This presentation provides an overview of how VR and AR technology will impact medicine, clinical care, and personal health and wellness, and how it will help to facilitate the shift of medicine to direct personal care. Although entertainment, social connection, and gaming will drive the initial adoption of Virtual Reality and Augmented Reality technology, the deepest and most significant impact of the next generation of VR/AR technology will be to enhance clinical care and to improve personal health and wellness. We know from decades of clinical research that VR/AR technology can provide breakthrough solutions that address the most difficult problems in healthcare - ranging from mood disorders such as Anxiety and Depression to PTSD, Addictions, Autism, Cognitive Aging, Stroke Recovery and Physical Rehabilitation, to name just a few. VR/ AR technology also improved clinical measurements and assessments, can greatly improve medical training such as surgical skill training and procedure planning. Personal health and wellness will be improved by using VR to promote healthy lifestyles and to reduce stress and anxiety. As the cost of healthcare rises, VR/AR technology can serve as an effective telemedicine platform to reduce costs of care delivery, and improve clinical efficiency. Walter Greenleaf, PhD Virtual Human Interaction Lab | Stanford University Keynote Presentation for the 2019 VR Health Symposium

1. Walter Greenleaf PhD
Virtual Reality and Healthcare:
The Past, The Present, and The Future
Presented at the VR & Healthcare Symposium
University of Arizona, Tucson March 7th 2019

2. Walter Greenleaf PhD
Virtual Reality and Healthcare:
The Past, The Present, and The Future

3. The Stanford Laboratory for
Brain Health Innovation and
Entrepreneurship
VR-IT
Stanford Virtual Reality
Immersive Technology Clinic
My Academic Affiliations

4. My Non-Academic Affiliations

7. Healthcare Crisis:
Aging Populations
0
50
100
150
200
250
300
350
400
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2015 2020 2025
Age 85+
Age 75-84
Age 65-74
Age 45-64
Age 5-44
Under Age 5

8. Transforming HealthCare with Technology

9. Digital Health
Revolution
• Mobile Health / eHealth
• Wearable Sensors
• Patient Centered
• Leverages Internet:
social, quantitative, collaborative

10. Every Medical Device Reinvented

11. Digital Health Platforms deliver interventions to patients, and
parse data for enhanced analysis and improved protocols

12. Medical Applications
of Virtual Reality &
Augmented Reality
Technology
Digital Health Revolution

13. Although entertainment,
social connection and gaming
will drive the initial adoption of
VR technology, the deepest
and most significant market
for VR will be in clinical care
and in improving health and
wellness.
Medical Applications of Virtual Reality Technology

14. Now is the time for VR & AR
VR technology is now affordable,
scalable and accessible
Facebook - Oculus
Samsung - GearVR Sony – PlayStation VR
Microsoft - HoloLens
HTC - Vive Google - DayDream

15. AR MR XR Technology

17. 11.3
16.9
27.3
41.5
56.2
68.0
Year 2 Year 3 Year 4 Year 5 Year 6Year 1
Initial adoption will be driven through
game console, PC gaming and
mobile phone bundling.
Within 3 years, VR will likely be
adopted by 30 million users.
*Based on agent based modeling by
Lieberman Research Worldwide
Within 6 years, VR will likely be adopted by 70 million users

18. https://www.statista.com/chart/4602/virtual-and-augmented-reality-software-revenue/
Within 6 years, VR will likely be $35B Market
The Medical
VR / AR
Market
Segment is
projected to be
$5.1 B in 2025

19. My Journey….

20. Treating Post
Traumatic
Stress
With Virtual
Reality
2008 Sichuan
Earthquake

21. Treating Post
Traumatic
Stress
With Virtual
Reality
2017 Mexico City
Earthquake

23. Academic research has indicated that Virtual Reality can effectively treat a
wide variety of clinical problems – ranging from addictions, to stroke, to PTSD

24. Phobias / PTSD
Stress Management /
Relaxation
Surgical Training /
Planning
Physical
Rehabilitation
Pain & Difficult
Procedure
Management
Exercise
Cognitive
Rehabilitation
Optical
Rehabilitation
Addictions
Neuropsychological
Assessments
Cognitive Training
Wellness Sports Medicine Disability Solutions Speech Therapy
Autism Spectrum
Disorder
Mood Disorders Patient Education Preventive Health ADHD Senior Care
270 Medical VR/AR Companies
20 Clinical Sectors

25. Investments in VR Health Startups

26. Over 30 years of academic
research and over 3000 studies
demonstrate that VR can
improve behaviors,
attitudes, and health
Until now, the technology was
expensive, bulky, and difficult to use.
Today, we have the advancements to
bring VR to scale in healthcare.
Why Now?

