‘Getting Heads in Headsets’: Exploring Virtual Reality Use in the VA

Virtual reality (VR), though initially relegated to the world of gaming, is increasingly being applied in healthcare. Healthcare research and provider organizations nationwide are actively exploring the use of VR technologies in various aspects of care delivery — and the Veterans Health Administration (VHA) is one such organization.

Evidence backing healthcare-related VR use is growing. From helping patients manage anxiety related to healthcare services to enhancing pain management to clinical staff training, VR can support healthcare delivery in numerous ways.

For Anne Lord Bailey, PharmD, interest in VR started growing in 2016 when she worked as an innovation specialist and pharmacy practitioner at a VA facility in Asheville, North Carolina. There, she met Caitlin Rawlins, a bedside nurse who had been a part of a work group at the facility exploring different ways to address postoperative pain and anxiety. In an evaluation of VR use in orthopedic care, Rawlins found that VR helped decrease opioid use and pain and was received well by patients.

“So, I took some lessons learned from that group of people, and we started convening frontline staff members, clinicians, researchers, administrators who were interested in learning more or even using this technology with patients,” said Bailey, who is now director for clinical tech innovation for VHA Innovation Ecosystem and immersive technology lead for the VHA’s Office of Healthcare Innovation and Learning (OHIL).

Bailey and Rawlins established VA Immersive in October 2019, which aims to improve care delivery and healthcare experiences by leveraging and scaling immersive technology, like VR, across VA facilities. The program provides standard operating procedures, guidance, tools, and documentation templates to help clinical teams deploy VR.

VA Immersive has deployed more than 1,200 VR headsets across more than 160 VA medical centers and outpatient clinics in all 50 states and Puerto Rico. The technology has been implemented in both inpatient and outpatient settings and is now being deployed in patient homes.

According to Bailey, the VA has documented more than 40 indications for healthcare VR technology. The most common indication is pain management, including addressing acute pain, chronic pain, phantom limb pain, and other difficult-to-treat indications. Additionally, VR is being used in physical rehabilitation, occupational therapy, falls risk assessment, neurological assessment, palliative care, suicide prevention, and treating substance use disorder and post-traumatic stress disorder (PTSD).

“Basically, what we're doing is taking an evidence-based approach and putting it into an engaging modality,” Bailey said. “So, using things that we know work, and then also adding that engagement and adherence feature [through VR].”

For instance, positive distraction, cognitive behavioral therapy, imaginal prolonged exposure, and in vivo prolonged exposure are all evidence-based approaches for addressing patients’ mental health needs. VR technology takes these approaches and enables patients to experience and engage with them in a virtual world.

“What we're able to do…is offer those experiences, the training, and education in a safe place where you can be at home and do it, you can be in a clinic and do it, but you're lowering the risk while also engaging the patient,” Bailey noted.

This is especially apparent when addressing mental health issues among veterans. The stigma surrounding mental health is often ingrained in the military and veteran populations, and they may not feel comfortable asking for help, Bailey said. VR technology has helped break down that barrier by providing discreet and convenient access to mental healthcare, even at home.

Similarly, in vivo prolonged exposure therapy, a common approach to treating PTSD, involves patients doing “activities where they gradually approach trauma-related memories, feelings and situations that are avoided because of the trauma.” This could mean patients having to go to malls or public places to help them readjust to crowded or noisy spaces. Bailey noted that with VR technology, these patients can receive in vivo exposure therapy without physically traveling to those places.

VR use in the VA has been associated with a “decrease in pain perception, decrease in anxiety, increase in perceived happiness, decrease in stress, increase in engagement,” Bailey said.

“[Patients are] more likely, we're seeing, to show up when they know that they're going to get this opportunity to do immersive technology and virtual reality specifically,” she added.

Another unique benefit of VR-enabled care is that it allows clinicians to target multiple conditions at once. For example, a patient receiving VR treatment for PTSD may also see their anxiety improve and social interactions increase as they become more present and overcome PTSD symptoms.

It’s not just VA patients who are gleaning the benefits of VR. In an effort to improve employee well-being, the VA has also extended access to VR technology to the staff.

Around 12 VA medical centers have implemented VR for employee well-being in different ways, including creating rooms where staff members can use a VR headset with mindfulness and meditation exercises. Staff can use these headsets during their breaks to engage in positive distraction. According to Bailey, the staff has found this very helpful.

Another use case for VR at the VA has been in gun safety counseling to prevent veteran suicides.

“While our veterans and military are comfortable with the language and terminology around firearms, caregivers, family members, even some of our staff aren't as familiar,” Bailey said. “And so, in that moment of crisis, it's really important that you know how to safely disarm and lock and store a weapon or just in general practice safety.”

The organization has taken its curriculum for firearm safety training and created an immersive VR program where users can interact with firearms and learn how to disarm them in a safe setting.

However, like with the adoption and usage of any technology, there are hurdles around implementing VR.

At a VA summit on immersive technology earlier this year, leaders from across the organization were asked about challenges to use that need to be addressed. A common response was that reimbursement and uncertainty around managing associated costs curb the adoption of VR technology, Bailey said.

Another challenge is training and education to ensure that VA staff and veterans alike can use and maintain the technology. And finally, there are concerns about data, including trust in the technology and a lack of clarity around whether the clinical outcomes linked to VR use are objective.

To help address these hurdles, VA Immersive is working toward increasing access to the technology, both by getting more headsets out to staff in the field and to patients. The program is also working with the VA’s IT team to better manage and support those devices.

Additionally, VA Immersive is working to ensure staff members who need to train asynchronously or hone specific skills get the VR resources and content they need at the right time, and it is looking to enhance data sharing between EHRs and VR devices.

VA Immersive is now preparing for the second year of a project to implement VR technology that leverages cognitive behavioral therapy to address chronic low back pain. As it conducts its implementation evaluation and prepares to address challenges, Bailey noted that the focus will remain on the foundational mission of “getting heads into headsets.”

“The VA is in the position and has the opportunity, and also the responsibility to continue to grow, test, evaluate, implement this technology and make it easier for other healthcare systems as well as to learn together,” she said.