Early Scaling of Immersive Technology within the Veterans Health Administration

Summary

Over the past several years, accelerated by the Covid-19 pandemic, immersive technologies — including virtual reality (VR) and augmented or mixed reality, also known collectively as extended reality or XR — have shown mounting promise in their ability to enhance clinical care delivery and support clinical staff. These immersive systems alongside standard of care in several areas and are at minimum used as additional ways to augment evidence-based therapies. These non-invasive and easy-to-use tools have demonstrated ability to effectively channel patient experience into therapeutic activities, facilitate home-based care, provide valuable longitudinal patient data, and enhance treatment adherence. Given this promise, immersive health care applications have spread across the Veterans Health Administration (VA), building additional evidence for efficacy and laying implementation groundwork. To date, VA has documented more than 40 indications for immersive technology utilization within our organization, with more in the pipeline. Early exploration of immersive technology in VA began with 5 sites and 10 staff engaged in a Community of Practice and has now grown to 172 sites and more than 2,300 engaged VA staff. The most uptake and impact has been seen in pain management, physical rehabilitation, and mental health care, including anxiety, depression, and post-traumatic stress disorder (PTSD). Crucial to further scaling the use of immersive technology, VA has developed standardized resources such as knowledge networks, implementation guides, electronic health record templates, and standard operating procedures. VA continues to offer opportunities for more heads in headsets, as this is an effective way to demonstrate to Veterans and staff how immersive technology can enhance care. Key to future success in VA will entail increasing equitable access; growing the scope of content; standardizing training for staff and patients; and improving processes for synthesizing and analyzing relevant data to optimize these tools. Through these activities and continued planning, VA is poised to define the landscape of immersive technology in health care and inform adoption beyond VA.

Graphical Abstract

With the Covid-19 pandemic, use of telehealth and other technology to support and remotely deliver health care increased dramatically at a moment when in-person encounters were considered high risk for all.¹ The elevation of virtual care from interesting to imperative opened our eyes to what was possible in the United States and health care more broadly. At the same time, immersive technologies — such as virtual reality (VR) and augmented or mixed reality, also known collectively as extended reality or XR — have continued to mature and expand into health care, especially for physical rehabilitation, mental health care, and pain management.

At the Veterans Health Administration (VA), which serves more than 9 million Veterans across 172 VA medical centers and almost 1,200 additional sites of care, our journey with these immersive technologies began with clinicians exploring use cases for post-traumatic stress disorder (PTSD),² phantom limb pain,^3,4 stress, and anxiety⁵ at five United States Department of Veterans Affairs Medical Centers (VAMCs). These efforts have gained momentum across the organization; as of 2023, immersive technology is impacting Veteran care for more than 40 indications across 90% of VAMCs in 2023 (Table 1).

Table 1.

