Kids undergoing a bone-setting procedure scuba dive with brightly colored fish while physicians complete their work. Residents of a skilled nursing facility use a headset to guide their physical therapy exercises.
It’s not science fiction or a video game: Healthcare organizations are increasingly turning to virtual reality to complement care.
Sometimes referred to as “augmented reality,” “the metaverse” or “extended reality,” technology connecting individuals with simulated three-dimensional worlds can be used for situations as simple as providing pediatric patients a distraction from the hospital setting. More complex applications, such as clinical training and pain management, may be fundamental to the delivery of medical services.
Use cases are still emerging, but some health system leaders and researchers believe virtual reality is the next large technology disruption in healthcare. Others remain skeptical, pointing to the need for broader interest and payer support. Confusion and curiosity
Although the terms are sometimes deployed interchangeably in a healthcare setting, augmented reality, virtual reality, the metaverse and extended reality refer to different ways of interacting with a digital environment. Augmented reality layers information onto what a user sees in real life—such as a car displaying speed and navigation on the windshield, so the driver doesn’t have to look elsewhere. Virtual reality conveys a completely different set of visuals, usually requiring goggles ranging from less than $10 for a piece of cardboard that holds a user’s phone to upward of $5,000 for more immersive set-ups. While the metaverse has been defined several ways since its creation in the early 1990s, its latest iteration, popularized by the company formerly known as Facebook, involves a 3-D social platform where users can interact with each other’s avatars. And extended reality is an umbrella term to describe any or all of the above concepts.
Curiosity about the use of technology to access a digital world is growing in the medical field. The number of studies and research articles mentioning virtual reality on PubMed, a biomedical literature database maintained by the National Center for Biotechnology Information, has increased each year over the past decade. In the first two weeks of 2023, the topic was mentioned more than 150 times.
Some leaders believe the technology has the potential to change care delivery. A report from Accenture last year found nearly half of executives from payer and health provider organizations believed digitally enhanced interactions would have a “breakthrough” or “transformational” impact on their systems.
“It’s important to start thinking about this, if you haven’t already,” said Rich Birhanzel, senior managing director and global health lead at Accenture.
Health systems have begun to use virtual reality to supplement education for new doctors. Five years ago, the Hospital for Special Surgery found it was dedicating significant staff time to training residents on the fundamentals of surgical procedures that could be learned just as easily outside of the operating room.
Leaders at the organization’s education institute proposed seeking an alternative. Dr. Michael Ast, chief medical innovation officer and an associate professor of orthopedic surgery at the academic health system, helped create a virtual reality training program for orthopedic surgery residents to complete before entering the operating room. By wearing goggles, residents at the main campus in New York City simulate several procedures they’re likely to perform during a surgery.
Ast said the virtual programs have helped residents make better use of their training time. While the organization doesn’t evaluate residents based on their performance in the modules, it is gathering data to potentially set eventual benchmarks.
“We ask our residents to go through the basic surgical procedures for each of those subspecialties—fracture, joint replacement, hand and pediatrics—right as they start the rotation,” Ast said. “Go through it 10, 20, [or] 50 times, whatever fits within their schedule.”
The training “allows them to get a lot more out of the rotation, since they really come in at a very different level of experience,” Ast said.
The hospital worked with Osso VR, a virtual reality surgical training and assessment platform, to help create the clinical training software. Ast said the level of vendor involvement enabled the program to grow over the past five years from a small number of modules to its campus-wide expansion.
“I think that’s just the way innovation is done,” he said.
Some older surgeons were initially skeptical, but Ast hasn’t encountered much pushback once they enter the virtual operating room and see the technology firsthand. He said finding clinical employees to work with technology officers and push for adoption internally is vital to integrating virtual reality in any health system.
“You want to find the person within your system who believes in it—who wants to put some time into understanding and developing how you’re going to implement it,” Ast said. “You want to find your champion.”
Dr. Justin Barad, Osso VR co-founder and CEO, said he presents the technology to healthcare organizations as a way to augment, rather than replace, training. Osso VR provided the platform and equipment for free, but the Hospital for Special Surgery has devoted what Ast characterized as significant staff time to developing and maintaining the program. The leaders are considering co-developing a training initiative for use at other orthopedic hospitals.
“This is going to take a little time to be implemented [in other health systems], but ultimately, I see this as eventually the standard of care for the training of orthopedic residents,” Ast said.
Osso VR offers a training and assessment platform aimed at enabling healthcare professionals to simulate procedures. A murky future
Other health leaders aren’t so optimistic. Around one-third of those surveyed in the 2022 Accenture report believed the metaverse’s impact would be incremental, while around 1 in 5 said it would be minimal.
Rema Padman, trustees professor of management science and healthcare informatics at Carnegie Mellon University, said while virtual reality has promise, the broad applications are still unknown.
“The question is: Is this technology really appropriate for wide dissemination, or is it really appropriate for niche kinds of deployment?” she said. “That is still not clear.”
