disorders, phobias, addictions, and other mental or behavioral issues. VR is particularly

promising in the field of exposure therapy, where patients are shown a digital rendering of some

traumatic event in a controlled environment, allowing the therapist or doctor to modify the environment

as needed until the effect of the event slowly subsides. Some organizations are testing how VR can be

combined with medications and cognitive behavioral therapy to improve a patient’s psychological

state. Some VR developers are also testing virtual avatars that can take the place of an actual human,

allowing patients to interact with the “therapist” at any time of the day to alleviate symptoms.

Sources: Rogers S, “How Virtual Reality Can Help The Global Mental Health Crisis,” Forbes, May 2019,

https://www.forbes.com/sites/solrogers/2019/05/15/how-v irtua l-reality-c an- help-the-global-m enta l-health-cris is/#7a960a7528f7; Lucas GM, et al., “Reporting Mental Health Symptoms: Breaking Down Barriers to Care with Virtual Human Interviewers,” Frontiers in Robotics and AI, 4 (2017): 51,

https://doi.org/10.3389/frobt.2017.00051; Norr AM, et al., “Virtual Reality Exposure versus Prolonged Exposure for PTSD: Which Treatment for Whom?” Depress Anxiety, 35, no. 6 (2018): 523-529, https://doi.org/10.1002/da.22751; Veling W, et al., “Brave New Worlds—Review and Update on Virtual Reality

Assessment and Treatment in Psychosis,” Schizophrenia Bulletin, 40, no. 6 (2014): 1194-1197, https://www.ncbi.nlm.nih.gov/pmc/artic les/PM C4193729/; USC Institute for Creative Technologies, http://ict.usc.edu/; Psious, https://psious.com/; Health Care IT Advisor research and analysis.

Examples from the field (cont.)

The Institute for Creative Technologies (ICT) houses a MedVR Lab that evaluates how VR can be

used for mental and behavioral health, motor skills rehabilitation, cognitive assessment, and clinical

skills training. In the area of mental health, ICT researchers have multiple ongoing projects evaluating

how VR can assist with the assessment, training, and treatment of stress-related disorders.

One of their most notable projects is “Bravemind,” a clinical VR-based exposure therapy program that

immerses a soldier in a virtual re-creation of a war zone or traumatic event. The VR experience is

supplemented with talk therapy to help patients relieve their symptoms through ongoing exposure.

The virtual environments can be modified as needed to control multisensory stimuli and monitor the

patient’s real-time stress responses for clinical assessment.

The ICT is sponsored by the US Department of Defense and works in collaboration with the US Army

Research Laboratory. They have been working with the US military for over a decade on how to use

VR to treat various mental health and behavioral issues related to depression, suicide, and post-

traumatic stress disorder (PTSD).

Psious

VR technology company • Barcelona, Spain

• Company develops mobile-based virtual environments that psychologists and other clinicians can use to treat anxiety disorders and multiple phobias through exposure therapy, along with other content promoting general mental health and wellness.

• Its VR kit includes a web platform, mobile app, and an HMD. The platform allows clinicians to monitor patient progress through dashboards and trend reports, while also adjusting the virtual environment in real time to evaluate patient responses through a biofeedback sensor.

• Psious also hosts a VR Therapy Expert Network where over 500 mental health experts can share their feedback and experiences with each other.

SPOTLIGHT

USC Institute for Creative TechnologiesAcademic research institute • Playa Vista, CA

CASEEXAMPLE

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VR for clinical skills training and surgical planning

Training surgeons is a time-intensive process that in many cases uses cadavers to replicate

procedures on the human body. Besides surgery, there are a number of other clinical skills that health

care providers need to train their staff on, including equipment training or emergency response

scenario planning.

VR technology can act as simulation programs for surgeons and others to practice their skills

repeatedly at lower cost and with no risk to actual patients. In the case of surgery planning, staff can

convert a patient’s own 2D imaging scans into a 3D visualization that can then be linked to an HMD,

allowing staff to interact with the model in various ways. Using multiple HMDs, a team of clinicians can

view the same model (in a class or remotely) while an instructor reviews a case.

