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Walter Greenleaf PhD
Virtual Reality and Healthcare -
The Past, the Present, and the Future
Digital Therapeutics and Healthcare
The Digital Health Revolution
Emerging and Confluent Technologies
Overall Landscape of XR Technologies
Neuroscience – Why XR Has Impact
History of VR - and Why it Matters
Current Status – Where There is Traction
Future Perspective and Predictions
The Stanford Laboratory for
Brain Health Innovation and
Entrepreneurship
VR-IT
Stanford Virtual Reality
Immersive Technology Clinic
Academic Affiliations
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
Transforming HealthCare with Technology
Ellipsis Health
Joyance
Partners
TAKE Pause
Digital Health
Revolution
• Mobile Health / eHealth
• Machine Learning
• Wearable Sensors
• Patient Centered
• Leverages Internet:
social, quantitative, collaborative
• Prevention and Wellness
• Objective Assessments
• Functional Training
• Improved Interventions
• Facilitate Adherence
• Distributed Care Delivery
Digital Health technology will significantly impact Medical Care
Every Medical Device Reinvented
Entering the Era of Medical Wearables
Digital systems are not just measuring the physical parameters of our health.
New methods are being developed that will allow us to collect and analyze
biomarkers that reflect our cognitive and emotional status.
Here are four examples…
Brain Health BioMarkers - Passive Data from Smart Phones
Voice Analytics as a BioMarker of Depression
Facial expressions in response to a VR Challenge
Cognitive function assessment using AR and smartphone sensors
Digital Health Platforms deliver interventions to patients, and
parse data for enhanced analysis and improved protocols
Prescription Digital Therapeutics
Combination Therapy - Digital Health Platform
App-based system
designed to enhance
medication efficacy
Medication with
clinical benefit
Prescribed
combination product
with enhanced
efficacy
=+
Prescription Digital Therapeutics
Create Value In Areas Of High Patient Need
Combination
Therapy
PDTs can monitor toxicity and personalize treatment
Can leverage sensor data.
Dose
Optimization
PDTs can monitor and address comorbid conditions: insomnia, poor
nutrition, anxiety, depression, activity levels, use of nicotine and alcohol, etc
Address Comorbid
Conditions
Software-based therapies have been shown to be effective as stand-alone
interventions – there is incremental effectiveness when PTDs are used in
combination with standard treatment
Facilitate
Adherence
Collect Utilization
And Efficacy Data
PDTs have several tools to facilitate adherence –provide key information,
close the feedback loop, show progress, connect to the care team, leverage
games and other motivational tools, provide reminders and sound alerts, etc
PDTs collect de-identified utilization and efficacy data – combined with sensor data
Advancing research, facilitating improved formulations, and allowing for personalized
protocols based on large-scale studies.
The “digital layer” creates value –
across all parts of the clinical care
• Standardizes data collection for clinical studies
• Tracks the supply chain to a pill-by-pill level via QR codes etc.
• Collects real-world data supporting regulatory submissions
• Enhances clinician touch-points via data-based dashboards
• Enhances therapeutic adherence and efficacy
• Provides real-world data to support reimbursement discussions
Discovery and
development
Supply chain
Regulatory
approval
Clinician detail
Patient use
Reimbursement
Enhanced outcomes - plus value for patients, clinicians, and payors
• More convenient care,
reducing transportation and
wait times
• Offers the better outcomes
for for patients
• Provides immediate care
allowing patients to access
therapeutic content when
needed
For patients For clinicians For payors
• Enables data-driven care
demonstrating efficacy and
engagement
• Leads to greater engagement,
fewer drop-outs, and
reduced no-shows
• Extends the reach of the
clinician – facilitating
improved follow-up and
reduced readmissions.
• Collects data to measure
and validate quality of
care
• Allows evidence-based
treatment to be widely
standardized
• Reduces overall care
costs for a large and
expensive patient
population
Intervention Key Components Example Targets Digital Adaption Possibilities
Cognitive Behavioral
Therapy (CBT)
• Capture thoughts that arise in response to
specific situations
• Check those thoughts to determine if they are
accurate or distorted
• Change distorted thoughts by substituting them
with more helpful thoughts.
• Target: depressive thoughts
• Identify thoughts that arise in
response to situations.
• Identify distortions in thinking.
• Identify accurate, more helpful
thoughts.
Gamified exercises:
• Catch it – identify automatic thoughts
• Check it – evaluate it against list of common
distortions
• Change it – come up with more accurate
interpretation of the event.
