How Doctors, Nurses, Allied Health Professionals and Patients Use Second Life


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2010 ICSI/IHI Colloquium on Health Care Transformation - Robin Ashford, MSLIS, May 5th, Innovation Track

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  • An overview of some of the activities by health professionals and patients in Second Life.
  • Screenshot of my login page from a specific date/time in January 2010. There is a different photo displayed each time a resident logs in to SL. The black box in the upper right corner shows the current time (main headquarters of Linden Labs is in San Francisco, therefore SLT is PST) and the number of people currently online (in this case 73,214), and the number who logged in during the last 60 days (in this case 1,423,469).
  • In September 2009 Linden Lab, creator of Second Life, announced that SL residents had transacted the equivalent of more than one billion US dollars with each other while spending more than one billion hours in SL, significant milestones. This announcement and other statistics can be found here:
  • The blue avatar in this snapshot is me, Robin Mochi in SL. So who am I and how did I become involved with the health information profession in SL? In April 2009, I responded to a Request for Qualifications (RFQ) from the Alliance Library System and the National Library of Medicine for an HIV/AIDS grant-funded project. I was granted an interview before a panel in SL and in May 2009 was hired as the new Consumer Health Librarian on Karuna Island. The presentation linked above describes my role in the project in detail. It was a remarkable experience, which ended April 1, 2010. I’m also an academic librarian who has been exploring educational applications of Second Life for almost 4 years. In SL I found an intelligent global community with whom I could easily connect, share, collaborate and learn. As an adjunct instructor for my university’s School of Education, I have taught graduate education students about the educational applications of virtual worlds. My courses are taught fully in SL and have included students from as far away as China.
  • This is the island where I was contracted to work 10 hrs. per week to provide HIV/AIDS information resources to visitors of Karuna Island. The primary building where I worked, named the Karuna Resource Center, is the dark mahogany building on the upper left of this snapshot.
  • This is the reference desk where I worked two pre-set hours per week to answer questions from walk-ins. I was also available by appointment. The remaining hours were flexible to allow for monthly presentations, collaborate on large projects with Karuna partners (i.e., World AIDS Day) and to research and update information content from government and non-profit websites such as the CDC, NLM,, etc. Next, we’ll take a look at a well known SL medical facility…
  • This is a screen shot of the inside entrance of the Ann Myers Medical Center (AMMC) – From the blog linked on the slide: “The Ann Myers Medical Center (AMMC) was founded by Doctor Ann Buchanan. The center was named for her mother, Ann Myers. Dr. Ann’s mother suffers from a rare brain tumor…” Training for medical students, health information and technique training for the general public, and actual patient advising by a few RL (real life) doctors takes place here. I’ll be sharing a number of slides from this place.
  • I had just teleported and was looking around when Dr. Vera Zhaoying, a Dutch volunteer and new resident physician, who has been heavily involved with the AMMC and is responsible for much of the content inside the Center, appeared and welcomed me. We had not met and she did not know I was coming but kindly offered to take me on a tour of the building.
  • Entry just past the welcome desk of the AMMC
  • We walked past several offices and labs to the Health Center for Women, a special project by Dr. Vera.
  • Objects can be clicked by avatars which can activate what are known as “animations” which allow one to do things such as washing your hands.
  • PowerPoint slides are loaded into a viewer which avatars can control by clicking the arrows forward and back.
  • The mammogram machine is clickable and positions my avatar to get a sense of a real life mammogram.
  • This was the most extensive animation in the Women’s Health Center. Each number is clickable and animates the avatar according to step, which are shown in text as they are clicked as the next slide will show.
  • The avatar animations align with the written steps as each is clicked. The Women’s Health Center is an effective way of teaching by providing information, an animation, and showing the steps in text for breast self exam.
  • Training room – When question mark is touched (clicked) the notecard in this screenshot is presented.
  • Medical student training instructions (timed). Clicking the “?” at the end of the bed shown in this slide pulls up the notecard in this screen shot and leads the student to additional information and further steps.
