Episode 59: Medicine’s Virtual Next Step

How far can virtual reality take medicine? Dr. Peter Buecker, Chief Medical Officer at BehaVR, and Dr. Allyson Brooks, the Executive Medical Director Endowed Chair of Hoag Women’s Health Institute, are here to share their goal of making VR the standard for maternal education, emotional health, and support. In this episode, you’ll learn how VR is being used to address health and wellness, the science behind it, and the realistic trajectory of where it can go from here.

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Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans and many of those humans have unbelievable stories to tell. Here we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together and here are some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to “The Paradigm Shift of Healthcare” and thank you for listening. I’m Michael Roberts here today with my cohosts Scott Zeitzer and Jared Johnson. On today’s episode, we’re speaking with Dr. Peter Buecker, he’s the Chief Medical Officer at BehaVR, and Dr. Allyson Brooks, the Executive Medical Director, endowed Chair of Hoag Women’s Health Institute. Dr. Buecker, Dr. Brooks, welcome and thank you so much for both coming on the show today.

Dr. Buecker: Yeah, thank you for having us.

Dr. Brooks: Thank you, we’re excited to be here.

Michael: This is so exciting for us as we get the chance to have two guests on today. So we’re just gonna open the conversation up and everybody can just jump in, as we feel comfortable with it. So, let’s start with the basics. How can virtual reality be used to address health and wellness and what conditions can currently be treated with it?

Dr. Buecker: Yeah, I’ll take that one. Today, virtual reality is an emerging technology. It’s something that’s been around for a long long time. It’s been used and studied for actually decades. But more recently, it’s coming more into the mainstream of medicine. And the places where it seems to be the most valuable are in aspects of behavioral health, which of course is our big focus at BehaVR, hence the name of the company. For those who are listening but may not see the show, it’s B-E-H-A-V-R, so we’re behavior but using VR to do that. So, behavioral health, so looking at anxiety disorders, attention deficit and hyperactivity disorder. Chronic pain has been a big focus of ours and some other of companies’ in the space, but really looking at…and of course this current project which we’re talking about today, which is in the realm of perinatal mood and anxiety disorders, so really looking at aspects of behavioral health. But it’s also been used for acute pain, for distraction, for procedures with kids. So there’s really a number of areas of healthcare where it’s being used effectively.

Michael: I’ve heard about specifically the pain, being able to treat pain patients in that way. And I think that’s really interesting, like…I don’t wanna put anybody on the spot but could you speak a little about how that’s working in that sort of pediatric environment, how that’s affecting patients in that space?

Dr. Buecker: So, in the pediatric environment, where it’s mostly been reported in more acute-type settings, so, whether it is in dental procedures, starting IVs, whether it’s doing like burn dressings. Those type of things. And some of those experiences are just distraction experiences, putting people in just immersive environments. For instance, you might imagine that you’re under the ocean and hearing whales sing or swimming with dolphins or you might have a gamified type of experience there. We have added some of that to our content but we really are more focused on the chronic-pain side of things because, again, that’s we see as more of a behavioral-type of intervention. So, of course, in our country, there’s this huge issue with chronic pain, it’s a huge point of emphasis and a huge point of expenditure in health care. But also, of course, we are all familiar with the opioid epidemic and kind of the crossover between the two. So we see it as a huge opportunity to make big impact with very powerful technology.

Michael: That’s awesome. I love that so much. You’re working to make virtual reality the standard for maternal education, emotional health and support. What does it take to get there? What kind of mindsets have to shift to make that happen?

Dr. Buecker: Yeah. I’ll take this and give Dr. Brooks the chance to weigh in from her perspective as well. But what we see, in general, adoption of new technology in medicine is nothing new but there are some hurdles with VR. For instance, we have to get people into a headset, we have to get people familiar with the headset and how to interface with the technology. It’s a little different than just clicking an app on your phone. So, sometimes getting adoption from providers and patients, as well as payers, there’s that sort of triangle that we have to get into, shifting to really see the value. And each of those stakeholders of course has a different idea of what that value might be.

So, I think, once we get people into the experience, as we start showing positive results, we start showing that we’re actually making clinical impact, of course that usually is the thing that will sort of shift the tide. I don’t know, Allyson, do you have something from your standpoint?

