The Need for Healthcare Modeling in Virtual Worlds

    Michael J. North,               Henry Bell             Susan O’Har...
2.4      Architectural Analysis                                        focus on streamlining and/or improving each process...
3D fly-throughs are sometimes animated using tools such as                   interest. Examples of such elements might be ...
during their experiences within the virtualization environment.        5     CONCLUSION
The user has to have appropriate a...
[11] NIST, Focused Program Competition 97-03: Information
Infrastructure       for       Healthcare,      Available at
htt...
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  1. 1. The Need for Healthcare Modeling in Virtual Worlds Michael J. North, Henry Bell Susan O’Hara, RN, Mark Sullivan, Jim Fackler M.D. MBA, Ph.D.* MPH AIA, NCARB Argonne National Smoky Mountain O’Hara HealthCare Mark Sullivan Johns Hopkins University Laboratory Simulation Services Consultants Architects School of Medicine ABSTRACT 2.1 Vulnerability Assessment Healthcare is a field ripe with both compelling needs and How well can a given hospital or healthcare system function if opportunities for development of applications in virtual worlds. there is a pandemic such as an outbreak of avian flu or a major Expansion and adaptations of current facilities and processes to earthquake? What would the nurses, doctors, and staff of a meet the dynamic healthcare environment compel solutions hospital experience while treating patients? What would the providers to develop improved planning and training patients themselves experience? Answering such questions often environments. involves expensive and time consuming mock disaster exercises that involve only limited numbers of healthcare providers. A well KEYWORDS: Virtual worlds, healthcare, medical architecture, agent designed virtual world can provide an opportunity to quickly based modeling and simulation. answer such questions, potentially on very large scales. INDEX TERMS: J.3 [Life and Medical Sciences]; J.6 [Computer- 2.2 Training Aids Aided Engineering]; I.6.3 [Simulation And Modeling – Virtual world healthcare applications offer an opportunity for Applications] people in the system or even the patients to experience environments that are uniquely difficult or dangerous to replicate 1 INTRODUCTION in the real world. If healthcare providers are able to experience Why have sick people in a virtual world? virtual disasters prior to the real thing, the healthcare community Current virtual worlds are largely devoid of healthcare issues. might be able to develop improved coping strategies for Many games show participants’ health status, however, death has healthcare workers and first responders. no more consequence than a time-out. Sometimes video game As mentioned above, many leading teaching hospitals have players can find food or other items to restore ‘health’ yet the surgical suites that double as working classrooms. Instrumented avatars rarely get sick and do not need or trauma units. and sophisticated manikins complete with respiration, pulse, Meningitis does not spread in virtual world college dorms. blood, and sound are already in use to simulate surgical events to Beyond such fantasy virtual worlds are arguably more mature test personnel and equipment. Virtual world healthcare virtual applications (e.g. military environments). Again, applications can extend those efforts, without requiring huge capital construction investments. healthcare modelling is rather limited. Allowing prospective healthcare personnel to experience not Healthcare modelling itself, albeit primitive, is decades old. just a single medical event, but rather an entire normal or Pulmonary physiology was modelled in the 1970’s [1]. The abnormal workday may help them to clarify the focus of their current state-of-the-art is far more sophisticated with interests and identify talents. Helping candidates identify job- extraordinary realistic virtual medical environments [2]. Yet related issues prior to expensive and time consuming training can facility based, or population based, simulation in the field of promote more efficient use of training investments. For example, healthcare is, at best, embryonic. better use of the virtual world might help combat the well known There is much to learn from the intersection of these two kinds high turnover rate for first and second year nursing professionals. of virtual worlds. Modelling in healthcare is showing relevance in The virtual environment might also pay a pivotal role in the design, both physical and operational, of healthcare facilities. training home healthcare providers and family members in how to Work is also ongoing in the use of models for prediction of patient deal with heath issues and patient care in a home environment. and population specific scenarios. 2.3 Facility Planning 2 MOTIVATIONS / APPLICATIONS New hospital construction in the next decade is expected to Developing successful virtualization solutions depends upon reach staggering proportions [3]. These new facilities, as well as understanding what compelling needs exist or will exist in the existing facilities, need to function in ever-changing regulatory, future world of healthcare. Who are the users of such virtual sociological, and physical environments. Virtual world healthcare systems? What are their needs? Are subject matter resources applications may allow facility designers and managers to ask available to help create healthcare applications in virtual worlds? design and maintenance questions that may otherwise be difficult What applications are currently under development? to answer. Example questions include where to put the facilities and how to size the buildings be based on the current and projected demographics of our patients, nurses and doctors? Michael North, north@anl.gov Facility planners must also consider issues such as what Henry Bell, Henry.Bell@SmokyMtnSims.com services will be offered at a certain location? Mundane issues such Susan O’Hara, ohc@comcast.net as utility interruptions, parking, traffic flow, and weather can Mark Sullivan, msarchitects@comcast.net substantially impact how well the facility meets its user’s needs. Jim Fackler, fackler@jhmi.edu
