2024 VA Immersive Summit: Dr. Walter Greenleaf Keynote
I do have, slides, but it won't be just my PowerPoint. They're going to be very brief, mostly fun illustrations and graphics to get my point across. I would love to have your input after my talk about any of the points I bring up worthy of discussion. What I will try and do right now is give a bit of a context of the digital health environment, where Immersive technologies fits into that. What's going on in terms of the underpinnings of research supporting where we are? Because I'm a neuroscientist, I will spend a little bit of time talking about why Immersive technologies VRA technologies as we've designed them have such strong impact I'll give a few examples of the spectrum of applications we see in health care I've asked a few of the people here who have been working in the field to talk about what they view as the notable accomplishments over the last year. So spend a minute or two on that.
Talk a little bit about some of the challenges that we have as a field, things we have to be very careful about and pay attention to. Then if there's time, I'll take the risky effort to maybe make a few speculations about where we will be next year. Again, the work we're doing here is very important. Very meaningful.
But we have to do it together. There's a lot of work to be done. We need to help shift the health care ecosystem to embrace a new technology that hasn't quite scaled at the home or at the enterprise level.
It has such an impact on health care that I believe that health care will be the first enterprise to really scale immersive technologies. But it's up to us to work together to help that happen. And just like, back in the nineties, the gaming industry only grew because the groups that were developing technology worked together to come up with standards to look at interoperability, to work with the council manufacturers, to scale the opportunity, that's now a multibillion dollar business larger than the movie industry, but only because the groups that could potentially viewed each other's competitors worked together. So think we're in a similar situation. We can help build a field, build an industry if we help each other.
My passion is driven by my concern about an aging population. I spent some time as the director of The Mind Division for the Stanford Center on Longevity, and I became very conscious of the fact that we have a big crisis looming, and I think it's potentially much worse than global warming. Our world population has doubled since the 1970's, but resources have been constrained and family sizes have shrunk. So we're in a position where as we live longer, as we live into be 100, 110, 120 years old with advances in health care, we won't have the caregivers to support cognitive aging issues involving Alzheimer's, neurodegenerative disease, etc.
So the only answer is to leverage technology. We have so many problems facing us as an aging population, which could bankrupt our economy if we don't get on top of it. It's not just the traditional problems such as cancer or, stroke or traumatic brain injury, Parkinson's. Today's lifestyle also creates additional problems involving obesity, burnout, addictions, etc. We have to shift where we intervene and when we intervene. The only way we can do that is by leveraging technology.
And, my favorite quote, from William Gibson is, the future is already here, it's just unevenly distributed. The answers to some of the problems that we're facing within aging populations have already been developed. We just need to scale them. One more reason for us to work together and one more reason to be thankful for our colleagues at the Veterans Health Administration for helping us scale. It's just remarkable how fast they've grown VR and AR technology throughout their health care environment. For that reason, I think it's important that we all work together, not just the academic groups but also many of the digital health groups.
I think we need to be aware that we're in the middle of a digital health revolution, shifting the center of care, the center of gravity, to where the patient is located. Every medical device over the last 10 years has been moved from an analog format into a digital format, and this allows us to do some fantastic things. We're entering the era of medical wearables. Many of you are wearing something right now that senses your heart rates, your steps, et cetera. There's a lot of data that can be collected passively from your cell phone that indicates your mental health status, your physical status.
We're entering into the era of combination therapy where it's not just a drug, it's not just a device, it's technology software as a medical device. The recent guidance from the FDA helps facilitate that combination therapy with pharmaceuticals with software. For example, cell phones are very powerful devices for collecting information that can be part of the health care ecosystem and snap on to what we're doing with immersive technologies. More than half the world's population has access to a smartphone. Now we can leverage that.
As we collect this data and put it together in a protected manner, we have such a tremendous resource for improving protocols, for reaching people, understanding in a precise manner what motivates them, what helps them. We are getting better at using machine learning and analytics to foster that. I'm excited by the fact that we now have new ways of leveraging unobtrusive data to help understand our emotional state.