VR also opens up new means of patient engagement, allowing patients to explore their own 3D

anatomy and conditions to learn more about their upcoming procedures.

Sources: Khor WS, et al., “Augmented and Virtual Reality in Surgery-The Digital Surgical

Environment: Applications, Limitations and Legal Pitfalls,” Annals of Translational Medicine, 4, no. 23 (2016): 454, https://www.ncbi.nlm.nih.gov/pmc/art icles/PMC5220044/;

University of Nebraska Medical Center, https://www.unmc.edu/iexcel/; ImmersiveTouch, https://www.immersivetouch.com/; Health Care IT Advisor research and analysis.1) Interprofessional Experiential Center for Enduring Learning.

Examples from the field (cont.)

University of Nebraska Medical Center (UNMC)Public academic health sciences center • Omaha, NE

CASEEXAMPLE

UNMC’s Davis Global Center is a simulation facility that aims to improve health care education,

training, and research through its iEXCEL1 program. The program will embed AR, VR, and other

visualization technologies into teaching modules and simulation environments for experiential learning

(e.g., telepresence and telementoring), skills development, and cross-discipline collaboration. The

facility will include a holographic theater, a 270-degree 2D interactive digital “iWall,” and a fully

immersive, five-sided 3D laser “cave” for learning and research.

Examples of VR use cases include replicating clinics, hospitals, and other care settings for simulating

emergency response events, team communication, or other patient care scenarios. Clinicians will also

be able to use VR to practice their surgical skills or other complex patient care procedures.

ImmersiveTouch

VR technology company • Chicago, IL

• Company offers its FDA-cleared ImmersiveView Surgical Planning platform that uses VR to allow surgeons to interact with a 360-degree virtual model of a patient’s anatomy.

• The platform provides tools to view cross-sectional anatomy, identify important features, and manipulate models with real-time haptic feedback using hand controllers.

• Using VR for surgical training allows surgeons to practice on patient-specific scans with zero risk, which helps reduce the likelihood of complications during actual surgery; users can create a virtual patient case library to train staff.

SPOTLIGHT

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Head-mounted displays

For health care providers to use VR, they need to acquire different types of input devices, hardware,

and software. Early VR equipment suffered not only from a lack of computing power, but also

hardware that was often too large and expensive (with headsets alone costing tens of thousands of

dollars), which hindered widespread adoption. However, given the exponential improvements in IT

capabilities over the past decade, VR components have become smaller in design, more user-friendly,

and more affordable.

HMDs are goggles or helmets that encapsulate the patient’s peripheral vision to show virtual

environments, either on a built-in screen or through the use of a smartphone. HMDs typically function

through stereoscopic vision, which provides separate offset images for each eye that the brain then

merges to form 3D images, giving a sense of environmental depth. Many HMDs also make use of

speakers or require headphones to provide audio features that enhance the virtual experience.

However, some treatments require that the patient hear the clinician’s voice for instructions or

guidance, such as with phobia or anxiety therapy. Some displays use cables to attach to a processing

source, while other models are wireless (such as those using a smartphone).

Providers can evaluate several online guides1 to compare popular HMDs on price and features. A

number of factors affect the user experience when using a VR system, including:

• Processing power: Displays that connect to PCs or game consoles typically have greater memory

and processing power than smartphones, which can affect the quality of the virtual experience. Most

HMDs in the market require that a computer source meet minimum specifications to run the VR

programs effectively. IT leaders should ensure that their PCs are adequately configured.

• Display resolution: Within an HMD, the quality of the display is crucial to ensure images are clear

and vibrant. Buyers can evaluate HMDs by their resolution per eye, which is measured in pixels.

Higher pixel densities provide greater image clarity. The average resolution for popular VR headsets

is 1080 x 1200 pixels. Many HMDs use liquid-crystal displays (LCDs) and organic light-emitting

diode (OLED) displays.

• Refresh rate: The refresh rate, measured in hertz (Hz), indicates how quickly the HMD updates

images on the screen. Popular VR headsets typically have a refresh rate in the range of 45Hz to

120Hz. The higher the refresh rate, the less likely the user is going to experience delays or latency,

which helps create minimal “drag” with physical movements and provides a more fluid VR

experience.

