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 . 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 . 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 . 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, firstname.lastname@example.org 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, email@example.com as utility interruptions, parking, traffic flow, and weather can
Mark Sullivan, firstname.lastname@example.org substantially impact how well the facility meets its user’s needs.
Jim Fackler, email@example.com
2.4 Architectural Analysis focus on streamlining and/or improving each process is underway
The architectural world faces the challenge of synthesizing a . 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” . Bernstein then goes on to state patients in other countries. Healthcare providers could also
the following : 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
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 . 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.
3D fly-throughs are sometimes animated using tools such as interest. Examples of such elements might be the processes
discrete event simulation . 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 :
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,
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 . 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)  project and the National Institute of distorted or ’fuzzy’ To answer question like, can a patient
Standards and Technology (NIST)  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
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
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
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