  • Room contains emergency information as well as a way to reach a real life psychiatrist for advice via a bell on the doctor’s desk.
  • This is the profile of Dr Ren Stonecutter, as he’s referred to in SL. (Every avatar in SL has a profile and anyone in SL can click to read the profiles of avatars around them, a common practice in SL). Dr Ren has been in SL for close to 5 years. He is the founder of the Second Life Medical Association for physicians and medics throughout all the cultures of Second Life. “An organization for promoting better health in SL, answering medical questions and providing medical education for the residents of SL. R/L physicians, nurses and other health care professionals are welcome to join and help out.” Ren is also heavily involved with the American Cancer Society in SL and is Chair of Corporate Sponsorship Relay for Life in SL 2010. The quote on this slide is from a presentation Ren gave over a year ago in SL. The link on the slide is to a notecard he provided of that presentation, which provides valuable insight.
  • From the Abstract: “Although the potential of SL has been noted for health professions education, a search of the world’s literature and of the World Wide Web revealed a limited number of formal applications of SL for this purpose and minimal evaluation of educational outcomes. Similarly, the use of virtual worlds for continuing health professional development appears to be largely unreported.”
  • Purpose: “The purpose of this project was to explore the potential of using a virtual world platform for medical education through the development of a one-hour, interactive seminar for postgraduate primary care physicians on the topic of insulin therapy for type 2 diabetes.” “ The organizers commissioned Dr. Elliot Sternthal (MD, FACP, Director of Outpatient Diabetes Program, Boston Medical Center) to provide the session content. The instructional emphasis was to understand the options around diabetes patient assessment, insulin administration, and titrating dosage.”
  • “ Of the 14 participating physicians, 3 were experienced Second Life residents who did not require coaching. The remaining 11, plus the seminar speaker, were coached in one-on-one sessions conducted by phone with coach and participant each on their respective computers. It required an average of 12 email communications, and an average of 78 minutes of coaching time per participant to gain required proficiency.”
  • Results – The Event: “ The event was held on Monday, June 15, 2009, from 7:00pm to 8:00pm (EST). Avatars were asked to arrive 30 minutes early to get everyone settled and to resolve any technical issues. The session officially ended at 8:00pm, but the physicians stayed until 8:30pm asking questions and socializing.” “ The organizers worked with Dr. Sternthal to create an instructional design for the hour-long session and build an avatar that resembled him in real life. Dr. Sternthal started with a PowerPoint deck to support a 40-minute insulin therapy talk. We found that this deck, which would work well for a face-to-face talk, was too long and did not allow opportunities for the interaction and activity afforded by the virtual world. The organizers worked with Dr. Sternthal to shorten the talk, focus in on the key concepts, add visual elements, increase the interactivity, and leverage the unique capabilities of Second Life.”
  • “ We also decided to introduce two mock diabetes patients to the session in order to apply the session content to a real-world scenario. This entailed designing two age-appropriate, overweight avatars. During the actual session, Dr. Sternthal gave a lecture interspersed with active engagement junctures. At those points, Dr. Sternthal asked questions related to his lecture, interviewed the patients, displayed their lab results, and requested input from participant doctors on treatment plans.”
  • Principal Results “Overall, this pilot was very successful. The participant physicians’ responses indicated that this was a positive and engaging experience that could meet their CME needs and fit their busy schedules. All respondents agreed it was superior to other methods of actual online CME they had experienced. In comparison with face-to-face CME, one-half of the respondents agreed Second Life CME was superior, one-third were neutral, and only two respondents disagreed “somewhat.” This is a remarkable endorsement of such a new educational method. Our results showed that the virtual world model can have a positive impact on learner self-efficacy and, based on gains demonstrated from the cases, suggested a potential positive impact on clinical competence as well.” “The results of this pilot suggest that virtual worlds offer tremendous opportunity to provide a space for constructivist learning at its best and to enhance learning outcomes beyond that provided by traditionally designed CME courses.”
