Focus on Health 2011

Immersive Internet Australia: Focus on Health 2011

AUTHOR, MANDY SALOMON IS A SENIOR RESEARCHER, SWINBURNE

UNIVERSITY OF TECHNOLOGY AND THE SMART SERVICES COOPERATIVE
RESEARCH CENTRE, MELBOURNE, AUSTRALIA

msalomon@swin.edu.au

This is an extract from ‘Immersive Internet Australia’, available at

http://digitaldownunder.org

A tour of London’s Imperial College virtual hospital in Second Life, 2009

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Contents
The Environment .................................................................. 1!
Virtual Hospitals..........................................................................................8!
Continuing Medical Education..................................................................10!
Games 4 Health .........................................................................................12!
Money for research?..................................................................................13!
REFERENCES ........................................................................................................................15!

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The Australian Productivity Commission has released several reports since 2005,
emphasising the primary role that digital systems must play in the quest to overhaul
healthcare infrastructures (Banks, 2008). Indeed, globally, governments are seeking to
improve unwieldy and outdated information systems, limited resources and cost blowouts
through better use of technology.
Medicine and patient care, by their very nature, are fields that attract innovators, so it is not
surprising that the dual drivers, need and the innovative spirit, have resulted in some of the
most adventurous and committed uses of immersive technology.

Better resourcing of health specialists in remote regions, establishing a social network

amongst chronic care patients, pain therapy for children using calming and meditative virtual
spaces are amongst the motivations, and a growing body of peer-reviewed studies supporting
the clinical and resources value-proposition (Virtual Ability, 2010).

In Second Life, where users themselves can create content, virtual clinics, community support
and outreach groups are proliferating (Norris, 2009). Amongst the many services are
rehabilitation tasks for stroke victims, cognitive exercises for people with brain injuries,
behavioural modelling programs for people with autism, and social opportunities for people
in need of chronic care or with disabilities (Beard et al, 2009).

Cigna Vielife’s ‘Healthy Eating’ pilot study In Second Life.

<http://work.secondlife.com/en-us/successstories/case/cigna/>

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An environmental scan undertaken by the author in 2009-10, noted early adopters and the
ways they were using immersive technologies. From this, a number of categories were
created (table 1).

TABLE 1: Virtual worlds incorporated into public and private health strategies
Health Services
Example Platform Organisation URL
in Virtual Worlds
Info Bus and live
chat with nurse to <http://www.Habbo.co.uk/groups/hpv>
Public Health
discuss HPV HABBO NHS (UK)
Campaigns
(Cervical Cancer)
immunisation
<http://www.remedylimited.com
Virtual Clinics Clinical support for Univ. San Diego
SL /blog/virtual_clinic_to_treat_stresses_of_
and groups war veterans (US)
war/>
Health Info Island -
National Library <http://www.healthinfoisland.blogspot.co
Library Resource library for medical SL
of Medicine (US) m/>
texts
Healthcare Island:
Patient
secure integrated <http://www.virtualworldsnews.com/2008/
monitoring and SL IBM (India)
centre for patients’ 02/ibm-opens-healt.html>
records
health record
Learning protocols
Clinical Imperial College, <http://secondhealth.wordpress.com/clini
f or medical SL
Scenarios London cal-scenarios/>
devices
Emergency
Allied Health http://www.saic.com/products/simulation/
response e.g. OLIVE
Training olive/
resuscitation
Behavioural <http://www.forterrainc.com/index.php/res
Remote therapy. ources/case-studies/79-greenleaf-
OLIVE Greenleaf Medical
specialists (Professor pioneers-virtual-worlds-behavioral-
Greenleaf) therapy>
DreamIsland <http://sliceofmit.wordpress.com/2009/01/
Patient
customised for SL 14/a-visit-to-the-virtual-hallucination-
rehabilitation
stroke patients center/>
Sophia’s Garden: Private family
Tele-
Carers extended family (user-created <http://Sophia’s garden.org>
place
support world)
AARecovery
Community Journey for people http://slurl.com/Second
SL
Support Groups with substance Life/ETSU/27/108/26
abuse

US Centre for
Data Collection Disease Control
SL
Quant/Qual /Univ Illinios,
Chicago

Prototyping and
Polyclinics SL NHS (UK) http://secondhealth.wordpress.com/
co-design

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The value of virtual worlds in enabling people who identify as disabled to participate and
socialise in ways they cannot do in the atomic world has been noted by researchers John
Norris, (2009); Denise Wood (2010) and the Virtual Ability NGO (2010). One of the most
prominent advocates is the British disability
activist, Simon Stevens, whose avatar is
‘Simon Walsh’. Stevens has cerebral palsy.
He established ‘Wheelies’, a wheel chair
community, offering peer-to-peer support in
Second Life. People meet on his resort island,
the home of ‘Wheelies’ nightclub (right),
where avatars can dance, with or without
their wheelchairs. Other parts of the island
have gardens, a swimming pool and training
centre (Stevens, 2010).

