VR Health Care: Best Practices for Clinical Implementation

Diane Gromala, PhD, Howard Rose, M.Ed, Frances Ayalasomayajula, MPH, PMP

Virtual reality (VR) technology has improved significantly in the last few years. With these advancements, the use of VR in the clinical setting is increasing. There are a lot of cited uses and benefits, including rehabilitation, pain management, and reduced feelings of anxiety, depression, and isolation. However, it is important to avoid unsubstantiated claims, establish protocols, and to seek validated and tested VR software and hardware.

Most recently, three experts came together to produce a series of recommended best practices for the use of VR in Clinical Implementation: Diane Gromala, PhD, Canada Research Chair in Computational Technologies for Transforming Pain, and the Founding Director of the Chronic Pain Research Institute and the Pain Studies Lab at Simon Fraser University; Howard Rose, M.Ed, CEO and Founder of Firsthand Technology; and Frances Ayalasomayajula, MPH, PMP, Worldwide Lead for Population Health and Patient Engagement at HP. They insist, “First, do no harm”.

Become familiar with the decades of human factor literature on VR. Consider the unique requirements of deploying VR technology, both in healthcare facility settings as well as in patients’ homes. Additionally, when deploying in your practice, evaluate the your current clinical workflow to determine the optimal integration points.

While all three authors stress the need for further research to be conducted on the long-term effects of VR exposure; they attest that these recommendations, based on years of observation, are a good starting point for those who are considering the adoption of VR in their clinical practices.

VR Healthcare Best Practices, April 2018

  1. Mitigate the risk of simulation sickness by deploying professional grade virtual reality technology.
  2. Select hardware that can withstand the use of hospital grade germicidal wipes and consider the use of VR covers.
  3. Assess patient physical and mental state prior to administering VR.
  4. Screen for patients with pre-existing conditions of motion sickness, dizziness, or lightheadedness.
  5. Make sure the patient knows risks and potential benefits, and provide demonstrated instructions prior to the patient taking on the full experience.
  6. Ensure the VR headset fits the patient, is not too tight or heavy, and adjust the focus of the VR headset.
  7. Children or adults with significantly reduced physical or mental capacity should be supervised, including when VR is used in conjunction with narcotic or other strong medication.
  8. Limit VR to 60 minutes and take breaks between sessions of at least 10–15 minutes.
  9. Provide the patient with a way to signal you if they encounter problems, and encourage them to do so.
  10. Monitor patients for potential problems: keep an eye out for a patient’s involuntary muscle twitches, reaching to grab onto something they can stabilize themselves on, loss of balance, growing frustration or anxiety.

© Diane Gromala, Howard Rose, Frances Ayalasomayajulaand, 2018.

May 2018

Here, the authors provide more in-depth recommendations and explanations.

VR Technology
Target little or no negative physical side effects from either the hardware, the software experience or the interface between the two. Examples include:
  • Headache, nausea, physical or mental fatigue
  • Physical stress to head, neck, limbs or body
  • Eye strain during VR or re-accommodating after the VR experience
  • Reduced function or disruption to balance during or after the VR experience.
VR Hardware Selection
  • Professional grade VR technology is best, because resolution, frame rate and refresh rate matter. To help mitigate VR simulation sickness, seek the highest rates of all three.
  • VR ready versus VR capable: low-end 360 videos can be experienced on a variety or compute devices; however, user experience is affected by the hardware chosen. For example, to achieve higher frame rates and refresh rates, discrete graphic cards must meet the minimum confirmed specifications outlined by the headset manufacturer.
  • Select among headsets that are designed to comply with safety and EMC standards applicable to Information Technology Equipment.
  • Use a VR headset that has successfully been tested and certified as free from causing electromagnetic interference is recommended. Look for hardware that is IEC/EN-60601-1 and -2 series approved, not just tested.
  • Integrated motion tracking requires less set.
  • Comply with infection disease control and prevention standards, by deploying sanitizable headset. Look for professional grade headsets that indicate germicidal wipe/saniwipes are are safe to use. Long-lasting, replaceable face cushions and VR covers are also recommended.
Clinical Protocols
  • Sterilize the VR headset, earphones and controllers between patients and between. Consider the use of VR covers, thin covers that go over the parts that touch a patient’s face.
  • Monitor patients for potential problems: keep an eye out for a patient’s involuntary muscle twitches, reaching to grab onto something they can stabilize themselves on, loss of balance, growing frustration or anxiety. This can be visually observed. In addition, some VAR systems integrate biofeedback or other sensors — certain of these sensors can also provide indications that a patient is becoming anxious.
  • The length of VR sessions should not exceed 60 minutes unless you have a good, tested reason for a longer session. Recommended breaks between sessions should be at least 10–15 minutes.
Clinician Preparation
  • Assess the state of VR patients: do they seem or report that they are tired, anxious, obviously stressed, intoxicated, or have a cold, the flu, a headache, an earache, or are dizzy?
  • Provide patients verbal and written information on the intended use and application of VR technology.
  • Do not rush through instructions: where possible, show the patient what the virtual environment looks like, and how they can interact with it, particularly if it has handheld VR controllers. Allow patients to try the controllers before they put the VR headset on, because once it’s on, patients cannot see the “real world,” and often cannot hear what you say, or cannot hear it well.
Patient Preparation
  • Provide the patient with a way to signal you if they encounter problems, and encourage them to do so.
  • Make sure the patient knows risks and potential benefits, particularly if they have immediate or long-term problems such as: pre-existing conditions: report becoming easily seasick or carsick.
  • Take the time to ensure that the VR headset fits the patient and is not too tight or heavy. Take the time to adjust the focus of the VR headset and its earphones.
  • Make sure they know how long the VR therapy session will last, and what they should do when it ends.
  • A patient requires a safe place. Because the VR headset “occludes” or covers a patient’s view of the physical world, the space where they use VR should be clear of potential obstructions that patients may easily trip over, bump into or hit their head on, and should be free of cables, people, small children, and pets. A stable chair (not one on wheels) is especially important.
Home Use: Instructions for Patients
  • VR should never be used to avoid professional medical diagnoses, treatment or advice.
  • Check with your physician before beginning the use of VR, if you have pre-existing conditions, particularly conditions of fainting, dizziness, motion sickness (including car sickness and seasickness), or lightheadedness.
  • VR is not recommended for children under 13 years of age, unless suggested by a clinician.
  • Children or adults with significantly reduced physical or mental capacity should be supervised when using VR at home. This includes use of VR in conjunction with narcotic or other strong medication.
  • Frequent breaks are recommended between VR sessions: 10–15 minutes suggested.
  • Clear a space free of potential obstructions, including wires, objects, and potential visitors such as toddlers or pets.
  • Space requirements will depend on the VR content being used. For VR content that requires sitting, be sure NOT to use a chair that has wheels and can swivel because this can lead to nausea.
  • Adhere to the instructions provided by the clinician.
  • The length of VR sessions should not exceed 30 minutes unless otherwise instructed by your clinician. Recommended breaks between sessions should be at least 10–15 minutes.
  • If you experience eye strain, headaches, dizziness or nausea, stop the use of VR and contact your clinician immediately.