Brennan Spiegel, MD, MSHS

 

If you’ve ever been hospitalized or visited someone in the hospital, then you know that patients can experience anxiety, uncertainty and boredom exacerbated by a radical change in living environment and loss of customary rights and privileges. Sitting in a hospital room for days or weeks, often in pain and distress, can be physically demanding, emotionally draining, and socially isolating. In many ways, the hospital room can be more like a bio-psycho-social jail cell than an uplifting healing environment.

Our digital health research team at Cedars-Sinai Medical Center has been trying to address this problem by using virtual reality (VR). Recent advances in VR technology offer a compelling opportunity to address inpatient distress. VR devices provide immersive, realistic, three-dimensional experiences that “transport” patients away from the four walls of their hospital room and into novel, positive, and emotionally enriching environments. We believe that VR has potential to alleviate negative aspects of hospitalization by providing multi-sensory information and allowing patients to “escape” to pleasant locations and realities.

Over the past year our team has studied over 150 diverse patients using a range of VR visualizations. We published our initial experiences in a peer-reviewed study and are now initiating the largest controlled trial to date of VR, testing its impact on pain management, narcotic usage, length of stay, and satisfaction with care among hospitalized patients.

We’ve been fortunate to work with AppliedVR, a cutting-edge VR company focused on creating and disseminating the technology for healthcare applications. Most recently, we partnered with Samsung Healthcare to test their Samsung Gear and Galaxy smartphone in our upcoming clinical trial.

Our VR research has resonated in ways we never expected. Coverage by NBC News generated over 4.3 million views online, and recent reporting by MIT Technology Review and NPR continued the trend of unabated VR media interest. Most recently, PBS and Bloomberg documented our use of VR at Cedars-Sinai and will be airing their reports in upcoming months.

I thought it would be useful to describe the “Top 10 Lessons Learned” from our initial experiences using VR in hospitalized patients. Some of the lessons are not surprising, but others are striking and unexpected. We continue to learn from each and every patient who uses VR at Cedars-Sinai. I hope that sharing these experiences can help others seeking to employ VR in hospitalized patients.

 

  1. You can literally see two distinct moments that prove when VR is working its magic

We’ve been watching closely as patients use VR. There are two distinct, indelible moments that indicate VR is working its magic. The first moment, which I call the Moment of Cognitive Immersion, typically comes within 20 seconds of use. The second moment, which I call the Moment of Physiologic Immersion, typically arrives about 3-5 minutes after initiating VR. I’ll break down the two moments here:

Moment of Cognitive Immersion: When patients first don VR goggles and view the images, they often stare straight ahead, not yet recognizing the immersive, 360-degree nature of the experience. Some patients will discover this on their own, whereas others require prompting from the research staff to move their head and explore the scene. But the moment they begin to move, invariably, there is a recognition that VR is different from anything experienced before. This is the Moment of Cognitive Immersion, when the patient becomes aware they are within a broader, more expansive environment than initially recognized. The patient almost always smiles, laughs, or says something like “that’s amazing!” It’s at that very moment the user recognizes that VR is special and different. It’s pretty magical.

Moment of Physiologic Immersion: Once patients cognitively recognize they are in a 3-D, immersive environment, the next step is for their autonomic nervous system to settle into the experience. Whereas the Moment of Cognitive Immersion registers in the intellectual centers of the brain, the Moment of Physiologic Immersion is more of a brainstem phenomenon, where the body automatically adjusts in rhythm with the experience. This is most evident when we use relaxing environments, such as a nature tour or a mindful meditation experience. We can actually see the moment the patient takes his or her first, deep, purposeful breath. The chest abruptly rises, then slowly falls, and the body posture changes markedly. The shoulders will fall back, the torso sinks deeper into the bed, and tension is released, all without conscious awareness. This involuntary physiologic cascade does not always occur, but when it does, we know VR is having its impact. We can see it without question. It’s a beautiful thing.

 

  1. VR can significantly reduce pain without the need of narcotics or other medications

We’ve tested VR for back pain, shoulder pain, foot pain, pain from infections, post-surgical wound pain, and severe abdominal pain, among others. It has been surprising to observe that VR seems to work on all types of pain with seemingly equal efficacy (with notable exceptions, described later). This doesn’t mean that VR works for everyone, but when it works, it really works – regardless of the specific type of pain. In our uncontrolled case series recently completed (manuscript in preparation), we preliminary found a 24% reduction in pain after only 10 minutes of using a special visualization called Pain RelieVR, created by AppliedVR and administered via Samsung Gear goggles. Specifically, the mean pain scores dropped from a baseline of 5.44 to 4.1 out of 10 (p-value<0.00001).