Virtual Ability Inc, a not-for-profit

corporation based in Colorado, conducts
research and patient support programs in
Second Life. The consortium coordinates a
diverse range special-needs initiatives; one is a partnership with the Telemedicine Advanced
Technology Research Center (TATRC) and the U.S. Army Medical Research and Material
Command (USAMRMC). Together, they have established the Amputee Virtual Environment
Support Space (AVESS), designed to assist U.S. war veterans adapt to the considerable
challenges of their injuries. Given the numbers of affected soldiers returning from Iraq,
military authorities are constrained in the kind of care they feel is needed (Virtual Ability,
2010). It is hoped AVESS will not only fill the gap, but also enhance existing rehabilitation
services by enabling veterans to establish friendships, play games, watch films, and socialise
with their families inworld, as well as provide remote counselling and monitoring services.
The current proof-of-concept is being undertaken via Second Life Enterprise, with a view to
establishing a private space behind the US military firewall (Virtual Ability, 2009).

Unfortunately, initiatives in the disability area are hampered by the limitations of virtual
world interfaces themselves, which are not designed for people with sight impairment or
those who lack dexterity. The release of motion-sensor games consoles, Nintendo’s Wii and
Sony’s Playstation Move, along with the hands-free console Xbox Kinect (formerly known as
Natal), demonstrate yet again that leads in the immersive Internet are strongly driven by
innovation within the games industry. However, Australian researcher, Dr Denise Wood of
the University of South Australia, is making inroads within the virtual world itself. Wood is
working on range of assistive technologies that enable people with disabilities to orientate and
work within virtual environments. She undertook ethnographic research, spending time on
Second Life’s Wheelie Island (Metaverse Journal, 2010) in order to observe the fundamental
problems. As a result, she is collaborating with a dispersed global team to create ‘Access
Globe’, an enhanced accessibility open source viewer and a Web 2.0-enabled interface to
virtual worlds. Its features include an audio notification system to assist the visually impaired
and alternatives to a mouse-driven interface. Another solution is ‘Max’ the virtual guide dog,

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whose object sensors equip him to lead sight-impaired users’ avatars around immersive
environments (Wood D, 2010).

Max, tguide dog to the visually impaired. Typing an avatar name or location with
aBraille interface, alerts Max to lead his user there. Image by iggyo, at
<http://iggyo.blogspot.com/2009/04/max-guide-dog-of-second-life.html>

There is mounting evidence that people find degrees of liberation in virtual worlds, as they
are not constrained by what cognitive scientist Andy Clark (2005), calls ‘our biological skin
bags’, finding purpose and agency in digitally generated environments that otherwise they
may not have. The experience of cerebral palsy-afflicted residents in a care centre in the US
demonstrates this. They have jointly created an avatar ‘Wild Cunningham’ who socialises,
rides waves and climbs mountains in the Second Life. Their caregivers report that the
participants, free of their wheelchairs and disease, experience a level of social acceptance not
possible in the physical world. This has resulted in ‘improved self-confidence’ and ‘a sense of
empowerment: and that participants express their creativity and humour in ways not
previously available to them’ (CBS, 2008).

Flying with a disability: a Cerebral Palsy group with their avatar ‘Wild Cunningham’ which
enables them to ‘experience’ activities not feasible in the real world.
<http://www.cbsnews.com/video/watch/?id=3547970n>

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TABLE 2: Health, healing and support in Second Life