Immersive Technology Use by Indication: 45 Indications and 17 Settings

Indication*	Care Setting	End User	VA Immersive-Specific Implementations** (N = 353)
Rehabilitation
Creative arts therapy	PMRS	Patients	20% (n = 72)
Physical therapy	PMRS	Patients	<10% (n = 34)
Functional rehabilitation in residential living centers	HPC, LTC, STR	Patient	<3% (n = 9)
Low-vision rehabilitation	BRS	Patients
Neurological rehabilitation	HPC, LTC, STR, PMRS, DU, IMH, ONC, OPC, PCC, SUDC, WHC	Patients
Occupational therapy	PMRS	Patients	<1% (n = 3)
Postoperative recovery	PMRS, SS	Patients
Prehabilitation	PMRS	Patients
Recreation therapy	PMRS	Patients
Kinesiophobia	PMRS	Patients
Pain Management
Chronic pain	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients	16% (n = 57)
Acute pain	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients	<13% (n = 44)
Phantom limb pain	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients
Behavioral Health
Negative behaviors	HPC, LTC, STR, IMH, SUDC	Patients
Social isolation	OMH, PCC	Patients	<2% (n = 6)
Posttraumatic stress disorder	HPC, LTC, STR, DU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, WHC	Patients	<11% (n = 38)
Agitation	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients
Addiction recovery	IMH, OMH, SUDC	Patients
Depression	HPC, LTC, STR, PMRS, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients
Disruptive behaviors	HPC, LTC, STR, ICU, IMH, SUDC	Patients
Phobias	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients	1% (n = 5)
Reminiscence therapy	OMH, PCC	Patients	<2% (n = 6)
Severe social avoidance	OMH	Patients	<2% (n = 6)
Sleep hygiene	HPC, LTC, STR, PCC, OPC, WHC	Patients	<1% (n = 1)
Stress management and reduction	HPC, LTC, STR, PCC, OPC, WHC	Patients	<3% (n = 9)
Substance use disorder	SUDC	Patients	<1% (n = 1)
Anxiety	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients, caregivers	1% (n = 4)
Boredom	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients
General Wellness
Well-being	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients, caregivers, staff	4% (n = 14)
Quality of life	HPC, LTC, STR, PMRS, DU, ICU, IMH, OMH, IS, ONC, OPC, PCC, SUDC, SS, WHC	Patients
Restorative care	HPC, LTC, STR	Patients
Training and Education
Prevention of sexual harassment	Various, clinical and nonclinical	Staff	<3% (n = 9)
Lethal means safety counseling: Firearms safe handling	Various, clinical and nonclinical	Patients, caregivers, staff	2% (n = 8)
Inpatient discharge empathy training	LTC, STR, ICU, IMH, SS	Staff	<3% (n = 10)
Diabetes prevention education	OSC	Patients
Empathy training	OSC	Patients
Other
Palliative care	HPC, LTC, ONC	Patients	1% (n = 5)
Falls risk assessment	HPC, LTC, STR, PMRS, IMH, PCC, SS	Patients	<1% (n = 3)
Neurological assessment	HPC, LTC, STR, PMRS, PCC	Patients	1% (n = 4)
Procedural use	SS	Patients	1% (n = 5)
Maternal health	WHC	Patients
Reproductive health	WHC, PCC	Patients
Presurgical planning	SS	Patients, staff
Voice therapy (resonant voice therapy relaxation)	OSC	Patients
Tinnitus management	OSC	Patients

N indicates the total number of implementations; n indicates the number of implementations per indication. Absence of an n indicates tha individual Veterans Affairs Medical Centers’ implementation was not overseen by Veterans Health Administration (VA) Immersive. VA = Veterans Health Administration, PMRS = physical medicine and rehabilitation service, HPC = hospice and palliative care, LTC = long-term care, STR = short-term rehabilitation, BRS = blind rehabilitation service, DU = dialysis unit, IMH = inpatient mental health, ONC = oncolog) clinic, OPC = outpatient pain clinic, PCC = primary care clinic, SUDC = substance use disorder clinic, WHC = women’s health clinic, SS = surgery service, ICU = intensive care unit, OMH = outpatient mental health, IS = imaging services, OSC = outpatient specialty clinic.

^*Inclusive of all indications reported to VA Immersive via the VA-wide environmental scan.

^**Breakdown of indications being evaluated by VA Immersive via single-site or multi-site implementations. Source: The authors

Immersive Technology in Health Care: Why It Matters

Immersive VR, here defined as digital stimuli that surround users and allow for naturalistic interaction through specialized computer hardware (e.g., VR headsets and hand controllers) and peripherals (e.g., body trackers), is perhaps best known for its gaming and entertainment applications. Use of immersive technology like VR for more serious pursuits, however, has grown significantly, leading to major contributions in domains such as skills training, education, research, and health care. Clinician leaders are increasingly embracing immersive technologies due to features that enable it to uniquely augment traditional clinical approaches in several important ways, including the ability to offer supportive care for pain management where pharmacotherapy is inadequate or ineffective. For example, the ability to situate users in a digital version of any imaginable setting and have that experience “become” psychological reality allows clinicians to replicate real-world environments that trigger anxiety, maladaptive behaviors, or trauma responses in a safe, supervised setting to support reactivity reduction and practice healthy responses.^6,7 Because users’ physical body movements are tracked and recapitulated in immersive environments, physical rehabilitation and related treatments provided in medical facilities and in the home can be tailored to patient needs and gamified, wherein patient movement data are used to both plot progress and trigger providers to adjust therapy targets as needed (Figure 1).⁸

Figure 1. Virtual Reality for Physical Therapy.