27. • Prevention and Wellness
• Objective Assessments
• Functional Training
• Improved Interventions
• Facilitate Adherence
• Distributed Care Delivery
VR and AR technology will significantly impact Medical Care

28. • Clinical Skill Training
• Surgical Skill Training
• Interpersonal Skill Training
• Use of Equipment and Tools
• Team Training - eg: Emergency
Department, Surgical Team
• Emergency Response Training
and Rehearsal
• Facilitate Empathy
Medical Training

29. Knee
arthroscopy
simulator
Surgical Training

30. Surgical Procedure Training

31. Medical Device Training

32. Virtual Patients for Clinical Skill Training

33. Team Training

34. Todd Chang. MD
Joshua Sherman, MD
CHLA Emergency Department

35. Disaster Preparation
Multi-Department Training and Rehearsal
Situation Awareness
Stress Inoculation
Staff Training – Team Training
Rehearsal for Unusual Situations
AR - Data Fusion, Situation Awareness

36. Empathy for the Patient Experience
Clinical Training

37. Patient Education & Informed Consent

38. Anatomy and Physiology Training
• Response to the acute shortage of human
cadavers
• Allows for repetitive training and self-study
• More detailed examination of micro-
features of organs, tissue etc.
• Integration of text, video and other media
to further enhance learning

39. Preoperative Planning & Image Guided Surgery

40. • Medical Image Review
• Neuropsychological
Assessments
• Activities of Daily Living
Assessments
• Physical Medicine – OT / PT
• Behavioral Medicine –
psychology, psychiatry
DIAGNOSTIC ASSESSMENTS

41. Standardized Environments for Neurocognitive Evaluation
New Approaches for Cognitive Assessment
Migrates traditional paper
and subjective evaluations
to a more sophisticated
level.
Provides robust
assessments that can
challenge cognitive skills in
a more natural,
standardized, objective
and reproducible manner.

43. Standardized Environments for Neurocognitive Evaluation
New Approaches for Cognitive Assessment

44. Standardized Environments for Neurocognitive Evaluation
New Approaches for Cognitive Assessment

45. BioMarkers - Cognitive and Emotional State
Collecting and analyzing emotional and physical
responses in VR

46. Improved cognitive function assessment at
the primary care level – using AR and
smartphone sensors
10 minute test
Diagnostic accuracy of 94%
FDA Class II Medical Device
Continuous data of everyday functions
250 features assessed at 300Hz
3D trajectory neuromotor parameters

47. • Stroke and Traumatic Brain Injury
• Physical / Occupational Therapy
• Acute and Chronic Pain Mitigation
Virtual environments are currently used clinically
Here are a few examples -

48. • Post-Traumatic Stress Disorder
• Generalized Anxiety Disorder
• Social Anxiety Disorder
• Depression
• Mild Cognitive Impairment
• Autism Spectrum Disorder
• ADHD
Virtual environments are used clinically to treat several
important mental and behavioral health problems

49. § Generalized Anxiety Disorder
§ Phobias
§ Obsessive Compulsive Disorder
§ Anger Management
§ Eating Disorders
§ Schizophrenia
Virtual environments are used clinically to treat several
important mental and behavioral health problems

50. New Approaches to Mental Health

51. • Improve Cognitive Function
• Promote Exercise & Weight Management
• Stress Management
• Mood and Resilience
HEALTH AND WELLNESS
• Disability Solutions
• Addressing Isolation
• Grief Counseling

52. Portable Telemedicine Platform

53. Virtual Humans For Training, Confidential Interaction,
and Telemedicine Support

54. Virtual Humans For Training, Confidential Interaction,
and Telemedicine Support
“Smart Avatar” with a virtual voice,
image and mannerisms via AI

55. Preparation and Training for Difficult Situations

56. Some Examples

57. PTSD, Phobias, and Anxiety Disorders
• Exposure-based treatments can be conducted in the safety and comfort of an office setting
• Effective tools for treating a variety of clinical problems, in particular anxiety and addictive
disorders
• Fully immersive environments, with include the use of a head mounted display, 3D sound,
tactile stimulation via shaking platform, and olfactory stimulus are used for PTSD therapy