  2. 2. 2.4 Architectural Analysis focus on streamlining and/or improving each process is underway The architectural world faces the challenge of synthesizing a [5]. Further government regulatory efforts add a many of new design for a space based upon a growing list of criteria to serve requirements each year. These requirements come from national, healthcare providers, patients, and visitors. Design experience is state, local, and even professional entities. Having a virtual world based on past events, yet the architect is designing for the future. to assess the impact of adding or changing a task would provide The design must be suitably flexible and adaptable for the future. an insight into whether the change accomplishes the goal of the Many of the factors that determine the ultimate success of the requirement or process, and allows for a search for unintended design may not have emerged. consequences from well-intentioned but misguided design A growing movement in healthcare architecture is evidence changes. The presentation of the processes in virtual worlds can based design. Simply put, this concept is that simulation modeling help bridge the gap between the process experts and neophytes. or other objective methods are used to perform non-subjective analysis of the designs’ performance. Virtual world healthcare 2.7 Legal Decision Making applications can provide future users, decision makers, and even Each year, the United States legal system handles a large the public with the ability to live within a design. Feedback from number of with lawsuits regarding medical treatment. In many the experience can help the architects hone their designs. The cases, juries make the decision of financial liability and architects can also use virtual worlds to better understand and responsibility. Just as traffic accident simulations or visualizations communicate the nuances of their own designs. Imagine how have played an important role for juries, an immersive healthcare much better the architect can immerse themselves in the design environment might provide juries with a better appreciation of the itself if they could experience the ragged edges of their design issues related to the case at hand. envelope. What would this emergency department look like if the facility was dealing with a huge influx of patients from a tornado 2.8 Cultural Exchange strike? Could a small but significant design change help the facility cope with the disaster? Standing in the middle of such an Virtual world healthcare applications provide a mechanism for event could provide the architect and other subject matter expert’s people to interact in a realistic, compelling, and non-threatening powerful insights. The world of architecture recognizes these environment. With a properly configured system, people could needs to obtain “more information from new visualization and tour virtual hospitals and experience what it might be like to be representation technologies” [4]. Bernstein then goes on to state patients in other countries. Healthcare providers could also the following [4]: experience what is like to treat patients from other cultures. …building information models (BIM) will become the basis for newly defined design deliverables. Digital models, 3 MODEL TYPES created as prototypes of physical construction, will provide Virtual worlds are the natural extension of the current of improved decision-making, visualization, and generation of healthcare models. With the advent of personal computers alternatives, as well as detailed and numerical analysis. mathematical models became simpler to construct. The science of Analysis tools, running in parallel with models, will report statistics and uncertainty drove a move to more advance real-time implications of design decisions as they are techniques including discrete event modelling. These modelling represented in the model, providing immediate indications of techniques are only just now becoming integrated into the future building performance. Eventually design models will architectural world of desktop facility models and Computer replace traditional drawings with databases that become the Aided Design (CAD) facility fly-throughs. A variety of spatial basis of construction administration and facilities- models with varying levels of realism have been used to represent management processes… Designing and building has never been so complex an endeavor... What’s demanded is nothing healthcare facilities including architectural desktop models, fly- less than a dramatic increase in the insight available to through 3D architectural models, building information modeling, architects as we do our work. We need changes that move and virtual reality models. Virtual representations of healthcare design and construction from an exercise in “lowest first facilities, people, and processes driven by agent-based modeling cost” to one of predictable outcomes. and simulation (ABMS) are the next step to providing a rich interactive experience. 