Behavioral
Activation
(BA)
• Identify life values and goals
• Identify activities that are aligned with those
values
• Create a hierarchy of activities
• Schedule these activities and track progress
over time
• Target: avoidant behavior
• Value identification
• Activity Scheduling
• Tracking mood and activities
Interactive feature with:
• Values clarification
• Identifying and scheduling activities to
support those values
• Tracking activities and mood
Mindfulness
Meditation
• Progressive muscle relaxation
• Guided imagery
• Guided meditation
• Target:
• Relax the body
• Relax the mind
• Be fully present
Guided meditation activities
(e.g Headspace, Calm)
Full meditation courses
One Example- Depression: Intervention and Digital Adaption Possibilities
Emerging and
Confluent
Technologies
5G connections will surpass one billion by 2023
Single-digit millisecond latencies with Edge Computing
Cloud-Rendered AR and VR content
Real-time Analytics for Machine Learning, Predictive Modeling
Machine Learning
Digital Twin Paradigm
For Precision Healthcare
Sensors Are Evolving, Connecting, Promulgating
Sensors 1.0
Sensors 3.0
Sensors 2.0
Measure and record
Integration with web;
Sharing and accessing data
Passive data gathering;
Aggregation and
meaningful interpretation
Ready or not…
The wearable tech, always
on, always online world
On the way - arriving soon.
Virtual Humans - Voice Recognition, Emotion Detection- Dynamic Response
Virtual Humans For Education, Training, Support
“Smart Avatar” with a virtual voice,
image and mannerisms via AI
THE LANDSCAPE
The Next Computer Platform
Work
Play
Educate
Socialize
Shop
Entertain
Communicate
Etc
Now is the time for VR & AR
XR technology is now affordable,
scalable and accessible
Facebook - Oculus
HP - Reverb Sony – PlayStation VR
Microsoft - HoloLens
HTC - Vive Apple -
Varjo HMD - 60 PPD for 20/20 vision resolution
Why use XR?
Uniquely Capable
Extension of existing virtual capabilities
Intuitive “spatial” language
natural interactions streamlines engagement
Deeply Personal
Learning content made meaningful through user’s interaction & feedback
Immersion enhances engagement, retention
Making experiences “personal” drives motivation to learn & keep learning
Highly Functional
Experimenting with systems & concepts to better understand
Applying learned concepts in practice
Can do things are otherwise expensive or impossible
-e.g. due to safety/cost
Fully immersed in an environment
Virtual Reality
Digital objects and overlays in the real world
Augmented Reality
The spectrum between AR & VR:
From blending ourselves with digital environments
to anchoring digital objects in the real world
Mixed Reality
1.3 Million Monthly-connected VR Headsets on Steam
Steam is a video game digital distribution service
Projected 2.75 million monthly-connected headsets by the end of 2020
VR and AR Technology is
Evolving Exponentially
11.3
16.9
27.3
41.5
56.2
68.0
Year 2 Year 3 Year 4 Year 5 Year 6Year 1
Within 3 years, VR will likely be adopted by 30 million users
Within 6 years, XR will likely be adopted by 70 million users
Medical Applications
of Virtual Reality &
Augmented Reality
(XR) Technology
Digital Health Revolution
XR Technologies
Currently Disrupting
Education & Training
Manufacturing
Maintenance
Product Design
Process Design
Healthcare
Simulation & Modeling
• Prevention and Wellness
• Objective Assessments
• Functional Training
• Improved Interventions
• Facilitate Adherence
• Distributed Care Delivery
VR and AR Technology Impacts All Sectors of HealthCare
Acute Pain
Addiction
Medicine ADHD
Anxiety
Management
Autism
Spectrum
Disorder
Chronic Pain
Cognitive
Assessments Depression
Disability
Solutions
Emergency
Medicine
Medical
Education
&Training
Ophthalmology
Orthopedics Palliative Care
Patient
Education Phobias PTSD
Physical
Medicine and
Rehabilitation
Preventive
Medicine
Respiratory
Medicine Senior Care Stroke & TBI
Surgical
Procedure
Planning
Surgical Skill
Training
Uncomfortable
Procedure
Mitigation
More Than 200 Emerging Medical VR/AR Companies
Targeting Multiple Clinical Sectors and Specific Indications
Significant Investment in XR for HealthCare
The Medical VR / AR Market is projected to be $5.1 B in 2025
Medical XR Can Address Several Key Problems
Annual cost of problems in the U.S. alone:
WEIGHT
LOSS
$289B
SMOKING
CESSATION
$528B
ADDICTION
$181B
CHRONIC
PAIN
$635B
POST
TRAUMATIC
STRESS
$300B
Stroke & TBI
$86B
Alcoholism
$223B
Autism
$126B
Conferences and Industry Organizations
Extreme Innovation in Healthcare
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:
VR is More Effective than Imaginal or In Vivo Exposure Techniques
VR exposure floods the visual thalamus and cortex,
activating both subcortical, threat detection and
response pathways as well as cortical, conscious
pathways
In this manner, VR exposure therapy is more effective
than imaginal exposure therapy - it activates both
exposure/cognitive processes and threat extinction
processes.
In vivo exposure is inconvenient, expensive, time-
consuming, difficult to standardize, difficult to monitor,
and imposable to provide in a graduated or controlled
manner.
Sensory Inputs
Sensory thalamus -> amygdala path -> (non-conscious)
Sensory cortex -> PFCvm -> amygdala path (conscious)
HPA Axis
Ability to change attitudes and behavior after “being” one’s future self.
