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NHS in virtual reality: second sight

The virtual world of Second Life has a health service, so you can now tour a cyber polyclinic. Daloni Carlisle explains

Where in the world would you find a mermaid addressing an otherwise perfectly serious international surgery conference? Or a blue dragon with purple scales touring a polyclinic? In Second Life, that's where.

OK, so Second Life is not a real place and the mermaid and blue dragon are avatars - the embodiments chosen by individuals to lead their virtual lives. But the virtual surgery conference really happened, a leading clinician did appear as a mermaid to address 200 of her peers and take questions in real time. The polyclinic is really there for exploring, as is a long-term conditions facility and urgent care centre.

They were developed by a team at Imperial College in London which is working on Second Health, which represents the health service within the virtual reality game Second Life. It is eye-popping in its detail and the possibilities it offers and you really should go and have a look at it. Dave Taylor, programme lead for virtual worlds and medical media at Imperial took HSJ on a guided tour. His avatar looks like his real life persona - a regular guy in casual clothes. He walks around a 3D world that represents what an urgent care centre of the future might look like.

All the signage looks - and reads - like NHS signs. "We had to design most of it although we bought some of the beds from a Second Life store," says Mr Taylor.

On the kerb, ambulances wait for a call-out. Inside these you can view films of what the health service is like now - and what it could be like in a post-Darzi future. In the main building are toilets, lifts, elevators, waiting areas (with seats that look too hard to sit on) and clinics. "We find people like to use the stairs rather than the elevators," muses Mr Taylor. "We don't know why."

He touches a wall and up pops a series of leaflets on different health conditions. "Although we designed this as a way of showing people environments that don't yet exist, we found that they came here expecting to find health information," adds Dr James Kinross, clinical research fellow on the project.

This was all developed for NHS London as part of its consultation on the future of health services. It was used to host one of the capital's consultative events, with 22 people attending the event - none of them Second Life users - where they met doctors, heard talks, watched slide shows and explored before voting in real time and seeing the results. There were some teething problems but on the whole it went well, says Dr Kinross.

"In theory you could run the same event again with people who cannot attend a real event because they are disabled or live at the other end of your strategic health authority."

But back to the tour. We spot a figure in the distance that turns out to be the island's lead designer (where the internet has pages, Second Life has islands that can merge to become countries and even continents). Mr Taylor talks to him - not using text (although that's possible too) - but in real time using his own voice. They are trying out some open source software that will lip-sync their speech with their avatar's mouth movements. The nearby conference area is set up in a conventional way - a platform with screens for showing PowerPoint presentations, seats for speakers and a lectern for the lecturer facing the audience. The backdrop is a seascape with a gentle wind blowing ripples, giving it a Californian feel.

Virtual conversations

It has been used twice so far. Once for the international surgery conference and then again as part of the Darzi consultations. The team streamed the Clinical Summit at London's Excel last November for an invited international audience of 100. Some speakers came off the stage and went to answer questions avatar-to-avatar in a so-called "green room" to the side of the main conference arena.

"We had people here who could not have come to the conference," says Mr Taylor. "They got to speak one-to-one with the conference speakers and, because we took questions in writing, we had some really high-quality questions compared to those over the microphones at Excel."

These areas - and the polyclinic and long-term care facility - are open to the public. They are based on SciLands, a mini-continent and user community devoted to science and technology. Near neighbours include NASA, the National Institutes for Health, some major US health libraries and medical research institutions.

The team's next project is not yet open to the public and is a replica of the operating theatres at St Mary's Hospital Paddington, six storeys below the team's base on the 10th floor of the QEQM building. The idea is to test whether medical students will be safer in a real theatre after they have familiarised themselves with its virtual counterpart. To get there, Mr Taylor does the sort of disconcerting thing that Second Lifers are prone to do: he flies, landing on the top of the theatres and a virtual walkway.