  • Feedback from the doctors was enlightening. “Many of the participants noted the convenience of an online seminar as one of the most important advantages—no travel is required, and they can participate from the comfort of their own homes. Since other online methods of instruction also offer this convenience, what justifies the expense of a virtual world course?” This pilot points to at least two important virtual world advantages: (1) the added sense of presence afforded by a representative avatar, and (2) the added real-life application provided by mock-patients. Judging by the participant comments, the injected realism of mock patients was effective and added to the seminar’s impact.”
  • DrDoug is well known in SL and famous for his amazing ovary and testis tour (an example of a very immersive experience wherein one sits on a “sperm car” and travels through a giant testis in the sky while the process of spermatogenesis is explained. DrDoug is currently collaborating with medical professionals and others on developing artificial intelligence (AI) avatars to provide his graduate medical students hands-on training on taking medical histories and more.
  • We met at the Ohio State Medical Center in Second Life and DrDoug explained that the building will be rebuilt soon with a new modern facility  This snapshot is of DrDoug and I having a conversation about his newest work with artificial intelligence avatars, in this case we were both using voice and I was simultaneously taking notes in an in-world notecard which I later copied and pasted into a google doc.
  • DrDoug rezzed the AI avatar while we were outside talking and then it was time to head inside for a demonstration. Before we entered the room I clicked the sign outside the door in the snapshot here and received the medical history of MsHelen Helendale, the artificial intelligence avatar patient with whom a student would be working.
  • MsHelen is already seated when we enter the room and DrDoug explains that he will be automatically recognized when he clicks the ball on the stool in the snapshot. There is also a written record of everything that takes place for assessment purposes.
  • As you can see DrDoug is writing the questions to the AI avatar and the avatar is pre-programmed to give answers. (The green sound wave lines in this case are showing because this is a screen shot which shows exactly as it appears in SL and Doug was using voice to speak with me. Green sound waves appear in SL when an avatar is speaking in voice.)
  • There are many nursing programs in the US and internationally using Second Life for the added value simulations can provide. The video linked here is of, John Miller, a registered nurse and 3D virtual nursing instructor at Tacoma Community College in Washington state. He has been teaching online courses to nursing students in Second Life for four years.
  • Exploring the simulation area inside Tacoma Community College of Nursing. The hand washing animation told me precisely how many seconds I washed my hands before stopping (22.8 seconds).
  • Clickable objects include animations that have your avatar perform CPR and more.
  • The video here will allow you to see exactly how this area is used to train nursing students to work with patients. This area is not private, however, the functionality is limited for the publlc who enter to explore.
  • A passer-by stops to see if all is well – LOL
  • After viewing the Cerner video linked on this slide, I went in-world to see the place for myself. This is a high quality publically available places showcasing medical equipment in SL (likely not built by volunteers  ).
  • Realistic x-rays.
  • Equipment to explore in each room.
  • There are many health support groups in SL. The “Path of Support” provides information on currently active groups in SL. The information notecard linked here is what is given out when an avatar first enters down the path and touches (clicks) the welcome sign. The notecard explains the benefits and limits of support groups in SL. The “Support” sign in the background states “Online groups can educate and support. However, sometimes you should seek real life help.”
  • John Norris, aka Knoh Oh, the maintainer of the “Path of Support” created an excellent notecard available in a few places along the path from an object that says “Do Groups Help.” The link on this slide goes to that notecard, which contains recent research articles (including his own) on the benefits of online health support groups.
  • When touched by an avatar (clicked) each poster hands out an information card on the group. This usually includes information on what exactly the group is about, dates/times they meet and where, contact information, how to join, etc. Most groups are free to join.
  • The American Cancer Society has a major presence in Second Life. The link here will take you to their website and provide additional information. From the website: “In addition to cancer information, education and support, the American Cancer Society holds annual Relay For Life and Making Strides Against Breast Cancer events in Second Life®, raising more than $215,000 in 2008.”
  • New to Second Life…
  • Presentations area – I’m looking forward to seeing what else takes place as this island develops.
