INNOVATIVE TECHNOLOGIES SUPPORT PERSONALIZED HEALTH CARE

By Scott R. Gourley

One continuing characteristic of Department of Veterans Affairs (VA) medical care is the embrace and application of innovative technologies to support the personalized health care of America’s veterans.

A noteworthy example over the last decade can be seen in the application of video telehealth. Still considered to be “cutting edge” by many in the 2010 time frame, video telehealth appointments have become commonplace across the Veterans Health Administration (VHA).

With a 3D-printed model of a patient’s aortic valve, doctors can test-fit a replacement mechanical valve before the implant procedure.

It prompts the question: When yesterday’s cutting edge becomes today’s commonplace, what new capabilities and technologies are emerging to facilitate health care for veterans today and tomorrow?

According to Thomas Osborne, MD, a physician and chief medical informatics officer at VA Palo Alto Health Care System, the answer to that question is “pretty exciting.”

Osborne, who also serves as the director of the National Center for Collaborative Healthcare Innovation (NCCHI), offered, “There are a lot of new technologies that we are leveraging to enhance care, such as virtual reality [VR], augmented reality [AR], 3D printing, big data, artificial intelligence [AI], sensor technology, and enabling technologies such as 5G. There is just so much going on in health care, and specifically at VA, that it’s a very exciting time.”

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In terms of both virtual and augmented reality, for example, Osborne noted, “There are multiple different categories of clinical use,” offering the representative example of treatment for veterans with post-traumatic stress disorder (PTSD).

“There are two general approaches with virtual reality for PTSD,” he said. “One is the approach of exposure therapy, where a mental health professional utilizes the system to help patients access and work through difficult memories in a supportive environment. The other approach is through relaxation modules that can reduce stress and anxiety with imagery as well as positive biofeedback. We’re actually working with both ends of that spectrum.”

He added that the exposure approach involves the application of technology from the University of Southern California’s Institute for Creative Technologies (a Department of Defense [DOD]-affiliated research organization) as well as extensive collaboration with the charitable organization SoldierStrong and the VA’s National Center for PTSD.

“The SoldierStrong system is very immersive and not just visual. It’s also audio, olfactory, and vibratory sensory. The project is being set up to do a comprehensive evaluation and assessment of the indications and efficacy of that treatment,” Osborne explained. “We were put on hold a bit as a result of COVID, because this immersive treatment involves going into a facility and putting on the equipment. However, as things are starting to open up, we’re going to be in a position to make this complementary treatment available.”

Additive manufacturing, also known as 3D printing, is another area where the VA has established a strong and growing presence over the last few years.

A 3D-printed replica of a patient’s kidney. The Department of Veterans Affairs is exploring ways in which 3D printing can solve a wide range of problems, such as pre-surgical planning.

“One of my favorite things to say about VA is that we were really an early adopter of this technology,” enthused Beth Ripley, MD, PhD, director for VHA’s 3D Printing Network, who was interviewed simultaneously with Osborne. “I am a radiologist by training, but I have spent the last seven years working on bringing 3D printing into hospitals and really exploring all of the medical applications behind that.

“In fact, we have had it in a couple of our hospitals for just shy of a decade now. And from 2017 to 2021, we’ve grown from three hospitals to over 60 hospitals with 3D printing technologies in house.”

Ripley said that the most long-standing and important applications focus on “assisted technologies for veterans to help them interact with their environment better.

“Examples include different types of adapters, depending on the veteran’s needs,” she said. “One might be something that could be put on the end of a prosthetic to more easily hold a fishing rod while another could be something that would facilitate interaction with an iPad. It’s anything you can think of. Obviously orthotics and prosthetics are huge areas for us, but we are also exploring areas like dental and pre-surgical planning.”

Another 3D research and interest area identified by Ripley involves bioprinting.

“There are hundreds of types of materials that you can use for 3D printing,” she said. “They include things like polymers, ceramics, metals, et cetera. Well, it turns out you can also print with living cells and other things that support cellular growth, such as collagen. So we have a ‘biobone’ project where we are working to perfect a recipe technique that will allow us to 3D-print living bone. If you imagine ground bone, and you use that as a paste with some collagen and micro vessels, you can print out bone in the shape of whatever the defect is. Not only is it made of bone, it is vascularized, so they can hook it up and receive vessels from the patient.”