Second Life Disability Resources Second Life Disability Resources

AA in SL, Hosp. And Inst. Group (professional Friends Fighting Cancer

community)
ADHD Research Friends of Bill W. (Alcoholics Anonymous)
Agoraphobia Support Headquarters Friends of Lois W. (Alcoholics Anonymous)
AICR (Association for International Cancer Research) Health Info Island + iVinnie Center + SL Health and
Wellness Center + Japanese Herb Garden + Consumer
Health Library + SL Medical Library + SL Health
Information Outreach Research Lab
AIDS and HIV Help La Ligue contre le cancer
AIDS and HIV Support Live2Give support group for cerebral
palsy <http://braintalk.blogs.com/live2give >
Alcoholics Manic-Depression
Alcoholics Anonymous MDSLA support group for muscular dystropy, ALS, and
other myopathies
All About Cancer Mind Blinder's club for those with autism spectrum
disorders
ALS Accessibility Center. Providing education and Mobility Impaired in Second Life
resources to all on issues related to disabilities and how
SL can enrich a person's life.
American Sign Language users MS Society
Anxiety http://www.anxietyaustralia.com.au
The Arthritis Society (founded in Spain) affiliated with the MS Support Group
Arthritis Foundation<http://www.arthritis.org/> Multiple Sclerosis Help and Support
Asperger Awareness Multiplicity multiple personality disorder support group
Aspies for Freedom <http://aspiesforfreedom.org/> National Institutes of Health
Autism Awareness/support for parents and caregivers N.D. Research and Support Committee support group for
neurological disorders
Autism Research Nexus Foundation <http://www.slcounseling.org/>
The Counselling Center annex, Boncarus (73, 41, 82)
Making an appt is easy. Check the calendar
at http://www.slcounseling.org/avalonbirke.htm. Look for
"AVAILABLE" times. Then send an IM to Avalon Birke
with the day/time you'd like.
BAVIEC (Blind and Visually Impaired Educational Obsessive Ambulatory Disorder
Center)
BEF (Cystic Fibrosis) Positive Mental Health
Bipolar Support Prostate Cancer Research
Foundation http://www.malecare.com/
Breast Cancer Awareness Prostate Cancer Support
British Sign Language Users - BSL Psychosis and Depression Support
Cancer Co-Op Self Injury Support
CF University (Cystic Fibrosis) Shock Proof (Stroke Survivors)
The Circle of Support (anxiety, depression, and other SL Cancer Research UK
mental illnesses)
Crohn's and Colitis Support SL Foundation for Diabetic Children
Dementia Interests (mainly for carers) SL Relay for Life- Furs for A Cure

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Second Life Disability Resources Second Life Disability Resources

Depression 24/7 Helpline SL Support for HIV/AIDSSL's Cancer Caregivers

Depression and other disorders SLCSS Social Anxiety Support Groups
<http://www.socialphobia.org/>
<http://www.sasfriends.com/>http://www.socialanxietysup
port.com/
<http://en.wikipedia.org/wiki/Social_anxiety>
<http://www.socialanxietyassist.com.au>
Depression Italy Successful Sobriety
Depression Support Group Survivors of TBI (Traumatic Brain Injury)
Diabetes Type 1 Community United Spinal Motorsports
Disability Guerillas (activists) Virtual Hallucinations (schizophrenia)
Disability Support Workers International Wheelies @ Second Ability (193, 115, 27) disability-
themed nightclub
Endometriosis support Youth Cancer (UK)
Fibromyalgia Support Friends

Source: Virtual Ability <http://virtualability.org/sl_resources.aspx

Virtual Hospitals
1. London’s Imperial College Medical School trialled a 3D world ‘game based learning’
program to help students familiarize themselves with operating room and equipment
protocols before the practical component began (Toro-Troconis, 2008). As the
custodian of eight islands in Second Life, including some specifically designed for
clinical training, the College ran tours of virtual ‘polyclinics’, a controversial
proposal developed by the Department of Health (Carvel, 2008) for a one-stop-shop
centre comprising GPs, specialists, imaging and allied health services such as a
wellness centre. In the Second Life facsimile, users completed an onsite questionnaire
with their responses, in effect, commenting on the draft plan, with their responses
becoming part of the design process. In the period of the study (2007-2008), 25,000
people visited the inworld sites and the same number viewed the machinima of an
avatar’s experience there, via YouTube.

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Imperial College Medical School and Virtual Hospital for training:

<slurl.com/second life/medical%20school/112/102/23>
Source: hvxsilverstream on Flickr (Second Health, London, 2009)

2. In another example of prototyping, Palomar West Central Hospital, San Diego,

California is under construction and due to open its doors in 2011. Ahead of the
physical opening, it opened its virtual doors in Second Life for people to explore the
layout and facilities ahead of time (Cisco, 2008). Within the virtual environment,
many proposed high-tech services are modelled, including smart environments that
adapt to patient preferences and a wireless mesh network throughout the hospital and
grounds. Avatars entering the virtual hospital are given RFID tags to wear, as they
would as patients in the actual hospital, and can enter the private rooms and interact
with the room’s customisable features.

