Walter Greenleaf: Intersecting Business and Academia to Improve XR
Faaizah Arshad and Jessica Hagen chat with Walter Greenleaf, a neuroscientist and medical technology developer at Stanford University, about the intersection between the academic and business realms in XR, and barriers that need to be addressed to improve patient care.
BIO
Dr. Greenleaf is a neuroscientist and a medical technology developer at Stanford University. With over three decades of research and product development experience in digital medicine and medical virtual reality technology, Walter is considered a leading authority in the medical XR sector. He is a Visiting Scholar at Stanford University's Virtual Human Interaction Lab and the Director of Technology Strategy at the University of Colorado National Mental Health Innovation Center. He also serves on the Science Advisory Board of several medical product companies.
Jessica Hagen
Hi, and welcome back to Psychiatry XR. I'm your host for this episode Jessica Hagen, and I'm joined by my co-host Faaizah Arshad. We're excited to welcome our guest Dr. Walter Greenleaf to the podcast. Dr. Greenleaf is a neuroscientist and medical technology developer at Stanford University with over three decades of research and product development experience in digital medicine and medical virtual reality technology. Walter is considered a leading authority in the medical XR sector. He is a visiting scholar at Stanford University's Virtual Human Interaction Lab, and the Director of Technology Strategy at the University of Colorado National Mental Health Innovation Center. He also serves on the science advisory board of several medical product companies. Walter, thank you for joining us today.
Walter Greenleaf
Hello, very excited to be here with you!
Jessica Hagen
You have been an integral part and influential person within the medical extended reality sector for some time. Can you tell me about your role in medical XR and how long you've been involved in exploring the use of immersive technology and medicine?
Walter Greenleaf
Well, sure, it's a bit hard to describe my role. I guess the phrase that I've been using lately is that I'm what is called a translational neuroscientist, meaning I work with academic groups, who are doing some of the basic research to enable some of the next generation of products that we have in behavioral medicine. I help them understand what's needed. I help them migrate what they're working on out to the commercial arena. And I work with many of the early-stage companies, what we call series A, series B in terms of their stage of financing. I help them understand both what the academic groups are bringing to the table and then also refine their product direction. I'm cross trained in both science and research, but also product development. I've had the opportunity to start several medical product companies. And then I also work to take these earlier stage companies and help them move forward and connect with the larger pharmaceutical or medical device or health care networks to really get these products out. So, it's the role is more of a activating enzyme that tries to move things forward and take it to the next level.
Jessica Hagen
Yeah, you're very much a liaison in both the academic world and the business realm of XR. So how do you balance the dialectic of being in both worlds?
Walter Greenleaf
Well, it's really, I think, in ways almost a matter of being bilingual or trilingual. All these worlds are working together to address some problems that have been haunting us as a, as a culture and as a species for a long time. We're all on the same side. And, but we don't always understand the needs, the constraints, the requirements for moving new interventions and assessments and in medicine forward. So, to me, it's just a matter of understanding the language, the perspectives, and then bringing people together. It's not really hard. It's a lot of fun, and it makes a big difference.
Jessica Hagen
And I've heard you speak at several different conferences, where you kind of drill in the importance of working together in the medical XR space and to truly make an impact on patients and researchers and businesses. So why do you think that it's important for these different sectors to work together, especially as XR is evolving?
Walter Greenleaf
That's a very good question. And there's several different answers. I do feel that at this stage of, well, first of all, in healthcare in general, we're all on the same side. But there are different investment groups, different companies that have similar products that compete with each other to, to be the dominant player in their arena. But for medical XR, it's not the case at all. It's like a unexplored continent, where we have different groups that have landed on the beach and are trying to make their way and moved what we want to do to make a difference in psychiatry, psychology, behavioral medicine, mental health care, to move it forward. And there's such an acute need and applications we're moving forward are going to make such a big difference, that I think there is more of a congruence of interest to raise awareness of the both the patients and the clinicians and reimbursement agencies and healthcare networks about the value of what we're bringing forward. And in many ways changed sort of the perspective and the culture of this part of medicine, to have people appreciate that a layer of technology can help and make a big difference as opposed to being a barrier between the clinician and the patient. I also think that we're establishing new standards, we need to come up with datasets that are unbiased that we can use in a federated manner, so that different groups can contribute to evolving large datasets for better assessments. And we can help each other so much by helping the arena grow if we find pathways to work together. And I think by and large, that is what's happening. Most of the, most of the groups that are in this area are finding ways to help each other and move everything forward.