In this photograph, David McAdon, physical therapist assistant at the Veterans Health Administration (VA) Central Iowa Health Care System, engages with a patient who is using virtual reality to work on seated balance and functional reaching activities aimed at improving upper extremity range of motion and core neuromuscular reeducation.

Source: Evan Davis, Project Manager, VA Immersive, and April Eilers, Public Affairs Officer, VA Fayetteville Arkansas Health Care System

NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

An example of the current and future promise can be realized in the story of a homebound Veteran with Secondary Progressive Multiple Sclerosis who began using immersive technology. At her most recent annual visit, she was found to have improved grip strength and improved mental health, and she attributed both to this new-to-her technology.^9,10

Multi-user immersive environments represent new ways of connecting with peers, providers, and others in enriched environments to engage in support, training, and other therapeutic activities while each individual remains in their own physical location.^11,12 Immersive technology also provides opportunities for staff who can train for novel, risky, or low occurrence events such as medical procedures, response to active shooter events, and sexual harassment prevention in realistic but virtual settings that enhance skill uptake, retention, and application, and where failure is risk-free.¹³ Due to opportunities like these, immersive technology is increasingly becoming acknowledged as a fundamentally different way of training and delivering health care. Integrating immersive technology into care delivery approaches holds potential to improve intervention efficacy, reduce reliance on high-risk care options such as pain medications, support movement of care to the home and subsequent aging in place, and fill gaps in delivery of medical care to those whose access may be currently limited. Translation of this promise into applications for care support has begun to bear fruit in several domains, some of which are already ripe for wider implementation.

In looking to the evidence base, in some cases research suggests that treatment efficacy of particular VR applications can exceed traditional approaches.^14,15 More frequently, efficacy is equivalent to standard of care, while also presenting collateral benefits associated with VR’s relatively low-risk, non-invasive, low-cost, and flexible profile. A primary example is the use of specialized VR applications for acute and chronic pain management. Here, VR-based approaches have shown efficacy for pain reduction across several contexts including procedural pain, wound care, phantom limb pain, and chronic back and neck pain.^15,16 In some cases, use of VR interventions can reduce reliance on pharmacological pain treatments and other higher risk approaches for patients.¹⁷ In the context of physical rehabilitation, certain VR applications have proven more effective than traditional therapy delivery models, while others deliver equivalent efficacy, resulting in improvements in outcomes such as strength, motor control, and gait abilities.^18–20 Evidence-based uses in mental health care include exposure therapy for anxiety, phobias, and PTSD, as well as simulation of key settings for cognitive-behavioral therapy treatment.^21–23 While these areas comprise many of the best-studied clinical uses, evidence is accumulating for VR applications in countless other practice areas. Add to this a burgeoning research agenda to support use of VR applications for wellness targets such as stress, sleep, social support, and physical activity.^24–26 Finally, the literature has many examples where VR has proven its usefulness as an aid to clinicians engaged in activities such as surgical and procedural planning.²⁷ In all, the evidence base as to when and for whom the array of VR clinical support applications can rival efficacy of standard approaches is maturing. There is also significant progress toward development of approaches to mitigate potential downsides of VR implementation, such as incidence of physical symptoms (e.g., dizziness, eye strain, nausea) during use, privacy and security risks, premature application of untested VR interventions, and widening of the digital divide. Pilot studies of years past are giving way to well-powered randomized control trials and investigations of comparative effectiveness. Funding for rigorous trials of VR-based therapies is on the rise and regulatory agencies are actively developing and implementing evaluation approaches as VR applications move toward readiness for broad implementation.²⁸ It is anticipation of this promising future that led frontline VA providers and staff to begin the journey toward adopting and refining immersive technology-based approaches to meet existing clinical needs.