Leveraging Mirror Neurons
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
Addition Mechanisms of Impact
Active Involvement: XR systems provide users with
immersive experiences that maximize cognitive
engagement.
Feedback: learning is reinforced by direct, immediate
and relevant feedback that reinforces the experience
and the lessons learned.
Engaging and Motivating: the dynamic nature of
VR/AR systems provides users with agency and can
provide immediate rewards for progress.
Team Training: Multiuser experiences can provide
and leverage group skill building.
Cost Effective: XR systems extend the reach and
reduce the cost of face-to-face training.
Novels
Theater
Film
Games
AR/VR
Wired for Narrative Stories
Research shows that STORY:
• Provides superior retention
(memory and recall)
• Provides improved understanding
• Creates context and relevance
• Creates empathy
• Promotes engagement and participation
• Enhances the creation of meaning and
personal relevance
First general purpose
and commercially
available VR
systems.
VR Technology Has Evolved
1987
My 36 Year Journey….
1984 – Stanford University
Mitigating Post
Traumatic Stress
With Virtual Reality
2008 Sichuan
Earthquake
12 Years Ago
Academic research has indicated that Virtual Reality can effectively treat a
wide variety of clinical problems – ranging from addictions, to stroke, to PTSD
Two Years Ago
Mitigating Post
Traumatic Stress
With Virtual Reality
2017 Mexico City
Earthquake
• Prevention and Wellness
• Objective Assessments
• Functional Training
• Improved Interventions
• Facilitate Adherence
• Distributed Care Delivery
VR and AR technology will significantly impact Medical Care
• 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
Knee
arthroscopy
simulator
Surgical Training
Surgical Procedure Training
Surgical Procedure Training
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
Virtual Patients for Clinical Skill Training
Todd Chang. MD
Joshua Sherman, MD
CHLA Emergency Department
VR simulation to train
medical students and staff
to respond in high-stakes,
low-frequency pediatric
emergencies.
Pediatric Resuscitation
VR simulation to train medical students
and staff to respond in high-stakes,
low-frequency pediatric emergencies.
“We discovered that VR training
modules should be targeted
towards younger, less
experienced trainees.
That’s why the CHLA residency
program and hospital have
greenlit VR as part of a required
curriculum for our interns prior to
setting foot in our emergency
department.”
Todd Chang MD -
CHLA Emergency Department
Preparation and Training for Difficult Situations
Understanding the Patient Experience
Clinical Training
Patient Education & Informed Consent
• Prevention and Wellness
• Objective Assessments
• Functional Training
• Improved Interventions
• Facilitate Adherence
• Distributed Care Delivery
VR and AR technology will significantly impact Medical Care
• Medical Image Review
• Neuropsychological
Assessments
• Activities of Daily Living
Assessments
• Physical Medicine – OT / PT
• Behavioral Medicine –
psychology, psychiatry
DIAGNOSTIC ASSESSMENTS
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.
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
BioMarkers - Cognitive and Emotional State
Collecting and analyzing emotional and physical responses in VR
Facial expressions reflect emotional status
Collecting and analyzing emotional and physical responses in VR
Lea Williams
Standardized Environments for Neurocognitive Evaluation
New Approaches for Cognitive Assessment
We use brain circuit biotypes to connect
brain imaging with VR
Neuroimaging measures
1. Scan brain at rest
2. Emotion regulation task
3. Cognitive control task
Virtual Reality:
1. Relaxing scene
2. Emotion regulation task
3. Cognitive control game
We envision a precision health model using VR to elicit
biotypes to help refine the intervention choices
Cognitive training TMS
Eliciting biotypes using
normed environmentsHeterogeneous
Disorder
Quantify and refine
biotypes
Relaxation Negative Scene
Positive Scene Cognitive Game
1st line Antidepressants
Mindfulness-based. TMS
Non-drug and
new drug options
Matching biotypes to the
intervention “menu”
Default Mode
Negative Affect
Positive Affect
Cognitive Control
With corresponding ratings of arousal, emotional valence, and other measures
A Public Database of VR Environments
• Prevention and Wellness
• Objective Assessments
• Functional Training
• Improved Interventions
• Facilitate Adherence
• Distributed Care Delivery
VR and AR technology will significantly impact Medical Care
Some Examples – VR and AR in Use Today
Preoperative Planning & Image Guided Surgery
Stroke and Traumatic Brain Injury
Physical / Occupational Therapy
New Approaches to Physical Medicine & Rehabilitation
New Approaches to Mental Health
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
PTSD, Phobias, 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
RISK AVOIDANCE TRAINING
Refusal skill training, Situational Confidence
! 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
• Social Anxiety Disorder
• Depression
• Chronic Pain
• Mild Cognitive Impairment
• Autism Spectrum Disorder
• ADHD
Virtual environments are used clinically to treat several
important mental and behavioral health problems
Multiple Programs - One Platform
DTx Programs
BALANCE Foundation
Mindfulness Relax Regulate
Chronic Pain
Acute
Pain Relief
Addiction
General Wellness Programs
Stress
+
Rx Adherence
+ Efficacy
Anxiety /
Depression
Acute + Chronic
Pain
Cloud-based System
Dynamic
Experience
Biometrics Service Social VR Engine*Analytics
Permissions &
Security
Virtual Hospital Tours Used To Relieve Pre-procedure Anxiety
Senior Care
Palliative and Hospice Care
• Improve Cognitive Function
• Promote Exercise & Weight Management
• Stress Management
• Mood and Resilience
HEALTH AND WELLNESS
• Disability Solutions
• Addressing Isolation
• Grief Counseling
Ability to change attitudes and behavior after “being” one’s future self.
