2022 Innovations in Simulation Summit Explores Extended Reality

Leading experts on how to launch and maintain medical education programs using extended reality (XR) and measure their effectiveness shared their insights at the 2022 Helene Fuld Health Trust Innovations in Simulation Summit, “Building a Sustainable Extended Reality Program in Academia,” held on November 11 at The Forum at Columbia University.

XR is an umbrella term covering virtual, mixed, and augmented reality, Kellie Bryant, DNP, assistant dean, Clinical Affairs and Simulations Center, and the event’s organizer, explained in her introduction at the event, the fourth in a series funded by the Helene Fuld Health Trust.

“Although the effectiveness of XR use in health care has not been widely documented, it does have the potential to enhance education and delivery of the education we provide to our learners and increase patient safety, and we know it has many uses,” Bryant said. “We’ve seen it used in anatomy and physiology, we’ve seen it used for clinical skills and procedural training, communication and even empathy training, and even practicing caring for patients in complex scenarios.”

Like any new technology, implementation of XR brings multiple questions, she added, including to how to start, fund, and sustain a program and how to evaluate its effectiveness, and she urged attendees to be inquisitive and network.

The event included plenary and breakout sessions with guests from the University of Michigan School of Nursing, Yale School of Medicine, and Case Western Reserve University School of Medicine; a Columbia XR Showcase; a vendor showcase with HP, Lumeto, SimX, and Oxford Medical Simulation; and a networking reception.

“I was extremely grateful for our expert speakers sharing information on their projects, research, and recommendations for implementing an XR program. I left the summit feeling inspired and with necessary knowledge to move forward with our XR program,” Bryant said after the event.

XR in Health Care Education

Kimberly Hieftje, PhD, and Asher Marks, MD, are the codirectors of XRP (XR Pediatrics) at Yale School of Medicine, founded in 2020 to focus on virtual, augmented, and mixed reality within research, clinical practice, and patient-family-provider education, with the overarching goal of improving the health of young people and their families.

Hieftje, the director of the play4REAL Lab and an assistant professor of pediatrics, noted that her behavioral change-based game interventions allow users to rehearse challenging experiences before encountering them in real life. For example, her VR vaping prevention game “Invite-Only,” named one of Forbes’ top games in 2019, has users take the role of a freshman angling for a party invite from a vaping senior in his health class. Other games have focused on tobacco use prevention, risk reduction for adolescents, HIV/STI prevention, bystander intervention, alcohol harm reduction, and more.

“When I think about game-based learning, it really is the opportunity to practice skills and less about the acquisition of knowledge and more about that skill-based learning,” she said.

Dr. Marks, a practicing pediatric oncologist, described developing his virtual reality-based support group for adolescents and young adults with cancer. Early challenges included undergoing Protocol Review Committee review, which led to the protocol being expanded from six to 36 pages and took several months, in part because of safety concerns raised about the unfamiliar technology.

“It was a great experience, but excruciating, really hard. Once that was done it flew through the IRB,” he said.  “This stuff is hard to start with because it hasn’t been done so people are trying to get their heads around it. I guess my lesson here is take your time with it. Know it’s going to take a little while.”

Dr. Marks and his team tested the VR support group in four groups of four patients each in a Phase 1-2 pilot trial, with a psychologist or social worker as moderator and an “invisible” PI or research assistant. Groups met weekly for six weeks in a row, and the attendance rate was 72.7%. “This is the number that I love to quote,” he said. “That sounds dramatic...The truth is we couldn’t get any of these kids into support groups before this started, and now they’re coming and they’re asking for more.” Patients also showed significant improvements in resilience.

One “big take home,” he noted, is to determine if XR will add value before including it in a project, and consider reach, accessibility, cost, and sustainability. Other technologies such as a web-based application or mobile app may be more appropriate.

Implementing an XR Program

Daniel Salcedo, MD, director of simulation and technology, Case Western Reserve University School of Medicine, spoke about the challenges of integrating XR into a simulation program. Three key questions should be thought through first, according to Dr. Salcedo:

• Why will we use XR?
• Who will be using it?
• How will we use it?

“The biggest and most important thing to understand is if you can do it on a 2D screen don’t waste your time and money doing an XR,” he said. “There has to be a purpose, a reason, that it is going to do something that you cannot get with other technology.”

Other vital questions: Will users be experienced with VR, or inexperienced and potentially at risk of “cyber sickness”? How is the tracking of the headset going to work? Should you choose a tethered (plugged into a computer) headset or one that can run independently?  How will you budget for replacing equipment? Is an app just for a single class, or can it be used for many different situations? Can the app be adjusted for different learners’ needs?

“All of these things are going to have an impact on how this is accepted into your community,” Dr. Salcedo said. It also requires effort to figure out how XR will fit into the curriculum, what educational outcome you are hoping to achieve, and how you will measure these outcomes, he added.

“If we can manage to come together to share ideas, to share experiences, to start thinking about what the best practices look like, then we can really make a change and introduce the technology that is going to revolutionize the way our learners are thinking and learning,” he concluded.

Creating a Center for Academic Innovation

Jeremy Nelson leads the XR initiative for the Center for Academic Innovation at the University of Michigan, which has brought XR for teaching and learning to all 19 schools and colleges at the Ann Arbor campus, as well as more than 10 million global learners.

The university’s XR innovation fund has given out three rounds of seed money, funding 25 of 34 proposals received.  to projects at 13 schools, Nelson noted. He has hired two software developers, and also has been able to hire student fellows to help develop XR scenarios.

Michelle Aebersold, PhD, a clinical professor at the University of Michigan School of Nursing, a certified health care simulation educator, and one of three faculty innovators in residence at the university, presented two 360 video projects she developed with funding from the Michigan Department of Health and Human Services, modeling care for veterans and for patients who are deaf or hard of hearing.

Using a headset, the user can “stand” in the scene and watch the patient and provider interact. Users can also watch the video on a standard screen or phone in 2D form.

Aebersold also developed “Under the Skin,” to help nurses and pharmacists handling chemotherapy—who face an increased risk of cancer themselves—to use their PPE effectively and avoid contamination with chemo drugs. The module includes a visualization where the user watches the effects of doxorubicin at the cellular level.

She emphasized the importance of international and external partnerships when developing XR projects and noted that collaboration can help to reduce duplication and leverage existing platforms and solutions.

XR Showcase

At the showcase, Associate Professor Jaime Panton, DNP, presented the XR module she is developing for her PNP students.

Panton and Assistant Professor of Nursing at CUIMC Deanna Schneider, DNP, wanted to find a “fun, innovative way” to teach their pediatric emergencies course, held in the program’s final semester. Their literature review found XR products for teaching medical students and bedside nurses, but little for NPs.

Panton and Schneider decided to create an XR version of one of the eight modules taught in the course. They received a grant from the Center for Learning and Teaching Emerging Technology to build the module, on diagnosing pediatric abdominal pain, and are working with Axon Park to develop the virtual reality scenario, which they plan to begin testing this spring.

“Any of you who work with kids know that can be a little intimidating to have to care for a child,” Panton noted. “It can be a little bit overwhelming, so we want to create an opportunity for students to feel like they can do that in a safe way. Virtual reality creates this breathing room where students can explore and make mistakes.”