• Field of vision: In a virtual environment, the patient’s field of vision will determine the widest angle

that the HMD can display an image. In essence, the wider the field of vision, the more immersive the

VR experience. Many HMDs in the market have a field of vision of about 100 degrees.

• Tracking: HMDs with high-performance sensors will adjust displayed virtual environments

according to a user’s position or movement. Sensors can be used for a variety of purposes, such as

tracking acceleration, location, or the physical tilt of the HMD. An HMD’s tracking ability can be

evaluated by how many “degrees of freedom” it provides.2 If the headset does not have built-in

positional tracking, vendors may sell base stations to capture movement around a room.

Sources: Chen C, King I, “Hospitals Try Giving Patients a Dose of VR,” Bloomberg

Technology, August 2016, https://www.bloomberg.com/news/articles/2016- 08- 29/hospitals -try-giving-patients-a-dos e-of-vr; Health Care IT Advisor research and analysis.

1) The Virtual Reality Society’s “Ultimate Guide to Virtual Reality Headsets” offers easy comparison of HMDs

available today: https://www.vrs.org.uk/the-ultimate-guide-to- virtual-real ity-heads ets/.

2) HMDs with fewer degrees of freedom track only rotational movements of a stationary user’s head rotation, but

cannot track bodily movements in any direction. HMDs with more degrees of freedom offer rotational and positional tracking, which means the HMD can sense not only head rotations, but also physical movement around a room.

IT components

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Other hardware and software

Additional hardware

VR bundles include the basic requirements to get the system running, but organizations may need to

purchase additional hardware or software for their specific use case. These additional items can

include video game or vendor-specific controllers, data gloves, speakers, force-feedback systems

(haptics), batteries, treadmills (to imitate walking), suspension systems, projection walls, or even a

traditional keyboard and mouse. Equipment can have a big impact on the quality of the patient

experience and efficacy of the VR treatment (e.g., a faulty or unintuitive controller will degrade the

sense of immersion and increase user frustration).

Software applications

Although hardware is crucial to use VR, the experience is only as good as the visualization content,

variety, and quality. VR software has evolved tremendously in line with smartphone apps and PC

programs, and developers can now create very realistic and immersive environments in a relatively

short amount of time, limited only by their creativity. HMDs that operate through a smartphone, such

as Samsung Gear, have some limitations compared to computer-based VR systems, mostly because

they sacrifice performance for lower costs and greater mobility. Computer-based HMDs, like HTC

Vive, can come with custom VR apps or can connect to web-based app marketplaces such as Steam

for content.

Health care organizations will need to decide if they want to build or buy their VR software. While VR

applications can be created in house (with the right resources and talent), it is much more likely that in

the earlier phases of adoption, providers will look to purchase VR programs directly from vendors.

Sources: Infanti J, “From Mindfulness to Medical Education: Penn Radiation

Oncology Explores the Potential of VR,” Penn Medicine News, August 2018, https://www.pennmedicine. org/news/ news-blog/ 2018/august/from-m indfulness-

to-medical-education-penn-r adiation- onc ology-explores-t he-potential -of-vr; AppliedVR, https://appliedvr.io/; Health Care IT Advisor research and analysis.

IT components (cont.)

AppliedVR

VR technology company • Los Angeles, CA

• Company produces therapeutic VR content that can be used to relieve chronic pain, acute pain, and anxiety associated with patient care.

• VR modules can provide coping skills for pain (e.g., breathing techniques), educational experiences, games for distraction, and relaxation content (e.g., mindfulness training).

• AppliedVR offers providers a trial kit that includes an Oculus Go VR headset and over 20 content modules. Hospital partners include Cedars-Sinai, Boston Children’s Hospital, and Inova Health System.

SPOTLIGHT

Penn Medicine

Academic medical center • Philadelphia, PA

• Penn’s radiation oncology department is using VR in the hospital waiting room and with staff who need a mental break during the day.

• The VR experience provides a voice-guided meditation program that runs less than 10 minutes to relieve patients who may be bored or anxious as they wait for treatment. Family and other caregivers can also use the program while waiting.