The Evolution of Immersive Technology in VA: the Path Forward

In 2017, one frontline nurse at the Western North Carolina VA Health Care System in Asheville sought to use VR to help Veterans manage post-operative pain and anxiety following total knee arthroplasty. To accomplish this goal, she pursued efforts that aligned with a non-pharmacological approach to post-operative care, gained leadership support, identified funding, and developed the protocol for both implementing and evaluating VR’s impact. This pilot revealed patient and staff engagement, relative ease of implementation, and positive patient-reported outcomes⁵ sparking a movement that continues growing.

A pharmacist provider, who saw VR’s benefits, joined forces with the frontline nurse, and the two became determined to gather further evidence and drive implementation. Over time, two strategies emerged:

1. Identify repeatable processes for implementing immersive technology within established clinical workflows, supported by standardized documentation templates, patient and staff training, operating and infection control protocols, and implementation guides to increase adoption and use of immersive technology; and

2. Build a virtual community aimed at fostering engagement and awareness; disseminating the repeatable processes and resources; establishing standardized, nationwide evaluation of solutions; and sharing lessons learned, barriers, and successes.

As this community began to grow, first through a single Community of Practice that convened monthly starting in 2019, and then through a cloud-based collaboration platform launched in 2020 to facilitate the sharing of these derived protocols and tools, the two learned that utilization within VA began as early as 2015 for indications such as PTSD, spinal cord injury, and phantom limb pain, providing further opportunity to share knowledge and collaborate. Much of the 2017–2019 period was spent focused on single-site case reports, feasibility studies, or small multi-site implementations and subsequent evaluations via validated rating scales for such indications as pain management, anxiety, and concerning behaviors (e.g., restlessness, agitation).^29–33 These early implementations also validated the need for standardized processes and shareable resources; robust and rigorous contribution to existing evidence; and an infrastructure that would support device and data management while easing the friction for obtaining devices and content.

By early 2020, the community had grown substantially, and the Covid-19 pandemic brought in-person trainings and many in-person clinic visits to a minimum, leading to rapid increases in social isolation, stress, anxiety, and mental health challenges for Veterans and staff.³⁴ This provided an opportunity to augment virtual care with an enabling tool to connect us. For both staff and Veterans, receptivity gave way to increasing acceptability of use with ensuing spreading and scaling of many virtual tools, including immersive technology.³⁵

From 2021–2023, VA saw significant increase in engagement and adoption of immersive technology, particularly in outpatient clinics, inpatient wards (including Covid-19 units), rehabilitation centers, and long-term residential care locations. In three years, the 239 staff across 81 VAMCs grew to more than 2,300 staff across 154 VA Medical Centers and 18 additional sites of care such as Community-based Outpatient Clinics and residential treatment centers in all 50 states, Guam, American Samoa, and Puerto Rico. Additionally, utilization expanded from the initial five indications noted in 2017 to more than 40 documented indications by 2023.

By 2021, in response to the rapid growth of immersive technology, the national VA Office of Healthcare Innovation and Learning developed a team to oversee and support national deployment of a focus area in immersive technology that became known as VA Immersive. Focused on continued convening of interested staff, both frontline and in the headquarters offices, VA Immersive continues to iterate on developed tools, with an aligned Introductory Guide,³⁶ Implementation Playbook,³⁷ and Event Guide to support further learning and ongoing implementation. It became apparent that ongoing iteration and expansion of these tools was critical to continued engagement and further growth of the community. The VA Immersive team leveraged a human-centered design approach of soliciting the day-to-day problems and questions of staff and Veterans through communication and feedback via a cloud-based collaboration platform, Communities of Practice, internal and external presentations, forums, and open office hours. The team iteratively tailored resources (e.g., presentations, guides, and playbooks) to address barriers and challenges more succinctly and directly, including appropriate terminology, how to order or purchase hardware or software, how to use and how to document use of immersive technology in clinical settings, how to ensure proper privacy and information security protocols are considered and in place, and how to effectively disinfect VR hardware.

