The leading digital health narrative emerging from the COVID-19 pandemic has been the rise of telehealth and live video consultations as a reliable modality for delivering care. In many ways, it was a case of preparation meeting opportunity – years of pilot programs, platform refinements, public funding projects and a number of very well established players all ready to adapt and expand when demand was at its highest.

But have other, younger health-delivery technologies been enjoying a similar rise in adoption? For virtual reality, the answer appears to be yes – with some caveats.

Healthcare VR programs and startups have had to navigate several unexpected roadblocks as a result of the outbreak, stakeholders told MobiHealthNews, leading to a number of in-hospital deployments and research projects being sidelined or modified. Others have stayed the course or even flourished, with at-home and remote-care deployments in particular finding little need to slow down.

A handful of startups and vendors, meanwhile, have been adjusting their offerings with new features, and some have so far been rewarded with sales numbers dwarfing those of 2019. What's more, the broader healthcare industry's recent ideological shift toward digital health technologies has stakeholders of all kinds anticipating a long-term boost to the adoption of VR for care. 

"Everyone is talking about telemedicine as sort of the solution to overcoming the physical barriers between patients and their providers, and there's no doubt that's taken off in a big way ... but there still are very important limitations to that that VR can help overcome," Dr. Brennan Spiegel, director of health services research at Cedars-Sinai and cochair of the VR/AR Association Digital Health Committee, told MobiHealthNews. 

"It is an opportunity for VR to shine right now – if we can figure out how best to do it."

In-hospital VR research programs hit a road bump ...

The last few months have seen all of Cedars-Sinai's hospital-based VR programs grind to a halt, Spiegel explained. 

"There's a few reasons. The first is that it's largely a research program, and research in general has slowed during this time. "We've been focused on essential activities. And obviously, the concern about cleanliness; if we're delivering the headset to people who may have the infection, we're very thoughtful about that. ... So we haven't been taking risks there, but that's out of an abundance of caution."

With that being said, a separate Cedars-Sinai program that was shipping VR headsets directly to patients' homes has been progressing as scheduled, "and people are using them," Spiegel said. He also noted that he is still working on new research proposals and projects for the time that research at his institution begins to pick up again.

Hoag Memorial Hospital in Orange County, California, meanwhile, ran into a similar slowdown, but managed to repurpose some of its in-hospital deployments. 

Dr. Robert Louis, endowed chair and program director at the Pickup Family Neurosciences Institute, and director of XR Development at Hoag Memorial Hospital, told MobiHealthNews that two projects aiming to use VR in a post-anesthesia-care unit weren't able to recruit enough participants. But with all of the headsets and cleaning systems already purchased, and a number of furloughed nurses in reserve, the hospital decided to improvise.

"We built these rolling carts using the UV Cleanboxes and with battery packs in the bottoms of them, so the carts could work as mobile charging stations as well as mobile decontamination stations," he said. "Then we just had shifts where nurses would go in teams of two from floor to floor to floor offering patients the VR experiences. Over the course of six weeks we treated 200-plus patients with VR, even though the hospital was only operating at 20% capacity." 

Those pivoted programs were among 15 VR initiatives Louis and Hoag had planned for 2020. The majority of the programs have been either delayed or adjusted in some way or another, but Louis (who also noted that the hospital hasn't been hit too hard during the emergency) said that he still expects roughly 12 to go forward before the end of the year.

"The research ones ... have been delayed a bit because of the decrease in elective surgeries. And three of them were around postpartum care, pain management for knee replacements and gynecology surgery, those kinds of things," he said. "Those have been delayed because we may not hit our target enrollment by the end of the year – but are still ongoing."

Louis said that Hoag's commitment is steadily looking forward, with the hospital acquiring extra headsets to continue its ad-hoc program and planning to purchase "thousands" of the devices for an upcoming project that will offer the technology to expecting mothers for home use. On a more personal level, he said that he has been providing more advice on how best to deploy VR than ever before.

"I have more inquiries than I can possibly keep up with right now," Louis said. "No exaggeration, I brought on a third staff member just to field and triage the different requests for my time to discuss and help develop these things, because it's all of a sudden recognized that [there is] a huge need for this, and we need it right now."

... But vendors report rising demand

Research programs and hospital adoptions of VR may be taking a short-term hit, but that doesn't seem to be the case among healthcare VR vendors. 

Eran Orr is CEO of XRHealth (formerly VRHealth), a Brookline, Massachusetts-based startup that develops VR applications and provides remote care for remote physical therapy, stress management, pain management and other conditions. He told MobiHealthNews that his company has been "seeing demand that we expected in a year’s time frame, in a month’s time frame." 

Interest comes from clinicians and patients alike, he said, and has largely focused on his platform's new remote-care capabilities. 

"Before COVID, we had two lines of business, basically: VR in the hospital, where we sold our technology through the hospital [or] healthcare facility; and ... we launched our VR telehealth clinic March 1," Orr said. "Now, two-and-a-half months in, we've basically stopped all the business activity selling our VR technology. We're not doing that anymore. All we are doing is telehealth VR. We already have more than 500 clinicians trained to be VR telehealth specialists and we have patients enrolling on a daily basis."

Similarly, a representative from Rendever, which provides VR for senior living facilities and families looking to curb loneliness among the elderly, told MobiHealthNews that the company prioritized the launch of several new features such as two-way voice communication (to encourage social connections during isolation) and expert-run live sessions. 