Dr. Brooks: I agree with that. I think, fortunately, all of the gaming has made it much more mainstream and acceptable. And there’s more willingness to try out or get the headset on so that you can have that immersive experience. I have a little bit of an interesting story, which is, before we even embarked on the relationship between behavior and maternal health or perinatal mood and anxiety disorders, this was brought to my attention and the question was, “Hey, Dr. Brooks, what do you think about putting a headset on women in labor and seeing if this will help in distracting them from the pain that comes every three minutes or every five minutes and whether there might be any reduction in their utilization of pain medication or timing of their epidural or other things?” And my initial response was, “If that’s their first introduction to a headset is when they’re in labor and combating, you know, that type of intense pain that’s coming on a tremendous frequency and regularity over many hours, it would be that that’s not gonna work.”

And that was actually how we started moving towards looking at what we could do in the maternity realm is, “Let’s introduce women, who are a captive audience, introduce it to pregnant women who are a captive audience and eager to participate in trying new things, especially the millennial population. And if we can get them to be aware of what’s possible and to experience it, then we can open up a wide range of opportunities for how VR may impact positively both their pregnancy, their labor, their postpartum experience, and their life later on.”

Michael: It’s really fascinating. It’s funny to say that, we are now blessed with our third child to add on to this year, and I’m just thinking back to the delivery process and how excited, or not excited, my wife would’ve been to have suddenly been introduced to a headset for the very first time and say, “Hey, this is something we’re gonna try. Let’s give it a shot.” You know, the guy from the sidelines, I can weigh in a lot of those things, right? Like all kinds of great ideas that I have read.

So, you mentioned some of the ways that it’s already starting to happen but let’s talk about that a little bit more. You know, what’s being done right now in this space and how have you been able to progress with this development of the platform, especially through the pandemic?

Dr. Buecker: So, for us, the collaboration with Hoag, even before we got into the throes of the pandemic, was really our impetus to bring our platform into the home, into the patients’ home. Previously, our programs have been deployed in clinics, in physical therapy clinics or in other clinical type of settings. So this was really the impetus to say, “Yeah, we want to get this because this patient is an outpatient population. We want the clinicians to be on board and to be able to deploy the platform but that a lot of the use to the platform will actually be with the patient at home.”

So, that being said, the pandemic…it sort of coincided nicely for us to say, “Yeah, it’s the time we have to get things into the home anyway because less people are wanting to come into hospitals or into clinical settings where they might encounter sick people and put themselves at risk.” And so, it helped us, not only develop the platform and build with the ability to go into the patient’s home and provide a lot of the instruction and the experiences in that environment but also helped us sort of think around, “Well, how do we use digital as an appropriate interface between the clinician and the patient to lessen the risk and also increase the benefits for both?” in other ways, which we can talk about in a moment.

But yeah, the pandemic has definitely shifted our thinking on how we, as a company, are approaching VR. But in this particular project, it really helped I think grease the wheels on something we were having to move toward anyway.

Dr. Brooks: And if I could add to that, Peter, those are really important points about bringing the platform into the home where the women are with the pandemic. But the pandemic itself has just really exposed the unmet needs of the pregnant patients in terms of how many questions she has and how she wants to move beyond the use of how-to-be-pregnant applications or the mobile apps. And the women, they’re really starving for more information, they wanna be met where they are, they wanna try something new and different, and they actually recognize and acknowledge that they’re undergoing a very transformative journey and they’re welcoming any additional support.

The pandemic has clearly created…I’ve seen the statistic that the anxiety experienced by women during pregnancy and the postpartum period has gone from a baseline of 10% to 15% to well above 30%. That’s really horrifying, when you think about it. This is supposed to be one of the most joyful times, planning for your future, there’s dreams, there’s really excitation. And instead, the pandemic has exposed or made us more aware of their feelings of vulnerability, their feelings of isolation, and not being able to experience many of the joys of pregnancy as they have been in the past, whether it’s baby showers, whether it’s getting together with other pregnant women in different locations. So, the opportunity to bring this to them in their home and provide that, not crutch, but actually intense amount of support, reassurance, and giving them the confidence to be an active participant in maternity experience.

Scott: It’s fascinating on a lot of different levels, I kinda wanted to jump in and think about a little bit…maybe the audience wants to know a little bit about the science behind VR in these types of applications. How does it essentially work?

Dr. Buecker: That’s a great question. So, there are sort of two main ways that we think about it from a scientific perspective. Number one is…well, let me back up a second and say that, in our experience, we kinda have three components that are central to the core of our design, and that is that we do education, we do motivation, and we do what we call activation. And the activation is kind of the central juicy core where we help people with their stress and anxiety and really we called our safe protocol, our stress, anxiety, and fear of extinction protocol. Because really fear is at the heart of so many of the behavioral-health problems that people have, this triggering of the fear response in the brain. 