Have a Dialog With your Future Self
Portable Telemedicine Platform
What Are The Constraints?
What are the gating-steps to adoption?
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
Perception of VR as a Gaming Platform
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?
XR Technology
Trends Impacting The Future
The Near-Future of XR
Currently Deployed or Under Development
Improved tracking: Tracking without dedicated external
sensors will improve, greatly increasing portability &
reducing setup
Large-scale tracking: Beyond room-scale to significantly
larger volumes, such as warehouse scale
Wireless connectivity: Battery-operated headsets with
wireless display/data link to a desktop computer or the
Cloud
New input methods: Controller interface hardware is
highly iterative
Mixed Reality: Seamlessly blending elements of VR with
the real world, convergence of VR/AR
The Near-Future of XR
All of this will affect development &
deployments done in the near-term:
Shorter generation cycle
(~2-3 years) than other consumer tech
Significant changes between generations
e.g. not an iPhone 9/10 gen
Old hardware may no longer be available
(replacements/spares etc.
Increased Use of the Digital Twin
and Future Self Paradigm
50 learning modules to
train 1M associates
•17,000 Oculus
headsets across nearly
4,700 U.S. stores
12 learning
modules
in 200 locations
Adoption
Deployment
Pilot
Pediatric Resuscitation Training
The CHLA residency program
and hospital use VR as part of a
required curriculum for interns -
required prior to setting foot in
the emergency department.
XR - A Key Component
Combination Therapy - Digital Health Platform
XR system designed to
enhance medication
efficacy
Medication with
clinical benefit
Prescribed
combination product
with enhanced
efficacy
=+
Digital Health Platforms deliver interventions to patients, and parse data for
enhanced analysis and improved protocols
Acute Pain
Addiction
Medicine ADHD
Anxiety
Management
Autism
Spectrum
Disorder
Chronic Pain
Cognitive
Assessments Depression
Disability
Solutions
Emergency
Medicine
Medical
Education
&Training
Ophthalmology
Orthopedics Palliative Care
Patient
Education Phobias PTSD
Physical
Medicine and
Rehabilitation
Preventive
Medicine
Respiratory
Medicine Senior Care Stroke & TBI
Surgical
Procedure
Planning
Surgical Skill
Training
Uncomfortable
Procedure
Mitigation
More Than 200 Emerging Medical VR/AR Companies
Targeting Multiple Clinical Sectors and Specific Indications
Acute Pain
Addiction
Medicine ADHD
Anxiety
Management
Autism
Spectrum
Disorder
Chronic Pain
Cognitive
Assessments Depression
Disability
Solutions
Emergency
Medicine
Medical
Education
&Training
Ophthalmology
Orthopedics Palliative Care
Patient
Education Phobias PTSD
Physical
Medicine and
Rehabilitation
Preventive
Medicine
Respiratory
Medicine Senior Care Stroke & TBI
Surgical
Procedure
Planning
Surgical Skill
Training
Uncomfortable
Procedure
Mitigation
Considerable Activity
Acute Pain
Addiction
Medicine ADHD
Anxiety
Management
Autism
Spectrum
Disorder
Chronic Pain
Cognitive
Assessments Depression
Disability
Solutions
Emergency
Medicine
Medical
Education
&Training
Ophthalmology
Orthopedics Palliative Care
Patient
Education Phobias PTSD
Physical
Medicine and
Rehabilitation
Preventive
Medicine
Respiratory
Medicine Senior Care Stroke & TBI
Surgical
Procedure
Planning
Surgical Skill
Training
Uncomfortable
Procedure
Mitigation
Relatively Underdeveloped – Significant Opportunities
In Summary
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 Therapeutics for Medicine
After years of study and use by early adopters –
validated systems are poised to move to the mainstream
On the horizon - enhanced, ubiquitous, informative and integrated
Digital Therapeutics are currently used for -
prevention, evaluation, treatment, and chronic disease
management
Digital Therapeutics for Medicine
The Digital Health Revolution
Emerging and Confluent Technologies
Overall Landscape of XR Technologies
Neuroscience – Why XR Has Impact
History of VR - and Why it Matters
Current Status – Where There is Traction
Future Perspective and Predictions
VR AND HEALTHCARE SYMPOSIUM - EUROPE
Dublin Ireland
December 5-6 2019
March 25-26 2019
Cedars-Sinai
Virtual Medicine
VR for Mental & Behavioral Health Conference
October 7-8, Denver Colorado
FDA Public Workshop –
Medical Extended Reality
March 5th
Virtual Reality and Healthcare - The Future
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
Digital Therapeutics for Senior Care
Walter Greenleaf PhD
Virtual Reality and Healthcare -
The Past, the Present, and the Future

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Virtual Reality and Healthcare - The Past, the Present, and the Future

  • 1. Walter Greenleaf PhD Virtual Reality and Healthcare - The Past, the Present, and the Future
  • 2. Digital Therapeutics and Healthcare The Digital Health Revolution Emerging and Confluent Technologies Overall Landscape of XR Technologies Neuroscience – Why XR Has Impact History of VR - and Why it Matters Current Status – Where There is Traction Future Perspective and Predictions
  • 3. The Stanford Laboratory for Brain Health Innovation and Entrepreneurship VR-IT Stanford Virtual Reality Immersive Technology Clinic Academic Affiliations
  • 4.
