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Love or hate it, technology is an established and growing part of our personal and professional lives. It wasn’t just the machine that went ping¹, technology has revolutionised the way we practise medicine. New technologies have improved our working efficiencies and enhanced patient care, but there are downsides. US research, for example, indicates primary care physicians spend nearly two hours on electronic health record (EHR) tasks per hour of direct patient care². It is therefore essential we understand the uses of digital health to be able to deploy them appropriately in the future.

So, what happens when a potentially ground-breaking technology emerges with applications in medicine, especially for patients?

Extended reality (XR) is an umbrella term for a set of technologies given to human interaction with computer generated environments. It includes Augmented Reality (AR), Mixed Reality (MR) and Virtual Reality (VR). You may have come across some of the headsets including those from Oculus³, HTC⁴, Microsoft⁵ and may have heard about the next big technology from Magic Leap⁶, touted as a possible replacement to mobile phones. Since 2014, engineering of headsets finally allowed indiscernable latency (the lag time on turning your head before the picture caught up), enabling experiences that minimised ‘cyber sickness’. As a result, XR technologies have been increasingly used in commercial, enterprise and now healthcare applications and is projected to be worth USD $209b over the next four years. Compare this to the wearable technology market projected to be worth USD $60b by 2020.

VR is a particularly exciting medium for us to consider in medicine. In 2015, American entrepreneur and filmmaker Chris Milk gave a powerful TED talk⁷ on the value of the medium as an ‘empathy machine’. Teaching and enhancing empathic skills are essential parts of the ‘Hidden Curriculum’ for medical and health professionals and are challenging to teach. VR gives us a potentially new powerful way to achieve this through the power of ‘presence’: being transported to an alternative environment and experiencing a vantage point that is not your own. Imagine experiencing being a patient in a hospital bed on a ward round where none of the team speak or engage with you. How would this make you feel?

Would an experience like this change your behaviour? Research evidence suggests it does⁸. VR achieves this in a way that simulation rooms and environments cannot: by completely immersing you in a realistic and captivating environment. The experience of becoming someone else (a man becoming a woman and experiencing unconscious gender bias for example) can drive a shift in your thinking, situational awareness and approach to common or uncommon scenarios. This is one of the reasons why police forces are using VR to train officers with empathy and situational awareness skills to reduce shooting incidents by police in Chicago⁹.

Amongst the other uses of VR include developing patients’ health literacy. This is often a challenging facet of the work we do, especially so for chronic conditions such as type two diabetes mellitus where physical manifestations may not present early in the disease course. Using AR, we can show people what it would be like to have diabetic retinopathy. Indeed, products¹⁰ exist to help individuals with ARMD ‘see again’ by enlarging the foveal area of vision to a size that their brain can interpret, allowing the registered blind to see again. Sensory overload from auditory stimulation for people living with dementia can lead to escalating challenging behaviours; VR experiences can show family members and care workers what it may be like to experience life with sensory changes leading to improved recognition of triggers and minimisation of the harmful drugs frequently used for ‘BPSD’. As a geriatrician, I have seen these eureka moments when families understand what their loved ones are going through; the impact on all involved in the patient’s care cannot be understated.

There are some impediments to using XR technologies. These include being able to scale the use of devices (only one person can use it at a time), onboarding (process of learners familiarising themselves with the headset), teachers not being able to see what the learners are doing, cyber-sickness in some individuals (up to 5%) and cost of both headsets and the interactable XR experiences. The first three have finally been solved using a world-first platform developed here in Sydney called the IQ system¹¹, allowing up to 50 people to enter VR or AR together and have a synchronised group experience, all controlled by a facilitator with a tablet. Cyber sickness can be mitigated by changing interpupillary distance and retinal focus length, features readily available on new headsets. The cost of making XR content remains high, however; and is frequently the biggest stumbling block, due to hours of backroom picture ‘stitching’ and expert software design and debugging.

The challenge now is how can we adopt XR for use in healthcare and medical education, traditionally notoriously slow and resistant industries for change integration. The headsets are available now and products can be readily downloaded, or bespoke training developed. The large corporate health services in the United States, as well as American tertiary institutions, are already quite advanced in developing and deploying XR technologies in various guises. Kaiser Permanente now has a medical division devoted to VR therapies¹². In 2017, The University of Nebraska Medical Centre built a USD$118.9m Virtual and Augmented Reality training centre, to train both undergraduate and postgraduates using XR technologies. This will be dwarfed by Kaiser Permanente’s vision of a fully integrated medical school opening in 2020, continually using the latest VR and AR technologies. At home, University of Adelaide’s Adelaide Health Simulation¹³, one of the most sophisticated XR healthcare facilities in Australia, will deliver a world-first anatomy training program in VR for first-year medical students.

But how do we utilise this potentially ground-breaking technology in our own practice? If XR is to become part of our clinical reality, it needs to be both cost effective and time neutral. Research will demonstrate these attributes though we need local projects to improve awareness and show how these technologies can make a difference to patients and healthcare systems. State digital health departments may incentivise projects and are a good place to contact.

Overall, XR technologies represent a major technological change in medicine. We may not immediately see the technology being used in clinical practice though in time, it is expected to revolutionise how we learn at medical school and how we interact with our patients. So much for the machine that went ‘Ping’!

Dr Mark Hohenberg (mark.h@curiious.com) is a geriatrician working at The Salus Clinic (www.salusclinic.com.au) and Chief Medical Officer for the technology company Curiious (www.curiious.com). He is a Conjoint Senior Lecturer at Western Sydney University and a Conjoint Lecturer at UNSW Australia.

Links & References

1. www.youtube.com/watch?v=wshyX6Hw52I
2. http://www.annfammed.org/content/15/5/419.full
3. www.oculus.com
4. www.vive.com/au/
5. www.microsoft.com/en-us/hololens
6. www.magicleap.com
7. www.ted.com/talks/chris_milk_how_virtual_reality_can_create_the_ultimate_empathy_machine
8. www.sciencedirect.com/science/article/pii/S0747563214003999
9. www.focustechnica.com/how-technology-helps-police-force-training/
10. irisvision.com
11. https://curiious.com/iq/
12. https://healthy.kaiserpermanente.org/
13. health.adelaide.edu.au/engage/facilities-and-services/adelaide-health-simulation