And VR is uniquely powerful in its ability to stimulate the brain in ways that it gets stimulated naturally without having to put the person actually in that fearful experience. So we can show somebody, put somebody in delivery room, for instance, at Hoag in this case, and let them experience that and let them regulate those feelings of anxiety and fear and give them tools in the moment to do that before they ever actually get there. And so, that’s a very powerful piece of VR. And so, one of the ways we do that is through an exposure type of experience. So we show them that experience, and then, we give them the tools in the moment and say, “Okay. Now, if you’re feeling anxiety, that’s normal. Here are some techniques you can use to overcome that.”

So that’s one thing, so, we activate the brain in the way that the neuroscientists and the psychologically-educated people call the bottom-up pathway. If you think about it…like, if we’re doing just straight up imaginal therapy, so, if we sat someone down and said, “Okay, imagine that you’re in the delivery room and the anxiety that you might feel. Now let’s do some breathing techniques to help pull you down.” That’s sort of a top-down approach. We’re sort of using a cognitive approach, having them do something imaginable to try to trigger an emotion to then get to the behavioral component. But in VR, we go in the what’s called the bottom-up. So, your brain doesn’t do such a good job of recognizing the difference between real and then something virtual like this. So, with an immersive experience where we put people into a situation, they’re experiencing it as if they’re really experiencing and the brain really doesn’t know the difference. So that’s a very powerful use of the VR technology.

The other piece that is I think very powerful in VR of what we do is the educational side. And we know that…for instance, if I’m trying to learn something new, so, if I have a module where Dr. Brooks is explaining to me, you know, what’s normal for me in week 30 of my pregnancy. I’m sitting in my home, I have my normal surroundings. I may have a cell phone or a tablet or a laptop and I’m trying to learn something while everything is going on around me that’s normal. So I’m in my normal environment and I’m trying to learn something new. And whenever you’re trying to learn something new in this way, again, we’re going through cognitive pathways where your brain’s trying to remember something new in its normal ways, it’s trying to compare it against known information or known anxieties or fears or whatever might be coming up. But in VR, we engage all the learning centers of the brain at the same time. So we’re able to take the person, we’re able to control the environment which they’re learning in, contextualize it, and then give them an experience of Dr. Brooks sharing this information. And they remember it in a way that’s experiential, as opposed to something they’re trying to commit the short term and then convert to long-term memory. So, those two components in particular are very powerfully done in VR.

Scott: You know, it’s really awesome. It is a bit of a different workflow and there’s two parts that I’m thinking about. One part would be of course that, with the pandemic, we’ve spoken to quite a few people where a technology has been pushed along because of the pandemic. And frankly, happily so. I’m thinking of very basic things like the ability to do a virtual visit, you know, telemedicine, which, as a patient every now and then, I’d much prefer to, you know, simply log on and say hi then have to wait a half hour for someone to speak to me about perhaps having a minor health issue, etc. What’s the workflow like and what’s the reimbursement like for VR? How do you alter that? I know there’s two parts to that. So, we’ll start with how do you change the workflow, and then, we can follow up with the conversation regarding reimbursement.

Dr. Brooks: So, maybe I could speak to the workflow initially. So, the main approach that we have taken, Hoag in conjunction with BehaVR, is to meet the women where they are. So we see this program or this offering as designed by women for women. And similar to, “How do we change mindsets and look at workflow?” we’ve gone out to the clinicians, both the obstetricians as well as the midwives who are providing the prenatal care and the aftercare following delivery, and ask them, “Hey, here’s this amazing product. Here’s how we’re going to engage women, help educate them, motivate and activate them. And this can be a win-win for your practice as well. Well, how would you envision this fitting into your workflow?” 

And for them it was really…they were very clear, they wanted the awareness to begin earlier on in the pregnancy, whereas, you know, our modules start at the 28th week and continue through the 8 week postpartum. So they wanted there to be some availability in the office so that the conversation started. They wanted the opportunity to have some demonstrations. And they wanted something turnkey where there could be distribution centers, where their patients could be referred and there would be an intelligent experienced individual who could introduce them to the product, help them sign up, help them better understand when to use, how to use, and what the intended results were.

And that made it much more interesting and palatable to them. They find it a differentiator…I mean, across the country, we’re seeing declining birth rates. And the clinicians that we’ve spoken with really feel that this is an additive or an enhancing experience for their pregnant patients that will make it easier for them in their office space and the limited time that they have to conduct their prenatal visits and postnatal visits.