2.5 Business Planning 3.1 Architectural Desktop Models The healthcare industry is spending huge amounts of money in the United States and the world. How do the business leaders Anyone who has sat through a Godzilla movie understands the make sure that the decisions they make serve society, their concept of miniature building models [6]. Architectural models stakeholders, and the users of these healthcare facilities? are much more sophisticated representations of facilities built to Unfortunately, the experiences of the healthcare management scale. Frequently, these models include removable roofs and notes professionals are not guaranteed to automatically align with the regarding service areas and space allocation. Users of the space patient or public perception. If a healthcare planner wants to see can use these models to get a better understanding of the space how the facility they propose fits into a historic neighbourhood, than they can get from drawings alone. For example, the users can visualization can be a strong ally. They can build the virtual map patient and nurse movements through the space. facility and use it to address public concerns expressed in 3.2 Fly-Through 3D Architectural Models planning board meetings. Ultimately, such a tool might shorten the zoning approval process by building public confidence in the In the 1990’s, computing graphics power allowed users of planned business. architectural CAD systems to build shaded and textured computer models directly from the same design inputs used to generate 2.6 Process Planning drawings. The tools evolved to allow the architect to move The healthcare industry has thousands of processes occurring through the designs as if a person was walking through the system each day in each major facility. Given the relatively recent holding a camera (i.e., a ‘fly-through’). These fly-throughs allow recognition of the magnitude of errors in healthcare, a serious a basic ability for people to immerse themselves in a design.
  3. 3. 3D fly-throughs are sometimes animated using tools such as interest. Examples of such elements might be the processes discrete event simulation [7]. The results allow the performance of and systems for handling a patient for day surgery, from some kinds of healthcare processes to be investigated and for sign-in, through surgery, and ultimately through discharge. users to view the results within 3D fly-throughs. However, these The virtualization must include the preparation areas, animations are usually not interactive in the ways expected in operating rooms, recovery areas, and even billing. These newer virtual reality systems. virtual patients might have complications that require the patient be admitted for long-term care. 3.3 Building Information Modeling • Healthcare Services Processes - Many other services may The architectural world has begun the shift to Building not involve direct patient interaction, but are key to Information Modeling (BIM). The transition will be a long accurate virtual worlds. Examples of these might be lab process but offers real benefits [8]: services, consulting services, dietary services, The acronym BIM (Building Information Modeling) was rehabilitation services, Radiology and Imaging Services, coined in early 2002 to describe virtual design, construction, etc. and facilities management. BIM processes revolve around virtual models that make it possible to share information • Supply Chain Processes – Delivery of key healthcare throughout the entire building industry. These virtual models supplies must be integrated into the virtual worlds. The are embedded with data which, when shared among design delivery of medications, supplies, and food needs to team members, greatly reduces errors and improves facilities. happen in the virtual world in ways that reflect real world BIM offers owners the ability to become more efficient and variability. Consider a simple example. Operating rooms effective by linking their business processes with their may use pre-built surgical carts, properly stocked with facilities. The federal government has predicted savings of surgical implements appropriate to the scheduled over $15.8 billion annually from integrated processes… procedure and patient. How do the carts get assembled, Where planning once relied on broad generalities and "rules transported, tracked, deployed, retrieved, and processed for of thumb", you can now simulate "real life" using BIM."… other patients? What happens if an instrument is missing BIM is not a software application. BIM is an information- that is supposed to be in the cart? What if an instrument is based system that builds long-term value and advances needed that was not anticipated? innovation. It improves how projects get designed and built. It builds economic value in many areas. It improves the • Facility Services and Processes – The hospital has services environment and people's lives… BIM is an evolutionary key to performing its mission. Power, HVAC, lighting, change in how people relate to the built environment. communication, water, waste management, elevators, The information contained in BIM provide a natural platform planning and numerous other systems and their related for virtual worlds as well as ABMS. processes provide elements for inclusion in the ABMS is a way to simulate a large number of choices by virtualization. If, for example, all medication orders travel individual actors [9]. ABMS shows how the consequences of through pneumatic tubes, the virtual world should include individual or “micro-level” decisions play out at the system or that restriction. “macro-level.” ABMS can be used to model the behaviour of 