Healthcare systems are expected to account for as much as $15 billion
of the total expenditure on information technologies within the next five
years. Virtual Reality is a very specific component of this total healthcare
technology budget, and one that is set to grow. The report below looks at
the Virtual Reality technology developments currently taking place within
the medical marketplace.
o
date, developers for VR in Medicine have been faced by a "tough, tough
market" in the words of Ciné-Med's
Kevin McGovern. Venture money has been shy. Corporate investment has been
limited to a few significant backers such as Johnson & Johnson, and
Abbott Laboratories. Colonel Richard Satava of the US Advanced Research
Projects Agency (ARPA) has estimated that less than $20 million is currently
being spent annually on Virtual Reality technologies for use in healthcare
worldwide. In the US, government funding is primarily coming from ARPA at
about $6 million per year.
There are two sources of economic blocks for commercial market development.
The first drawback has been the cost of the technology. In order to produce
a sense of realism for medical purposes, developers are faced with providing
organ fidelity, interactivity, physical and physiological properties of
organs, and sensory input. Together, that integrated package requires extreme
amounts of computing power. Heretofore, only expensive systems such as SGl's
RealityEngine have had the capabilities to even begin to integrate all those
requirements. The costs of such computing power for full scale medical simulations
have thwarted many interested healthcare professionals. (Pictured left
is 'Oscar', a virtual patient subject created by High
Techsplanations, Inc. for surgery simulations).
The second set of monetary drawbacks for VR's use in Medicine stems from
medical economics and the cutbacks in medical funding. There are no easy
ways for health care professionals to fund their use of Virtual Reality.
As it currently stands, VR offers no revenue enhancement to medical practitioners.
A medical procedure must directly affect the patient before it can become
directly billable to the patient. Neither a hospital nor a solo practitioner
has a way to pass along the expense of VR to the patient as can be done
with medication.
Medical researchers interested in Virtual Reality development also face
stiff tests. While the payoff in VR is currently seen by medicine as being
offered in basic research, purchases by medical colleges must be justified
to a board typically headed by financial and CEO-type business professionals.
Too many times, a request for a VR system is seen as expensive and/or frivolous.
Especially with funding cutbacks in graduate medical education, state-subsidised
medical schools may well feel that the money must be spent on basic needs
today.
But over the next five years - certainly by the time the $15 billion
information technology total has been expended by healthcare - the economic
barriers to VR's use in medicine will be much lessened. Basic computing
power is dropping in price and VR developers are already working on products
based on lower-cost desktop systems. Further, an alternative solution is
emerging that is based on part-task training or 'pieces' of a total learning
experience.
Products that 'break apart' a total learning experience and provide training
for subsets of a medical procedure typically require less computing power
and less cost than a full blown VR simulation. One of the first development
firms to utilise this approach is London-based Virtual
Presence, which has created MIST, a training package that teaches the
standard psycho-motor skills necessary for laparoscopic surgery. Surgeons
can practice movements such as tissue cut and lift, or arterial/duct clipping
on MIST with the attached "surgical scissors" (Immersion
Corporation's Virtual Laparoscopic Interface). The individual user's
movements are analysed against a large database that assesses specific physical
skills and provides spreadsheet feedback. By separating the psycho-motor
skills and using simple geometric objects on-screen, Virtual Presence avoids
any requirement for the interactivity or organ fidelity/receptivity of full
scale simulation graphics. Therefore, the firm is able to sell a complete
non-haptic system based on a Pentium P133 with Windows NT Workstation software
for $15,000. A haptic version under development will have an estimated price
of $30,000.
Healthcare's potential use of Virtual Reality technologies is broad. To
date, most of the public media's attention has centred on two application
areas: Surgical Training, and VR and Disabilities. However, the possible
uses are much broader than these two kinds of applications. Dr Walter Greenleaf
of Greenleaf Medical Systems
has suggested eight categories of medical VR: surgical training, surgical
planning, medical education, VR facilitated rehabilitation, disability solutions,
telemedicine, anatomically keyed displays with real-time data fusion, and
patient evaluation and behavioural intervention.
The commercial development of products for any of these categories of medical
VR products is in its early stages at best. This report will look at several
areas that lead in commercial product development for VR in Medicine and
also provide examples of products either at or nearing market.
Surgical Training
VR is especially applicable in simulations for surgical training. VR
allows surgeons to practice hundreds of procedures prior to patient contact-and
the practice carries no risk to live patients. Since doctors with less experience
are in general more likely to produce errors, VR simulations could theoretically
reduce physician error. VR will also reduce the high costs of training resources
such as lab animals and physician's time. Perhaps insurance companies will
see that simulators are a way to increase surgeon proficiency and thereby
decrease the number of mal-practice suits, but as of March 1996, no insurance
companies had come forward to assist with funding. (Above and below:
Graphical anatomical simulation's from Ciné-Med).
VR surgical simulation development has been concentrated on Minimally
Invasive Surgery (MIS)-partly because the paradigm for MIS already involves
a physician looking at a monitor. An MIS simulation involves putting the
instruments through openings and displaying a computer generated model overlaid
upon visuals of surgical representations. Organs for Virtual Reality surgery
should not only look like real organs, they should act like real organs-they
should undulate and change light reflection when touched; compress when
squeezed or cut. Additionally, research is underway at Myron Krueger's company,
Artificial Reality Inc., to add smell
to VR surgical simulations.
Three developers have pioneered the VR for Surgical Training field, Ciné-Med,
Ixion and High Techsplanations
(HT).
Ciné-Med is a medical
education company with a generational history in product development for
healthcare education. Ciné-Med is developing a VR skills simulator
for minimally invasive procedures based on research at the University of
California San Francisco Medical School and the Institute for Defence Analysis.
While Ciné-Med has been at the forefront in VR simulation and press
attention, company president McGovern explained that the media attention
may have actually "done a big disservice" by creating over-inflated
expectations. McGovern commented that VR simulators are of high cost not
only to end-users, but also to commercial developers. Therefore, Ciné-Med
is pursuing its version of the 'break apart' product development strategy
mentioned above. Its product range is based on a multimedia approach and
Virtual Reality is only one part of an electronic media mix that includes
video, CD-ROM, and a Web-based medical curriculum.
Ixion has has been developing medical training products for a number of
years and received wide attention earlier for its CPR mannequin. Beginning
in the early '90's, Ixion began work on a surgical skills simulator for
laparoscopic surgery; that effort resulted in the creation of Ixion's MultiSim
multi-processor approach which enables it to keep its systems under $100,000.
Ixion's current product, GastroSim, is in beta test at three major teaching
hospitals, and comprises an integrated multiprocessor system that provides
real-time coordination of the G.l. endoscopic experience. The real-time
manipulations are monitored by an expert system, and the graphics processing
supports a flexible geometry model for the stretchable tissue of the G.l.
tract.
Below: To convert a geometric database into a physically-based one, HT's
TELOS simulates the behaviour of tissues as flexible bodies based on mass
elements and springs.
High Techsplanations'
(HT) surgical simulation system was entered into the Smithsonian Institution's
permanent collection in January 1996, for "epitomising the innovativeness
of the medical and healthcare communities and their use of Information Technology".
HT's Teleos software adds to the realism of VR simulations through features
such as real-time collision detection, pulsation, elasticity, stretching,
and deformation. A mechanical armature mimics the mechanics of the actual
instrumentation.
High Techsplanations addresses the problem of the high cost of purchase
by leasing its complete VR Indigo2Impact-based VR system for $3,000 a month
to medical colleges. Greg Merrill, HT President has analyses that document
the cost effectiveness of VR simulation for medical education. Merrill explained
that a weekend seminar training 100 doctors in interventional radiology
can easily mount up costs of $450,000 ($3,000 registration apiece, three
stents at $1,000 each, lab animals at $600 apiece). He compared that to
the $250,000 price of one VR system providing the same training- which is
a cost saving of $200,000 for one seminar when used by 100 students.
Surgical Planning
A surgical planning device takes actual physical data from an individual
patient and combines it with computer-generated data; it incorporates real-time
interaction with computer graphics that mimic a patients anatomy. This is
then used to make a simulation that will help plan and rehearse a surgical
procedure - both for training and advanced planning of an operation.
A surgical planning product scheduled to be officially announced in early
May is 'DentalByte', from the Australian company Integra
Computer Systems, which will allow the 'in house' digital rendering
and manipulation of an individual patient's virtual oral environment (provided
from 2D and 3D data sets) for purposes of planning dental treatment. According
to the developers, accurate digital patient jaw and teeth structures and
functions can be manipulated and interpolated in four dimensions. Each jaw
can be positioned as might be necessary for treatment planning for surgical
correction. The projected treatment of teeth and jaws can be practised on
screen and the results assessed. The simulations are claimed to closely
match real life dental procedures, and to help the specialist evaluate and
understand the range of options. In addition to surgical planning, DentalByte
has applications for research in dental occlusion, tooth movement studies,
forensic studies, and teleteaching.
Medical Education
Medical education is distinguished from simulation within the Greenleaf
definitions set. He suggests that the role of Virtual Reality in medical
education is in the area of visualisation focussing on the use of three
dimensional inter active graphics to give the student a much better feeling
for and understanding of anatomy than can be gained by looking at 2D pictures
or by reading text.
Telemedicine
Telemedicine overall is quite broad and refers generally to the use of information
technologies such as satellite transmission, video conferencing or electronic
data transfer for healthcare education, consultation, and delivery. The
area of telemedicine that overlaps Virtual Reality is the use of 'telepresent'
medical experts, who will be given the ability to act and interact remotely
from a patient by making use of VR technology. Ideally, this will reduce
the cost of medical practice and bring expertise into remote areas. Telemedicine
will also include telesurgery- the provision of VR-based systems to enable
telepresent surgeons to perform surgery on remote patients.
However, the notion of virtually present medical experts has raised
serious legal and policy issues, not the least being the cross-licensing
between jurisdictions of physicians both within a country and across international
borders. In late 1995, the Centre for Telemedicine Law (CTL) was formed
to focus on the legal issues that have impeded the development of telemedicine
(telemedlaw@dgs.dgsy.com). Briefly, the problems facing telemedicine
include confidentiality of patient information, licensing of providers across
borders, reimbursement, malpractice issues, antitrust limitations, fraud
and abuse laws, and telecommunications contracting. (Left: An HT simulation
screenshot).