Padman said small-scale programs could gain traction, but it would take fundamental shifts in the health industry to spark mass adoption. She compared the technology to telehealth, which did not see a significant uptick in provider and patient use until the COVID-19 pandemic shut down nonessential health services. Although it’s possible clinical staffing challenges might present opportunities for virtual reality to expand into care delivery or training, she said it’s too early to tell.
“I think completely disrupting the current mode of care delivery is kind of hard to imagine,” Padman said.
Dr. Brennan Spiegel, director of health services research at Cedars-Sinai in Los Angeles, pointed to growing interest in the technology’s applications as evidence of its potential.
“In the United States alone, maybe 100 to 150 hospitals [that] I’m aware of are using virtual reality,” he said.
According to Spiegel, providers in Europe and Asia are beginning to implement the technology too. He’s seen record levels of interest in requests to speak at a yearly international conference he hosts on virtual reality in medicine.
At Cedars-Sinai, Spiegel’s 15-person virtual medicine team is conducting three active National Institutes of Health trials examining how the technology can help patients dealing with different types of pain. A 2019 study published in the journal PLOS ONE, on which Spiegel was the lead author, found virtual therapies were effective in lowering hospitalized patients’ reported pain scores.
“It’s not a toy. It’s actually making people feel better,” Spiegel said. “We need to figure out why and how to implement it.”
In March, Spiegel and his team will launch a study with Mayo Clinic to examine how virtual reality can aid patients with irritable bowel syndrome. Through the program, participants will access different “treatment rooms” in a virtual clinic every day for eight weeks to learn more about the causes of IBS and develop cognitive behavioral therapy techniques to help with long-term management of the syndrome.
In addition to the trials, Cedars-Sinai has a single cart with virtual reality goggles intended for use as pain relief for patients undergoing care at the medical center. Clinic staff can request the goggles via email; Spiegel’s long-term goal is to have multiple carts that can be ordered through the health system’s electronic health record.
To date, Cedars-Sinai has used the technology to treat about 3,000 people, either on an inpatient basis or through research studies.
“We don’t need to rely on medications as much as we think we do,” Spiegel said. “This is not instead of traditional therapies, but it can radically augment traditional therapies.”
Spiegel defended investments in virtual reality, noting that the price for hardware is low compared with other tools. He’s found a cart costs between $5,000 and $6,000, though provider organizations may have to pay for software from vendors in addition to the labor and time it takes to train clinicians on the equipment.
Right now, Cedars-Sinai is not charging patients for the service, although it eventually hopes to do so.
“To be honest, it’s a rounding error on a hospital budget to support a VR service,” Spiegel said. “The equipment is really inexpensive compared to, let’s say, a Da Vinci robot or the thousands of other pieces of heavy equipment we use in a hospital.”
Top: An exam room in a virtual reality-generated clinic at Cedars-Sinai to help patients with irritable bowel syndrome. Maya the robot serves as the patient’s guide.
Bottom: A map shows the various “treatment rooms” available. Paying the bills
The technology may be relatively inexpensive, but researchers and health system leaders said payer support for its use will be critical for broader adoption. With some exceptions, patients pay out-of-pocket for virtual reality-based treatments that aren’t part of research trials. Insurance reimbursement often requires a billing code and a documentation framework in electronic health record systems to better quantify the services being provided.
“As soon as there’s a code and a billable code service, then we can enumerate the number of encounters where virtual reality is used,” Spiegel said. “Until that time, it’s a little bit of a black box.”
According to Spiegel, the push for a billing code is already underway: Some researchers and vendors are urging the Centers for Medicare and Medicaid Services to classify virtual reality as durable medical equipment, as one of several possible pathways to coverage. He said the CMS process is moving forward, albeit slowly.
Other vendors have partnered with payers on small-scale projects. In New York state, AgeWell, a managed care organization for Medicaid and Medicare recipients, will begin covering virtual reality-based mental health therapies this year for members on its institutional special needs plan, which is available to residents of long-term care facilities. AgeWell purchased software and about a dozen headsets from the company MyndVR to be distributed across its nursing homes. Coverage will fall under CMS’ alternative therapies designation, meaning AgeWell will pay for the service without a designated code. But only 200 patients will have access to the therapies, and AgeWell isn’t committing to coverage beyond 2023.
In the meantime, other developers are creating more software focused on using virtual reality for behavioral health, especially among older populations.
Rick Robinson, vice president of AARP’s AgeTech collaborative, said a growing number of companies have sprung up targeting seniors, offering the chance for individuals in long-term care facilities to gather in virtual spaces or helping them relax through guided meditation.
Sometimes it takes hands-on experience to see the technology’s possibilities, Robinson said.
“Once [stakeholders] in many cases, put on the goggles, it’s kind of an ‘aha’ moment,” he said.
Foto: A patient at Cedars-Sinai Medical Center uses virtual reality to get relief from pain and anxiety.