Just like the real thing, he has to enter using a key code. When he tries to go into a theatre without scrubbing up, alarms ring and a video screen flashes, alerting him to a film about infection control and the proper technique for hand washing. Inside the theatre, a patient is lying prone on an operating theatre. Mr Taylor can manipulate the patient while a screen on the wall explains in which operations different positions might be used. Useful for students, perhaps, but how useful for patients - another of the team's targets for exploring virtual reality possibilities? Can Second Life and other systems be used to get information over to patients more effectively? Some of the positions look, well, undignified at best and horrifying at worst. "That's something we need to explore," says Mr Taylor. "How do you give people the information they need without scaring them?"

In the post-operative area, another patient is waking up. "Have you peed yet?" Mr Taylor asks him. "I am not programmed to respond to that question," replies the patient. Some work to do here on scripts before release, then. On the day HSJ visited it was eerily quiet. There were no other visitors and no one apart from the designer to talk to. That is not always the case. The polyclinic has been host to groups of students led by teachers, for example. "We get about 300 visitors a week who spend an average of 35 to 45 minutes exploring," explains Mr Taylor. "Compare that to the 10 seconds people spend on a website on average."

"It's an immersive 3D world," says Dr Kinross. "After about 10 minutes your brain switches off and stops telling you this is a simulation. You experience suspended belief." The ability to speak - which came about a year ago - has changed the experience, he adds. "You can see the person you are speaking to and chat to them."

If all this sounds like a rather exotic, but ultimately self-indulgent, experiment in virtual reality design, then that is quite the wrong impression.

This is a serious attempt to explore how virtual reality can impact health and health services. The team is based firmly within Imperial and its academic structures. The Biosurgery and Surgical Technology unit within which it sits also brings in surgical education, including high-spec surgical simulation, robotics and the National Centre for Safety and Quality, and it has links with the Institute of Bioengineering. Lord Darzi heads up the whole surgery department.

"We look at surgery as a whole, from education and the patient perspective right the way through," says Dr Kinross. The research group's interests span the broad range of new media and social networking, with work in virtual reality just one aspect.

"The key discriminator - and this is fundamental to what we do - is that one of the key benefits of virtual worlds is that they promote an interdisciplinary approach to problem solving, and that is crucial in health and particularly in surgery," adds Dr Kinross.

In virtual reality - unlike the internet - people can meet and discuss. "You don't know how many people are looking at an internet page or who they are," he continues. "In virtual worlds you can see them and talk to them and in a space such as SciLands you meet serious scientists who are very open to communication.

"I have met scientists and medics in virtual reality that I would never have met in real life. And that's something I never thought I would say."

That's because Dr Kinross never thought of himself as a computer-type person and certainly not as a gamer. "It isn't about computing but I think people have fairly strong preconceived ideas about what this is about. Because it is born out of computer gaming, they see it as a game, which it isn't. Or they see it as something for teenagers, which it also isn't."

Serious forum

The typical profile of a Second Lifer is 30 and over, with men and women equally split. So, SciLands and the Imperial team are very serious and are asking serious questions about education for doctors and nurses and whether virtual reality has benefits for consulting about future healthcare services.

"Can we use this to improve health?" asks Dr Kinross. "Can we influence people's behaviour to improve their health? That's the kind of research questions we are working on."

"Everything we do is underpinned by some very serious research questions," says Rachel Davies, head of strategic development for biosurgery and surgical technology.

They do not have results yet. People liked the conferences and there were definitely environmental benefits of travelling to a virtual conference rather than travelling to a real one, but that's not the same thing. And maybe it's too early to expect any. The work has been going for less than two years and much of the energy so far has been building convincing virtual realities.

It is also early days for virtual reality. "I liken it to where the internet was in 1994," says Mr Taylor. In other words, pre-Google when searching was an art and most people could not see the relevance of the web to their daily lives.

The general expectation is that virtual reality is about to make a quotidian leap and will, in the next five to 10 years, become as common to our everyday experience as the internet is now.

So in the five to 10-year time frame, Dr Kinross hopes to see techniques evolve to the point where doctors can use it to develop technical skills, for example simulated keyhole surgery. In time it might be possible to visit your doctor in Second Life - although that would pose some serious ethical and practical issues, such as how can you be sure that avatar with the Gladstone bag really is your doctor.

"Maybe we could create conferences within a cell or a molecule rather than on a conventional stage," says Dr Kinross. "You're only limited by your imagination."

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