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Advancing cardiac surgery case planning and case review conferences using Virtual Reality (VR) in medical libraries: An evaluation of the usability of two VR applications (Preprint)
Abstract
BACKGROUND
Care providers and surgeons prepare for cardiac surgery using case conferences to review, discuss and run through the surgical procedure. Surgeons visualize a patient’s anatomy to decide the right surgical approach using Magnetic Resonance Imaging and Echocardiograms in a pre-surgical case planning session. Previous studies have shown that surgical errors can be reduced through the effective use of immersive Virtual Reality (VR) to visualize patient anatomy. However, inconsistent user interfaces, delegation of view control, and insufficient depth information cause user disorientation and interaction difficulties in using VR applications for case planning.
OBJECTIVE
The objective of the study was to evaluate and compare the usability of two commercially-available VR applications—Bosc and Medical Holodeck—using the HTC Vive VR headset to evaluate ease of use, physician attitudes towards VR technology, and viability for pre-surgical case planning. The role of medical libraries in advancing case planning is also explored.
METHODS
After screening a convenience sample of surgeons, fellows, and residents, ethnographic interviews were conducted to understand physician attitudes and experience with VR. Gaps in current case planning methods were also examined. We ran a usability study, employing a concurrent think aloud protocol. To evaluate user satisfaction, we used the System Usability Scale (SUS) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). A post study questionnaire was used to evaluate the VR experience and explore the role of medical libraries in advancing pre-surgical case planning. Semi-structured interview data were analyzed using content analysis with feedback categorization
RESULTS
Participants were residents, fellows, and surgeons from the University of Washington with a mean age of 41.5 (SD=11.67) years. A total of eight surgeons participated in the usability study, three of whom had a prior exposure to VR. Users found Medical Holodeck easier to use than Bosc. Mean adjusted NASA TLX score for Medical Holodeck was 62.71(SD=18.25) vs. Bosc’s 40.87(SD=13.90). Neither application passed the mean SUS score of 68 for an application to be considered usable, though Medical Holodeck (66.25(SD=12.87)) scored a higher mean SUS than Bosc (37.19(SD=22.41)). One user rated the Bosc usable, while three users rated Medical Holodeck usable
CONCLUSIONS
Interviews highlighted the importance of precise anatomical conceptualization in pre-surgical case planning and teaching, identifying it as the top reason for modifying a surgical procedure. The importance of standardized user interaction features such as labeling is justified. The study also sheds light on the new roles medical librarians can play in curating VR content and promoting interdisciplinary collaboration.
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Background
Design processes such as human-centered design (HCD), which involve the end user throughout the product development and testing process, can be crucial in ensuring that the product meets the needs and capabilities of the user, particularly in terms of safety and user experience. The structured and iterative nature of HCD can often conflict with the necessary rapid product development life-cycles associated with the competitive connected health industry.
Objective
The aim of this study was to apply a structured HCD methodology to the development of a smartphone app that was to be used within a connected health fall risk detection system. Our methodology utilizes so called discount usability engineering techniques to minimize the burden on resources during development and maintain a rapid pace of development. This study will provide prospective designers a detailed description of the application of a HCD methodology.
Methods
A 3-phase methodology was applied. In the first phase, a descriptive “use case” was developed by the system designers and analyzed by both expert stakeholders and end users. The use case described the use of the app and how various actors would interact with it and in what context. A working app prototype and a user manual were then developed based on this feedback and were subjected to a rigorous usability inspection. Further changes were made both to the interface and support documentation. The now advanced prototype was exposed to user testing by end users where further design recommendations were made.
Results
With combined expert and end-user analysis of a comprehensive use case having originally identified 21 problems with the system interface, we have only seen and observed 3 of these problems in user testing, implying that 18 problems were eliminated between phase 1 and 3. Satisfactory ratings were obtained during validation testing by both experts and end users, and final testing by users shows the system requires low mental, physical, and temporal demands according to the NASA Task Load Index (NASA-TLX).