Although the program is currently in the research and development stage, Ripley pointed to “promising early results,” adding, “we’re really excited about it and we’re hoping that we’re going to see it ‘in action’ in the next couple of years.”

The VA is investigating 3D bioprinting of bone, such as the sample shown above, with promising early results.

Other exciting developments are reflective of new enablers like 5G wireless technology.

“Here at the Palo Alto VA, we have become the first VA, and one of the first hospitals in the world, to be 5G enabled,” Osborne said. “That milestone was [reached] on Feb. 4, 2020, and since that time, we have initiated a number of different projects that are using 5G as an enabling infrastructure. Not every system or every technology needs this infrastructure, but for some of them, it is critical for success. This is particularly true for those systems that utilize a lot of data and cannot afford to have any lag or delay in responsiveness.”

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One of the first technologies that is already benefiting from 5G is augmented reality.

“As part of a broad collaborative effort, we are working with Verizon, which brought 5G to VA Palo Alto, Microsoft, which brings the virtual reality HoloLens headset and developmental expertise, and Medivis, a medical software company that brings the advanced augmented reality software and the first FDA-cleared surgical AR system. With these innovative partners, we’re on an exciting path to bring augmented reality to the surgical suite, to enable more precise, accurate, and safe surgical guidance. With the combined system, you can take someone’s own CT or MRI scans, turn them into a three-dimensional holographic image, and then superimpose that image on someone’s real body. In doing so, we can provide a detailed virtual three-dimensional overlay that allows clinicians to literally see into someone. This allows you to know exactly where to go, the most appropriate approach, and the best angle to efficiently address a medical issue while avoiding nearby critical structures.”

In addition to the future vision of integrated technologies, Osborne identified a number of related efforts and applications.

“As examples, we have begun using the AR technology for general anatomy and physiology education for providers and students. We have also begun working with the system for clinical training of routine medical procedures such as vascular line approaches and spinal taps. It’s in the early stage, but we’re also working on more complex surgical approaches for head and neck surgery, as well as for hand surgery,” he said.

Osborne continued, “Just a couple of days ago, I was in a session with one of our excellent surgeons, Dr. Davud Sirjani, and his trainees, who were absolutely amazed because they were able to interact with an enlarged interactive three-dimensional model to discuss the complexities of anatomy and physiology in ways that were not possible before. The difference is transformational.”

The Palo Alto VA is the first VA hospital, and one of the first hospitals in the world, to become 5G-enabled.

While 5G wireless technology is clearly in the spotlight, Osborne acknowledged the enabling infrastructure it provides is not required for every technology or application.

“It’s like a pipeline for information,” he said. “If you think about 4G, for example, which most people use for their phones, it can only move so much data at a time. For the sake of analogy, let’s call that a dirt road. And 5G is more like a five-lane superhighway. Sometimes when you need to move things from place to place, a dirt road is fine. However, if you want to move a large amount of information efficiently, then you really benefit from that 5G infrastructure.”

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Elaborating on the impact of new technologies on medical scanning and imaging, Osborne added, “these types of systems represent a new frontier; the ability to transform two-dimensional data into a more intuitive and interactive three-dimensional format makes this information more useful and accessible for those who are working to make important clinical decisions.”

“That makes it easier to make datainformed decisions,” Ripley echoed. “That’s the really exciting frontier we’re facing.”

A somewhat related aspect of health care being facilitated by these scanning and information technologies involves “portability” and the desire to push health care out to rural veteran populations.

U.S. Army Maj. Ryan McCormack, an operations officer with the 17th Fires Brigade, tests the Bravemind interactive system at Joint Base Lewis-McChord, Washington, April 18, 2013. Bravemind is a virtual training system, designed by developers with the Institute for Creative Technologies, which is used to assess and treat post-traumatic stress disorder.