Dr. Buecker: Yeah. And to the question of reimbursement, that’s kind of the golden question when it comes to any new technology in healthcare. And so, there are a couple ways that different companies are going about it. Some are going down an FDA-regulated path of hoping to get, you know, approved as a Class-2 medical device, for instance, and then be able to go to the insurance companies and say, “Hey, we have an approved device. Will you reimburse for this?” Others are going like us, we’re going more the sort of the silicon-valley-light sort of approach, or the pharma-light approach, which is we say, “Okay, we’re gonna develop a new product that has a lot of value. We’ve done a lot of iteration, we know that it works,” and so, we show value by people going through it to get the payers to buy. 

Then, maybe we go down a digital therapeutic path with the FDA, once we know that we’re on the right track with that. So, we today engage in this product, for instance, as a digital-wellness product. It’s not making any claims to treat or prevent anything, it’s just meant as a way, as an adjunct to the normal care that someone would get. So, we can do that through subscriptions that the patient would pay for and that the hospital would partially subsidize through their global charges for this care. There are a number of ways this is actually being done but we are, you know, piloting another program with a major payer to see, you know, if we can do that sort of demonstration of value to the payer and for the patient, preventing expensive treatments, preventing complications that may come from those treatments. And then, hoping that will also be a route to reimbursement because we feel, of course if we can get payers bought in, then that’s a win-win for everyone.

And there is one other potential way that people can get reimbursed and that is through the collection of data and use of real-time physiologic parameters from the patient as a way to do remote patient monitoring and utilizing those codes. Although that remains to be seen if if that’s a viable route for a lot of the payers.

Jared: Well, that even right there kinda speaks to the evolution of things. When you mentioned several of the options you just discussed even being able to have the real-time remote monitoring data or subscription services as even potential options. I mean those are things that haven’t always been on the table, so I imagine those are some of the paths that are enabling this technology to even be developed and why the timing might be right right now, I mean for both of you, for Dr. Buecker, Dr. Brooks. So I got to say I’ve had the pleasure kind of being a passenger in the vessel, as Michael and Scott have been, driving these conversations with industry leaders like yourselves, so, those who are pioneering new ways of thinking about and delivering care.

And so, I kind of consider myself an objective third party…well, pretty objective, but I’ve been able to see how Michael and Scott are able to continually find the sweet spot, which is the spot that’s the best case scenario for the company that’s developing the tech and for the provider and for the patient. It’s the piece that, you know, if that’s the north star, then we’re gonna tend to have better success all around. And so, to that end, I think about one piece we usually speak about in nearly every conversation that we’ve had is the provider’s perspective, the clinician’s perspective. And we recently had a guest, Dr. Ray Costantini with Bright.md, he described how physicians are not resisting technology. It was a great conversation, it kind of opened up the…we’ve all heard it before, anyone with any type of digital-health developing technology has gone through this or is going through it now, the conversation of, “Oh, well, how are providers going to adopt that?” because they resist technology. 

But this was a really good conversation because Dr. Costantini was explaining, you know, that providers don’t resist tech in general, what they resist is tech that doesn’t make their jobs easier. And that’s where the battle lines can be of like, “Okay, well, how do we discover that?” And that can be the sweet spot of, “Well, if it does make the physician’s job easier, they’re not gonna have a problem adopting it.” And that usually means it’s something that is better for the patient, hopefully, and for the tech itself. So I’m curious, just overall, you know, as we try to find that sweet spot, how can VR make the clinicians’ job easier?

Dr. Brooks: I just wanted to comment that, you know, unfortunately providers have been scarred by the conversion to the electronic health record. You know, and not only has it added significantly to the time and effort to document a patient visit or patient encounter but it has been, you know…it’s felt to be a detraction from that intimate relationship and that there’s always a screen between the patients and the provider. Really interestingly there are individuals, Dr. Brennan Spiegel [SP] is one, who considers VR, the virtual reality experience, an actual empathy machine or an empathy engine and that, by allowing the provider to experience what their patients would be experiencing, as well as the woman to experience this immersive interaction that is on her terms, in her own environment, with enhancements that make them more confident, when they come into the doctor’s office, make them ask more intelligent questions instead of saying, “How much tuna can I eat in a week without worrying about birth defects?” 