Palomar West Central Hospital partnered with Cisco to build its prototype in Second Life.
Left: construction of the real hospital as it looked in March, 2010
Right: the virtual version opened to the public in 2008.

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Screen shot from a machinima describing Palomar West’s imaging technology

<http://www.cisco.com/en/us/hmpgs/index.html>;<http://www.youtube.com/watch?v=kddiebxgcwa>;

Continuing Medical Education

A study conducted by Boston University in 2010, placed 14 primary care physicians in an
hour-long, highly interactive event in Second Life on the topic of Type 2-Diabetes.
Participants completed surveys to measure their confidence in the application, their
performance on test cases, and to assess the learning value.

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Boston University/U.N. -W.H.O.Trial in Second Life <http://www.jmir.org/2010/1/e1/>

The post-survey findings were reported in the Journal of Medical Internet Research (Wiecha,
J. et al, 2010). Of the 12 participants who completed the survey, all agreed that the experience
in Second Life was an effective method of medical education, that the virtual world approach
to CME was superior to other methods of online CME, that they would enrol in another such
event in SL, and that they would recommend that their colleagues participate in a SL CME
course. Only 17% (2 of 12) disagreed with the statement that this potential Second Life
method of CME is superior to face-to-face CME.
The summary of the findings included:
! Fits busy schedules, no travel component, tasks can be done in the comfort of own
home.
! Positive and engaging experience, superior to other methods of online CME
! Some respondents preferred it to dealing face-to-face (F2F) contact with their
instructor
! Positive impact on learner and their sense of self-efficacy
! Suggested a positive impact on clinical competence
! An added sense of presence
! An added sense of real life application (the use of mock patients and role play
! Advantage of using backchat via instant messaging for logistical, technical and casual
enquiries (Dr > Dr; Dr > Instructor)

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!
Boston University Study: The Diabetes Learning Module, using The Second Life Platform
<http://www.jmir.org/2010/1/e1/>

A growing number of pilot studies indicate social worlds have a place in Continuing Medical
Education (CME), although a study undertaken by nursing colleges in New Zealand and the
U.S. (Honey, M.L.L. et al, 2009), in which Second Life was used to create a simulation for
haemorrhage management, found a number of obstacles. These included students requiring
preliminary orientation training before the simulation exercise could begin, indicating that the
user interface was not intuitive enough. It also noted that creating the clinic and props was
time intensive, and that technological glitches were ‘likely to occur’. However there was
strong approval of the interactive elements. Comments such as, ‘was weird and fun’; ‘seemed
real’; ‘We had to think and act quickly’ and ‘taught me about responding and thinking on my
feet’ indicate that respondents were strongly engaged.

Games 4 Health
PULSE is a ‘serious games’ platform for learning complex medical practices and technical
knowledge: diagnoses of illnesses, ER services and complex surgical procedures. Through
immersion in virtual environments, medical students are put into complex situations such as
understanding how a patient’s medical history impacts on their response to drug treatments.
Based on game technology, variables are programmed into role-playing and instruction
modules to better prepare students for un-expected situations and anomalies (Breakaway,
2010).

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Pulse is a virtual learning environment for health care professionals. Research funding has come
from the U.S. Department of Navy’s Office of Naval Research, in partnership with Texas A&M
University World<http://www.breakawaygames.com/serious-games/solutions/healthcare/ >

Money for research?

Snapshot from 2008’s Relay for Life, in which 1700 avatars went
on a walkathon and raised $(US). 215,000
‘The track was themed ‘Quest For a Cure’ and was
created by more than 75 volunteers. Avatars were treated to
virtual scenes from action and adventure stories.
Participants `encountered opportunities along the way to
have fun while donating money - lighting virtual luminaries,
and participating in events such as musical performances,
sky diving, roller coaster rides, and treasure hunts’.

http://www.cancer.org/docroot/GI/content/GI_1_8_Second_Life_
Relay.asp

Whilst the use of virtual environments for clinical purposes, for education and training and
for patient outreach is establishing, there is one area that is less recognised but that warrants
closer attention: virtual worlds can be used to create revenue. Leads are coming from all over
the web, wherever virtual goods are transacted. The world’s biggest social network – it
describes itself as a ‘life platform’ - is China’s QQ, recording 568.6 million registered users

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in March 2010 (TenCent, 2010). Morgan Stanley reports that money spent customising
avatars and purchasing game items in 2009 amounted to $(US)1.4bn revenue for its parent
company TenCent, up 94% on the previous year (Morgan Stanley, 2010). If medical research
groups could form sponsor partnerships with such companies, might they not learn how to
direct some of the explosive consumer interest their way? This is an area for deeper
investigation; certainly establishing a virtual presence would be one way to start.