By 2022, VA Immersive launched two hallmark events: the VA Immersive Summit, an event designed to allow executive leaders to hear from frontline staff and Veterans about the impact of this technology on their experiences; and Veteran eXpeRience (VXR), a Veteran-requested, Veteran-focused demonstration event hosted at VAMCs across the country, allowing Veterans to put their heads in headsets and experience the impact of immersive technology. These events fed into VA Immersive’s human-centered design approach, garnering real-time feedback on the hardware and virtual experiences, as well as programmatic approaches to evaluation and implementation. For example, during the 2022 VA Immersive Summit, an event targeted to VA executives, a Veteran panelist asked why such events had not been created to raise awareness among Veterans. As a result, VA Immersive began collaborating with local VAMCs across the country to host VR demonstration events. In connection with these events, we coined the term heads in headsets to suggest that the best way to reach potential users, and address potential skepticism, is to facilitate firsthand engagement in an immersive experience. The opportunity to experience and thus understand and appreciate the potential of immersive technology for health care is important for staff, patients, and all others involved in the Veteran care process. By providing opportunities to host demonstration events at VAMCs, VA Immersive works with facilities to bring awareness to Veterans, caregivers, families, and staff about the availability and impact of this technology.

Additionally, VA Immersive’s attention to community feedback revealed the need and opportunity for VA- and Veteran-centered immersive experiences. Throughout the design and development process, VA Immersive, together with subject matter experts (SMEs), has traveled to various VAMCs to gather end-user feedback and further refine the content and program deployment to ensure the right approach. Adapting the experiences to fit in a real-world health care setting is foundational to VA Immersive’ s approach, supporting both engagement and adoption. VA Immersive has leveraged this approach to develop and deploy immersive content to providing the Veteran’s inpatient discharge experience, providing lethal means safety counseling, and training empathy-based bystander techniques to help prevent sexual harassment.

By early 2023, in response to requests from staff for more training and education, VA Immersive developed Extended Reality 101, a consolidated, introductory curriculum offering continuing education units to 20 clinical disciplines and covering key terms and definitions, contraindications, and precautions, troubleshooting, lessons learned, and key considerations. This curriculum, too, has expanded to include additional courses over the past year, as we address questions from end-users, such as: when utilizing immersive technology, how often do side effects truly occur and how might the clinician mitigate that occurrence; and what core programmatic elements must be in place when starting an immersive technology effort at a VAMC? Between February 2023 and August 2023, 190 clinical staff have successfully completed the one-hour course.

By leveraging human-centered design and continuing to engage end-users, VA Immersive has been able to further tailor presentations, education and training, and other resources to lower the barriers of adoption, while enabling a standardized and consistent approach. As of December 2023, VA Immersive hosts 5 different Communities of Practice; oversees 20 implementations evaluating 17 different indications across 120 VAMCs in 44 different states and U.S. territories; has made available Guides and Playbooks; and has hosted multiple in-person events (e.g., Immersive Summit, Veteran eXpeRience events, and a Congressional demonstration day) that have collectively impacted more than 1,400 attendees.

Early evaluation approaches are beginning to bear fruit; data from VA Immersive implementations for chronic pain show notable improvement including 28% reduction in pain intensity (n=72) and 28% decrease in anxiety (n=79) among those receiving VR experiences for positive distraction, mindfulness, and meditation. Similarly, for staff training, of 214 staff members who completed VR-based inpatient discharge training, 93% said the training helped them experience empathy for patients, 91% said the training would positively impact their care delivery, and 88% said that VR was a more engaging training modality than traditional methods. From these beginnings, VA Immersive continues to focus on systemizing and increasing evaluation rigor to inform the program’s future.

Important throughout this journey of scaling and spreading immersive technology in VA has been collaboration with outside experts from academia, industry, and other government agencies. Their continued input in conjunction with the VA Immersive team’s drive to implement with frontline clinicians has facilitated VA’s success in developing the foundation to support immersive technology development. In April 2023, VA Immersive hosted an Executive Roundtable convening thought leaders with an appreciable track record of impact in health care and technology implementation who focused on evaluating the current landscape and future trajectory of immersive technology in health care, especially in the areas of evidence gathering, knowledge dissemination, patient safety, and adoption beyond government. Recommendations from the Executive Roundtable include:

• leveraging VA experience in implementation of VR and other immersive technologies to inform patient-centered and safe design of hardware and immersive experiences.