Conclusions
From our observation of older adults’ interactions with smartphone interfaces, there were some recurring themes. Clear and relevant feedback as the user attempts to complete a task is critical. Feedback should include pop-ups, sound tones, color or texture changes, or icon changes to indicate that a function has been completed successfully, such as for the connection sequence. For text feedback, clear and unambiguous language should be used so as not to create anxiety, particularly when it comes to saving data. Warning tones or symbols, such as caution symbols or shrill tones, should only be used if absolutely necessary. Our HCD methodology, designed and implemented based on the principles of the International Standard Organizaton (ISO) 9241-210 standard, produced a functional app interface within a short production cycle, which is now suitable for use by older adults in long term clinical trials.
h i g h l i g h t s Virtual reality simulators provide basic surgical skill training. Skills obtained through virtual reality simulation training can be transferred on the operating room. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures. a b s t r a c t Virtual reality simulators provide basic skills training without supervision in a controlled environment, free of pressure of operating on patients. Skills obtained through virtual reality simulation training can be transferred on the operating room. However, relative evidence is limited with data available only for basic surgical skills and for laparoscopic cholecystectomy. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures. Evidence suggests that performance on virtual reality simulators reliably distinguishes experienced from novice surgeons Limited available data suggest that independent approach on virtual reality simulation training is not different from proctored approach. The effect of virtual reality simulators training on acquisition of basic surgical skills does not seem to be different from the effect the physical simulators. Limited data exist on the effect of virtual reality simulation training on the acquisition of visual spatial perception and stress coping skills. Undoubtedly , virtual reality simulation training provides an alternative means of improving performance in laparoscopic surgery. However, future research efforts should focus on the effect of virtual reality simulation on performance in the context of advanced surgical procedure, on standardization of training, on the possibility of synergistic effect of virtual reality simulation training combined with mental training, on personalized training.
A precise understanding of the anatomical structures of the heart and great vessels is essential for surgical planning in order to avoid unexpected findings. Rapid prototyping techniques are used to print three-dimensional (3D) replicas of patients' cardiovascular anatomy based on 3D clinical images such as MRI. The purpose of this study is to explore the use of 3D patient-specific cardiovascular models using rapid prototyping techniques to improve surgical planning in patients with complex congenital heart disease.
The Kinect-based virtual reality system for the Xbox 360 enables users to control and interact with the game console without the need to touch a game controller, and provides rehabilitation training for stroke patients with lower limb dysfunctions. However, the underlying mechanism remains unclear. In this study, 18 healthy subjects and five patients after subacute stroke were included. The five patients were scanned using functional MRI prior to training, 3 weeks after training and at a 12-week follow-up, and then compared with healthy subjects. The Fugl-Meyer Assessment and Wolf Motor Function Test scores of the hemiplegic upper limbs of stroke patients were significantly increased 3 weeks after training and at the 12-week follow-up. Functional MRI results showed that contralateral primary sensorimotor cortex was activated after Kinect-based virtual reality training in the stroke patients compared with the healthy subjects. Contralateral primary sensorimotor cortex, the bilateral supplementary motor area and the ipsilateral cerebellum were also activated during hand-clenching in all 18 healthy subjects. Our findings indicate that Kinect-based virtual reality training could promote the recovery of upper limb motor function in subacute stroke patients, and brain reorganization by Kinect-based virtual reality training may be linked to the contralateral sensorimotor cortex.
We have done a systematic review of articles and reviews published about the theme: “Virtual Reality in Medicine”. We used the search query string: “Virtual Reality”, “Metaverse”, “Second Life”, “Virtual World”, “Virtual Life” in order to find out how many articles were written about these themes. For the “Meta-review” we used only “Virtual Reality” AND “Review”. We searched the following databases: Psycinfo, Journal of Medical Internet Research, Isiknowledge till September 2011 and Pubmed till February 2012. We included any source published in either print format or on the Internet, available in all languages, and containing texts that define or attempt to define VR in explicit terms.
We retrieved 3443 articles on Pubmed in 2012 and 8237 on Isiknowledge in 2011. This large number of articles covered a wide range of themes, but showed no clear consensus about VR. We identified four general uses of VR in Medicine, and searched for the existing reviews about them. We found 364 reviews in 2011, although only 197 were pertinent to our aims.