  • A beautiful and high quality build, the CDC provides visitors information, labs to tour, a hazmat suit visitors can receive and wear, animated microscopes that show slides of various organisms, and more.
  • The NLM has an island mainly devoted to “Tox Town” but also has a NLM library of HIV/AIDS resources as well. The gentleman in the suit here is the NLM representative and was one of our Karuna island partners.
  • “ Second Life Enterprise Beta (SL Enterprise Beta) is the most secure, content-rich, and flexible virtual workplace solution that exists today, built on the most robust virtual world platforms in existence. The SL Enterprise Beta combines all of the benefits of Second Life such as enhanced communication and collaboration, advanced prototyping and reduced travel costs with extra layers of security, privacy and administrative control.” – The Children’s Memorial Hospital Chicago is one of several case studies available.
  • Another health related case study of Second Life Enterprise.
  • Concept hospital created in 2008 to showcase the architecture and advanced technology of the RL hospital to be completed by 2011.
  • Includes many areas including Clinical Scenarios: From the website: “ A major challenge in medical education continues to be the balancing of limited teaching resources with the delivery of engaging, student-orientated programmes that place patient safety as a central theme.  In modern, time-pressured curricula there is often reduced clinical contact and limited ward-based teaching.  In response to this and to important concerns over patient safety and the reduction of medical errors, leaders in medical education have developed a range of specialized simulation instruments that enable participants to develop their skills in key areas. The Department of Biosurgery and Surgical Technology at Imperial College London are world renowned for their work in this field.”
  • Will virtual worlds continue to see growth? Will they ever be mainstream or will they remain more of a niche? What might need to happen for mainstream adoption to take place? Would browser based virtual worlds make more sense? What about mobile devices? Will the private enterprise version of Second Life replace meetings and web conferencing systems? What new technologies may develop that could completely replace virtual world technologies?
  • The document linked at the bottom of this slide is a dynamic public google document. That means the document development will be ongoing as I continue researching how health professionals are using SL.
  • How Doctors, Nurses, Allied Health Professionals and Patients Use Second Life

    1. 1. How Doctors, Nurses, Allied Health Professionals and Patients Use Second Life Robin M. Ashford, MSLIS May 5, 2010 2010 ICSI/IHI Colloquium on Health Care Transformation
    2. 2. What is Second Life® – The Internets largest user created, 3D virtual world community – It’s NOT a game
    3. 3. More about Second Life (SL) Launched in 2003 - 18 million plus registered users from over 150 countries - approximately 45% from U.S. (currently approx. 1.4 million active users - i.e., those logged in during last 60 days) It's large - If it was a physical place, it would cover 1.8 billion square meters of land which is about the size of Houston, Texas Used by hundreds of enterprises, governments, and educational institutions Anyone in Second Life can create content and it's easy to do It has a vibrant "in-world" (inside SL) economy - over $360 million USD in user-to-user transactions in 2009
    4. 4. About Me A Consumer Health Librarian’s National Library of Medicine Funded Project in Second Life®
    5. 5. Karuna Island - HIV/AIDS Support & Education
    6. 6. The Karuna Resource Center Reference Desk
    7. 7. Medical Training & Patient Advising: Ann Myers Medical Center (AMMC)
    8. 8. AMMC - Welcome from Dr. Vera Zhaoying
    9. 9. AMMC Tour
    10. 10. Health Center for Women
    11. 11. Information and Health Training for Women
    12. 12. Resources & Contact Info
    13. 13. Mammogram Machine
    14. 14. Breast Self Exam Technique Training
    15. 15. Click Numbers for Steps in Text and Avatar Movement
    16. 16. AMMC - Emergency to Recovery Training
    17. 17. AMMC - Emergency Training
    18. 18. AMMC – Emergency Psychiatry Information and on-call RL Psychiatrist