  • 5. 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. Digital Health Revolution • Mobile Health / eHealth • Machine Learning • Wearable Sensors • Patient Centered • Leverages Internet: social, quantitative, collaborative
  • 9. • Prevention and Wellness • Objective Assessments • Functional Training • Improved Interventions • Facilitate Adherence • Distributed Care Delivery Digital Health technology will significantly impact Medical Care
  • 10. Every Medical Device Reinvented
  • 11. Entering the Era of Medical Wearables
  • 12. Digital systems are not just measuring the physical parameters of our health. New methods are being developed that will allow us to collect and analyze biomarkers that reflect our cognitive and emotional status. Here are four examples… Brain Health BioMarkers - Passive Data from Smart Phones Voice Analytics as a BioMarker of Depression Facial expressions in response to a VR Challenge Cognitive function assessment using AR and smartphone sensors
  • 13. Digital Health Platforms deliver interventions to patients, and parse data for enhanced analysis and improved protocols
  • 14. Prescription Digital Therapeutics Combination Therapy - Digital Health Platform App-based system designed to enhance medication efficacy Medication with clinical benefit Prescribed combination product with enhanced efficacy =+
  • 15. Prescription Digital Therapeutics Create Value In Areas Of High Patient Need Combination Therapy PDTs can monitor toxicity and personalize treatment Can leverage sensor data. Dose Optimization PDTs can monitor and address comorbid conditions: insomnia, poor nutrition, anxiety, depression, activity levels, use of nicotine and alcohol, etc Address Comorbid Conditions Software-based therapies have been shown to be effective as stand-alone interventions – there is incremental effectiveness when PTDs are used in combination with standard treatment Facilitate Adherence Collect Utilization And Efficacy Data PDTs have several tools to facilitate adherence –provide key information, close the feedback loop, show progress, connect to the care team, leverage games and other motivational tools, provide reminders and sound alerts, etc PDTs collect de-identified utilization and efficacy data – combined with sensor data Advancing research, facilitating improved formulations, and allowing for personalized protocols based on large-scale studies.
  • 16. The “digital layer” creates value – across all parts of the clinical care • Standardizes data collection for clinical studies • Tracks the supply chain to a pill-by-pill level via QR codes etc. • Collects real-world data supporting regulatory submissions • Enhances clinician touch-points via data-based dashboards • Enhances therapeutic adherence and efficacy • Provides real-world data to support reimbursement discussions Discovery and development Supply chain Regulatory approval Clinician detail Patient use Reimbursement
  • 17. Enhanced outcomes - plus value for patients, clinicians, and payors • More convenient care, reducing transportation and wait times • Offers the better outcomes for for patients • Provides immediate care allowing patients to access therapeutic content when needed For patients For clinicians For payors • Enables data-driven care demonstrating efficacy and engagement • Leads to greater engagement, fewer drop-outs, and reduced no-shows • Extends the reach of the clinician – facilitating improved follow-up and reduced readmissions. • Collects data to measure and validate quality of care • Allows evidence-based treatment to be widely standardized • Reduces overall care costs for a large and expensive patient population
  • 18. Intervention Key Components Example Targets Digital Adaption Possibilities Cognitive Behavioral Therapy (CBT) • Capture thoughts that arise in response to specific situations • Check those thoughts to determine if they are accurate or distorted • Change distorted thoughts by substituting them with more helpful thoughts. • Target: depressive thoughts • Identify thoughts that arise in response to situations. • Identify distortions in thinking. • Identify accurate, more helpful thoughts. Gamified exercises: • Catch it – identify automatic thoughts • Check it – evaluate it against list of common distortions • Change it – come up with more accurate interpretation of the event. Behavioral Activation (BA) • Identify life values and goals • Identify activities that are aligned with those values • Create a hierarchy of activities • Schedule these activities and track progress over time • Target: avoidant behavior • Value identification • Activity Scheduling • Tracking mood and activities Interactive feature with: • Values clarification • Identifying and scheduling activities to support those values • Tracking activities and mood Mindfulness Meditation • Progressive muscle relaxation • Guided imagery • Guided meditation • Target: • Relax the body • Relax the mind • Be fully present Guided meditation activities (e.g Headspace, Calm) Full meditation courses One Example- Depression: Intervention and Digital Adaption Possibilities
  • 20. 5G connections will surpass one billion by 2023 Single-digit millisecond latencies with Edge Computing Cloud-Rendered AR and VR content Real-time Analytics for Machine Learning, Predictive Modeling
  • 22.
  • 23. Digital Twin Paradigm For Precision Healthcare
  • 24. Sensors Are Evolving, Connecting, Promulgating Sensors 1.0 Sensors 3.0 Sensors 2.0 Measure and record Integration with web; Sharing and accessing data Passive data gathering; Aggregation and meaningful interpretation
  • 25. Ready or not… The wearable tech, always on, always online world On the way - arriving soon.
  • 26. Virtual Humans - Voice Recognition, Emotion Detection- Dynamic Response
  • 27. Virtual Humans For Education, Training, Support “Smart Avatar” with a virtual voice, image and mannerisms via AI
  • 28.
  • 30. The Next Computer Platform Work Play Educate Socialize Shop Entertain Communicate Etc
  • 31. Now is the time for VR & AR XR technology is now affordable, scalable and accessible Facebook - Oculus HP - Reverb Sony – PlayStation VR Microsoft - HoloLens HTC - Vive Apple - Varjo HMD - 60 PPD for 20/20 vision resolution
  • 32. Why use XR? Uniquely Capable Extension of existing virtual capabilities Intuitive “spatial” language natural interactions streamlines engagement Deeply Personal Learning content made meaningful through user’s interaction & feedback Immersion enhances engagement, retention Making experiences “personal” drives motivation to learn & keep learning Highly Functional Experimenting with systems & concepts to better understand Applying learned concepts in practice Can do things are otherwise expensive or impossible -e.g. due to safety/cost
  • 33. Fully immersed in an environment Virtual Reality
  • 34. Digital objects and overlays in the real world Augmented Reality
  • 35. The spectrum between AR & VR: From blending ourselves with digital environments to anchoring digital objects in the real world Mixed Reality
  • 36.
  • 37.
  • 38.
  • 39. 1.3 Million Monthly-connected VR Headsets on Steam Steam is a video game digital distribution service Projected 2.75 million monthly-connected headsets by the end of 2020
  • 40. VR and AR Technology is Evolving Exponentially
  • 41. 11.3 16.9 27.3 41.5 56.2 68.0 Year 2 Year 3 Year 4 Year 5 Year 6Year 1 Within 3 years, VR will likely be adopted by 30 million users Within 6 years, XR will likely be adopted by 70 million users
  • 42. Medical Applications of Virtual Reality & Augmented Reality (XR) Technology Digital Health Revolution
  • 43. XR Technologies Currently Disrupting Education & Training Manufacturing Maintenance Product Design Process Design Healthcare Simulation & Modeling
  • 44. • Prevention and Wellness • Objective Assessments • Functional Training • Improved Interventions • Facilitate Adherence • Distributed Care Delivery VR and AR Technology Impacts All Sectors of HealthCare
  • 45. Acute Pain Addiction Medicine ADHD Anxiety Management Autism Spectrum Disorder Chronic Pain Cognitive Assessments Depression Disability Solutions Emergency Medicine Medical Education &Training Ophthalmology Orthopedics Palliative Care Patient Education Phobias PTSD Physical Medicine and Rehabilitation Preventive Medicine Respiratory Medicine Senior Care Stroke & TBI Surgical Procedure Planning Surgical Skill Training Uncomfortable Procedure Mitigation More Than 200 Emerging Medical VR/AR Companies Targeting Multiple Clinical Sectors and Specific Indications
  • 46. Significant Investment in XR for HealthCare The Medical VR / AR Market is projected to be $5.1 B in 2025
  • 47. Medical XR Can Address Several Key Problems Annual cost of problems in the U.S. alone: WEIGHT LOSS $289B SMOKING CESSATION $528B ADDICTION $181B CHRONIC PAIN $635B POST TRAUMATIC STRESS $300B Stroke & TBI $86B Alcoholism $223B Autism $126B
  • 48. Conferences and Industry Organizations Extreme Innovation in Healthcare
  • 49. 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:
  • 50. VR is More Effective than Imaginal or In Vivo Exposure Techniques VR exposure floods the visual thalamus and cortex, activating both subcortical, threat detection and response pathways as well as cortical, conscious pathways In this manner, VR exposure therapy is more effective than imaginal exposure therapy - it activates both exposure/cognitive processes and threat extinction processes. In vivo exposure is inconvenient, expensive, time- consuming, difficult to standardize, difficult to monitor, and imposable to provide in a graduated or controlled manner. Sensory Inputs Sensory thalamus -> amygdala path -> (non-conscious) Sensory cortex -> PFCvm -> amygdala path (conscious) HPA Axis
  • 51. Ability to change attitudes and behavior after “being” one’s future self. Leveraging Mirror Neurons
  • 52. 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
  • 53. Addition Mechanisms of Impact Active Involvement: XR systems provide users with immersive experiences that maximize cognitive engagement. Feedback: learning is reinforced by direct, immediate and relevant feedback that reinforces the experience and the lessons learned. Engaging and Motivating: the dynamic nature of VR/AR systems provides users with agency and can provide immediate rewards for progress. Team Training: Multiuser experiences can provide and leverage group skill building. Cost Effective: XR systems extend the reach and reduce the cost of face-to-face training. Novels Theater Film Games AR/VR
  • 54. Wired for Narrative Stories Research shows that STORY: • Provides superior retention (memory and recall) • Provides improved understanding • Creates context and relevance • Creates empathy • Promotes engagement and participation • Enhances the creation of meaning and personal relevance
  • 55. First general purpose and commercially available VR systems. VR Technology Has Evolved 1987
  • 56. My 36 Year Journey…. 1984 – Stanford University
  • 57. Mitigating Post Traumatic Stress With Virtual Reality 2008 Sichuan Earthquake 12 Years Ago
  • 58.