Just examples of collecting data from your smartphone about how fast you're typing or voice analytics as a biomarker for anxiety and depression, or facial expressions or body language. It's a very powerful possibility that we now can move things from the subjective world of self report into more objective measurements. We need to be aware that there's a lot of emerging and confluent technologies that are supporting what we're doing with immersive technology.
Sensors are promulgating we're going to see them embedded in almost everything that we use or buy. We're evolving ways to model the data from the sensors into large complex systems and use machine learning to analyze that data. And it's not just the individual data that we collect.
We collect timely data from families, communities, groups and how they interact, companies and their behavior. With the right sort of analytics, we can make patterns to understand health on an individual, on a family, and on a group basis. We're coming up with new ways of collecting information, so I'm excited about what's going on with FNIRS technology and brain function. We're getting new ways to collect information about our metabolic function just by sensors that can be mounted on the skin.
Again, we have the tools now to make sense of this gush of data. Things are also shifting in terms of the business world. The tech titans are moving into health care. We're seeing shifts in the regulatory landscape; covid changed that dramatically. Telemedicine is getting traction both on a reimbursement and on a technology level, but also an acceptance level.
Patients are feeling more comfortable and clinicians are feeling more comfortable of doing some things in a telemedicine manner. We're now much more aware of the importance of, mental health and hopefully the stigma of addressing mental health issue is gradually dissipating. One thing I want to emphasize is where the tech titans will be going over the next 10 years: their next user interface. They are going to be using AR technology, VR technology, wearable sensor technology, to personalize our interaction with each other.
They will be using technology to capture our eye gaze, our pupil dilation, our facial expressions, our voice tone, to improve their user interface, how we work with technology, how we connect with each other, how we interact with our smart cars, all will be impacted by the next generation of user interface brought to us by the tech titans. This is going to be important for health care because we can leverage the same approaches, the same algorithms, the same sensor technology to move it into psychiatry, psychology, behavioral medicine. This is on its way, it's already part of the design stage. It's already here.
This is the field of affective computing, where we can use sensors and analytics to come up with a score for cognitive and emotional state. It's in a complex area, you need to be careful not to have biases in the data, and be sure to have data that really represents in a culturally diverse age appropriate manner, the status of the user, but it's on its way. It's available now and it can be used.
I'm excited by what M.Tech, one of our friends in the UK is a company collecting information about eye gaze and using it as a way of scoring emotional state. I'm excited about one of the companies I work with, InteraXon the maker of the Muse Headband; collecting EEG data along with other biosignals to come up with a score of state. One of the projects I'm particularly excited about is working with a group at NASA on the mission to Mars. They're very concerned about the fatigue levels and the anxiety levels and stress levels in constrained environments where to be tired or to be distracted can be fatal.
And they're working to come up with new ways of both measuring and implementing scoring systems, in those hostile environments. I was excited and I think it was a pioneer effort by the work that MindStrong did to come up with digital biomarkers just from passive data, typing on your cell phone, as an index of cognitive status. Very tight correlation of the standard attention test with the signals you can get just by typing on your cell phone.
That work has been carried forward by other groups, there's a group out of the University of Chicago that's developing work using smartphone data as a digital biomarker for neurocognitive function. Ellipsis Health is using voice as a biomarker for stress, anxiety, and depression. And we're seeing other groups, using smartphone behavior and keyboard dynamics to predict suicidal ideation, for example. Very clear work in this area that's just scaling as we get better to interpret this data and bring it out to larger populations. I'm especially excited by what I'm seeing with eye gaze information.
And as you know, our VR headsets are getting better and better at capturing not just gaze direction, but pupil dilation and how much time we spend looking at a particular object in the virtual field. This can be used to come up with a score for cognitive load or fatigue. There's a company that I'm excited about called Harmonize, that can take has a huge data set collected over the last 10 years of eye gaze data that can be collected from any device, a webcam, a VR headset, and apply that data to come up with a score of fatigue level and attention and distraction. I'm excited by what, the company ViewMind is doing in terms of using a VR headset as a platform to do a complete executive function test in a matter of minutes, highly correlated with the standard ways of doing these assessments.