"The new features we've rolled out have been well-received by the industry," the representative wrote in an email. "We cannot publicly disclose detailed sales figures, but we will share that, for each month in 2020, we've grown our sales performance consistently compared to 2019."

Hoag noted that his hospital is continuing to work with VR vendors such as XRHealth and BehaVR, which focuses on in-home pain management. And adjacent to VR vendors themselves is Cleanbox Technology, the maker of a UV-based sanitation device designed for VR headsets, eyewear and masks that is used by Cedars-Sinai, Hoag and others inside and out of healthcare. 

"Their business has jumped 100-fold overnight. Literally, 100X year-over-year," Louis, who serves on the company's board of advisors, said. "And for [the VR] space, from a purely business standpoint, this is a home run."

Despite this, Spiegel said that he worries some of the VR industry's younger players might get lost in the frenzy of new challenges COVID-19 has introduced.

"The biggest concern I have is how this has affected the startup companies that are trying to develop really high-quality software, and whether this pandemic might halt development of products and services in healthcare," he said. "I'm concerned that it's a rather fragile startup ecosystem still, and I just hope there's enough companies that can sustain this." 

Reimbursement, regulatory changes offer long-term opportunities

Over the course of the COVID-19 health emergency, digital health players have applauded recent decisions to temporarily expand reimbursement and waive certain restrictions on telehealth, remote care and other digital health services. 

"Years happened in months, basically, with regulation and reimbursement," Orr said. "The regulators, CMS, Medicare, private insurance and the states, understood that telehealth can alleviate a lot of the burden on healthcare facilities. And the steps that they decided to do [are] a part of driving this industry forward." 

As VR continues to demonstrate its therapeutic efficacy for certain conditions, many in the industry have targeted payment as one of the next major hurdles to widespread adoption. Orr, Louis and Spiegel each said that these developments provide a clear opportunity to jump-start that effort.

"Before this all started, we were working with AMA to think about CPT codes, for example, for virtual analgesia," he said. "But now that there's such a liberalization of billing for reimbursement of virtual visits, it seems more relevant than ever to understand the billing opportunities for remote digital-therapeutics when administered in the context of telemedicine. I think we need to untangle that a bit [and] understand where the value is, because we know clinically there is value, and the use case is more important than ever to overcome the barriers to health delivery created by COVID-19."

These actions have strengthened digital health's case for payment from private insurers as well. Speaking on the delays in care for mental health and other conditions COVID-19 has caused, Spiegel said that payers across the board "would be interested in figuring out how to intercept those costs before they expand out of control, and that's about getting to people early and often with evidence-based therapies." But beyond COVID-19, Louis said that other cost-savings benefits of VR have already caught the interest of some big names.

"Once the payers start to catch on to the fact that one out of every 10 patients that would have been addicted to opioids that we used this on now is not, the downstream savings on that is unbelievably big," he said. "We've engaged and have ongoing conversations with UnitedHealth Group on co-sponsoring some of these studies together."

VR's benefits outweigh infection fears

Sanitation and infection control are key considerations when deploying VR headsets in a healthcare setting, and are particularly relevant in the midst of an infectious disease outbreak. As healthcare providers continue to plan for the pandemic's long tail, the VR researchers were in agreement that sanitation concerns should not disqualify new VR programs.

"There's a fear in hospitals that if this one patient in the hospital has COVID, it's going to be passed from person to person," Louis said. "Hospitals are experts at maintaining sterility and sanitation. You'd be more at risk getting it going out in the community than you are using a VR headset in the hospital. We have a very strict protocol that was developed by our infectious-disease doctors and approved by them."

As an asynchronous, self-administered, home-based treatment, VR, like other digital therapeutics, has a number of uniquely relevant strengths in terms of care delivery during the ongoing crisis, Spiegel said. Limiting adoption, either in the hospital or via at-home delivery, simply for fear of infection, would be a missed opportunity for patients and for the healthcare industry. 

"As people are at home and are going to stay this way for the foreseeable future, ... there's going to be this gap between supply and demand, particularly for mental health services," he said. "I don't think there's anything incompatible with delivering VR headsets during the time of a pandemic. ... We use basic stuff that cleans this thing completely, we carefully put it in the box, and we ship it so that our patients can get this stuff remotely, in a FedEx shipment, preloaded with the software, so they can use it in the time and place of their choosing."

The past few months have also shown examples of healthcare providers implementing VR to directly counter the challenges of COVID-19. In hard-hit Italy, researchers and healthcare systems say they have had success distributing the headsets and applications among staff to help them manage stress and anxiety. Rendever CEO and cofounder Kyle Rand also noted in an email that senior living facilities, which face some of the highest mortality rates among their residents, can more easily maintain mental health and enforce social distancing using VR platforms "that allow people to share in joy and laughter and happiness, despite not being physically together."

For VR vendors like Orr, it's understandable that not all hospitals or clinics were in a place to adopt new technologies amidst the COVID-19 scramble. However, the momentum that virtual care, digital health and VR services like his have gained over the past few months isn't likely to disappear soon.

"This ship has sailed," Orr said. "Even if there will be a new normal, I think the telehealth industry as a whole – and we as a VR telehealth company – will be able to prove in a matter of months that this technology is effective, will improve access, reduce costs, and is fun and engaging. And I think it will become a new gold standard in a short time frame."