Jessica Hagen
There's a very unique community in that regard, where people are very open to speaking with each other and learning about what the other companies are doing. And I think that's very important.
Walter Greenleaf
Let's hope we can keep that sense of community and collaboration and working together as we move forward.
Jessica Hagen
Absolutely.
Faaizah Arshad
And, Walter, what are some barriers to the competitive nature within the business realm that you see negatively impacting the XR space? Like, what are some gaps that need to be addressed?
Walter Greenleaf
Well, I think right now, part of what's holding us back is that there's not a lot of portability between different hardware platforms. If a product is developed on the Oculus Quest, and another product is developed on the HTC Vive, another product is on the Pico system. And a clinic wants to bring in these products, they don't want to have a variety of headsets, plus even if they are on the same headset, they don't necessarily have the same heuristics, the same user interface, the same data structures. So there's a lot of work of coming up with an ecosystem that allows us to move very powerful products forward in a way that makes sense. So I think that's where there's an opportunity to together establish some agreed upon standards: as we come up with new ways of measuring objective measurements of mood and cognitive functioning, as we come up with better VR enabled AR enabled challenges to to evoke a response that we can use for helping with post-traumatic stress or with phobias or with addictions. We need to have some standard shared datasets as part of how we do research in other parts of the scientific and medical arena. And our, our arena needs to establish that too. So that's one of the barriers is some technology disparities, some lack of perception by the healthcare networks as the value of our products, and then an easy way to share data and to share VR experiences that can be part of a clinical trial, for example.
Jessica Hagen
Absolutely, there's also this kind of nomenclature that needs to be established still, as far as medical XR goes.
Walter Greenleaf
That's right. You know, VR, AR, XR, MR, extended reality, medical extended reality. There's a number of terms and then within that some sort of sub terms that still floating around. So that's one good spot for us to start.
Faaizah Arshad
And you talked about building that ecosystem and making sure that we have agreed upon standards. How would you suggest clinicians work with industry folks to improve the value of XR in patient care and to really build that ecosystem? Who do you see as being important stakeholders? For example, clinicians?
Walter Greenleaf
Well, I think I think everybody is required to contribute to the dialogue, we need to hear what the full stack of people who are providing care— if a clinic owner or clinic manager says we're bringing this new technology, and they don't get feedback from the people who are actually deploying it with the patients about how it's going to impact, if it causes them to need to stay later at night, or who's going to charge the batteries. So it really needs to be everybody who's being impacted by the implementation of the technology, including in a hospital, the people that are involved in IT, and making sure that the data is secure and that any systems that are on the network or are not going to open up a breach and provide access to it patient information. We also need to, of course, understand the patients. And we need to understand the payers. We need to have everybody contribute to this dialogue. And I think one thing that we do need to pay special attention to is, as we start coming up with these normative data sets of both evocative environments that might be used to evoke cognitive states and, and come up with a way of assessment, we need to make sure they're culturally diverse, age appropriate and, and more than culturally diverse, also, cognitive function diverse. We need to come up with a large library of, of systems that can be used in a standardized way for clinical trials and for measuring patient progress. So there's many things that needs to be done. The good news is there's already, a lot of the building blocks are there. We just need to sort of have a dialogue of how to describe them, how to share them, and how to position them.
Faaizah Arshad
Since this is Psychiatry, XR, what do you see as being the primary purpose of psychiatrists in this realm? How can they really contribute to being helpful in improving extended reality for patient care?