“In some areas [of the Pacific Northwest], we have patients who have to travel by boat and by plane to go to the doctor,” Ripley said. “So, from an imaging perspective, we are looking at new portable innovations that can be hooked into a cell phone and can go just about anywhere.”

Asked about new technologies that veterans might see introduced into their own personal health care over the next five years, Osborne identified several likely candidates.

“Absolutely agree with the important insights that Beth just shared regarding point-of-care imaging,” he began. “That is an important way to democratize care. Another frontier is the ability for providers to collaborate more efficiently at a distance. For example, in the near future, a clinician at a more remote site will be able to collaborate virtually with an expert in a totally different location. We may have two or more providers sharing the same complex information, in the same virtual room, but potentially located physically on the other side of the world. In other related areas, we are also working with the Department of Defense innovation unit on the development and testing of a new AR- and AI-enabled pathology microscope, which, among other things, may also enable efficient collaboration at a distance.”

Osborne was also quick to praise the innovative work being performed by others across VHA, including that of Caitlin Rollins, RN, who is focused on VR projects for pain distraction and anxiety therapy. “That work has a huge amount of potential and is particularly attractive because it is nonpharmacological care that represents an alternative to opioids,” he said. “In other examples, colleagues in our rehabilitation department such as Esmeralda Madrigal, Jerome Sabangan, and Dr. Maheen Adamson are leading VR-enabled home rehabilitation and exercise therapy at a distance, so people can receive the same type of care in the safety of their own residence, thereby limiting travel and hospital exposure. We have also been working with the DOD innovation unit and great colleagues such as Dr. Catherine Curtin on other projects, such as utilizing smartwatches for physiological monitoring and early detection of infectious diseases such as COVID. Suzanne Shirley [clinical social worker and VHA Innovation Ecosystem director of Partnerships & Community Engagement] is also in our group [NCCHI] with Beth and I, and we’re working with her on some really great projects to end diabetic limb loss using advanced sensors and sensor technology. In collaboration with our excellent ICU nurses at Palo Alto, we are driving a comprehensive fall-prevention smart sensor technology project. We are also very excited about a ‘smart cane’ for the blind we are collaborating on that is being developed by Brian Higgins from our Western Blind Rehab Center [WBRC], which is going to open a new frontier of helping blind veterans navigate the world.”

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Expanding on work in the 3D arena, Ripley highlighted the late February arrival of the first-ever FDA approval for compassionate use of a special 3D-printed device for a particular veteran.

“This patient has a really rare form of progressive hearing loss and there’s no off-the-shelf treatment for him at all. So his team at the Charleston VA worked on a device designed exactly for him that could be 3D printed. VA just recently registered with the FDA as a medical device manufacturer at three of our sites, so we can deliver that. And that’s just the first of what I expect will be many, many patient devices in our future,” she said.

In terms of her takeaway messages for veterans, Ripley asserted, “There is no better time to be in VA.”

She added, “Our mission is to serve, and our innovation mission is to make sure that veterans are the first in line for all of the new innovations coming out in the medical space. We really want to make sure that developers, designers, entrepreneurs are thinking of veterans first and what they need, and we want to be delivering those to our patients as fast as possible. So stay tuned and keep your eyes peeled. There should be a lot of really amazing things coming through the pipeline to veterans. We want them to have these technologies first so they can show them off to their non-veteran friends.”

Osborne added, “This is an exciting time in health care. Never before have we seen these extremes of challenges, not just with COVID, but in general. Against that, we have never had the depth of the technological tools available to solve these problems. On top of it all is the fact that VA is a really unique and wonderful place in so many ways. We’re missiondriven and passionate to serve those who serve. It’s a really noble cause and I feel fortunate to be part of this dynamic learning health care system.”

He concluded, “VA does so much positive work, but we could do a better job sharing that information. There are so many dedicated professionals throughout the agency who are driven and working long hours to provide outstanding care and services. Beth and I are very excited about our work, but there are so many people throughout VA who are working on other impactful projects. As Beth alluded to, we are focused on positive impact for our veterans. However, it’s also important that the things we do at VA can be inspirational and utilized to help others throughout the country and the world, thereby scaling positive impact further.”