From Pokémon Go to 3D COVID-19 Lung Models: The Clinical Utility of Augmented/Virtual Reality in Health Care

By Chezka Mae Baker posted 04-22-2020 20:37

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Why is augmented (AR) or virtual reality (VR) relevant in health care?

”Let’s take a walk around the lake so we can catch Water Pokémon.” This was a common invitation in 2016, when an augmented reality game called Pokémon Go encouraged millions of users all over the world to catch Pokémon with the app. Pokémon were caught by walking outside and facilitated social interaction with other app users. In a study by Xian and colleagues published by AHA in 2017, the Pokémon Go app increased the daily steps of 167 app users from 5678 to 7654 steps within a period of 3 weeks, roughly a 35% relative increase from baseline¹. In the United States where there is a 40% adult obesity rate², augmented reality can be a technology we can use to promote physical activity and wellness in our communities.

Fast forward four years later in 2020, and we are met with a jarring different reality: the novel coronavirus, SARS-CoV-2 (COVID-19), has forced the world to careen to an abrupt halt. Extraordinary lockdown measures are sanctioned daily all over the globe in a unified effort to slow the spread of the virus. Working from home is the new norm for those who are able, and cancellations of major conferences such as SXSW and HIMSS have deterred valuable networking and face-to-face learning opportunities. As a result, social interaction and physical activity may inevitably decrease.

AR/VR conferencing can be an alternative solution to holding remote meetings, especially when sharing spatial data like 3D models. Virtual reality is also being used by George Washington University Hospital in Washington, DC to convert the imaging of an infected COVID-19 lung to a comprehensive 3D model³. Dr. Keith Mortman, Chief of Thoracic Surgery at GW Hospital, advocated that “you do not need an MD after your name to understand these images. This is something the general public can take a look at and really start to comprehend how severe the amount of damage this is causing the lung tissue.”

So why is augmented or virtual reality relevant in health care? Simply put, these technologies can enhance the dissemination of health care information, encourage human physical and online connectivity, and boost health care research.

What is virtual reality, and how is that different from augmented reality?

Virtual reality presents a completely digitized version of the real world, and augmented reality presents an overlay of digitized elements to enrich or “augment” your real surroundings. Virtual reality affords a full immersion into a virtual world which is very helpful in training that requires spatial awareness (i.e. performing surgery, flight training, combat simulations)⁴. In contrast, augmented reality is more commonly accessible through mobile apps like Google Translate and Yelp to deliver information, and often does not require a headset.

How is this technology used in pharmacy and in health care?

Patient Education

The Vascular Surgery team at VCU School of Medicine in Richmond, VA utilized a 3D model of an Abdominal Aortic Aneurysm (AAA) to educate 19 patients on their disease state, the majority of which did not have prior virtual reality experience. Each patient was given a Google Cardboard to view the model on a mobile device. Around 90% of the patients enjoyed the technology, and felt more empowered about their health status⁵.

Patient Engagement

Vanderbilt School of Nursing in Nashville, TN piloted a virtual reality program called Second Life to simulate in-person visits for clinical management of diabetes by nurse practitioners. Patients were given a pre-visit questionnaire that was discussed during the virtual visit. The patients and the nurse practitioners who participated in the project both concluded that the program can be used as an alternative to face-to-face patient engagement visits, but noted a barrier to learning the platform⁶.

Provider Training

There are a multitude of programs available to help student practitioners learn while in school or as continuing education. One example would be anatomy; in addition to or perhaps instead of relying on a steady supply of cadavers and sharing between a few students at a time, students can practice dissection using virtual reality as many times as they need to become proficient⁷. More recently virtual reality was used to render a COVID-19 patient’s lungs for better visualization of the damage caused by the coronavirus, leading to faster education of providers on the front lines⁸. More complex virtual reality simulations allow both students and practitioners to “step into” various scenarios in real-time and see how they would fare against their peers given the same exact parameters⁹.

Patient Treatment Options

In addition to pharmacologic therapy, pharmacists are well positioned to critically assess and recommend supplemental and supportive virtual or augmented reality options to patients. Those with Post Traumatic Stress Disorder (PTSD) may have safe opportunities to process trauma and divulge buried facts about their experiences through virtual reality, which may improve the efficacy of medications and perhaps reduce dependence on them⁹. Pain severity mitigation through distraction is another area where virtual reality is being trialed, thus potentially shortening recovery times and possibly length of stay¹⁰. Lastly, virtual reality may help patients with autism prepare for new or uncomfortable scenarios in a safe environment with Cognitive Behavioral Therapy, rather than waiting for real-life situations to trigger events. Caregivers of those with autism can also experience what it is like by “walking in their shoes” virtually¹¹.