We have found that there is not a clear consensus about the meaning of the term VR in Medicine. We found numerous articles published on these topics and we decided to group these reviews in four areas: 1. Communication Interface (11 Reviews); 2. Medical Education (49 reviews); 3. Surgical Simulation (49 Reviews) and 4. Psychotherapy (88 Reviews) in order to provide a systematic overview of the subject matter.
This paper reports on the development of a hand to machine interface device that provides real-time gesture, position and orientation information. The key element is a glove and the device as a whole incorporates a collection of technologies. Analog flex sensors on the glove measure finger bending. Hand position and orientation are measured either by ultrasonics, providing five degrees of freedom, or magnetic flux sensors, which provide six degrees of freedom. Piezoceramic benders provide the wearer of the glove with tactile feedback. These sensors are mounted on the light-weight glove and connected to the driving hardware via a small cable.
Applications of the glove and its component technologies include its use in conjunction with a host computer which drives a real-time 3-dimensional model of the hand allowing the glove wearer to manipulate computer-generated objects as if they were real, interpretation of finger-spelling, evaluation of hand impairment in addition to providing an interface to a visual programming language.
High workload of nurses in Intensive Care Units (ICUs) has been identified as a major patient safety and worker stress problem. However, relatively little attention has been dedicated to the measurement of workload in healthcare. The objectives of this study are to describe and examine several methods to measure workload of ICU nurses. We then focus on the measurement of ICU nurses’ workload using a subjective rating instrument: the NASA TLX.
We conducted secondary data analysis on data from two, multi-site, cross-sectional questionnaire studies to examine several instruments to measure ICU nurses’ workload. The combined database contains the data from 757 ICU nurses in eight hospitals and 21 ICUs.
Results show that the different methods to measure workload of ICU nurses, such as patient-based and operator-based workload, are only moderately correlated, or not correlated at all. Results show further that among the operator-based instruments, the NASA TLX is the most reliable and valid questionnaire to measure workload and that NASA TLX can be used in a healthcare setting. Managers of hospitals and ICUs can benefit from the results of this research as it provides benchmark data on workload experienced by nurses in a variety of ICUs.
Observations obtained through concurrent think-aloud and protocol analysis offer new understanding about the influence of social learning on student nurses' acquisition of Information and Communication Technology (ICT) knowledge and skills. The software used provides a permanent record of the underpinning study method, events and analyses. The emerging themes reflect the dimensions of social engagement, and the characteristics of positive and negative reactions to ICT. The evidence shows that given the right conditions, stronger learners will support and guide their peers.
To explore the use of concurrent think-aloud and protocol analysis as a method to examine how student nurses approach ICT. To identify the benefits and challenges of using observational technology to capture learning behaviours. To show the influence of small group arrangement and student interactions on their ICT knowledge and skills development.
Previous studies examining social interaction between students show how they work together and respond to interactive problem solving. Social interaction has been shown to enhance skills in both ICT and collaborative decision making.
Structured observational analysis using concurrent think-aloud and protocol analysis.
Students displayed varying degrees of pastoral support and emotional need, leadership, reflection, suggestion and experimentation skills.
Encouraging student nurses to work in small mixed ability groups can be conducive for social and ICT skill and knowledge development. Observational software gives a permanent record of the proceedings.
Copyright © 2015. Published by Elsevier Ltd.
The System Usability Scale (SUS) is an inexpensive, yet effective tool for assessing the usability of a product, including Web sites, cell phones, interactive voice response systems, TV applications, and more. It provides an easy-to-understand score from 0 (negative) to 100 (positive). While a 100-point scale is intuitive in many respects and allows for relative judgments, information describing how the numeric score translates into an absolute judgment of usability is not known. To help answer that question, a seven-point adjective-anchored Likert scale was added as an eleventh question to nearly 1,000 SUS surveys. Results show that the Likert scale scores correlate extremely well with the SUS scores (r=0.822). The addition of the adjective rating scale to the SUS may help practitioners interpret individual SUS scores and aid in explaining the results to non-human factors professionals.