Another early signal for fundraising comes from The American Cancer Society. Its renown
fundraiser ‘Relay for Life’ attracts participants from around the world, many who have used
the Society’s online resources in Second Life, or who attend the many cancer community
discussion groups held at its virtual precinct. ‘Relay for Life’ was first held as a Second Life
event in 2004, with 99 avatars having raised $(US) 2,000. The following year, $(US) 5,000
was raised. By 2008, 2230 avatars had secured $(US) 218,000 via their sponsored activities
inside the world. Donated funds as of 2010, total $(US) 655,500 (Secondlife 2010).

Screen shot from the American Cancer Foundation’s Relay for Life, 2009.
<http://www.avatarsunited.com/groups/relay-for-life-of-second-life>

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The author’s avatar ponders the resources on Health Info Island in Second Life, 2009.

REFERENCES

Banks, G. 2008, ‘Health Costs and Policy in an Aging Australia,’ Productivity

Commission, Health Policy Oration 2008, Menzies Centre for Health Policy. Paper presented
at the John Curtin School of Medical Research, ANU, Canberra, 26 June, retrieved March
2009,<http://www.pc.gov.au/speeches/?a=81758>
Beard, L., Wilson, K., Morra, Keelan,J., 2009, ‘A survey of health-related activities on
Second Life’ Journal for Medical Internet Research . 2009 May 22;11(2):e17, retrieved
September 2009,< http://www.ncbi.nlm.nih.gov/pubmed/19632971>
Breakaway, 2010 ‘Serious Games for Healthcare markets’, retrieved March, 2010
<http://www.breakawaygames.com/serious-games/solutions/healthcare/ >

Carvel, J. 2008, ‘New NHS polyclinics will damage patient care, warns think tank’ The
Guardian, retrieved March 2009, <http://www.guardian.co.uk/society/2008/jun/05/nhs.health
>

Cisco, 2008. ‘Cisco Helps Palomar Pomerado Health Open 'Hospital of the Future'
Three Years Ahead of Schedule - In Second Life’, (media release), retrieved September 2008,
<http://www.cisco.com/en/US/hmpgs/index.html>

Clark, A. 2004, Natural-Born Cyborgs: Minds, Technologies, and the Future of Human
Intelligence, Oxford University Press.

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Norris, J. R. 2009, ‘The Growth and Direction of Healthcare Support Groups in Virtual
Worlds’, Journal of Virtual Worlds Research Vol2, No 2: 3D Virtual Worlds for Health and
Healthcare., retrieved October 2009, <https://journals.tdl.org/jvwr/article/view/658/500 >
Second Life 2010, ‘Relay for Second Life’, retrieved August, 2010
<http://wiki.secondlife.com/wiki/Relay_For_Life_of_Second_Life>
Stevens, S. 2010 ‘The Wheelies Story’, blog, retrieved May 2010,
<http://simonstevens.com/blog/?m=20100514 >
TenCent 2010, retrieved May 2010,
<http://www.tencent.com/en-us/at/pr/detail.shtml?id=at_2010_20100618>

Virtual Ability, 2010, ‘Medical Benefits’, retrieved January 2010

<http://virtualability.org/va_medical_benefits.aspx>
Wiecha, J., Heyden, R., Sternthal, E., Merialdi, M., 2010,
‘Learning in a Virtual World: Experience With Using Second Life for Medical Education’
J Med Internet Res 2010;12(1):e1, retrieved April 2010
<http://www.jmir.org/2010/1/e1/><doi: 10.2196/jmir.1337><PMID: 20097652>

Wood, D. 2010, ‘Communicating in virtual worlds through an Accessible Web 2.0

Solution’. Telecommunications Journal of Australia, 60 (2): pp. 19.1 to 19.16. DOI:
10.2104/tja10019.

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