Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month, and author of the book Health Literacy from A to Z. I also produce and host this Health Literacy Out Loud podcast that focuses on many aspects of health communication, patient education, and health literacy.

Today’s guest is Dr. Linda Ciavarelli, who is a doctor of podiatric medicine and board certified specialist in primary podiatric care. With over 20 years of clinical experience, Linda honed her expertise in preventative, orthopedic, and dermatologic podiatric medicine. In addition to her clinical background, Linda is founder of Housecall VR, an innovative startup dedicated to creating virtual reality patient education. Housecall VR aims to improve health literacy and outcomes using immersive technology. Welcome, Linda!

Linda Ciavarelli: Hi, Helen. Thank you so much for having me on Health Literacy Out Loud.

Helen Osborne: I have done hundreds of podcast pisodes, and this is the first time ever that the topic is immersive technology. Tell us all, what is that term and why now?

Linda Ciavarelli: Immersive technology is also called XR. You might have heard about some of these technologies. Most people are familiar with virtual reality. That’s one of these technologies.

Virtual reality, a lot of people who are familiar with gaming know about this. There are some popular products out there. Meta has a VR headset that people use for this. Put a headset on and you are completely immersed in a world. So that’s virtual reality.

There are two other aspects to this immersive technology piece. The virtual reality, you’re fully immersed. Then there’s augmented reality. I think the best way to explain that is if you’re thinking about buying a couch from Ikea and you hold up your phone and it shows the couch in your living room, that’s augmented reality.

Helen Osborne: Okay. That is kind of eerie.

Linda Ciavarelli: Yes, that’s augmented reality. There’s a third term. It’s called mixed reality. Mixed reality is where you see the room in front of you, the actual environment, but there’s a digital overlay that is interactive on top of it. A good way to think about it is there’s a movie with Tom Cruise, The Minority Report, where he’s moving things around, That’s mixed reality. So there’s virtual reality, augmented reality, and mixed reality.

Helen Osborne: And what was the term you said in the beginning with an x in it?

Linda Ciavarelli: That’s XR. Extended reality or XR is the umbrella term over all of these. That’s the industry term for immersive technology where it covers all three of these aspects.

Helen Osborne: Okay. Why now? Why health literacy? Why your business? Tell us more. This is a new world to me. I’m old school and still write in a calendar and take notes. Tell me more.

Linda Ciavarelli: First of all, thank you again for being so curious about this. I kind of fell into it. One of my kids got one of those VR headsets for Christmas several years ago. Honest to goodness, I put this thing on and had kind of an aha moment. I said, “Oh my gosh, why can’t I use this tool to show my patients what I’m trying to tell them?” For 20 years, I’ve been treating patients with chronic disease. I see the disastrous endpoints of what can happen with chronic disease. I also understand the challenges that patients face in comprehension. This is a very complex system. Healthcare is very complex, our bodies are very complex.

It’s very difficult in the time-constrained world of practice that we have today for clinicians to not only explain what something is in a way that’s understandable, but then to make it real and actionable.

I’m always interested in finding solutions for that. I really thought that if I could just put somebody inside of their body, like magic school bus meets WebMD kind of thing, then I could helppeople better understand what’s going on in their health.

Helen Osborne: Let me see if I understand. You as a clinician have a hard time teaching and explaining something complicated. And you’re finding that your patients are having difficulty understanding what’s going on in a hidden part of their body when all kinds of physiology and anatomy is going askew.

Put this into words for us. A podcast is auditory only. I’m going to challenge you. We don’t have any of those XR tools at this moment. We have audio only. Make this real.

Linda Ciavarelli: Like i said, it’s kind of like magic school bus meets web md. I put somebody inside their body, and not in some scary complex technical way but through storytelling. It’s really narrative medicine. How can I tell a story for a patient to experience in three dimensions something that might be very, very complex and to break that down and make it an experiential understanding of what’s happening. That’s addressing the why before we address the what and the how.

In health care, in a 15-minute visit, I may not have time to really explain something in depth. So if I have a tool, that can help me do that by creating experiential understanding. An example might be what we’ve developed content around diabetes. We sort of put somebody inside the body. I’m doing air quotation marks with my fingers. It’s inside a space that represents the inside of the body in a very cartoony way.

