October 16, 2018
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Pediatricians explore ways to use virtual reality in practice

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Researchers and pediatric specialists are working to find new, innovative ways to use virtual reality to improve patient care.

Kate Donovan, PhD, MBA, MS, clinical director of immersive technologies at the Innovation & Digital Health Accelerator and innovation technology coordinator for Medicine Patient Services at Boston Children’s Hospital, has been working with various departments in her hospital to explore ways this technology can help its youngest patients.

One recent study that Donovan conducted with hospital staff focused on giving virtual reality (VR) experiences to pediatric patients undergoing gastroenterology procedures — including upper endoscopies and colonoscopies — to relieve their anxiety. The children used headsets and headphones augmented by smartphones to experience a clinically validated game called “Bear Blast” by AppliedVR, in which they would use balls to knock down cartoon bears — similar to bowling.

The study focused on the preprocedural waiting area to see if the children’s VR use would impede the workflow of nurses. Donovan and colleagues found that although the VR program added about 5 minutes to the nurses’ procedures before surgery, it saved time in the post-anesthesia care unit (PACU) because it calmed the children, requiring less sedation going into the procedure. The researchers plan to conduct additional studies to verify these results.

In an interview with Infectious Diseases in Children, Donovan said she looked at the VR “from the perspective of how the kids can be immersed into these fantastical places and completely separated from the clinical environment that they are in.”

Donovan called the study results a welcome success in moving this technology forward in the pediatric clinical environment.

“I knew the kids would adopt VR rather quickly because it is fun, and ‘Bear Blast’ is a game that they wanted to play. But what I found by looking at the entire process is that it required less time in the PACU. With that finding, VR actually saved the patients and the family financially.”

Kate Donovan

Donovan has been at Boston Children’s Hospital for 25 years, having worked in the anesthesia, gastroenterology and nursing departments, and has created multimedia educational material for patients, nurses and physicians.

“I was always looking for new ways to educate folks, and through my outside gaming interests, I found virtual reality while getting my MBA and PhD at MIT,” Donovan said. “The benefit of my background is that I have been at the bedside the entire time I have been at Boston Children’s.”

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She added that she has had Crohn’s disease since she was a child, “so I know what it’s like to be in the hospital and be scared, and I know what that pain feels like.”

Donovan recommended using VR in any procedure that requires local sedation, including IV and central line placements.

“I think VR and augmented reality [AR] and mixed realities are an exciting new technology that have many applications in health care,” Michael Docktor, MD, a gastroenterologist in the Center for Inflammatory Bowel Disease and clinical director of innovation at the Innovation & Digital Health Accelerator at Boston Children’s Hospital, told Infectious Diseases in Children.

Docktor is working with Donovan on a separate study in gastroenterology involving an app called Health Voyager. The app, developed at Boston Children’s Hospital in collaboration with Klick Health, allows physicians to take the clinical findings from a procedure such as a colonoscopy and create an interactive tour of a patient’s intestinal tract to show where disease may be present. An example would be if a patient comes in for an endoscopic procedure and Crohn’s disease is discovered, the app could allow the patient to “navigate” through their own intestines to see where the inflammation was found and educate themselves on their condition.

Donovan said that the Health Voyager app will allow children to understand their Crohn’s disease better, and she compared the app to “The Magic School Bus” animated series by Scholastic Entertainment, which helps children learn about science.

 
Figure 1. Tech companies working with health care organizations charge between $4,000 and $7,000 for VR headsets, smartphones and content licenses.
Source: Kate Donovan, PhD, MBA, MS

“What I think is unique and compelling about Health Voyager is that it is a highly personalized educational experience, which allows for what we hope is a more engaging and overall higher value experience for the patients and their families.” Docktor said. “The ability to customize the ‘voyage’ based on the specific clinical findings for that patient allows for a much more tailored and memorable experience. Beyond the initial gastrointestinal use case, we are excited about expanding the personalization of medical education to a more precision-education initiative across other disease processes and anatomic areas.”

Donovan said the Health Voyager app is just one of many ways that VR could be used in preprocedural and postprocedural processes for pediatric patients.

She said there is clearly an upward trend in VR’s use in health care, based on the increase in academic publications. There has been an approximate 30% increase in publications reporting on VR over the past 3 years, based on a quick search of PubMed, Donovan added.