And a lot of work in terms of just collecting information such as, heart rates, blood oxygenation microexpressions and using this as a predictive model for suicidal ideation. It's exciting what we can do. Now, how do we apply this? The best way to do it is to take a precision medicine approach, where we can look at the user, collect information from them across the month, across the week, and be able to intervene when there's a crisis to prevent the crisis getting worse. For example, with multiple sclerosis, the company Octave Biosystem, collect biomarkers related to multiple sclerosis. And if there's a flare up in process, they can bring the patient in, intervene earlier, reducing substantially the degree of injury to the patient, but also reducing health care costs substantially.
All this analytic and sensor data and new ways of impacting a patient is changing the role of the clinician. It's become more of an informatics based profession. And many people worry, "Although this will reduce the cost of health care and allow us to extend our reach, will it make the clinician's role obsolete?" Of course not. I think what it will require is us as designers and implementers of the technology and for clinicians to realize that they need to embrace and understand the power of this technology and how it can be applied to health care.
I'm excited by what Sidekick, some of the people here, are doing in terms of coming up with agents that can support and intervene early to prevent a health care crisis. I'm especially excited about where we're scaling within the immersive arena. We've had more than 30 years of research and development providing us with the underpinnings. and foundation for the work that we're starting to scale. I think with the reduction in cost and the gradual acceptance and proof points that the VA Health Administration has shown, things are poised to really scale in a much faster way.
It's worth remembering that all aspects of health care are being impacted by the technology. It's not just the clinical care. It's not just the health maintenance of the individual. It's really the full stack: training of the clinicians, more objective assessments, better ways to intervene, but also other ways to reach people in a distributed manner and ways to provide health and wellness preventive health applications.
I first got involved back in 1987. It's amazing to see how fast and how diverse the technology has come back from those days. I always like to give an acknowledgement to my colleagues such as Skip here in the front row and others who have served to come up with a substantial research background validating the approach. Now, of course, we have to take these early studies, extend them to larger patient populations, and with today's technology.
But the fact is, we now have a foundation that shows us the pathway. And many of the groups who are coming in to develop VR technology now haven't taken the trouble to look back to see some of the problems that were solved in those early days. It's amazing how I'll often see a VR system that causes some simulator sickness, feelings of nausea, but it's the design of how the user moves through the environment that is causing that problem rather than the technology itself. I encourage you, if you haven't, taken a look at the foundational research literature we have as you go to design your products; there's actually quite a substantial amount of foundational work that's worth taking a close look at. And things are changing. We're getting new types of technology.
New ways of having haptic impact, for example. New ways of having olfactory stimulation. VR technology is evolving at a pretty rapid clip. Our avatars are becoming much more like us, with facial expressions and body language, and the casual behavior that you might see, where a couple of avatars are standing around talking to each other, and another avatar walks up automatically, they may change, without you having to hit a control key to do it, to adjust their position. The things that we take for granted, in terms of our human behavior are pretty rare.
We're now starting to migrate to our multi user virtual worlds, and we're starting to see much larger, much more photo realistic virtual worlds with cloud based rendering and distributed systems and edge computing. We are starting to have virtual worlds that really are as complex or as intricate as we'd like them to be. Really, the full stack of health care is being impacted. I have yet to really find a area of health care that has not been impacted by immersive technologies, and it's not surprising that we are seeing so many groups bring in VR and AR technology. The mechanism of impact, in my opinion, for immersive systems is mechanism of adherence.
Compared to mobile technology because we can do storytelling because we can have interactivity for so many different reasons. We see much higher adherence rates when we use of an immersive system. This allows us to come up with a whole level of narrative storytelling that can fit on top of our applications. So it's not just a one experience. We can connect people over their health care journey using immersive technologies, take some lessons from our friends in the movie industry and from the gaming industry about how best to address and adapt evolved systems that follow the user. Keep them cognitively engaged.