58. Palliative and Hospice Care

59. Cognitive Assessments for ADHD
• Enhanced Continuous Performance Test (CPT) in a real-
world classroom environment
• Can introduce visual and auditory distractions during CPT
administration
• More familiar for children than traditional PC-Based CPT
• Performance and response times more closely
approximate true classroom
• Can become a skill building platform

60. RISK AVOIDANCE TRAINING
Refusal skill training, Situational Confidence

61. Virtual Hospital Tours Used To Relieve Pre-procedure Anxiety

62. VR for Pain Distraction
Clinical Research and Validation
Interactive virtual environments significantly
reduce pain from as much as 44% during
the most painful procedures
(ex: burn wound treatment)
Diverts patient attention away from perceiving
and feeling pain; (selective attention theory)
Decreases pain-related brain-activity
Reduces need for anesthesia, opioid medication
No pharmacological side effects

63. Digital Health Platforms deliver interventions to patients, and
parse data for enhanced analysis and improved protocols

64. VR & AR - A Key Part of a Combination Therapy
Digital Health Platform
Patient-facing software
designed to enhance
medication efficacy
Medication with
clinical benefit
eFormulation-
pharmaceutical
product with
enhanced efficacy
=+

65. A Fully Integrated, Closed Loop Solution for Mental Health and Wellness -
Enabled on a Mobile, Digital Health Platform
Miniaturized, programmable,
low power electronic
architecture w/extensive therapy
delivery options

66. The Neuroscience of How VR Promotes Behavior Change

67. The Neuroscience of How VR Promotes
Behavior Change
VR can promote behavior change by
taking advantage of the way our brain’s
learning and reward systems function
Activate neuroplastic change via reward
systems
Shorten the reward feedback loop –
show progress
Leverage mirror neuron systems
VR systems can:

68. Neuroscience Rationale
Repetition is required
It is critical to engage the
brain's reward systems
It is necessary to activate the associated brain system
to enable neuroplasticity

69. Ability to change attitudes and behavior after “being” one’s future self.
Leveraging Mirror Neurons

70. Your Future Self
Students interacted with 3-D avatars of future self.
Participants who interacted with future self put more than twice
as much money into retirement account.

71. Why Use Interactive / Immersive Systems for Health?
• Active Involvement: AR/VR systems provide
patients with immersive experiences that make
them feel more involved in their care.
• Feedback: behavior is reinforced by direct,
immediate and relevant feedback that reinforces
positive behavior.
• Engaging and Motivating: gives patients
something to control and can provide immediate
rewards. (Contingency Management)
• Social Connections: provide and enhance
social resilience. (Social Physics)
• Cost Effective: Systems extend the effect of
therapy while reducing the cost of face-to-face
contact.
Novels
Theater
Film
Games
AR/VR

72. Wired for Narrative Stories
Research shows that STORY:
• Provides superior retention
(memory and recall)
• Provides improved understanding
• Creates context and relevance
• Creates empathy
• Makes readers/listeners pay attention
• Enhances the creation of meaning

73. What Are The Constraints?
What are the gating-steps to
adoption?

74. Rapid evolution = fears of obsolescence
Mobile / PC-Based vs. All-in-One
Which platform will prevail?
Graphics-based vs. 360 video
Concerns over infrastructure needs
Lack of IT support
No Clear Technology Path – Too Many Options

75. Body of literature is expanding with encouraging results,
But remains insufficient
Available research varies by condition treated
Lack of randomized controlled trials
Population-specific studies
Obsolete platforms and equipment
Small sample sizes
Research Gaps

76. Perception of VR as a Gaming Platform

77. Full practices – no need to attract new patients
Evidence-based treatments are already available
Products need to be aligned with
healthcare system needs
What is the financial and time benefit?
Does it interfere with the clinic workflow?

79. Improved Assessments and Diagnostics
Addressing Isolation and Loneliness
Acute and Chronic Pain
Depression and Anxiety Disorders
Physical and NeuroRehabilitation
Design for Disabilities
Post-Discharge Follow-up
Staff Training: not just procedures, but
empathy
Virtual Environments and Senior Care

80. • Current technologies and concepts are founded on more than 30 years of research and development
• Recent changes in cost and access make digital health technology affordable
• Digital health technology is currently used for prevention, evaluation, treatment and chronic disease
management
• After years of validation and use by early adopters – validated systems are poised to move to the
mainstream
• On the horizon: enhanced, ubiquitous, informative and integrated
Digital Health Technology For Medicine

81. Walter Greenleaf PhD
Virtual Reality and Healthcare:
The Past, The Present, and The Future