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Other children’s hospitals across the country are experimenting with VR as well. At Children’s Hospital Los Angeles, researchers are studying it for children and adolescents undergoing painful procedures, including blood draws. Their hypothesis is that the children using VR will report significantly less procedural pain and anticipatory anxiety, lower heart rates and less behavioral distress compared with patients receiving the standard of care, including topical anesthetics.

A phase 2 trial being conducted by St. Jude’s Children’s Research Hospital is studying the efficacy of VR when added to standard pain management of patients with sickle cell disease who are experiencing an acute pain crisis in an ambulatory care setting. The primary objective of the study, which is expected to enroll 76 participants aged 6 to 25 years, is to measure the patients’ pain 30 minutes after the intervention.

‘Exposure therapy’

At Boston Children’s, Donovan also is working with her colleagues on creating an experience for MRI procedures so that children can see what the MRI machines look like beforehand. She described it as “kind of exposure therapy.”

She explained that sometimes children will come in for an MRI appointment and will not be able to tolerate the machine, requiring cancellations and rescheduling. In the VR model, an accelerometer in the headset is used by the patient for about 4 minutes before the MRI appointment to see if a patient can stay still for the required amount of time. The experience includes the sounds of an MRI to expose them as if they were actually in an MRI machine.

Michael Docktor

Another project Donovan is developing is a VR tour of the psychiatric unit for children who arrive in crisis to the ED, so they can see the facilities before being admitted, and to possibly relieve some of their stress for the patient and the family.

“What we found with that study is that the handoff from the ED nurse to the psychiatric unit nurse required much less time because the kids were familiar with the space prior to admission,” she said.

Donovan and colleagues worked with inpatients in the psychiatric unit and asked them to give insight to what they wanted to see before they came up to the unit. She added that she is actively working on creating similar VR programs for other areas of the hospital.

Challenges with VR

A drawback with VR is that parents cannot be involved in what their children are experiencing, Donovan said.

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“When using virtual reality with a child, you are completely immersing a child in VR, which essentially removes the parent, and that can be a little bit tricky,” she said. “Boston Children’s Hospital takes a family-centered care approach to using VR with children. We are present for every VR experience and make it a priority to educate the parents about the VR process by explaining what will go on before and during their child’s VR experience.”

Donovan said that parents “are excited about the technology and want to know what is going on inside the headset, what their child sees in VR.”

“Many times, their curiosity can interrupt their child’s immersion, so we try to reiterate the importance and benefits of complete VR immersion while the child is in the headset,” she added. “In addition, we have to understand that they can be just as anxious as the child, so we have to be empathetic and understand how removing them from the experience may be stressful for them.”

On the other hand, this can be an advantage, she said. Parents may need to answer very specific questions during the preprocedural period, but the child does not necessarily need to be part of that discussion. For some children, hearing information about a test or procedure can compound their stress, so VR is a great distraction.

Another obstacle to using VR in a health care setting is infection control.

“One of the challenges is getting VR to the bedside of patients because of the potential of cross-contamination if people don’t clean the equipment appropriately,” Donovan explained. “When selecting a VR headset for the health care environment, you have to make sure that the materials used on the headsets are not porous and are able to be disinfected to hospital standards between patient use.”

The future of VR

The future of VR is changing as the technology evolves. Currently, many tech companies that are working with health care organizations charge for the headsets, smartphones and content licenses, which usually cost between $4,000 and $7,000 per year, according to Donovan. The headsets are drastically coming down in price, she added, and the newer headsets are standalone devices, eliminating the need for additional smartphone equipment.

“This makes it extremely useful for the patients who are not tech savvy,” Donovan said.

Donovan said that she would like to see more health content made available on consumer headsets “so kids could come in for procedures prepared or take the technology home with them. It would be cool to send kids home with a headset to use as a companion to educate them post-procedure or post-diagnosis.”

Other VR projects that Donovan is working on at the hospital involve sickle cell disease, dialysis, oncology, pain management and injury prevention in children.

Docktor sees VR playing an increasingly larger role in how physicians reach their patients.

“Early use cases offer compelling ways to distract and reduce anxiety in our young patients undergoing procedures and anxiety-provoking experiences in health care,” he said. “In the near future, better ways to train, educate and engage both providers and patients will be more commonplace. VR/AR and other immersive technologies will be a ubiquitous element of the lives of our patients and we would be wise to understand it and leverage its capabilities for our patients.” – by Bruce Thiel

Disclosures: Donovan reports no relevant financial disclosures. Docktor reports being cofounder of Health Voyager.