We introduce a cell. We talk about how cells need glucose for energy and how that glucose needs to get into the cell. The way that that happens is insulin. Insulin acts like a key. So we actually have a key that is then grasped by the person by their hand. They grasp it digitally by using their handand insert it into the cell, turn the key, and allowi the glucose to go in. That’s like a very basic understanding of a very complex physiological process.

Helen Osborne: You’re also introducing a metaphor and you’re using it visually, that key. We don’t have keys in our body, unless a little kid swallowed a key. But you’re using that metaphor to show it. And then you talked about cartoons. There’s a visual component, a metaphorical one. Is there audio too? Or do you put on the glasses and what you see is what you see?

Linda Ciavarelli: There’s an audio overlay. Currently we create content in both English and Spanish. We use AI voice generation so we’ll be able to create content in any languagefairly easily. We do have humans checking, don’t worry. Always.

Helen Osborne: I am worried. You’re introducing many variables in this. You’re not on firm ground with me yet. I want you to make a case about this a little bit more.

Linda Ciavarelli: As I should. There is an interactive part of thisand this is important to know that we’re not creating things that could be done on a two-dimensional screen. I can show you a video of a lock and a key in a cartoony space. I can create that metaphor. I can have a voiceover. I can have sound. I can do all of that.

What you can’t do in a two-dimensional interface like a tablet or a phone or a video or whatever is, is to interact. We actually interact with the environment. The person actually, with their hand, reaches out, grasps this digital key and puts it into the digital lock. That’s a totally different experience from just seeing it on TV or tracking a mouse.

Helen Osborne: What if they can’t get the key in the lock or don’t get the concept? Then what? Does this AI voice try again? Or forget it and say go watch the video?

Linda Ciavarelli: We have a timed force forward. If someone can’t grasp the key, it’s not working, or for whatever reason they can’t do it, after a certain period of time, the item happens by itself. That’s also from an accessibility perspective. Let’s say someone has limited motion. We’re asking them to move. We wanted to make sure that these experiences were available to as broad a range of people as possible.

Helen Osborne: How much time do you spend explaining it? Does that person do it with you right there? Or do they do this on their own? I’m still trying to make sense of how this fits into patient education.

Linda Ciavarelli: That’s the real question, Helen. How do you create something that works in an actual workflow? That was a huge part of how we developed this. We were able to participate in an 18-month cooperative research and development agreement with the VA.

Helen Osborne: Oh, the Veterans Administration Hospital.

Linda Ciavarelli: Correct. Who incidentally is the largest user of medical immersive technology in the world.

Helen Osborne: Oh, I had no idea.

Linda Ciavarelli: It’s amazing the work that they’re doing. We were able to do deep discovery. It was six VA sites nationwide through a specific program called the Greenhouse Initiative.  What are the clinical problems? How is it clinically difficult? How is your workflow work? So could develop a product eventually that really worked in workflows and solves problems. I always want to mention that the VA in no way endorses us. It’s very important to say we did work together in a collaborative way, but it’s not an endorsement.

What it allowed us to do, Helen, was be really thoughtful about how we integrate into clinical workflow. To answer your question, the way that it works is, first, it’s completely offline. We know that a lot of hospitals and health institutions have terrible Wi-Fi. We wanted to create something that worked totally offline, there’s no login, nothing like that.

Helen Osborne: Okay, that means no login or anything.

Linda Ciavarelli: Correct. I typically would call it, say, a video and then say it’s in three dimensions, and that was fine if they agreed. Then I would move on to the next patient and my medical assistant comes into the room. The way the system works is within 30 seconds, the patient is fully immersed. That’s how long it takes for the medical assistant to fit the VR headset on and turn it on.

Helen Osborne: Do they put something on their face?

Linda Ciavarelli: Yes, yes. The VR goggles are placed onto the patient’s face and turned on. Then my medical assistant pushes two buttons on an iPad and the whole thing starts. The modules are about five minutes long.

A medical assistant sort of leaves the door open, keeps an eye on the person. Nobody’s moving around. It’s all seated. There are no controllers or anything complicated. People interact just using their hands naturally, like putting locks and keys and things like that.