I was excited to hear that our friends at Virtual Therapeutics have teamed with Akili to move their technology onto their platform. I think that's going to be a substantial move forward for our field. So I think it's important to realize that immersive systems have several key ways of impact.
We actively can engage the user in their health care. We can do feedback on their progress. We can come up with systems that are culturally diverse and age appropriate to keep them engaged and motivated and when well designed we can have cost effective solutions. And that's really key. So many groups feel that if they build an amazing product, it will be readily accepted. But that's not the case.
We need to design our systems to match the economic needs of the clinic to and the time constraint needs of the clinic. So one of the reasons immersive systems are so powerful at promoting adherence is that as humans, social animals, we are designed to listen to stories and pay attention to stories. We can put that layer of storytelling on top of the products that we develop and bring forward. Let's skip ahead a little bit for the sake of time.
If I'm five minutes late, would that be okay? Okay, thank you. I do think we can do some powerful things using virtual environments that we just can't do in any other aspect of health care. For example, one of the things that we have done at the Stanford Virtual Human Interaction Lab is to show that If we can connect someone with an age progressed avatar have their future self have a dialogue with them and give them feedback about their behavior there, whether they're exercising or whether they're drinking too much alcohol, it can shift attitudes and behavior quite profoundly, somehow connecting and closing a feedback loop about how the behavior and decisions you make today impact you over the long run can make a big difference. Just one example again of something we can only do; leveraging immersive technology.
In addition to improved interventions, we have remarkably improved assessments, new ways of doing cognitive assessments; by challenging an individual instead of asking them how they felt yesterday or how they felt in response to a particular medication. We can see how they behave and challenge them in a standard way using a virtual environment. I'm excited by what the company Neo Auvra is doing in terms of coming up with some very realistic challenges that challenge both the physical, the cognitive, and the emotional aspects of someone's behavior and function. Important to be able to get objective data on that.
One of the things we're missing though is a library of evocative environments. We started a project at Stanford's Virtual Human Interaction Lab to come up with a library of publicly available environments. but we haven't added to it, so it's one of the challenges we see, and one of the opportunities is for us to, as a group, come together with, a standard library that for research and for clinical care can be used to evoke emotional states of sadness or joy or stress; the whole spectrum of emotions we need to be able to evoke in a way that's reproducible and can be used for research across different groups. I'm excited by what my colleague at Stanford, Leanne Williams, is doing in terms of identifying subtypes of depression to come up with different treatment pathways. And part of that is using virtual environments to evoke a cognitive state to measure the response. I think we need to be able to be better at this, to take a more precision approach to mental health care, where we identify different subtypes before we send someone down a treatment pathway.
I'm excited by what Adam Gazzaley's lab is doing at UCSF in terms of seeing how an interactive virtual environment can change someone's executive function score, from a group in their 60s can start scoring in the same zone as people in their 20s. Adam followed up with that five years later and saw that the learnings and the changes in executive function that can be achieved by using a virtual environment can be applied and persist over several years. I'm going to skip a little bit ahead here. I've asked some of the people here in our community to talk about some of the notable achievements over the last year. One finding was very impressed by the Made for VA, Immersive VA effort that is going on here to come up with interoperability and standards for how we interact with virtual environments.
I asked Aaron Gani, for example, what he felt were some of the notable achievements over the last year. Aaron, I'm wondering if you want to stand up and tell the group a little bit about, what you see as a big accomplishment. We recently, in one of our products, it's a social anxiety disorder product, which is a partnership with Sumitomo Pharma.