    19. 19. Ren Stonecutter – Real Life (RL) Board Certified Family Physician, Assistant Visiting Professor of Family Medicine at the University of Virginia “Finally there are emerging in SL actual professional groups and associations of r/l health care practitioners who offer counseling, medical advice, and limited care as part of their SL personas. A few sims now exist in SL where r/l medical education is being undertaken using the virtual world as a platform.” Cont: Founder of the Second Life Medical Association for Physicians and Medics-395 member
    20. 20. METHODS: “We designed and delivered a pilot postgraduate medical education program in the virtual world, Second Life.” J Med Internet Res 2010;12(1):e1 URL:
    21. 21. Virtual Worlds Best Practices in Education - Second Life Presentation
    22. 22. Goals • Explore the potential of VWs for medical education • Explore possible instructional design approaches • Understand the barriers and limitations • Measure participant learning outcomes and feedback Participants • 14 primary care physicians • Average 16 yrs in practice • 7 states, all doing it from home • 3 with some SL experience • Average of 78 minutes coaching time with each doctor Wiecha J, Heyden R, Sternthal E, Merialdi M Learning in a Virtual World: Experience With Using Second Life for Medical Education J Med Internet Res 2010;12(1):e1 URL:
    23. 23. Continuing Medical Education – Docs in SL
    24. 24. Mock Patient With Medical History - Type 2 Diabetes
    25. 25. Comments from the Docs
    26. 26. Douglas R. Danforth, Ph.D., Associate Professor, Department of Obstetrics and Gynecology Director - Ohio State University, College of Medicine Creator of famous SL Testis & Ovary Tours: Interview Tour New work with artificial intelligence (AI) bots developed to instruct medical students in medical history taking skills
    27. 27. Ohio State University SL Medical Center
    28. 28. Sign gives AI avatar patient's medical history notecard
    29. 29. Pre-programmed AI Avatar “Bot” as Patient
    30. 30. AI Demonstration Question to AI avatar patient: "Are you having any pain” Answer - "Yes, I have had crampy pain on the right side on and off that started this morning” Second Q & A - "How bad is the pain” – “It is about a 2/10”
    31. 31. Simulations - Tacoma Community College of Nursing Medical Simulation in the Virtual World of Second Life by MUVErs:
    32. 32. Simulation Video:
    33. 33. Cerner - Clinical and Healthcare Management Solutions Perioperative Demo Live in SL:
    34. 34. Cerner Corporation - Radiology
    35. 35. Radiology and Pharmacy
    36. 36. HealthInfo Island: Path of Support - Information Notecard:
    37. 37. Mental Health & Disabilities Groups Do Online Groups Help? by John Norris:
    38. 38. Health Support Groups
    39. 39. American Cancer Society
    40. 40. Mayo Clinic
    41. 41. Mayo Clinic – Presentations Example: Mayo Clinic to Host Colon Cancer Event in Second Life
    42. 42. Centers for Disease Control and Prevention
    43. 43. National Library of Medicine
    44. 44. Case Study: Children's Memorial Hospital Chicago - Preparing for a Disaster Without Disrupting Patient Care ”A virtual world allows us to engage our employees in an experience… for situations and events that we can’t replicate in the real world.” – Judi Smith, Information Management Department, Strategic Projects, Children’s Memorial Hospital Chicago
    45. 45. Case Study: CIGNA–vielife in Second Life: Engaging and Interactive Health & Lifestyle Training for the Global Workforce "vielife's goals were simple: to discover how participants would respond to a virtual learning environment and assess what kind of behavior modification could be achieved” PDF of case study with images available at:
    46. 46. Future hospital? In SL and RL: Palomar West YouTube Video
    47. 47. Healthcare of the Future: The Second Health London Local Community Hospital and Polyclinic
    48. 48. Q4 2009: 803 million registered accounts in approximately 400 virtual worlds K-Zero, a UK research firm, forecast: virtual worlds will continue to grow and develop with approximately 900 such platforms being available to the public by 2012 Future implications? Virtual World Statistics
    49. 49. Contact & Resources Robin M. Ashford, MSLIS IM Robin Mochi in Second Life Email – Twitter - Blog - Posterous Blog - Flickr - YouTube - Delicious - Slideshare - LinkedIn - FriendFeed - Google doc of resources used in this presentation and more: