[This link-filled story from HealthTech Magazine describes how presence-evoking technologies are being deployed more often and for more applications in the large Department of Veterans Affairs (the VA) in the United States. –Matthew]
Telehealth and Virtual Reality Expand into Mainstream Care at the VA
Federal health agencies find that virtual visits (and VR) make appointments more convenient for patients.
By Calvin Hennick, a freelance journalist who specializes in business and technology writing. He is a contributor to the CDW family of technology magazines
October 30, 2023
In a pilot physical therapy program run by the Veterans Affairs Medical Center in Asheville, N.C., veterans work to save a medieval village from a fire-breathing dragon.
“While they’re tracking the dragon, they have to keep it in their line of sight,” says Caitlin Rawlins, deputy director of clinical tech innovation in the VA’s Office of Healthcare Innovation and Learning.
“Clinicians are able to see their range of motion — whether they’re able to track that dragon and save the town by moving their head to the left and right or up and down — and then we can track all of those movements over time.”
Rawlins, who is also the program manager for VA Immersive, is describing Rotate, a virtual reality app from XRHealth that veterans use as part of their physical therapy. The gamification and immersive nature of the app help veterans stay engaged and push past previous physical limits.
And because veterans can do their physical therapy at home while clinicians track and interact with them in real time, it is a form of telehealth — giving patients the benefits of a clinical visit in the comfort and convenience of their homes.
“It really changes the face of telemedicine,” Rawlins says.
New Applications for a Pandemic-Tested Technology
Dr. Joseph Kvedar, immediate past chair of the American Telemedicine Association, says that the COVID-19 pandemic taught clinicians which use cases made the most sense for telehealth.
But even as healthcare providers settle into this new normal, he says, clinicians and IT vendors are continuing to explore ways to expand use cases by incorporating technologies such as virtual and augmented reality.
“There are great applications for virtual reality, particularly in behavioral health and for conditions such as phobias,” Kvedar says. “Overall, behavioral health is a good application for telehealth, because even the diagnostic exam usually involves talking to the patient, which you can do over video.”
The Asheville VA pilot kicked off in March with just a handful of veterans, but Rawlins says early results are promising. For one, she says, patients are more likely to adhere to their physical therapy programs when their at-home sessions don’t feel like work. In one module, veterans play a pinball game with their feet.
Some veterans also use their VR headsets for apps that provide a distraction to assist with pain management — potentially helping them to reduce their reliance on medication.
This “productive distraction,” as Rawlins calls it, also helps users overcome previous limitations. For instance, some have improved their range of motion without realizing it while using a VR app.
“I’ve seen patients who have chronic shoulder issues trying to lift a baby bird into a nest in virtual reality, and all of a sudden they’re able to lift their arms higher than they have in 20 years,” she says. “They’re not focused on that fear of movement or that fear of pain.”
The applications and sensors from XRHealth that are being used in the VA pilot are compatible with a number of headsets, including the HP Pico Neo and the HTC Vive Focus. As the veterans use the apps, clinicians can not only monitor their progress but also make tasks easier or more difficult as needed.
Rawlins predicts that telehealth will continue to incorporate more technologies beyond video. “We’re already seeing that shift,” she says. “There’s a lot that you can do with the technology, and I think we’re still just scratching the surface of what is possible.”
NIH Adopts Tech for Seamless Telehealth Capability
In the early days of the pandemic, the Clinical Center at the National Institutes of Health began using a telehealth platform that runs on top of commercially available solutions such as Microsoft Teams, while also streamlining integration with other tech systems and offering one-button simplicity for users.
“One of the greatest features is that it’s a fully integrated platform,” says Tricia Coffey, chief health information officer for the NIH Clinical Center. “We have the ability to support not only virtual visits but also virtual rounding, where teams can round on patients even if the entire team isn’t here onsite. It also manages telehealth appointments, so we don’t have to set up multiple feeds to other systems.”
Before the organization adopted the solution, patients had to download a videoconferencing solution to their own devices to participate in telehealth appointments, notes Marisa Owens, assistant chief for patient engagement and system integration.
“The solution uses the default browser on the user’s device, which was huge for us,” she says. “We have a wide variety of ages in our patient population, so it’s nice that people can just click on a link and it brings up their visit.”
The Clinical Center averages about 50 telehealth visits a day, with the NIH’s National Cancer Institute and the National Institute on Alcoholism and Drug Abuse being the largest users. Owens says telehealth is especially useful for follow-up appointments; the Clinical Center draws patients from around the country, and even for locals, traffic can make in-person follow-ups inconvenient.
The initial learning curve for telehealth solutions has “leveled off,” Coffey says, and clinicians are now exploring ways to further expand use of the technology.