Helen Osborne: For your patients, this might be the first time they’re ever experiencing something like this. I don’t know if your population are traditionally gamers who are used to doing this all day long, or might they be someone who, like me, writes an appointment in a paper calendar. Do you have new adopters who are like, “What?’ I trust my doctor. I trust this person telling me. But what in the world is this? Do they get comfortable? Are they anxious? What’s the reaction?

Linda Ciavarelli: I love that question because that was also a big concern of mine going into this. I never wanted to create something that didn’t honor the people that I’m creating it for. I wanted to create something that was meaningful for patients, not just to make cool tech.  That’s not what I’m doing.

I’ll tell a little anecdote that I think helps explain this a little. We have a current study ongoing at the University of Georgia in an uninsured population. Before that, we did some sort of A-B testing, not a study, where we had two days where we were sort of trying out some of these modules. One day was with pharmacy students. These are people in their like late 20s, early 30s. They’re ayounger population trying these modules. They thought it was cool, saying it’s interesting and I could see this working in a pharmacy, blah, blah, blah.

The next day, we invited a small cohort of less than 10 people over the age of 65 — the investigators, parents, the admin, just whoever we could sort of round up in the area that they were interested in.

Here’s what’s really amazing. During the student testing, things were pretty quiet. During the older adult testing, there was whooping and knee slapping , with comments like “oh gosh, and I can’t believe this is amazing”

That was in the older population, definitely not something that I had anticipated. It’s showing up in the research that’s happening in Georgia now, in the population of people in their 40s to 80s. A significant amount of people, like a large percentage of the people, after the VR experience say, “We want VR to teach us more.”

Helen Osborne: Wow!

Linda Ciavarelli: I know. It was really a surprise for me. We saw it across the VA. It’s just such an amazing thing.

Helen Osborne: You started off your story by saying you had your aha when one of your kids got a gift and you tried it. You had enthusiasm from the beginning. But it sounded like it was brand new to you. Like, what is this thing?

Now you’ve got people who use this kind of technology going, that’s cool. And then people who are newbies going, wow. You’ve got a lot of enthusiasm. Enthusiasm will get us pretty far. But what about the role of teaching? This podcast is all about health communication and patient education and health literacy. What are you learning about this type of technology as a tool for patient education?

Linda Ciavarelli: I’m definitely not the first person to use immersive technology or virtual reality to teach people. There’s been decades of research showing that this medium, putting people into an experience, helps people learn better. We know that. We know that humans are meant to learn experientially. To learn something by just reading it is one way. An example I like to use is the Statue of Liberty. Most people have seen an image of the Statue of Liberty before they go to actually see her. You see the image, you recognize, yes, at Statue of Liberty. Then you go and you’re on the ferry and you see Liberty Island. Maybe you go on the island. You see this enormous thing. You have a different experience after that.

Helen Osborne: Oh, you do. I’m picturing that right now. I’m on that ferry and with a granddaughter and like, oh, my goodness. Wow. Okay.

Linda Ciavarelli: and I think that’s a great way to sort of illustrate how experiential learning really redefines how we relate to things. You go back and see an image of the Statue of Liberty now and you have a different relationship to that.

We wanted to make sure that we were using best practices, using plain language, creating that standard, being at the forefront of VR patient education. We know that we’re sort of setting this standard and in that space. We wanted to be very, very sure. As part of our development, the 2019 Diabetes Educator of the Year has been a part of our team. That’sdecades of experience in patient understanding. We also have a brilliant scientist who has worked in immersive technology in behavior change as one of our people who helped us develop this. Also an artist who has decades of experience in using this technology. We are pulling from all these different places to make sure that what we develop is correct, useful, and approachable for everyone.

Helen Osborne: That’s great. It sounds like you’re cbringing in those health literacy principles, too. For almost everything in medicine, there are benefits and risks. Is there a downside to this?

Linda Ciavarelli: There are some people this is not well-suited for, such as someone with very low vision. This is largely a visual medium. I think that that might be challenging. Also, people who have active vertigo or a seizure disorder, it’s not recommended.

And that’s okay. I will say anecdotally, in the thousands of modules we’ve tested thus far, we have had two people say that they didn’t feel well and didn’t like the experience. This is much less than I would have expected. If you look at the literature, it probably should be closer to not 0.2%, but more like 2%. We’re very careful before anyone is assigned this to make sure that the clinicians understand the limitations for who should and shouldn’t have this.