  • 59. Academic research has indicated that Virtual Reality can effectively treat a wide variety of clinical problems – ranging from addictions, to stroke, to PTSD
  • 60. Two Years Ago Mitigating Post Traumatic Stress With Virtual Reality 2017 Mexico City Earthquake
  • 61. • Prevention and Wellness • Objective Assessments • Functional Training • Improved Interventions • Facilitate Adherence • Distributed Care Delivery VR and AR technology will significantly impact Medical Care
  • 62. • 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
  • 66. 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
  • 67. Virtual Patients for Clinical Skill Training
  • 68. Todd Chang. MD Joshua Sherman, MD CHLA Emergency Department
  • 69. VR simulation to train medical students and staff to respond in high-stakes, low-frequency pediatric emergencies.
  • 70. Pediatric Resuscitation VR simulation to train medical students and staff to respond in high-stakes, low-frequency pediatric emergencies.
  • 71. “We discovered that VR training modules should be targeted towards younger, less experienced trainees. That’s why the CHLA residency program and hospital have greenlit VR as part of a required curriculum for our interns prior to setting foot in our emergency department.” Todd Chang MD - CHLA Emergency Department
  • 72. Preparation and Training for Difficult Situations
  • 73. Understanding the Patient Experience Clinical Training
  • 74. Patient Education & Informed Consent
  • 75. • Prevention and Wellness • Objective Assessments • Functional Training • Improved Interventions • Facilitate Adherence • Distributed Care Delivery VR and AR technology will significantly impact Medical Care
  • 76. • Medical Image Review • Neuropsychological Assessments • Activities of Daily Living Assessments • Physical Medicine – OT / PT • Behavioral Medicine – psychology, psychiatry DIAGNOSTIC ASSESSMENTS
  • 77. 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.
  • 78. 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
  • 79. BioMarkers - Cognitive and Emotional State Collecting and analyzing emotional and physical responses in VR
  • 80. Facial expressions reflect emotional status Collecting and analyzing emotional and physical responses in VR
  • 82. Standardized Environments for Neurocognitive Evaluation New Approaches for Cognitive Assessment
  • 83. We use brain circuit biotypes to connect brain imaging with VR Neuroimaging measures 1. Scan brain at rest 2. Emotion regulation task 3. Cognitive control task Virtual Reality: 1. Relaxing scene 2. Emotion regulation task 3. Cognitive control game
  • 84. We envision a precision health model using VR to elicit biotypes to help refine the intervention choices Cognitive training TMS Eliciting biotypes using normed environmentsHeterogeneous Disorder Quantify and refine biotypes Relaxation Negative Scene Positive Scene Cognitive Game 1st line Antidepressants Mindfulness-based. TMS Non-drug and new drug options Matching biotypes to the intervention “menu” Default Mode Negative Affect Positive Affect Cognitive Control
  • 85. With corresponding ratings of arousal, emotional valence, and other measures A Public Database of VR Environments
  • 86. • Prevention and Wellness • Objective Assessments • Functional Training • Improved Interventions • Facilitate Adherence • Distributed Care Delivery VR and AR technology will significantly impact Medical Care
  • 87. Some Examples – VR and AR in Use Today
  • 88. Preoperative Planning & Image Guided Surgery
  • 89. Stroke and Traumatic Brain Injury Physical / Occupational Therapy New Approaches to Physical Medicine & Rehabilitation
  • 90. New Approaches to Mental Health
  • 91. 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
  • 92. PTSD, Phobias, 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
  • 93. RISK AVOIDANCE TRAINING Refusal skill training, Situational Confidence
  • 94. ! 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
  • 95. • Social Anxiety Disorder • Depression • Chronic Pain • Mild Cognitive Impairment • Autism Spectrum Disorder • ADHD Virtual environments are used clinically to treat several important mental and behavioral health problems
  • 96. Multiple Programs - One Platform DTx Programs BALANCE Foundation Mindfulness Relax Regulate Chronic Pain Acute Pain Relief Addiction General Wellness Programs Stress + Rx Adherence + Efficacy Anxiety / Depression Acute + Chronic Pain Cloud-based System Dynamic Experience Biometrics Service Social VR Engine*Analytics Permissions & Security
  • 97. Virtual Hospital Tours Used To Relieve Pre-procedure Anxiety
  • 100. • Improve Cognitive Function • Promote Exercise & Weight Management • Stress Management • Mood and Resilience HEALTH AND WELLNESS • Disability Solutions • Addressing Isolation • Grief Counseling
  • 101. Ability to change attitudes and behavior after “being” one’s future self. Have a Dialog With your Future Self
  • 103. What Are The Constraints? What are the gating-steps to adoption?