4.1.2 Environmental Factors and Stimuli simulated participants in virtual worlds. The more familiar elements of creating a compelling solution 4 CONSIDERATIONS FOR A VIRTUAL HEALTHCARE WORLD apply in healthcare systems as well, but with subtle adaptations. To apply virtualization to the current simulation-based solution • Visual – The solution must present an appropriate visual toolset there are certain factors to consider. First, a definition of representation. Here some unique considerations may what’s needed for virtualization is appropriate. Then, a review of factor into the visualization. The user may want the tools and data sources that are currently used is presented. There visualization from the prospective of a patient with are efforts underway through the Research into Global Healthcare impaired vision. So, the visualization may need to be Tools (RIGHT) [10] project and the National Institute of distorted or ’fuzzy’ To answer question like, can a patient Standards and Technology (NIST) [11] for standardization of with limited vision still find the way to the places they healthcare infrastructure, including modeling tools. These efforts need visit? have the potential to play a role in the integration discussed later. • Audio – The audio presented to the user of the visualization needs to be compelling and commensurate 4.1 What Constitutes Realistic Environments? with the real system experience. The advent of 3D sound engines allows complex and rich sound to be integrated One goal of realistic virtual environments is to immerse the user into the visualization. As with visual impairment, the in a world that represents the experience of the target needs of patients with hearing issues must be modelled. environment. For virtual world healthcare applications to provide the greatest benefit, solutions must provide fine grained • Haptics – The model should include tactile sensory inputs interactions between the user and a simulated environment with when possible. For example, a nurse in training might complex behaviors. To achieve this, the virtual world must have to take a virtual patient’s pulse. The nurse would succeed at both the conceptual and environmental levels. need to feel the patient’s wrist and pulse. Tactile impairment needs to be modelled here as well. 4.1.1 The Conceptual Level 4.1.3 Situational Awareness and Experience Tracking The virtual world healthcare solution must provide a mechanism for supporting different system level definitions: Some elements of the virtual world are key to leveraging the user experience. For example, user may become disoriented or • Patient Treatment Processes – The solution needs to confused while experiencing a virtual world. If the user is an accurately depict elements of treatment processes of architect, they need the ability to capture what insights they gain
  4. 4. during their experiences within the virtualization environment. 5 CONCLUSION The user has to have appropriate affordances and queues to allow The world of healthcare is them to understand the situation in which they are embedded. fertile ground for the development of virtual world 4.2 Current Tools Need To Coalesce applications. The benefits of Many elements of the solutions exist today, but need to be focusing effort in developing integrated and enhanced to achieve the healthcare visualization these applications are potentially environment required. substantial. We have Today’s mainstream CAD systems do not typically export 3D championed the role of representations of structures into a virtual world engine file healthcare, architecture and formats with the needed fidelity and convenience. Tools are modeling as a paradigm for needed to perform this in a seamless and convenient fashion. creating simulation models for By and large, most process planning tools do not yet provide a Figure 1 Copyright the healthcare domain for several O’Hara HealthCare smooth way to integrate them with behaviours virtual world years as shown in Figure 1. Our Consultants, LLC simulation software. multifaceted approach includes Figure 1: There are many scheduling and resource planning tools but they healthcare systems and the Integrated do not generally have links to virtual world simulation software community as shown in Figure Modeling for quickly realizing resource strategy changes. 2. A number of virtual reality visualization tools exist today. There is a need to fully integrate these tools with architectural modeling tools and planning tools. 4.3 Current Data Sources Need To Be Integrated A variety of data sources impact directly on healthcare modeling. However, to be effectively used these data sources need to be seamlessly integrated. The U.S. Census Bureau and other agencies provide significant demographic information. However, it is currently difficult to manipulate the data to drive the demographics of simulated patients, visitors, and staff. The census bureau also provides population planning for detailed geographic ‘communities’ but often the population growth or decline and the morbidity and mortality by disease classification has to be merged and correlated. The ‘perfect’ database that combines population, Figure 2 Copyright O’Hara HealthCare disease and healthcare delivery systems is not yet available. Consultants, LLC The Department of Health, CDC and other agencies at the federal, state and local levels maintain databases containing Figure 2: Multifacted Modeling substantial amounts of healthcare related data. The Agency for REFERENCES Process HealthCare Quality Research promotes the use of health care data [1] N. 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