• Other uses include giving patients virtual department tours and using VR for proton therapy training courses.

CASE EXAMPLE

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Expected barriers remain, but research has shown real potential value

VR has already shown promise across multiple industries, and health care organizations have much

to gain by adopting this technology. Academic research over the past 30 years has produced

thousands of studies showing how VR can effectively improve behaviors, attitudes, and patient health

across multiple clinical sectors.

However, despite the technology’s potential benefits, there are still a number of barriers to adoption

related to procurement, funding, and scaling VR initiatives. Past research has often struggled with

small sample sizes and a lack of randomized controlled trials.

Source: Health Care IT Advisor research and analysis.

VR opportunities and challenges

“You have all these guys in garages that don’t know clinically what is needed. Clinicians need to meet with app developers. Creation of good content will be the key to moving forward.”

Ted Jones, PhD, CPE

Clinical psychologist, Pain Consultants of East Tennessee

Care improvements

• VR as digital therapy can reduce reliance on drugs (e.g., opioids) and help avoid unnecessary medical interventions.

• VR allows clinicians to take “virtual risks” to improve real-world outcomes (e.g., surgeons can use an HMD to test multiple approaches to a procedure on a virtual patient).

VR opportunities VR challenges

Operational benefits

• VR has the potential to reduce readmissions and shorten hospital length of stay. The cost of VR technology is less expensive than an unreimbursed hospital stay.

Deployment and adoption

• Technological limitations of the past resulted in unwieldy hardware and poor image quality.

• Many clinical VR tools are likely to require FDA approval. In addition, coding standards, common nomenclature, and scoring systems need further development to streamline clinical validation.

• Translating a VR solution from a controlled academic setting to a large-scale field deployment can be challenging.

Cost considerations

• Although VR technology has become more affordable over the years, it may still be at a price point that is prohibitive for high-volume purchases.

Patient ineligibility or resistance

• Apart from medical status that may exclude a patient’s eligibility to test VR, there are also patients who are afraid to use it, or skeptical of its value, and will refuse it.

Patient engagement

• VR enhances the patient experience in terms of their clinical outcomes (e.g., pain management), education, and satisfaction survey scores.

• VR improves access to care for geographically dispersed populations (e.g., virtual doctor consultations), and can extend ongoing therapy to the home.

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VR technology continues to improve, driving new interest

Current adoption

Health care providers have typically struggled to justify VR investment, primarily due to the expense

and lack of demonstrated scalability. However, VR has experienced a resurgence of interest in line

with a new wave of low-cost, broadly available hardware options. Medical VR has gained the most

traction as a skills-training and education tool. Building on this strong foothold, health care providers

and VR vendors are now actively applying VR technology to address rehabilitation, PTSD, pain

management, and other medical conditions.

Medical VR is still in the early stages of adoption as providers seek greater clarity on regulatory

compliance and medical device status. The bulk of existing VR research and development is

academic and focuses on controlled clinical applications with some private industry collaboration.

Many VR solutions are still in pilot stages or serve distinct niches, but the medical field is ripe for

innovation, and VR holds great potential to disrupt not only inpatient care, but also outpatient therapy,

and retail health. The ongoing developments in HMD products, and billions invested in the market by

vendors such as Google and Facebook, have served as a catalyst for greater adoption in the future.

Future outlook

Medical VR holds promise, and this is shown through the recent rise in venture capital funding,

hardware innovation, and new start-ups entering the market. As VR transitions from the academic

research setting to the enterprise market, it can significantly change treatment paradigms to benefit

health systems, consumers, and a range of other health care stakeholders. Although industry reports

vary, many predict that within ten years the health care VR market will produce billions of dollars in

revenue.

One of the primary determinants of VR’s future success will be whether or not the technology can

meet the “hype” or expectations of the users. VR vendors will continue to be pressured to deliver

diverse software content, better resolution displays, sophisticated sensors, and precise haptic

feedback, while incorporating other features such as artificial intelligence—all at affordable prices.