• establishment of novel personnel roles to support standardized knowledge dissemination across health systems.

• determination of critical evidence that VA could gather to support streamlined regulatory and reimbursement evaluations; and

• collaboration between VA and private health systems to better understand what research and analysis is needed to support broader adoption outside of VA.³⁸

These recommendations serve as guideposts as we plan VA’s way forward with immersive technology.

Strategic Enablers of Immersive Technology

Our learnings over time in conjunction with the structure and culture of VA will support our efforts in scaling immersive technology in health care for several key reasons. First, the size of the VA’s patient population — and their enrollment over a lifetime — allows us to get beyond any paucity in sample size to demonstrate longitudinal impact. Second, the development of a nationwide Community of Practice that supports clinicians and other staff using immersive technology has been a unifying and empowering force. Importantly, the foundational Community of Practice, focused on general information gathering and knowledge dissemination, has now spawned four additional Communities of Practice for specific areas of use (e.g., Mental Health, Pain Management, Rehabilitation, and Employee Well-being) to support the convening of groups around a particular topic, while also being able to tailor information around a particular indication or population. Of note is the role that non-physicians play in VA in implementation and utilization of immersive technology, eliciting contributions from the full clinical workforce, including recreation therapists, social workers, low-vision rehabilitation specialists, and various clinical technicians. Third, the VA Immersive team has strategically leveraged input from experts outside of VA. As noted above, industry, academia, and other government agencies have helped co-design the path forward. Fourth, we have found that the greatest way to increase acceptance of this technology in health care is by allowing individuals to experience it for themselves. Additionally, the involvement of local VAMCs helps all those involved realize the current impact and future potential of immersive technology to revolutionize care delivery and positively impact health outcomes.

Barriers

As with any new initiative, barriers exist that must be overcome. As an innovation that began as a ground-up endeavor, getting those at headquarters to understand the level of staff and patient engagement and support for the growing use of immersive technology in VAMCs has been challenging at times. In August 2023, VA Immersive Summit was located in Washington, D.C., allowing for ease of attendance by several headquarters and regional leaders, who were able to put their heads in headsets and hear from Veterans and frontline staff about their experience with and the impact of this technology.³⁹ The Summit led to leadership’s support and financial commitment to increase equitable access to immersive technology like VR, both at VAMCs and in patients’ homes. This support has also facilitated movement from a decentralized, ground-up approach to the centralized, systematized approach now in place that allows for shared protocols and economies of scale.

Another barrier has been the lack of technical infrastructure and the requirements needed to ensure seamless deployment of devices and experiences. VA Immersive is working closely with VA teams who specialize in areas such as cybersecurity, enterprise architecture, privacy and information security, legal review, device management, procurement, regulation, evaluation, and more to address the need for infrastructure and stated requirements.

Current funding approaches grew from the initial ground-up approach, which presents potential financial barriers to substantial growth in use of immersive technology throughout the VA. As part of centralized system development, VA Immersive is laying the groundwork for holistic understanding and management of total cost to the system. Assumptions about the cost of implementation often focus on hardware, while, in fact, much of the expense relates to content development and acquisition. To address this, VA Immersive, along with partner health care systems, will need to work with industry to establish the most cost-effective and cost-efficient approaches to providing libraries of effective immersive applications at scale.

Finally, and importantly, is the evolution of data needed to evaluate impact of the experiences continuously and rigorously within the devices. At the present time, in early 2024, VA patients and clinicians manually report and track qualitative and quantitative data. Continued efforts are underway to build and automate ingestion of objective data available through immersive systems and integrate them with patient records. As the aforementioned infrastructure and requirements are in place, data gathering, and analysis will become more objective and less cumbersome. VA Immersive continues to innovate and create solutions to these broad system-wide barriers with an eye toward repeatable processes that could be replicable or adaptable for outside systems that wish to build or expand their own immersive health care programs.

Recommendations for Impacting Care via Immersive Technology

1. Get heads in headsets.

Verbally explaining the impact of immersive technology in health care is insufficient to convey the importance and opportunity of continued and expanded implementation. Offering opportunities for staff and Veterans (patients) to try this technology is often met with excitement, hope, and optimism about the ability to aid even those with unmet clinical or social needs. This is particularly true in those with chronic illnesses and who have limited ability to travel to brick-and-mortar clinical care sites.

