Big Ideas: Virtual Reality Becomes Reality

Improvements in technology and decreased cost of equipment have poised virtual reality to change the education of healthcare professionals and the clinical treatment of patients.

This article first appeared in the December 2016 issue of HealthLeaders magazine.

For most people, a quick trip to the gas station isn't a big deal. Gas is pumped and paid for, and sometimes coffee and a donut are purchased. But for someone with a history of alcohol abuse, a trip to the gas station can mean the difference between staying sober or not.

"You're going to go get gas one day, and guess what, there's going to be alcohol in the gas station," says Patrick B. McGrath, PhD, clinical psychologist and director of the Center for Anxiety and Obsessive Compulsive Disorders at AMITA Health Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Illinois. "Or you're going to be with a buddy that needs to stop at a liquor store and pick up a bottle of wine for a party that night. Do you just want to stay in the car every time? Or can you learn that you can walk through that and handle triggers and cravings and not have to drink?"

McGrath's goal for his patients, who include those with phobias, PTSD, and drug and alcohol issues, is for them to be active participants in life rather than sitting on the sidelines. One tool, he says, that has the potential to help them achieve this is virtual reality—the use of computer technology to immerse users in an interactive, sensory-rich environment that simulates the real world.

McGrath has been using virtual reality technology in his clinical practice for about eight years. But because of the cost of equipment and the need for a powerful computer to provide a high-quality, realistic experience, virtual reality's use has not been widespread across the healthcare industry.

But that is about to change. Big players such as Facebook, Samsung, and Microsoft are getting in on virtual reality and creating more affordable and accessible devices that provide high-resolution graphics.

"Now we can use virtual reality for diagnosis, for treatment, and for teaching," says Alberto Odor, MD, adjunct professor for the Betty Irene Moore School of Nursing at the University of California, Davis, and for the UC Davis School of Medicine Health Informatics Program. "I think it's going to be coming beginning next year. It's going to be coming pretty quickly because the hardware and the software are now something we can afford."

The anatomy of accessibility
Virtual reality has been around for decades, but until now its use in healthcare was not practical. "The equipment needed was expensive and very difficult to use," Odor says.

The large virtual reality system McGrath uses ran in the $30,000–$40,000 range in 2008 and was paid for with grants from the Illinois Department of Veterans' Affairs. Now, however, the technology has started becoming more accessible and affordable.

"We can use virtual reality for diagnosis, for treatment, and for teaching. It's going to be coming pretty quickly because the hardware and the software are now something we can afford."

"A couple of years ago it became a reality because it's now possible to have high-quality virtual reality using one of the computers you use every day and equipment that is not more expensive than the price of a cell phone and a $100 viewer," Odor says.

One example is Gear VR, a wireless virtual reality headset created through a partnership between Samsung and the virtual reality company Oculus, which is owned by Facebook.

For a 360-degree virtual reality experience, users can snap their Samsung Galaxy phones into the device, which resembles a diving mask, and see the virtual world through the viewer.

With improvements in the technology's resolution, graphics, and price, Odor sees big potential for its use both in healthcare education and in the clinical realm.

In anticipation of its increased prevalence, Odor retooled his course, Virtual Reality, Simulation, and Robotics for the UC Davis 2016 fall semester, and his students will now be creating virtual reality applications during the course.

The technology can also help educate physicians and nurses, Odor says. He points to the work being done through a partnership between Case Western Reserve University and Cleveland Clinic.

In 2015, the Ohio-based institutions broke ground on their joint venture, the $515 million, 485,000-square-foot Health Education Campus, which is slated to open in 2019. The goal of the space is to promote interprofessional education and offer advanced technology.

For example, to learn about human anatomy, students can use Microsoft's HoloLens, a wearable holographic computer that resembles the visor on a motorcycle helmet and allows users to interact with high-definition 3-D holograms of the body and its systems.

This type of technology is called augmented reality—the use of computer technology to add elements like graphics or sound to a person's real environment—and Odor says it's still an excellent way to learn.

"It's going to be very useful and probably will allow medical schools to avoid the anatomy-of-cadaver labs," he says. "These might actually be much better than cadavers because cadavers lose their natural colors. The detail that you can have with the HoloLens is really interesting."

