GENERATIVE AI (ARTIFICIAL INTELLIGENCE) has been the focus of this column for the last several issues. The advancements and discussions surrounding generative AI have continued to prove exciting, and the field remains one of the most rapidly growing areas of technology. Those previous columns explored general and health-related uses of generative AI. This time, the focus will be on a similarly exciting and expanding field: immersive technologies. We begin with a review of the foundations of immersive technologies.
Three main types of immersive technologies are virtual reality (VR), augmented reality (AR), and mixed reality (MR), which are known together as extended reality (XR). Immersive technologies allow the user to experience a virtual, simulated environment by activating the senses through sight, sound, touch, and smell. Unlike the real world, the likelihood of unexpected or harmful events can be controlled and minimized in a virtual world. With these technologies, users can experience an event or environment that may otherwise be too expensive, too risky, or otherwise inaccessible.
VIRTUAL REALITY (VR)
VR creates 3D images of a virtual world and can be computer based (viewed on a computer screen) or immersive. Immersive VR uses headsets, also known as head-mounted displays (HMDs), to completely immerse the user in the virtual world such that none of the actual physical world is visible. Examples of HMDs recently released include the Meta Quest Pro and the HTC VIVE XR Elite. VR works by creating the illusions of place, plausibility, and embodiment to promote suspension of disbelief in the user. In other words, VR makes the virtual environment seem very real.
In terms of health-related applications, VR has been successfully used to manage both acute and chronic pain, in the treatment of depression, and in mindfulness meditation and stress reduction. In these applications, VR uses distraction to transport patients to a place where they are removed from the physical and mental discomfort of their condition.
VR is also used in exposure therapy, a type of psychotherapy in which psychologists expose patients suffering from post-traumatic stress disorder, social anxieties, phobias, and other anxiety disorders to situations they fear or try to avoid, in a safe environment. It allows therapists to guide patients through experiences that require the user to confront their fears. Advantages of this approach are the therapist’s ability to control the situation and to escalate or de-escalate exposure as needed.
VR has also been used for clinical skill development, including communication training. Examples include training on how to respond appropriately to angry patients and caregivers, how to demonstrate empathy without judgment, and how to effectively use reflective listening and nonverbal communication in interprofessional interactions. An application called Bodyswaps uses VR to train counseling professionals to engage patients who require difficult conversations.
It allows the user to experience the interaction from the perspective of both the therapist and the patient. The same platform can be used to train health professionals in teamwork and leadership skills, which are vital to team-based care. Have you ever worked with someone whose teamwork skills need improvement? The addition of artificial intelligence to VR results in a powerful training tool with adaptive feedback and assessment. AI allows for the adjustment of content, difficulty, and pace of learning activities for individual learners, creating a more personalized learning environment.
AUGMENTED REALITY (AR)
In applications using AR, virtual elements are superimposed onto a physical space in the real-world environment. The user can view both the virtual image and the surrounding physical environment simultaneously, reducing the disorientation that can occur in VR. AR has been used in healthcare for clinical skills development, rehabilitation, and patient education. Visible Body is an AR application used to aid health professions students in learning anatomy and physiology. It can be used with the camera of a smartphone or tablet computer and allows the dissection of a virtual cadaver to view structures from various angles.
The use of AR for health-related applications is not limited to health professions students. Cognihab is an AR tool that provides information to patients and supports patient decision-making. The ability to superimpose virtual elements onto the real environment enhances patient understanding of anatomical structures and pathophysiology. Cognihab can also demonstrate surgical procedures and other approaches to treatment. The same application can be used for rehabilitation after a stroke through games, exercises, and journeys.
MIXED REALITY (MR)
The term mixed reality is sometimes used interchangeably with AR, but the generally accepted meaning of the term is an application where virtual objects are superimposed onto the actual physical space, as with AR, but the user can interact with the virtual object. Devices such as the Microsoft HoloLens have been used to train learners to perform procedures such as surgeries and placement of epidurals. Novarad’s OpenSight Augmented Reality System is one example of the use of AR for pre-operative surgical planning. The first of its kind to be approved by the FDA, it uses Microsoft HoloLens to superimpose virtual 3D images onto the patient to highlight relevant anatomy and position virtual tools and systems to guide the surgeon in planning their approach.
THE FDA HAS TAKEN NOTICE
As previously addressed in this column in the context of AI and digital therapeutics, FDA approval for use of immersive technologies is an important milestone. Due to the rapidly expanding use of immersive technology in patient care, the FDA has begun to consider how this trend is impacting medical devices. In November 2021, AppliedVR received FDA approval for RelieVRx for treatment of chronic lower back pain.
The FDA’s monitoring radar will certainly include potential risks of VR and other immersive technologies, including physical effects, psychological effects, and threats to privacy, especially as use expands to more vulnerable populations such as pediatric patients. These risks must be weighed against potential benefits, including greater access to care and less invasive procedures.
FUTURE DIRECTIONS
In his 2015 TED Talk, Chris Milk, cofounder and CEO of Within, a virtual reality company, referred to virtual reality as the “ultimate empathy machine. ” VR is already being used in health professions programs — including pharmacy — to impart empathy for patients among learners. In our college of pharmacy, first-year students use VR paired with arthritis simulation gloves in a hands-on activity to promote empathy for patients with physical limitations due to arthritis that impact their day-to-day lives. Students complete a series of everyday tasks in VR, like brushing their teeth and sorting pills into pill boxes, wearing the gloves to restrict movement in the joints of the hands.
Allowing the user to experience firsthand the challenges that some patients face carrying out their daily tasks can support more compassionate, patient-centered care. Researchers are currently taking this idea a step further and studying the use of VR in patients with progressive diseases to impart “empathy for future self.” Might this use diminish how some patients minimize the future implications of current decisions? In this way, VR can be used as an educational tool, both to deliver content and to enable the patient to experience the effects of natural disease progression, assisting in treatment decisions. Your questions and comments are welcome. CT
Kim Garza, Pharm.D., M.B.A., Ph.D., is an associate professor, and Brent I. Fox, Pharm.D., Ph.D., is a professor, in the Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University. The authors can be reached at kbl0005@auburn.edu and foxbren@auburn.edu