2. Immersive technology can increase equitable and personalized access.

Immersive technology can support care for patients in their homes through clinical and interchangeable content that is tailored to individuals. The current and common model of hardware-plus-software bundles has helped with early exploration and implementation by limiting requirements for external connectivity (e.g., Wi-Fi) or streaming; however, this model significantly limits sustainable scaling by requiring individual and separate headsets supporting a few experiences where these headsets could host a library of interchangeable content, personalized to individual patient needs. A system-wide and managed deployment would ensure the crossing of the digital divide through supported patient use (e.g., mobile device management, standardized patient training on use) decreasing the likelihood that early adopters and those prone to use of technology are the only ones to benefit.

3. Data ownership and the safe use of data.

As the headset vendors work to meet the needs of patients, and evidence for data utility from headsets become available, we must both define data ownership (e.g., patient-generated health data versus health system–owned data) and find safe ways to appropriately use this data that provide opportunities to continuously improve quality of care delivered. Patient-generated health data, both from the headset and via peripherally worn technology such as smart watches, fitness trackers, and biosensors continues to improve the overall, integrated picture of care at the patient and population level; however, clarifying data ownership and ensuring the safety of that data as it gets aggregated is of paramount importance.

4. New content needs to be designed by both the technology companies and the end users.

As much of the technology industry has learned, human-centered design is paramount to the real-world utilization of any given technology. Both patients and clinicians must work closely with technology companies for optimal design of immersive content and hardware that will best meet needs and demonstrate impact. Structured and collaborative communication and constructive feedback allow companies and end-users to produce a product that meets patient and clinician needs, while also addressing the greatest challenges in health care.

Looking Ahead

To further enhance the flexibility and broad utility of immersive technology, one must recognize the impact of immersive experience enhancements that connect peripheral devices and sensors to the headset and incorporate artificial intelligence (AI) in the creation and personalization of experiences and analysis of resultant data. Though in the early stages today, resultant data and its use to improve and personalize care will likely become increasingly automated and objective.

The current demand for quality health care far exceeds the resources in clinical care. By leveraging the current impact and future potential of immersive technology, VA is deploying engaging tools that are leading to improved outcomes and targeting decreased costs, while offering opportunities to explore additional and expanded utilization in the future. By moving evidence-based practices into an engaging modality like VR, recognized clinical approaches such as positive distraction, cognitive behavioral therapy, prolonged exposure, and other practices may lead to increased access and improved outcomes through adherence and compliance to prescribed protocols. Given the relatively low cost of VR devices themselves (as low as $300 each) and the negligible length of time to training and certification of clinical providers to provide immersive therapies, it is far easier to multiply headsets and embedded evidence-based curriculum or protocols than it is to multiply providers. Immersive technology offers a unique opportunity to truly augment clinical care and meet currently unmet and difficult to meet health care needs.

Driving toward increased accessibility of immersive technology across VA could also provide much needed resources for Veterans who report lacking a sense of belonging and connection, providing an opportunity to find community and solace in virtual worlds. VA is currently evaluating opportunities to make immersive communities more available to Veterans, whether enrolled in VA care or not, to help connect Veterans to resources and Veterans to Veteran peers. Should this prove viable and helpful, the ability of VA to leverage immersive technology to expand the footprint of the health care system and health care offerings would grow expansively, enabling more seamless connectivity, furthering engaging care delivery and, broadly, personalizing health care.

Through our work with immersive technologies today — devising and testing implementation approaches, identifying and refining immersive applications with clinical efficacy and traction with patients, sharing best practices, and increasing exposure — we are laying the groundwork for the future promise. While technologies and possibilities will undoubtedly shift in the intervening years, we see an integrated future for immersive technology.

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What began organically as a ground-up effort to improve clinical care through virtual reality and other immersive technology has developed over nearly a decade into a multi-faceted, system-wide effort that can serve as a guide to others in how to work collaboratively inside and outside the health care organization to improve patient care delivery.