In one case, I treated a patient with 8 out of 10 abdominal pain of unclear origin. Narcotics didn’t work and she was receiving an intravenous drip with ketamine – a powerful analgesic that forces patients into a trance-like state. That didn’t work well, either. But within 10 minutes of using VR she reported “zero pain.” She literally said: “I’m ready to go home, as long as I can bring this thing with me.” The patient was discharged the next day after nearly a week in the hospital.

VR is by no means a miracle cure and some patients have no response. But when it works, it works. After practicing medicine for 18 years, I cannot think of any other treatment I’ve used (short of life-saving maneuvers) with a greater immediate impact on patients than VR.

 

  1. Even a negative response to VR can be clinically useful

We find that roughly 80% to 90% of patients have at least some kind of response to VR, even if it’s not longstanding. That still leaves about 1 in 5 patients who report little to no therapeutic benefit.

But to our amazement, we’ve seen some examples where a completely negative response is also clinically useful.

For example, I recently evaluated a young woman with 8 months of chronic, severe abdominal pain. She had been extensively evaluated by many doctors and all the tests were negative. She was losing weight and could not eat because of the pain, but a clear-cut explanation could not be identified despite extensive testing. Doctors suspected that she was suffering from psychogenic pain and anorexia nervosa. We decided to try VR. Nothing happened. She said the experience was “cool,” but that her pain broke straight through the illusion without abatement. It was a complete therapeutic failure.

The failure was so absolute – so complete – that it caused us to re-think the cause of her pain. If it were at all psychogenic, then we might have expected at least a minor response. It’s unusual for psychogenic pain to break through the powerful illusion of VR completely. We dug deeper to find an organic explanation for her pain, and ultimately found a rare but treatable condition called median arcuate ligament syndrome. The major blood vessels in her abdomen were crushed by a ligament on her diaphragm that was surgically removed. Her pain had an obvious and striking physical cause, and the lack of VR response forced us to look harder and find it.

 

  1. Many patients are medically ineligible to use VR in the hospital

In our first published study we found that despite evaluating 510 inpatients for VR, only 30 (6%) were both eligible and willing to experience the technology. Strict application of exclusion criteria, including presence of motion sickness, stroke, seizure, dementia, nausea, and isolation status for infection control, rendered 83% of subjects ineligible for VR. In other words, lots of patients are already in the hospital because they have a relative contraindication to VR, making it difficult to find a perfect candidate for therapy.

If we loosened our criteria by allowing use of VR goggles in patients with minor nausea or neurological symptoms, then we could greatly expand the pool of eligible patients. In addition, if extensive infection control precautions are employed with VR goggles, then they can potentially be used in patients on contact precautions or infection control protocols, which are highly prevalent in modern tertiary care hospitals.

In other words, it’s not like we can just walk in and use VR in any given hospitalized patients. We have to be very, very careful about not spreading infection in vulnerable patients, not worsening neurological symptoms, and not precipitating new adverse symptoms in patients already trying to recover from illness. The hospital has special considerations for VR, just as it does for any other new biomedical innovation.

 

  1. Many patients still do not want to use VR in the hospital

In our published research, fully 66% of eligible patients refused to participate in the study. This may seem like a very high number, but consider for a moment what it’s like to be a hospitalized patient asked to wear a pair of unfamiliar, toy-like goggles.

The very first patient I approached for our study was a 45-year-old woman who, a month before, developed a “cold” she couldn’t shake. It turned out she didn’t have a cold at all; she had metastatic lung cancer without ever having smoked a day in her life. She had a young child and a supportive family at her bedside. We approached her with a set of goggles, explained how the VR technology might help with pain management, and described how the experience might offer a temporary “escape” from the hospital. She looked at us, silently and unblinkingly, as if we were dropped into her room from another planet. She politely turned down the VR, but I could see in her eyes that our request was simply out of place. She died days later.

I tell this story because we cannot lose track of the very human element of healthcare. What may sound like a fantastical voyage to the well may seem like an unwelcome intrusion to someone with advanced illness. There is tremendous hope and hype around VR, but VR cannot cure cancer and should be recognized for what it is – a single tool that, in some people, can help relieve distress in concert with a panoply of other treatments. I have sometimes heard that VR is “transforming” healthcare. I think that is an overstatement and we should be careful to recognize its limitations while also acknowledging its benefits.

