Three-perspective multimethod analysis of medical extended reality technology.

Abstract

For nearly 30 years, extended reality (XR) technology has been proposed as the medical industry's future, and yet we continue to see the slow adoption of this technology. XR is an umbrella term for virtual reality (VR), augmented reality (AR), and mixed reality (MR). Three factors contribute to the adoption of XR technology: research (Mazur et al., 2018), user-centered design (Zweifach & Triola, 2019), and mature technology (Riener & Harders, 2012). Mature technology reflects Riener & Harder (2012) report that current XR technology was still immature and needed further development for advanced medical scenarios. Each year, more companies and researchers present feasible methods to replace traditional training and planning methods with high-quality simulations. Amidst the medical industry's technological advancements and interest; many simulations are severely simplified, and surgeons continue to practice medicine on live patients (Chan et al., 2013). The purpose of this research was to identify constraints, challenges, and opportunities that exist in the development, design, and usage of medical XR technology.Justification of Research The medical industry recognizes the need to develop high-quality simulations but is also risk-averse and conservative by training (Zweifach & Triola, 2019). Meanwhile, XR companies are actively developing XR solutions for the medical industry based on Silicon Valley's mantra of “fail hard, fail fast, fail often.” These two trains of thought are in opposition resulting in the slow adoption of medical XR technologies. Medical professionals seek mature technology with validated research to justify the technology fadoption for their specific user needs. Meanwhile, XR companies are trying to find a niche based on limited research and market-ready solutions while building a business case to justify the financial return on investment (ROI). This research analyzes the current status of medical XR technology from three perspectives. User-Centered Design Framework This research, guided by a user-centered design framework, improves the adoption of medical XR technology (Zweifach & Triola, 2019). User-centered design (Kling, 1977) is an iterative process that uses various methods and tools to understand the user's needs (Figure 1). The five steps in the process include analyze, define, design, evaluate, and implement. The first step (analyze) focuses on the context of use and the user's needs. The second step (define) establishes the requirements based on the user's needs. The third step (design) creates a solution based on the requirements. The fourth step (evaluate) assesses the solution based on the requirements. The final step (implement) puts into practice the solution.

Figure 1. The user-centered design process. Three Perspectives The five steps of the user-centered design process were applied to develop three perspectives for this research (Figure 2). In chapters one through four, the first perspective analyzed clinical use cases from a clinical viewpoint for medical XR technology. Chapters one through three develop three clinical use cases. Chapter four surveys medical professionals who collaborated on the XR use cases to understand how they anticipated it fitting into their practice. These chapters presented the doctor’s perspectives of using medical XR technology. The second perspective defined, designed, and evaluated a solution for a specific use case in chapter five. This chapter explored developing a medical XR technology to plan the placement of deep brain stimulation (DBS) electrodes and presented the developer’s perspective of creating medical XR experiences. In chapter six, the third perspective reviewed implemented medical XR technology. This chapter reports survey results from individuals working to produce medical XR technology to understand their processes and attitudes and presented the industry’s perspective of advancing medical XR technology.