Why has there been a slow adoption to AR and VR in the healthcare setting?

There has been extensive research in utilizing virtual reality in the healthcare setting, yet adoption remains low. Similar to the integration of automation in healthcare, there are several factors that could contribute to the slow adoption process. Some of the potential barriers include development of current technology and implementation process¹².

Earlier we spoke of Pokémon Go and of its wild success when it first launched in 2016, but this success did not simply develop overnight. It required trial and error from the Niantic game developers during the creation of its predecessor Ingress -- another augmented reality location-based game. This helped fine tune the formula and created the necessary groundwork for Pokémon Go. It is possible that AR/VR still needs additional development in order for it to effectively meet the needs of our clinicians. Unlike video game developments, application and framework and impact of AR/VR still needs to be refined before it is ready for mass adoption¹². An example of effective integration augmented reality in the clinical setting comes from a technology developed to improve the process of inserting a peripheral intravenous catheter¹³. This technology (AccuVein®) utilized projection-based augmented reality to allow the user to view a real-time image of a patient’s vasculature¹³. A study published in 2014 concluded that although AccuVein helped create a two-dimensional visualization of the veins, it lacked the ability to show depth and did not significantly improve cannulation of patients in the emergency room. This research highlights the continual improvement needed for this technology before it is utilized across all healthcare sectors.

Some other limitations to implement AR/VR in particular is cost for both patients and clinicians. The average cost of a virtual reality headset can range from $150 up to $1000 and augmented reality devices such as Microsoft HoloLens® start at $3500. This steep adoption cost can be a major hurdle for certain clinical settings without adequate funds to implement such technology. However, our mobile devices are more than capable of functioning as a virtual reality headset if it is paired with Google cardboard which prices start at $10. Although several barriers exist to AR/VR, organizations still continue to pioneer the technology and lay the necessary framework until development meets clinical practice needs and becomes affordable.

Authors
Chezka “Mimi” Baker, Pharm.D. Pharmacy Informatics Specialist. Banner Health. Phoenix, AZ.
Raymond Chan, Pharm.D. Pharmacy IS Specialist; PGY2 Residency Program Director. Sentara Healthcare. Virginia Beach, VA.
Vinh Luong, Pharm.D. Informatics Pharmacist. Oregon Health & Science University. Portland, OR.

References
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3. Klaproth B, Mortman K. Covid-19: the Novel Coronavirus. GW Hospital Healthcast. 2020. https://www.gwhospital.com/resources/podcasts/covid19-vr-technology (accessed 2020 Mar 24)
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8. Graf, Heather. See how COVID-19 can damage a person’s lungs in 3D virtual reality. https://abcnews4.com/news/coronavirus/see-how-covid-19-can-damage-a-persons-lungs-in-3d-virtual-reality (accessed 2020 Mar 25)
9. Asgedom, Surafeal. Technology is radically improving care for veterans. https://www.healthcareitnews.com/blog/technology-radically-improving-care-veterans (accessed 2020 Mar 25)
10. VR tech being developed for use in everyday medical treatment. https://www.med-technews.com/news/vr-tech-being-developed-for-use-in-everyday-medical-treatmen/ (accessed 2020 Mar 25)
11. Rogers, Sol. How Virtual Reality Can Help Those with Autism. https://www.forbes.com/sites/solrogers/2019/04/03/how-virtual-reality-can-help-those-with-autism/#63af7c4e198e (accessed 2020 Mar 25)
12. Glegg SMN, Levac DE. Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review. PM R. 2018;10(11):1237–1251.e1. doi:10.1016/j.pmrj.2018.07.004 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752033/)
13. Aulagnier J, Hoc C, Mathieu E, Dreyfus JF, Fischler M, Le Guen M. Efficacy of AccuVein to facilitate peripheral intravenous placement in adults presenting to an emergency department: a randomized clinical trial. Acad Emerg Med. 2014 Aug;21(8):858-63. doi: 10.1111/acem.12437. PubMed PMID: 25176152.

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