Clinical uses
Virtual reality also has applications in the clinical setting and can play a role in neurosurgery pain management, treatment of phobias, PTSD, and substance abuse.

Neurosurgeons at the University of California, Los Angeles, have used CT and MRI scans to create virtual reality representations of actual patients. This allows the surgeons to plan and practice a surgery before stepping into the operating room, thus improving precision, clinical outcomes, and surgical time.

At the University of Washington, burn patients who used medications and SnowWorld—a virtual reality application where users throw snowballs at penguins and woolly mammoths—reported feeling 35%–50% less pain during painful medical procedures compared to when medication alone was used.

"I'd say it's moving from research to actually being used clinically now," says McGrath, who has used virtual reality technology as a tool to provide exposure and response prevention (ERP) therapy for patients with anxiety, phobias, and PTSD. Through exposure, therapy patients expose themselves to the thoughts, feelings, objects and situations that cause anxiety. Response prevention helps them learn that they can make the choice not to engage in a specific behavior.

Over the past two years, he has been using ERP in pilot groups to treat drug and alcohol issues.

With the virtual reality system he is currently using, which requires a powerful computer to provide a high-quality virtual reality experience, McGrath can place patients in challenging settings. He can have them walk past the gas station beer cooler, go to a party and be offered a drink, or walk through a house that contains drug paraphernalia and, using a smell machine, wafts marijuana odors, and have them practice making choices.

"You can't talk people out of drinking. You can't talk people out of being anxious. You have to have the patient practice," he says.

There are also virtual reality scenarios for patients with phobias of spiders, elevators, or flying.

"The only way to have someone overcome a fear is to have somebody do the thing they're afraid of and learn that they can handle it," he says. "If you're afraid of an elevator, what do you eventually do? You need to get on an elevator."

McGrath has used virtual reality to treat military veterans with PTSD. In this simulation, he can place veterans in a virtual Humvee and have them experience a simulated blast through a rumble pad under their feet.

"Our first patient who did it, when I turned on just the night vision, he about had a panic attack the first time I met with him," he says. "By session 15, I blew off 20 minutes of straight bombs and grenades and noise and gunshots and explosions and he was able to take the goggles off and say, "OK, I'm good. It doesn't bother me anymore."

Virtual reality's bright future
McGrath estimates that over the past eight years, about 20 veterans have done intensive one-on-one therapy for PTSD, which includes the use of virtual reality, and he is hoping the numbers will increase in the future.

"It's been difficult getting the VA to give up patients," he says. "But now with the Veterans Choice Program, I'm hoping that we're going to have more veterans that are going to come through and decide that they want to try it." The Veterans Choice option allows veterans to go to non-VA facilities and still receive care under their veteran's benefits.

"The future's amazing with this. It's going to be the next wave of things that we'll be able to do, and I think in 20 years we'll look back on some of the therapies that we used to do and just kind of chuckle and think, 'Why did people do that?' "

And when AMITA Health Alexian Brothers Behavioral Health opens its new 48-bed residential treatment center in 2017, patients will have access to virtual reality treatment for anxiety and drug and alcohol abuse. McGrath says the plan is to train clinicians in the organization's group practice, residential practice, and intensive outpatient programs to use virtual reality as a treatment tool.

"Our big push in the next six to eight months is to incorporate virtual reality availability into all of our different programs."

McGrath says the affordable, high-quality, smartphone-based virtual reality applications will bring virtual reality therapy within reach for even more clinicians and more patients.

"You can do that for a couple hundred dollars," he says. "I don't think that's a huge investment for a therapist to have that in their office."

Perhaps someday, this type of treatment will be available beyond a physical office, says McGrath.

"There will even be the ability to start to do something like this over the phone in people's homes," he says.

For instance, a person who has not left his or her home for years because of agoraphobia—an anxiety disorder in which a person fears and avoids places and situations where they may panic or feel trapped—might be able to receive a phone and virtual reality headset and practice being outside.

"The future's amazing with this," says McGrath. "It's going to be the next wave of things that we'll be able to do, and I think in 20 years we'll look back on some of the therapies that we used to do and just kind of chuckle and think, 'Why did people do that?' "