Walter Greenleaf
Oh, in so many ways, we need to understand how they feel, what we think will be useful to them really is, what makes it useful for them in terms of both extending their reach so they can help people when they're not in the clinic. We need to understand what is valuable to them in terms of a report about the use of the technology, what is extraneous information, what is a time saver, and what is a time consumer. And what, what is the economic impact of bringing technology into their practice. Will it be revenue neutral, will it cause them to need to invest both time and resources to get it going. But after that it moves forward and in a positive way. And how will it impact their particular sector of care. There's so many different indications that they're addressing. And we may have something that would help with what we think is a particular group of patients, but there's different subtypes within that. And again, culturally, we need to make sure that we're not excluding anyone by having something that is not appropriate for them culturally. And also, we need to make sure we keep the patients safe, that if we're, for example, treating post-traumatic stress using a virtual environment to do exposure therapy, that we give the clinicians enough control and viewpoints on what's going on, so that they can use these very powerful tools for exposure in a way that is under their control and safe for the patient. So there's, but these dialogues aren't hard to have, but we need to have.
Faaizah Arshad
Yeah, and I think what you're also referring to is that there's so many important lessons that we can learn from the different subgroups that are involved in medical XR. And so what are some of those lessons that you think we should be taking away? Or, in other words, where do you see the most promise for immersive technologies in patient care?
Walter Greenleaf
In the field of psychiatry, I feel that one of the things that XR will bring is more objective measurements. All too often when we're providing a therapy and might be a medication for example, we, we ask the patient to self-report on how they're doing or how did they do last week and that's there's a problem with recall, there's a problem with really assessing your own feelings and describing them accurately. And then there's maybe people who are symptom magnifying or symptom minimizing so the more we can use, the technology we, we bring to come up with more objective, reproducible evaluations, it gives a roadmap to the clinician to help make choices of care and manage progress. I think the other thing that we can, we can bring to the field that, in addition to more objective measurements is more effective tools to allow a clinician to teach skills to their patients. If we can evoke a mood, we can evoke a cognitive state, we can teach the patient through cognitive behavioral therapy and other approaches, how to manage that response to a trigger. So we have a very powerful way for them to go beyond just asking the patient to imagine how to respond to a situation. We can give them a an arena where they can practice that, and practice it on their own as homework and then come back and practice it with the clinicians guide. So we're giving them new tools beyond just conversation and prescription writing, to make and recommending cognitive behavioral therapy approaches to really impact the patient and to record their progress. I think the other thing that we can do, and we're still have a lot of work to make this fully functional, is we can identify different bio types. If you're teen depression, or you're treating anxiety or you're treating any of the serious mental illnesses, within that diagnosis there's different subpopulations who will respond differently to different approaches. And identifying which subpopulation a patient may be in can save a lot of time, a lot of effort and make it more likely to have a successful outcome. And we're starting to be able to do that with the use of wearable sensors, machine learning and analytics and using VR as a evocative and response measuring environment.
Jessica Hagen
So as you brought up, there's a lot of different aspects within technology that are expanding as far as wearables. And you know, AI is really making an impact in the healthcare space as far as data collection and data analytics go. There's a lot of talk about the metaverse and how this is going to affect, you know, society in general. And what are your thoughts on the metaverse, and how do you think that medical XR kind of fits into that idea?
Walter Greenleaf
Well, when it comes to the metaverse, we need to see beyond the name, the term and all the hype behind it. In many ways, we've had a metaverse in various forms for a long time. What is new and what is exciting is that, that concept of having us have a presence in a shared virtual environment. All too often, especially in the clinical virtual environments, it’s sort of a lonely experience, it's you doing something and interacting with something, but you often don't have a third person view of yourself, and also, where's everybody else? And I think what's going to come out of this excitement about the metaverse as, as it becomes more of a social platform, more as a way for people to work to have a meeting as an avatar instead of a zoom call video call. It's going to allow us to have better avatars in behavioral medicine. What's missing right now in behavioral medicine is shared virtual environments where if we do have a shared virtual environment, now, people tend to be robotic. They don't have facial expressions, they don't have great body language nonverbal communication, we can’t easily hug another avatar, we can’t easily shake hands with another avatar. Or if we're in a group of people in a virtual world talking and somebody else walks up to join our conversation. We automatically as humans, adjust our position to welcome them to the group or if we're, for some reason, don't want to welcome into the group we signal that too non-verbally. Our avatars don't have any of that nonverbal communication right now and that's such an important part of conveying emotional state, conveying community and togetherness or not. And we just don't have that. So I think what the metaverse will bring to psychiatry, psychology, behavioral medicine in general is better, better avatars, better nonverbal communication, as part of those avatars and more richer communities to do things in, which is the platform for healthcare.
