The doctor will see you now … in the metaverse?

The metaverse is coming — so we’re told — though it’s hard to know exactly what that means. There are companies using virtual reality to recreate office life down to the conference rooms, for some reason. And, of course, VR is big for gaming and other diversions.

But virtual reality is also increasingly being used in health care, especially as more services go remote.

About 200 hospitals in the United States are using virtual reality tools to not only help train doctors, but also help manage patients’ pain from surgery, irritable bowel syndrome or cancer, said Brennan Spiegel, the director of health services research at Cedars-Sinai Medical Center. And recently, the technology’s applications have grown to include diagnosing conditions like glaucoma.

The following is an edited transcript of host Meghan McCarty Carino’s conversation with Spiegel.

Brennan Spiegel: An example of using VR for glaucoma emerged during the pandemic, when there was one example of a patient at home who really needed to have his eyes checked. And his doctors developed a software program so he can do it at home, in the VR headset, to actually make decisions about whether he needs to be seen or be treated and so forth. And so whether it’s that or it’s any number of other conditions, virtual reality is proving to be a very interesting platform to allow for accurate home-based diagnosis.

Meghan McCarty Carino: It seems like this kind of home diagnosis with a home device has the potential to reach populations who might be less likely to go into a doctor’s office. But aren’t those the same demographics who are probably less likely to own a VR headset, which right now costs hundreds of dollars?

Spiegel: You’re absolutely right. And currently, we have a study that’s funded by the National Institutes of Health to deliver virtual reality therapies to rural America. And so the idea is we can deliver mental health services at home in rural Alabama, in Louisiana and in Central California using virtual reality to help manage pain. And we increasingly need to rely on insurance to begin paying for these types of evidence-based treatments, rather than, let’s say, continuing to just support opioids for pain. It seems both effective and cost effective to support other non-opioid treatments for pain that can be delivered remotely to people’s homes.

McCarty Carino: What is the current status of whether insurance would cover treatments like this or devices like these? And could they cover these in the future?

Spiegel: Absolutely, they can and likely will. This is an evolving area. The Food and Drug Administration, of course, has gotten involved now in this field and, in fact, has a name for it. It’s now called MXR, or medical extended reality. And since the FDA has gotten involved, and we’re starting to see FDA-cleared treatments, insurance companies are, of course, starting to take note. And in some cases, insurance is covering VR when used as part of an already billable service, but isn’t itself a separately billable service. So we’re going to have to keep pushing this in, but time will tell.

McCarty Carino: What do some of those medical VR therapies actually look like? Can you sort of walk me through what a patient might experience?

Spiegel: Yeah, so for example, for a home-based clinic in virtual reality, when a patient gets into the headset, they’re actually in a clinic. They can see a lobby, there are hallways and treatment rooms that we progressively unlock from our end. And people can start to move through these different rooms step by step. And so these range from relatively straightforward environments, like being in a modified exam room and then becoming a doctor and examining a patient in a role-reversal scheme, to something totally fantastical, like entering a movie theater that represents your own mind and then seeing the scenes on the screen, which represent your thoughts. And this starts to confront people with this notion that they can think about thinking, and that the projectionists in the back of the movie theater is putting thoughts up on the screen that they may not be able to control. And this brings up all sorts of interesting philosophical and psychological discussions that are very hard to have in a regular treatment room or even with a therapist. So with VR, we can do all sorts of fantastical things — put people in and out of different bodies, teach them information about their mind and body and how to help control their condition. And so these are just a few examples of the different sorts of environments that we create in VR.

McCarty Carino: Last year, we saw research on artificial intelligence being used to help diagnose skin cancer, but it was less accurate on darker skin, in part because of the pictures it was trained on. What’s being done to avoid some of those same mistakes for these VR tools?

Spiegel: Yeah, absolutely correct that we need to think about all of our patients when creating really any innovation in health care, not just digital tools. But in health care, what we’re also learning is we need to work with a wide variety of patients early and often before programmers go off and start creating these treatments. So in this field of medical extended reality, we now have developed a three-step process to develop and validate treatments in partnership with patients. And just like the FDA has phase one and phase two and phase three trials, here we now have what we call VR one, VR two and VR three trials. And the VR one trial is all about working with a diverse group of patients and end users who represent the target population for the proposed treatment, and learning from them about what their needs are, their preferences, knowledge, attitudes and beliefs, and incorporating those using user-centered design into the development of the treatment itself.

McCarty Carino: What do you see as the future of how this technology could be integrated into the health care system?

Spiegel: Well, I think it’s inevitable that it’s going to happen. It’s already happening. We’ve heard a lot about the metaverse, and I think in health care it’s our responsibility to figure out how to develop a corner of this metaverse that is specifically designed to support human health using evidence-based treatments ideally that are eventually approved by the FDA. And the future will be prescribing these therapies to people at home who already, increasingly, have access to these headsets or will be able to get access through insurance.

Related links: More insight from Meghan McCarty Carino

Here’s more information about some of the use cases for virtual reality treatment that Spiegel and Cedars-Sinai are researching, including some promising studies on pain management. Late last year, the FDA approved the marketing of a prescription virtual reality system to treat chronic lower back pain. It’s part of a new wave of prescription software-based treatments known as digital therapeutics.

According to a new piece at trade publication MedTech Dive, those include a game to treat ADHD in kids, software that helps cancer patients manage their symptoms and apps to treat substance use disorder and insomnia.

There’s a lot of investment in the space, but as Brennan Spiegel noted, these face hurdles getting covered by insurance, which is important because the price of these programs can be pretty steep, reflecting the intensive clinical testing that has to go into something approved by the FDA as a treatment.

MedTech Dive reports the anti-insomnia app Somryst is priced at $899. And I don’t think you can get it for free if you allow those distracting banner ads.