“We’re thinking about how we can leverage telehealth to do more remote screening of patients for our studies so they’re not having to travel long distances just for their initial screening visit,” she says.
Owens predicts that the organization will soon incorporate other technologies, such as wearable devices, into its telehealth programs.
“We definitely are headed in that direction,” she says. “A lot of our research is dependent on patient information like blood pressure, temperature and other data that could be collected from a patient at home.”
Army’s BRAVE Program Takes Telehealth Around the World
The Army Virtual Medical Center, operated by the Defense Health Agency and headquartered at Brooke Army Medical Center in San Antonio, was started in 2018 to stand up military telehealth solutions around the world.
Then, when demand spiked in 2020, the center was bombarded with requests to train military clinicians who wanted to rapidly implement new equipment and practices.
Last November, the center launched the Behavioral-Health Resources and Virtual Experience (BRAVE) program, aimed at connecting behavioral health service providers with active-duty service members across the globe.
“We try to find the sites that are most in need of help, places that lack those providers,” says Lt. Col. Gary Legault, a surgeon and director of the Virtual Medical Center. “It’s extremely important that we have this help available, that there’s somebody service members can reach out to and talk to. Hopefully, we can catch people before they reach a breaking point or crisis.”
For security and compliance reasons, service members stationed outside the U.S. must still visit clinics to use telehealth solutions. To support them, the Virtual Medical Center has invested in telehealth carts equipped with Cisco Webex stations featuring a 23-inch display.
The Virtual Medical Center has also incorporated remote patient monitoring in its telehealth offerings, illustrating how telehealth continues to evolve.
“During the COVID-19 pandemic, we sent patients home with these remote monitoring kits, and that helped save space in the hospital,” Legault says.
“We’ve ended the program now that our capacity is less strained, but we’re looking at other plans for remote patient monitoring as we go forward. There are so many possibilities.”
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[Sidebar:] VA Uses VR in the Treatment of Numerous Conditions
Imagine a medical treatment so versatile that it can be used to alleviate chronic pain, treat anxiety and depression, and address behavioral health issues such as addiction.
Clinicians at the Department of Veterans Affairs are using one form of treatment for all of these conditions — and more. It’s not a pill or a shot. It’s virtual reality.
“We are seeing incredible patient impacts from virtual reality,” says Anne Lord Bailey, the immersive technology lead in the VA’s Office of Healthcare Innovation and Learning. “We’re seeing improvements in anxiety, depression and pain management, and we’re seeing patients who have progressive disease actually get stronger because of the work they’re doing in VR. It is really a brilliant technology.”
Already, the VA has deployed more than 1,200 VR headsets to medical centers in all 50 states and several territories. When veterans are surveyed about their use of VR, Bailey notes, they give the experiences an average rating of 8 out of 10.
“Ninety-one percent of the patients that we’ve worked with say they want more virtual reality,” she says. “That’s why the VA is really leaning into this technology.”
The agency has adopted a mix of off-the-shelf and custom applications for more than 40 use cases, including the following:
Pain Management
VR solutions have been shown to help treat both chronic and acute pain. One method is through what Bailey calls “positive distraction.” Just as a parent might distract a child from a skinned knee by putting on her favorite television show, an immersive VR experience can help redirect patients’ attention from even significant pain.
VR applications can also deliver cognitive behavioral therapy experiences that help patients cope with pain, Bailey notes. By reducing pain, she says, VR experiences may also help veterans become less reliant on medication.
Mental Health
The VA has used VR applications to treat depression, anxiety and post-traumatic stress disorder, and it has even used them in the agency’s suicide prevention efforts. “We’re developing virtual reality versions of specific experiences that are known to be triggering for PTSD,” Bailey says.
“Veterans will wear the headset and enter an environment that can be triggering, such as a restaurant or a grocery store, without having to actually go into those physical spaces,” she adds. “They can be side by side with a clinician, or even at home, and they can start to get that exposure and learn the skills and practices that will help them in their daily lives.”
Addiction
Similarly, VR can be used to simulate common addiction triggers, such as being in a social environment where others are using drugs or alcohol. “One thing I’ve heard people say about virtual reality is that ‘mistakes are free,’” Bailey says. “It helps people learn behaviors that will help them respond differently when they encounter those triggers or cravings in the real world.”
Training
In addition to its clinical work with veterans, the VA is using virtual experiences to enhance employee training. These include training on simple administrative tasks such as patient discharge as well as more fraught topics such as gun safety.
“We’re using VR to help people who may not be familiar with firearms learn how to safely disarm and lock weapons,” Bailey explains.
Social Connection
So far, consumer applications of social VR haven’t really taken off. Still, Bailey says, virtual reality has helped isolated veterans to build meaningful connections with each other. And in therapy, the headsets have helped some veterans to open up more than they would if they were looking at a clinician eye to eye.