Jay Sanders at the Medical College of Georgia reports that the legal irregularities
will be worked through and that this particular market will "explode
very soon." Sanders is evaluating at least one telemedicine project
that fits the telepresence definition and that is set to become a commercial
project. That product will be the "electronic housecall," a service
that will bring the health care provider electronically into the home environment
of the patient to provide assessment intervention. At the time of this writing,
the only technical details for release explain that the device will be in
a TV platform.
VR-facilitated Rehabilitation
These type of systems adapt VR technology for rehabilitation and therapeutic
applications. This is of special benefit for shaping a rehabilitative program
to an individual student. Attention by developers in this sub-market is
focused on the use of VR components such as the DataGlove and DataSuit.
Both offer a basis for collecting data dynamically in 3D space, and enable
human motion capability measurements to be used as the basis for decisions
about treatment.
Greenleaf Medical Systems
is developing a VR based rehabilitation workstation suitable for patients
receiving orthopaedic and/or neural therapy. The workstation will break
rehabilitation into small, incremental steps, and aims to make rehabilitation
more realistic by simulating real life tasks such as lifting boxes, or steering
a large boat.
Disability Solutions
Here, VR technologies are used as adaptive devices to enable individuals
with physical disabilities to accomplish tasks and have experiences otherwise
not available to them. Head-mounted displays, position/orientation sensing,
tactile feedback, eye tracking, 3D sound systems, data input devices, image
generation and optics are all under study for possible use as adaptive technologies.
This field had early leadership and co-ordination from Dr. Harry Murphy,
Founder and Director for the California State University Centre on Disabilities.
Consequently, numbers of prototype VR projects are underway for the disabled
community.
General Reality Company is
one of the companies working to integrate VR technologies for disabled individuals.
Its CyberEye HMD is being used in a system that enables a person whose vision
is impaired to be able to read 'large virtual pages' displayed in the HMD.
Termed a "virtual computer monitor," the system is in stage one
clinical trials with SRI and the National Eye Institute, and is headed for
commercial development. General Reality's Arthur Zwern reflected on VR and
Disabilities as a commercial arena, "the markets are small, but there
are a reasonable number of applications." (Above and left: The DataGlove
and CyberEye HMD developed by General Reality).
Anatomically Keyed Displays with Real-time Data Fusion
These systems give the physician "quasi-X-ray eyes" with which
to integrate real-time data from an actual patient into a medical procedure.
For example, images presented via a "heads up" display could in
principle provide a surgeon with an MRI defined map of the surgical field,
scaled to actual size and location. A surgeon using a surgical microscope
would be able to mount a VR display device on the microscope that will overlay
a three dimensional image of the patient's tumour within the defined targeting
area.
Patient Evaluation and Behavioural Intervention
This medical sub-market will involve the use of VR technology to accurately
measure human movement. Applications in neurology, ergonomics, human factors,
behaviour modification all require the ability to accurately and objectively
measure the human body. Greenleaf has also included the area of behavioural
intervention in this category. This has treatment possibilities for cognitive
intervention for treatment of phobias or cognitive impairments.
Physicians and medical professionals are very interested in the potential
of Virtual Reality. Their interest is evidenced by the ever-growing attendance
at the annual 'Medicine
Meets Virtual Reality' conferences held each January in San Diego (see
Diary section). The 1996 conference had over 700 attendees, and had several
major corporate sponsors including Johnson & Johnson, Ethicon Endosurgery,
US Surgical, AT&T, and Kodak. Highlight of the event was the 2nd Annual
Richard Satava Award, given to Michael J. Ackerman from the National Library
of Medicine and Victor Spitzer of the Centre for Human Simulation at the
University of Colorado Health Sciences Centre, for the development of the
the 'Visible
Human Project'.
Above: Images from the Visible Human Project, a mammoth undertaking
to document the entire body in 3D volumetric data.
The Visible Man and Visible Woman form part of the National Library of Medicine's
project to build a digital biomedical library representing the entire anatomy
of a man and a woman in volumetric electronic data, obtained by scanning
millimetric cross-sectional slices of frozen cadavers. The work was carried
out at the University of
Colorado's Health Sciences Centre. The Satava award is given each year
at "Medicine Meets Virtual Reality" to an individual demonstrating
unique vision and commitment to the transformation of medicine through communication.
It is still early days for VR in medicine but the technology is gaining
credibility among the medical community, whilst the superior price/performance
ratios of today's hardware is making virtual reality more acceptable from
an economic standpoint. As momentum continues to grow, the future looks
bright for this technology sector. Those interested in VR are well advised
to attend the next 'Medicine Meets VR' conference on 22-25th January 1997.
In the meantime, Imaging Online will be running regular
features on this exciting field.
This article was adapted from VR in Medicine, first published in VR
News; April 1996, Volume 5, Issue 3.
© MCMIVCVI Calyx Productions