  • 104. 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
  • 105. Perception of VR as a Gaming Platform
  • 106. 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?
  • 108. The Near-Future of XR Currently Deployed or Under Development Improved tracking: Tracking without dedicated external sensors will improve, greatly increasing portability & reducing setup Large-scale tracking: Beyond room-scale to significantly larger volumes, such as warehouse scale Wireless connectivity: Battery-operated headsets with wireless display/data link to a desktop computer or the Cloud New input methods: Controller interface hardware is highly iterative Mixed Reality: Seamlessly blending elements of VR with the real world, convergence of VR/AR
  • 109. The Near-Future of XR All of this will affect development & deployments done in the near-term: Shorter generation cycle (~2-3 years) than other consumer tech Significant changes between generations e.g. not an iPhone 9/10 gen Old hardware may no longer be available (replacements/spares etc.
  • 110. Increased Use of the Digital Twin and Future Self Paradigm
  • 111. 50 learning modules to train 1M associates •17,000 Oculus headsets across nearly 4,700 U.S. stores 12 learning modules in 200 locations Adoption Deployment Pilot
  • 112. Pediatric Resuscitation Training The CHLA residency program and hospital use VR as part of a required curriculum for interns - required prior to setting foot in the emergency department.
  • 113. XR - A Key Component Combination Therapy - Digital Health Platform XR system designed to enhance medication efficacy Medication with clinical benefit Prescribed combination product with enhanced efficacy =+
  • 114. Digital Health Platforms deliver interventions to patients, and parse data for enhanced analysis and improved protocols
  • 115. Acute Pain Addiction Medicine ADHD Anxiety Management Autism Spectrum Disorder Chronic Pain Cognitive Assessments Depression Disability Solutions Emergency Medicine Medical Education &Training Ophthalmology Orthopedics Palliative Care Patient Education Phobias PTSD Physical Medicine and Rehabilitation Preventive Medicine Respiratory Medicine Senior Care Stroke & TBI Surgical Procedure Planning Surgical Skill Training Uncomfortable Procedure Mitigation More Than 200 Emerging Medical VR/AR Companies Targeting Multiple Clinical Sectors and Specific Indications
  • 116. Acute Pain Addiction Medicine ADHD Anxiety Management Autism Spectrum Disorder Chronic Pain Cognitive Assessments Depression Disability Solutions Emergency Medicine Medical Education &Training Ophthalmology Orthopedics Palliative Care Patient Education Phobias PTSD Physical Medicine and Rehabilitation Preventive Medicine Respiratory Medicine Senior Care Stroke & TBI Surgical Procedure Planning Surgical Skill Training Uncomfortable Procedure Mitigation Considerable Activity
  • 117. Acute Pain Addiction Medicine ADHD Anxiety Management Autism Spectrum Disorder Chronic Pain Cognitive Assessments Depression Disability Solutions Emergency Medicine Medical Education &Training Ophthalmology Orthopedics Palliative Care Patient Education Phobias PTSD Physical Medicine and Rehabilitation Preventive Medicine Respiratory Medicine Senior Care Stroke & TBI Surgical Procedure Planning Surgical Skill Training Uncomfortable Procedure Mitigation Relatively Underdeveloped – Significant Opportunities
  • 119. 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 Therapeutics for Medicine After years of study and use by early adopters – validated systems are poised to move to the mainstream On the horizon - enhanced, ubiquitous, informative and integrated Digital Therapeutics are currently used for - prevention, evaluation, treatment, and chronic disease management
  • 120. Digital Therapeutics for Medicine The Digital Health Revolution Emerging and Confluent Technologies Overall Landscape of XR Technologies Neuroscience – Why XR Has Impact History of VR - and Why it Matters Current Status – Where There is Traction Future Perspective and Predictions
  • 121. VR AND HEALTHCARE SYMPOSIUM - EUROPE Dublin Ireland December 5-6 2019 March 25-26 2019 Cedars-Sinai Virtual Medicine VR for Mental & Behavioral Health Conference October 7-8, Denver Colorado FDA Public Workshop – Medical Extended Reality March 5th
  • 122. Virtual Reality and Healthcare - The Future
  • 123.
  • 124. 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 Digital Therapeutics for Senior Care
  • 125. Walter Greenleaf PhD Virtual Reality and Healthcare - The Past, the Present, and the Future