Figure 2. The user-centered design process aligned with the three perspectives of this research. Perspective One: Clinical Use Cases (Case Study Research) The first perspective in chapters one through four analyzed the user needs for a clinical setting. The demand for simulation-based training in the medical industry has increased as organizations began moving away from traditional cadaver laboratories and 'see one, do one, teach one' learning models (Riener & Harders, 2012; Stanney et al., 1998). Research has shown simulation improves clinical training, offers repeatability, and reduces teaching costs compared to traditional models (Delorme et al., 2012). VR is a valuable tool to create high-quality simulations (Juhnke, Mattson, et al., 2019) and has seen increased use in the medical industry (Chan et al., 2013). The purpose of this perspective was to develop user-driven medical simulations using a shared methodology and identify challenges and opportunities for medical VR technology. The clinical use cases chapters present a series of use cases and the survey results from nine doctors involved with the cases. The use cases developed a pre-clinical model of Legg-Calvé-Perthes disease (LCPD) (Chapter 1), sized a double-lumen endotracheal tube for a pediatric lung lavage procedure (Chapter 2), and planned the separation of conjoined twins (Chapter 3). The use case series examined how to visualize patient-specific anatomy and medical devices. The survey results presented these early adopters' perceptions and vision for VR technology fitting into their clinical workflows. Four learnings and future opportunities, from the doctor's perspective, were identified. Perspective Two: Deep Brain Stimulation VR Tool (Applied Research) The second perspective in chapter two developed two medical VR technologies to plan the placement of DBS electrodes. As the demand for simulation-based training in the medical field increases, developers look to the literature for best practices and guidelines to support design decisions. Unfortunately, few examples exist to demonstrate, evaluate, and validate XR technologies in general (Vi et al., 2019) before even considering the complex challenges which continue to limit the use of XR technology in the medical industry (Chan et al., 2013). The purpose of this step was to apply the user-centered design approach by combining the user-driven learnings from perspective one with the available literature and domain expert feedback to produce two VR experiences specific to DBS. The DBS chapter develops a use case through four steps. The first step defined the procedural tasks for a complete clinical workflow. The second step investigated design guidelines for medical XR technology. The third step created three-dimension (3D) models appropriate for the DBS use case, and the fourth and final step designed two VR solutions to support the user's tasks. Perspective Three: Industry Review (Grounded Theory Research) The third perspective in chapter three explored how companies implement their medical XR solutions and documented gaps, challenges, and opportunities from an industry lens. From small start-ups to large corporations, a growing number of companies have developed XR technology for use cases across the medical industry. Early adopters' experiences are essential to understand as they drive adoption and guide future research (Zweifach & Triola, 2019). The academic literature is currently limited in scope to proof-of-concept studies or small-scale studies that lack adequate controls and statistical power (Mazur et al., 2018). Additional environmental barriers exist in the adoption of medical XR technology (Zweifach & Triola, 2019). The purpose of this step was to research XR technology from the perspective of the medical industry to understand the landscape of technology development, including constraints, challenges, and opportunities during the development, design, and usage of XR technology. The industry review chapter examines professional's experience developing medical XR technology. The medical industry is buzzing with the potential of XR technology as many try to find their niche. Individuals working in the medical XR technology were surveyed to define the state-of-the-art for why they are developing the technology, what hardware and software are using, how are they evaluating the usability of the solutions. The results explored the technology landscape, from demographics of participants and companies, their current progress, to their hopes for medical XR technology. Connection between Perspectives These three perspectives are necessary to explore the gaps, challenges, and opportunities of XR technology in the medical industry. The adoption of medical XR technology relies on a symbiotic relationship between XR companies and medical professionals. XR companies must develop compelling and attractive XR experiences that are clinically relevant to profit from their effort. At the same time, medical professionals seek clinical and economic evidence that the proposed solution will outperform existing technology at a lower cost (Laupacis et al., 1992). The first perspective developed three use cases that represent three different ways to apply XR technology. The first was a preclinical model to understand human disease state. The second was a clinical model to predict patient outcomes based on the fit of a medical device. The third was a clinical model to make procedural plan decisions. These use cases were guided by clinical care teams and specifically designed for their needs, independent of financial viability. The use cases used existing XR technology to produce minimum viable products to learn about clinical needs. The results show how early adopters perceive medical XR technology and their vision for using the technology in their clinical workflows. The second perspective demonstrated the depth of medical XR technology by developing a single-use case. This used the first perspective’s learnings to fully define a working prototype. One learning from the first perspective was the importance of matching the medical workflow for the procedural planning process in the XR experience. The technology design considered the many experts who contribute to the planning process and medical environment. The XR experience was designed specifically for the clinical need, independent of financial viability. The results demonstrate a method to develop a user-centered XR technology to meet a clinical need and integrate with the medical environment. The third perspective flips the script to explore XR companies developing solutions for medicine. This research identified where they are running into roadblocks and what challenges they are facing. This knowledge highlights the unique position of medical XR companies, which derive from Silicon Valley’s mantra of “fail hard, fail fast, fail often,” but are working in the highly regulated medical industry where evidence is necessary for technology adoption and utilization. Due to the newness of XR technology, these companies are still figuring out how to succeed. The stakes are high, as research has shown 90% of software startups will fail (Giardino et al., 2014). It is critical to understand the position of these companies, as they are necessary for XR technology to become a mainstream tool in the medical industry. This research demonstrates what is possible with medical XR technology and the challenges faced across the industry to reach adoption and utilization. Technology adoption and utilization are critical to advancement, especially as the medical industry tries to reduce its dependence on cadaver labs, animal models, and ‘see one, do one, teach one’ training models (Riener & Harders, 2012; Stanney et al., 1998). By highlighting the challenges and the opportunities, we can begin exploring how to successfully bridge the gap between the risk-averse medical community and the business-driven rapid iteration of software startups. Conclusion My dissertation's purpose was to examine the gaps, challenges, and opportunities remaining based on the current status of medical XR technology. This research applied a user-centered design approach; analyze, define, design, evaluate, and implement, to explore medical XR technology. The information presented in this dissertation will be of value to medical professionals, medical XR technology developers, and regulators. As medical XR technologies continue to grow, it is essential to understand the state of the technology and how these technologies are serving the needs of users.