 

  1. The headsets are getting better, but there is still room for improvement

We used Samsung Gear headsets in our study and they were generally well received. In our initial experience we found that 17 of 28 patients interviewed had a positive view about the device. However, patients were split on the comfort level; 14 found the device comfortable and 13 found it uncomfortable (one abstained from answering). When asked regarding improvements on the device, most patients requested enhancements in fit, form, and weight, while others indicated it was hard to achieve focused images. Since staring to use newer headsets we’ve heard fewer complaints, although some patients still feel the device is obtrusive. For patients who already have lost control of their environment by virtue of being hospitalized, some are hesitant to cede more control by covering their face with a headset and losing temporary command of their visual and vestibular systems.

 

  1. If VR is a therapy, then we need an evidence-based “VR Pharmacy”

VR is just a platform. What really matters are the visualizations themselves; i.e. their content, duration and quality. We have found that some patients really like to relax on a beach, while others prefer to play games. Some want to traverse dynamic environments, while others seek stationary tranquility. Some like computer graphics, while others prefer real-life footage. And so forth.

What this means is that if VR is a therapy, then we need a “VR Pharmacy” of evidence-based, well-characterized visualizations that clinicians can pull of the shelf and “prescribe” to individual patients. It would also help to have a formal way to match patient knowledge, attitudes, beliefs, and preferences with specific off-the-shelf visualizations.

We imagine that a new type of provider, called The Virtualist, will emerge to fill this role. The Virtualist will be trained in clinical medicine, bio-psycho-social illness models, and VR technology (also augmented reality [AR] and, in the future, mixed reality [MR]), and will evaluate patients to determine the correct VR prescription. The Virtualist will determine the best combination of experiences, dosages, frequency, intensity, and outcome measures to evaluate treatment response. This may become a medical specialty one day. At Cedars-Sinai, we are testing a “Virtualist Consult Service” that other doctors can call to help with pain, anxiety, and inpatient distress.

We will need more high-quality, rigorous, properly powered, adequately controlled trials to determine which visualizations should be included in the expanding VR Pharmacy.

 

  1. We need to compare VR against an appropriate “sham” control to really test its benefits

We need to begin testing visualizations against appropriate sham controls. It is not good enough to test VR in an uncontrolled case series or against no visualization at all. Instead, we should test new visualizations against different types of controls, such as watching the same experience on a TV set, or even projecting the image in the VR goggles but without the immersive, 360-degree panorama (like watching a movie in the goggles with head tracking). Our new trial, starting soon, will compare VR against the currently-used 24-hour “nature channel” that all patients in our hospital already watch as part of usual care.

 

  1. VR has potential to be cost-effective

While the use of VR in the hospital is promising, no study has yet examined the costs associated with implementing VR in the hospital setting. We recently performed an analysis comparing the cost minimization potential of an inpatient VR therapy program designed for pain management versus usual care. In this analysis, we considered costs related to VR therapy implementation, savings from potential decreases in narcotic utilization and hospital length of stay (LOS), and effects on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and resulting adjustments in Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (VBP) payments.

In short, we found that VR therapy may be cost-saving for a hospital system if it can shave the LOS for patients. In isolation, direct cost-savings from reductions in narcotic utilization and increased HCAHPS-related reimbursements may not be enough to make up for the costs associated with implementing a VR therapy program, but if VR can reduce LOS, then the return on investment will be substantial. For this reason, we are including LOS as an outcome in our upcoming clinical trial. We are currently preparing the full economic analyses for peer-review with more to report in time.

 

  1. Doctors, nurses, and other hospital staff are absolutely intrigued by VR

One thing is for sure – using VR in the hospital turns a lot of heads. Wherever we travel in the hospital with VR goggles, we receive questions from doctors, nurses, and other hospital staff intrigued by the concept of using VR for patient care. It’s hard to leave a unit without allowing curious doctors and nurses to try the headsets (after meticulous cleaning between users, an important point whenever using a hospital-based device).

We have seen near exponential growth in interest among our clinical staff at Cedars-Sinai. Our lab routinely receives calls and emails from clinicians asking us to use VR in their patients. The main limitation has been time and equipment availability. This bodes well for a successful future of VR in hospitals; clinicians understand the potential value of VR and are interested in trying it with their patients. Time and evidence will tell if this excitement should be sustained. We think it will.

For more information about our VR program at Cedars-Sinai, please watch this brief video or visit our lab’s website here. We are always happy to discuss our experiences with VR to enable other hospitals to begin exploring whether and how to use VR in their own clinical environments.