They’re working and operating on a much higher level that really creates a long-lasting connection between, not only the patient and her provider because they’ve offered this to her, but between the woman and her developing baby and actually her partner who can participate in this virtual-reality experience just by exchanging the headset from one individual to another. So I think there’s tremendous opportunity there. And, as, you know, Dr. Buecker outlined, where we are now and where we can go with this, it feels like it’s a blue ocean opportunity. And we look forward to multiple iterations and the feedback from the users and, you know, eventually showing that there can be improved outcomes and improved confidence and a better overall experience and long-lasting connection between the woman and her child and the woman and healthcare.

Dr. Buecker: And, from our perspective, what we see is…and Allyson mentioned the data on the increasing rate, the alarming increasing rate of perennial-mood and anxiety disorders in the pandemic time, but what we’re seeing is that’s also a trend in mood and anxiety disorders in general, that people reporting symptoms of anxiety and depression are up two to three times this year as a result of the pandemic compared to, you know, this time a year ago. So, we see VR, or digital in general, but of course our hearts are with VR, VR as a powerful way to meet the scale of the moment. 

We can scale technology, we can’t scale humans, we can’t suddenly train three times more providers, create three times more clinics. We can scale technology to help meet this demand of behavioral health in a system that was already flooded before the pandemic. And a lot of people weren’t getting care or you might, you know, if you’re having a panic attack and, you know, you needed your medications looked at or you just needed a therapist to talk to, it may take you a few weeks to get in. So, that was before. And of course now, with all the changes, it’s much harder. So, we see VR as a powerful way to deliver digital interventions to the patient in their home, in the moment of need. 

Which also has the benefit of decreasing acuity of the patient, hopefully, when they actually come in, and then, it also helps the providers not be flooded with people that they may or may not be able to help for long periods of time. So we see digital as a thoughtful solution to meeting the needs of both the patient and the provider in the middle. So the patient may get on, get triage of some level of acuity, receive a digital intervention. If they need to speak to a human, then we can connect them immediately to a telehealth provider for instance. And while they may have a 20-minute, you know, wait in the queue that they’re in, good, we can deliver another digital intervention in that time and, hopefully, get their level of acuity down.

On the flip side, the provider then of course, like i said, is not necessarily getting flooded with people who may not need to see a provider, they just may not have another option, another viable option for themselves. So, if they go from a level, you know, 8 Acuity down to Level 3 with digital intervention, they can say, “Okay, we’ll, you know, see you in 2 weeks. That would be appropriate,” or whatever.

The other thing that we have in our experiences which kind of gets to a couple of the topics I’ve come up today is we also believe in the collection of data that might be clinically useful. So we also have the ability…we’re collecting biometrics in real time in our experiences, right now mostly heart rate. We’ve done something called galvanic skin response, which is a loose measure of stress, like sympathetic nervous-system activity. We’re also working on heart-rate variability, which is a good thing to measure and monitor stress response in the body. And we collect that in real time and the experiences so we can see what’s happening with the patient in real time. 

And then, we also have the ability to take that data and deliver it back to the electronic health record so that the clinicians, even though their patients doing this at home, they’re getting real-time data on what modules has the patient been through, how do they respond to it, you know, what’s their level of anxious arousal during these experiences. And so, the provider can get real intimate insight into what’s going on with the patient without having to go through all the hoops and difficulties, that Dr. Brooks outlined, in dealing with the electronic health record and having somebody in the office. And especially during this time of pandemic where everybody’s volumes that they’re able to see in the office are down, it’s harder for patients to get in. So, a long way of saying, “We see this as a powerful way to decrease the anxiety in the patient and the workload on the physician.”

Michael: I love it, I love it. You know, this year, we were fortunate enough to be able to deliver a baby, a healthy baby. And the anxiety around how that was gonna go, how we were gonna get into the hospital, how we were going to…like which door to go in. Like all of those little-bitty questions that you have to kind of tick off in order to get there. And then, we had friends, you know, that had the chance to deliver. And so, each of us were kind of comparing experiences afterwards. What was your experience like? You know, how did you handle this part? How long did you have to wait here? All of those different things. 

And to have anything that shortens that cycle, that brings down that level of stress is just amazing. And I think the broader implications of like how this can work in behavioral health in general, I certainly know a lot of folks that are going through, you know, a lot with all of this. So, hats off to both of you. Thank you both so much for joining us today. It’s always a pleasure to talk about this kind of stuff. So, thank you. And as always, thank you for listening today.

Announcer: Thanks again for tuning in to “The Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neural practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.