Helen Osborne: That’s great. I’m thinking about when I go to Disney. I do get motion sick watching some of this type of technology. You started this because you know your patients don’t understand something. In this case, you’re talking about some principles of diabetes. Are they learning through this five-minutes of virtual reality? l

Linda Ciavarelli: Yes. can objectively say yes at this point. Before, it was more anecdotal. But looking at the early research that’s coming out of the university in an uninsured population, we see a significant increase in not only understanding, but also intent to act. That’s an early signal, specifically around medication adherence.

We have some modules on diabetes medications. A large percentage of the patients had moved from being somewhat motivated to take their medications to being extremely motivated which is really great. There’s a learning aspect, too. Again, the research is ongoing. It’s also looking back at the data on using virtual reality in patient education. You can see that there is a significant increase in understanding that’s been demonstrated through other modalities.

Helen Osborne: I’m thinking of the practical side of this, too. It sounds awesome. Is everything available. On the practical side, can clinicians or anyone access this? Is it expensive? If they are enthusiastic enough to at least give this a try or think it might work where they are, what then?

Linda Ciavarelli: As you know, adopting new technology in health care is not always easy. From a commercial perspective, the way that we put it together is a very low annual subscription fee with limited use. I made that something that I really wanted to focus on as we were developing this. I wanted to make sure that this would be available for FQHCs, libraries, and really anywhere that’s available without a huge price tag. From an integration perspective, because we don’t collect any PHI or touch the Internet.

Helen Osborne: PHI is personal health information.

Linda Ciavarelli: Correct. Protected health information. None of that is collected at this point. We really sit outside of any of those challenges within in a health care system.

The most challenging part of creating. Integrating a new technology and making sure that it’s being integrated in a way that’s not disruptive to the clinical flow. That is something that’s always been something that we want to be thoughtful about. We certainly have had success and are moving towards that in some of the pilots that we’re running.

Helen Osborne: Thank you. I’m excited about this. You said yours is not the only technology company doing this., I want listeners to be able to try it and learn more.  is there a URL or a link you might send us to do our own learning about this?

Linda Ciavarelli:  Of course. HousecallVR.com. The reason why we call it Housecall is because we really wanted to make the patient at the center. In a housecall, the patient is trulyat the center of the healthcare system. That’s a big part of how we’re designing this. We’re always happy to speak with anyone. I am excited to share these new technologies and see how they are being used for health literacy programs to bring us into the next century.

We’re moving beyond some of the more challenging ways that we’re trying to educate patients that are time intensive and may not be as effective as we want. Using these technologies is a way to make that more available to more people in a standardized way.

Helen Osborne: Linda, I’m going to be a little candid. You approached me about this topic, and I think, “Ugh, another person trying to sell me something or just wants a few minutes of podcast fame. I’m not so sure.”

Then you and I connected a bit more and had a conversation. You won me over to the point that we are doing this podcast episode. I’m impressed with your commitment to health literacy, to patient education, to action, to all those principles we’re trying to do.

You are an entrepreneur and visionary, trying to look at new tools that are available. I applaud you for that. I am so glad you’re a guest on Health Literacy Out Loud. Thank you for all you’re doing, Linda, and for initially emailing me with this great idea.

Linda Ciavarelli: Well, Helen, thank you. Thank you for the opportunity to be on here and share a little bit more about what we’re doing. I really appreciated our conversations. I feel like in a lot of ways, both of us have created something that started with an entrepreneurial spirit. It is really a deeply creative process–to make something where there wasn’t a thing before. I think that’s a great way to do so and am really glad that we connected.

Helen Osborne: I’m cheering you on. Take care, Linda

Linda Ciavarelli: Thank you so much.

Helen Osborne: As we just heard from Linda Ciavarelli, it’s important to consider the many ways of teaching, the old-school ways and the brand-new ways. But communicating in ways that all people can understand can be a challenge. For help, take a look at my book, Health Literacy from A to Z. Feel free to also explore my website, hwww.healthliteracy.com, or contact me directly at helen@healthliteracy.com. New Health Literacy Out Loud podcast interviews come out the first of every month. You can get them all for free by subscribing at www.healthliteracyoutloud.com or wherever you get your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters. Until next time, I’m Helen Osborne.

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