This report documents the state of development of enhanced and virtual reality-based systems in medicine. Virtual reality systems seek to simulate a surgical procedure in a computer-generated world in order to improve training. Enhanced reality systems seek to augment or enhance reality by providing improved imaging alternatives for specific patient data. Virtual reality represents a paradigm shift in the way we teach and evaluate the skills of medical personnel. Driving the development of virtual reality-based simulators is laparoscopic abdominal surgery, where there is a perceived need for better training techniques; within a year, systems will be fielded for second-year residency students. Further refinements over perhaps the next five years should allow surgeons to evaluate and practice new techniques in a simulator before using them on patients. Technical developments are rapidly improving the realism of these machines to an amazing degree, as well as bringing the price down to affordable levels. In the next five years, many new anatomical models, procedures, and skills are likely to become available on simulators. Enhanced reality systems are generally being developed to improve visualization of specific patient data. Three-dimensional (3-D) stereovision systems for endoscopic applications, head-mounted displays, and stereotactic image navigation systems are being fielded now, with neurosurgery and laparoscopic surgery being major driving influences. Over perhaps the next five years, enhanced and virtual reality systems are likely to merge. This will permit patient-specific images to be used on virtual reality simulators or computer-generated landscapes to be input into surgical visualization instruments. Percolating all around these activities are developments in robotics and telesurgery. An advanced information infrastructure eventually will permit remote physicians to share video, audio, medical records, and imaging data with local physicians in real time. Surgical robots are likely to be deployed for specific tasks in the operating room (OR) and to support telesurgery applications. Technical developments in robotics and motion control are key components of many virtual reality systems. Since almost all of the virtual reality and enhanced reality systems will be digitally based, they are also capable of being put "on-line" for tele-training, consulting, and even surgery. Advancements in virtual and enhanced reality systems will be driven in part by consumer applications of this technology. Many of the companies that will supply systems for medical applications are also working on commercial products. A big consumer hit can benefit the entire industry by increasing volumes and bringing down costs.(ABSTRACT TRUNCATED AT 400 WORDS)
This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy.
Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR.
No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores.
Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.
Two-dimensional transesophageal echocardiographic (2D TEE) assessment of the mitral valve requires mental integration of a limited number of 2D imaging planes. Structural display in three dimensions from any perspective may be of advantage to the surgeon for better judgment and planning.
Feasibility, accuracy, and limitations of preoperative three-dimensional transesophageal echocardiography (3D TEE) was assessed in 51 patients with mitral valve disease. The width of the anterior mitral valve was measured with either method and compared with the operative finding. Three-dimensional dynamic sequences of the reconstructed mitral valve were shown preoperatively to the surgeon and later compared with the intraoperative finding.
The quality of the 3D reconstruction was graded as good in 25 patients (49.0%), fair in 16 patients (31.4%), and poor in 10 patients (19.6%) where atrial fibrillation did not allow ECG gating. Thirty-nine patients had successful mitral valve repair and twelve patients required valve replacement. Based on intraoperative findings, sensitivity for the diagnosis of mitral valve prolapse using 2D TEE and 3D TEE was 97.7% and 92.9% (p = ns) respectively and specificity was 100% by both methods. Sensitivity for the diagnosis of rupture of chordae tendineae using 2D TEE and 3D TEE was 92.3% and 30.8% respectively (p < 0.05) and specificity was 100% by both methods.
Dynamic 3D echocardiography is feasible and can provide good insight into valvular motion and allows adequate preoperative planning when reconstruction is being considered. However dynamic 3D reconstruction is currently limited by the quality of the original 2D echo cross sectional images which can be adversely affected by minimal patient movements, breathing, or cardiac arrhythmia, thus limiting accuracy of the 3D TEE significantly compared with 2D TEE.
Role of virtual reality in congenital heart disease
"Role of virtual reality in congenital heart disease." Congenital Heart Disease, vol. 13,
no. 3, 2018, pp. 357-361.