We just completed a multi center, randomized, double blinded, placebo controlled trial; which was not easy and takes forever. But we did build a sham intervention in VR, and we put our social anxiety disorder product up against the sham, clear separation, handily beat the sham, and the responder profile, much improved or very much improved our intervention versus the sham actually had a remarkably similar pattern to what the approved drugs for social anxiety had against their placebos. Then coupled with some of the emerging guidance from the FDA on prescription drug use related software, which is a whole topic I won't get into now, it is accelerating or creating tailwinds for that drug; plus digital paradigm that Walter referred to. Chipping away for many years and we're getting to a point where we have a highly validated, proven effective therapeutic that can excel even in the domains of the pharma nerds. Thanks Walter. So notable, so important.
I asked Lighthouse to talk about their accomplishments over the last years. Anyone here want to mention that? Maybe just 30 seconds, describing what you feel is the big accomplishment over the last year. We basically had studied treatment completion. Jared and his, team has been looking at that. And we found that people that are not using the VR, 60 percent of them were completing treatment. Then we found that the people that were using the VR, 86 percent of them were completing treatment.
So that's a fairly significant finding, and we're still looking into more of that. One more example of promoting adherence using well designed VR systems. I was so pleased when I asked, Gita from Penumbra and the Real System about what she viewed as some of the noble accomplishments in immersive therapies and in her zone over the last year and true to form, I'm always so impressed by this, she turns it back to how many patients have we impacted, where have we made a difference, and she talked about the clinicians getting very excited about the use of VR, and that's so important. It's one thing for us to make a fantastic product, but if the patients aren't excited about it, clinicians aren't excited about it, it's not going to go any place. I was excited to hear what Mynd Immersive is doing in terms of their validation and extension of their work both at Stanford and with the VA system and with the state of Indiana.
AppliedVR has also published some really significant findings related to their products for back pain. Also establishing a CMS code for reimbursement; that's key for us scaling. It's happening; several notable achievements. I'm very excited to see what's happened with virtual therapeutics and working with Akili to scale products for attention deficit disorder forward. I was excited to see that from our community.
Vena Salmeretti being on PBS to talk about her products for stroke rehabilitation. Again, getting the word out to the larger community. Then XR Health merging with Amelia XR, and the strong work you've done, Aaron, in helping with the challenges in Israel and treating post traumatic stress and other problems using your technology. Thank you for that. I am definitely over my time. Housecall VR also mentioned that they'd had some notable events.
Just to wrap up very briefly, thank you for your patience. Let me go over for a few minutes. What are the constraints? What do we have to work on to scale and move forward? For one thing, I think we have a big issue. I talked earlier in my presentation about taking subjective measurements related to cognitive and mental health.
This is also something that is very precious data that we need to be careful to protect. I'm impressed by the book by Nita Farahany The Battle for Your Brain: Defending the Right to Think Freely in the Age of Neurotechnology. As we get deeper and deeper into this technology arena, this very important data that could be used for health care can also be used to sell us things, to change and influence our attitudes.
Or if we happen to live in a dictatorship to identify dissidents. We have to be careful about the use of this technology. There's still a lot of research gaps that we need to fill with today's technology and with larger sample sizes. VR and AR technology is still viewed as more of a gaming platform. We have to change that attitude.
Again, we need to be better at aligning our products with the needs of the health care system. It's wonderful to come up with something that's impactful therapeutically, but we also have to make sure that it fits in, doesn't consume too much time, and is cost effective for the health care ecosystem. We have to make sure that we solve the interoperability problem.
It's not okay to have five different headsets to address comorbid conditions on one patient. I'm excited. I talked about earlier how I'm concerned about an aging population, the health care issues there.
There are a number of fantastic applications relevant to senior care, so I'm heartened with that. But we also have to be careful that we don't overly technologized our lives. It's bad enough as it is with smartphones commending so much of our attention. I think if we start putting more sensors and collecting information, there's a trade off. And I think we have to be good at our design to make sure they're unobtrusive if we're gonna have them.
Things are moving forward. I think things are poised for us to scale if we work together. But again, we do need to work together or else we won't be at a rise to the occasion. Okay, thank you very much.
2024-07-06 23:39