Despite VR’s potential, the technology still has very real limitations, and it is too early for VR to

become a standard part of patient care. It will likely require another five to ten years for VR to reach

peak adoption in health care and become fully integrated with existing care models. From an IT

perspective, there are still concerns about data storage requirements for virtual displays and

bandwidth speeds for VR streaming, however it is possible that emerging 5G and edge computing

solutions can help improve functionality.

From the clinical perspective, future VR adoption will depend upon larger, randomized controlled trials

that provide evidence that VR is clinically sound, produces long-term positive effects, and is cost

effective.1 VR can help health care organizations personalize care, increase patient satisfaction,

reduce pain and drug dependency, and boost preventive care measures. However, VR initiatives will

likely fail if they are isolated or sporadic, or if they don’t leverage the support of a multidisciplinary

group of IT experts, device manufacturers, clinicians, regulators, academics, and other stakeholders.

Sources: Bellini H, et al., “Virtual & Augmented Reality: Understanding the Race for the Next

Computing Platform,” Goldman Sachs Research, January 2016, http://www.goldmansachs.com/ our-thinking/pages/technology-dr iving-innovation-f older/virtual- and- augmented-r eality/report.pdf;

Delshad SD, et al., “Economic Analysis of Implementing Virtual Reality Therapy for Pain among Hospitalized Patients,” npj Digital Medicine, 1, no. 22 (2018),

https://www.nature.com/articles/s41746- 018-0026- 4; Health Care IT Advisor research and analysis.

1) A committee known as VR-CORE (Virtual Reality Clinical Outcomes Research Experts)

recently developed a methodological framework to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.

Findings and recommendations can be found in this publication: Birckhead B, et al., “Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an

International Working Group: Iterative Study,” JMIR Mental Health, 6, no. 1 (2019), https://mental.jmir.org/2019/1/e11973/.

Market adoption

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Steps IT leaders should take to plan for VR implementations

Build the business case for VR.

IT leaders will need to make a compelling case to invest in large-scale VR projects. Past academic

research has shown the positive impact that VR can have on patients and providers alike, but a fair

number of skeptics remain. Having C-suite support or a clinician to champion VR initiatives will be

crucial.

Determine your use case(s).

Most VR systems have specific use cases, which can make it difficult to justify the initial outlay costs if

a health system has a diverse patient population with a range of clinical problems. Some VR vendors

offer solutions that cover multiple applications, such as a vendor that uses VR for pain management

and exposure therapy.

Test wisely—VR does not work for all patients.

Not all patients want to use VR, either due to skepticism, fear, or discomfort with the HMD. And some

patients aren’t good candidates for VR therapy because of preexisting conditions or susceptibility to

side effects, such as those who may be psychologically unstable (e.g., delirium), have epilepsy, or

easily get motion sickness.

Evaluate the possibility of a “VR pharmacy.”

VR is a form of digital therapy, and as the field of “digiceuticals” starts to gain attention, there is a

vision that industry stakeholders have of prescribing evidence-based visualizations to patients. Ideally,

VR content would be prescribed and tracked through the EHR just like medication, and a clinician

would tailor the visualization and session frequency to match each patient’s individual needs.

Consider partnerships.

Since many HMDs and software developers are still new to the market, they may seek to enter into

development partnerships or sponsor health care providers to use their systems for pilots. This

scenario can not only help to ensure proper setup and maintenance, but may also ease the transition

into a full-fledged, independent VR initiative. Universities that cover VR research can offer other

partnership opportunities.

Sources: Spiegel B, “Top 10 Lessons Learned Using Virtual Reality in Hospitalized Patients,” Virtual Medicine

Program, Cedars-Sinai, June 2017, https://www.virtualmedicine.health/single-post/2017/06/26/Top-10- Les sons-Learned-Using-Virtual- Real ity-in- Hos pita liz ed-P atients; Health Care IT Advisor research and analysis.

Action items

“Medicine takes a long time to adopt new things, but at least the underlying principles and research are already there. We’ll probably need to redo many pilot studies, but we know where the blind alleys are, and I don’t think it will be hard to extend the research that we have done before to make substantial claims about VR’s efficacy.”

Walter Greenleaf, PhD

Behavioral neuroscientist and VR expert, Stanford University

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