Jessica Hagen
Sounds like you see a lot of promise in it. Do you see drawbacks? Are there things that you think people need to be careful as they develop this Metaverse to really take into consideration as far as behavioral health goes?
Walter Greenleaf
In general, I worry about having a monoculture, having things being sort of homogenized or having things be not accessible. I think we need to design for providing access to people with disabilities, as we build the metaverse. We need to make sure that people are safe in the metaverse not in a position to be harassed. It's just like any community. We need to make sure that we're designing it the right way and looking out for it. You know, it's going to be wonderful for the field of psychiatry to be able to take our behavior in a virtual environment as a measurement of how we're doing, cognitively and emotionally. It's also, though, going to be easier for companies that want to sell us things, for companies that want to, governments that might want to identify the radicals within their, their populace, to exploit the affordances we're gaining by having affective computing, where we study the emotions that are presented by our behavior in these virtual environments. That can be used for really-amazing things to improve healthcare. It can also be used in a deleterious ways. So I think we need to get ahead of it and come up with the right guidelines for proper use of this technology, because it is very easy to come up with a score for someone's skills aptitudes, but also their challenges and their weak points and how does, how to exploit them. And so we need to make sure that we are very careful about this very rich data, we will be able to harvest by the building the metaverse. And again, I think in our field, looking at psychiatry, we're going to be able to really do much more precision medicine. But let's just hope it doesn't allow other people to do precision exploitation.
Faaizah Arshad
I'm curious to know how you would like to see XR being used in psychiatric care, say 20 years from now. And what we need to do to solve, what what do we need to solve to get there?
Walter Greenleaf
Well, I think what would be ideal is if we can have a way for people to understand themselves and understand the people that are part of their system, and look out for each other right from the very beginning. Using these motifs of the metaverse for people to learn social emotional skills, learn how to do emotional first aid to our friends, have it be a way where we can choose to express our strengths and maybe be aware of our weaknesses. So I guess this I would put in the side of health and wellness and preventative medicine, for stress, anxiety, etc., then I would also love more for people when they do have a problem, to be able to have the tools that a clinician or a coach or an advisor can use to help them again understand more about themselves and to to be successful. And again, I hope we're able to do a good job with designing for disabilities and not just physical disabilities and impairments, but also cognitive ones so that people who have different learning styles, different approaches to issues who maybe need to work on a problem like anger management, where we can give them the tools to get help and to maybe do some self self care too in these arrangements. So you know, I think there's great potential. But again, we're designing the metaverse now, so we have to look downstream to decide where we want to be and build around that foundation.
Jessica Hagen
Walter thank you so much for your insight today. Is there anything else that you'd like to share with our listeners?
Walter Greenleaf
I guess I would ask your, your listeners to identify what they feel is both the most exciting aspect of this technology and what's the most worrisome, and then talk to the people who are building these environments about your concerns and about your excitement. I think that's really what's going to make this a wonderful arena is if we can make sure that the people who are building it, hear from the people who will be using it, the clinicians and also the patients. So I think the more we can just have conversations like this, the better.
Jessica Hagen
Thank you again for your time. We very much appreciate it.
Walter Greenleaf
It’s been wonderful to have this conversation with you. Thank you.
Jessica Hagen
That's it for this episode of Psychiatry XR we hope you gained a new perspective on using extended reality in health care and thanks for listening. This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology in mental health. For more information about Psychiatry XR, visit our website at www.psychiatryxr.com. Be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR use in psychiatric care. You can join us monthly on Apple Podcast, Twitter, Spotify or wherever you get your podcasts. Psychiatry XR was produced by Dr. Kim Bullock, Faaizah Arshad, and myself Jessica Hagen. Please note this podcast is distinct from Dr. Bullock’s clinica,l teaching, and research roles at Stanford University. The information provided is not medical advice and should not be considered or taken as a replacement for medical advice. A big thanks to Austin Hagen for music and audio production. See you next time.
The following is a transcript of the episode: