key: cord- -j b y a authors: cooley, laura title: fostering human connection in the covid- virtual health care realm date: - - journal: nejm catal innov care deliv doi: . /cat. . sha: doc_id: cord_uid: j b y a as telehealth becomes more mainstream, finding ways to add compassion and understanding to your communications with patients and colleagues is increasingly important. here are some evidence-based, relationship-centered tips for enhancing these virtual encounters. in a single day -a -fold increase over its baseline rate. other health systems have noted similar rises. most health care providers and patients have had limited experience with, or preparation for, telehealth encounters. so they are collectively facing communication challenges during the transition from in-person to virtual visits or consultations. the quality of experience in telehealth encounters can be hampered by: ) the inability to engage in usual nonverbal social behaviors, such as handshakes/fist bumps, leaning in, and facial cues, ) difficulties in gathering accurate information without a physical exam, and ) the sense of disconnect and distraction created by technology, such as diminished sense of authentic personal interaction, glitches with video, sound, or internet connectivity, or other distractions like emails on the screen. these barriers during virtual visits compound the existing obstacles to interpersonal interactions, such as cultural and language differences between the parties or clinicians reviewing and updating the electronic health record during appointments. in addition, having providers now virtually enter patients' homes to conduct telehealth visits raises privacy concerns if the patient lives in a communal situation, as well as the possibility that an environment of domestic violence can negatively influence an encounter. on the other hand, patients before covid- generally reported overall satisfaction with telehealth experiences, and recent reports indicate those positive perceptions have continued. patients cite the ease with which they can discuss personal problems when mediated by technology. in addition, these virtual "home visits" allow patients to avoid traveling to a clinical setting or waiting there with frustration for a provider who runs late. they can also give clinicians a window into their patients' home environment -and potentially helpful clues about the social determinants influencing their physical and emotional health. human connection is vital to patient-provider relationships. research suggests that conveying empathy and understanding of a patient's health beliefs and values enhances the patient experience and may lead to better clinical outcomes, due to increased patient adherence to providers' recommended treatment plans. despite some barriers, empathy remains viable in virtual communication. for example, lloyd b. minor, dean of the stanford university school of medicine, describes how emergency medicine clinicians have used computer tablets to video conference with patients grappling with covid- : "our physicians report that as they've used the ipads, they've been able to bring empathy back to the bedside. many found that being encased in ppe severely constrained their ability to build trust and rapport with patients. meeting virtually has enabled them to strip away these layers, creating space for empathy at a time when it is needed most." when participants discuss the personal and professional toll that covid- has taken on individuals and the team, these huddles can deepen connections and thereby enhance work." covid- distancing requirements have also accelerated the adoption of interactive digital tools to facilitate team connections, including the use of video conferencing and online discussion forums. health care organizations hold virtual q&a sessions to exchange up-to-date covid- information with staff. in addition, team huddles in some primary care settings, previously held in person, have restarted over virtual media. when participants discuss the personal and professional toll that covid- has taken on individuals and the team, these huddles can deepen connections and thereby enhance work. peer support groups are also happening online. for example, the anesthesia department at ucsf provides weekly virtual support sessions via zoom conferencing software for faculty and trainees to share concerns, emotions, and experiences. given the challenges of electronics-enabled communications, here are some tips for increasing personal connection in your virtual encounters by video or phone. they are based on relationshipcentered communication skill sets published by the academy of communication in healthcare. (table ) . uncertainty, fear, grief, and mistrust are exacerbated during times of societal crisis, such as the covid- pandemic. since psychological disorders are linked to an increased risk for poor health and performance outcomes, paying attention to the emotional well-being of patients and colleagues is more important than ever. be "present": prepare for your virtual encounters to ensure the quality of your technical and interpersonal connections. for video meetings, paying attention to your camera set-up, background appearance, ambient noise, and lighting can influence the other person's perception of trust and comfort. pause to collect your thoughts before entering the virtual space. when we offer brief introductions (or re-introductions) and establish rapport at the beginning of telehealth encounters, we build a foundation for stronger relationships. use open-ended questions, such as "you scheduled this visit because of xyz, what else would you like to discuss today?" to encourage more meaningful conversations. although patients may schedule a telehealth visit for an explicit reason, they may actually have multiple needs, some of which they may be hesitant to express immediately. clinicians often fail to elicit a list of concerns at the outset, leading to late-arising issues and wasted time during the encounter. in either patient-facing or team-based meetings, when we invite others to share ideas and expectations up front, we are more likely to address their most salient needs. listen: listen carefully, avoid interrupting, and pay attention to emotional cues. clinicians often interrupt patients very early in encounters. virtual sessions present added distractions, such as emails, texts, or even family members, and they intensify the need to listen carefully. attentive listening allows for better diagnostic assessment of the person's concerns and explicitly demonstrates nonverbal respect. noticing emotional cues, such as non-verbal indicators (sighs, tears, raised voice, etc.) and words or stories that represent feelings, gives you the opportunity to respond with more accuracy and compassion. respond with empathy: listening attentively, as described above, prepares us to respond empathically to both the content and emotion expressed in the virtual encounter. provide a short summary, briefly name the emotion, and offer a supportive statement to help establish a strong human connection. demonstrating empathy can actually save time by acknowledging the emotion and validating the other person, thereby enabling a more productive conversation. share information: make sure your patient or colleague understands the material you're conveying. the combination of physical distance and non-verbal communication barriers inherent in telehealth heightens the importance of clear information sharing. clinicians often use medical jargon without checking on patients' understanding. technology glitches, such as frozen video streaming or muted audio, may also interfere with delivering information during the encounter. pausing to ask questions can maximize understanding, which leads to better outcomes for both patients and health care teams. the human element of an in-person health care encounter cannot be fully replaced by a virtual one. after all, a provider's gentle (and appropriate) touch can sometimes convey empathy in a way that words cannot. however, identifying and improving one's skills for engaging in meaningful virtual " communications with patients and colleagues can help ensure that human connection prospers in the midst of, and beyond, the changes wrought by the covid- pandemic. senior director, education and outreach, academy of communication in healthcare, nashville, tennessee disclosure:: laura cooley is employed by the academy of communication in healthcare, a (c) ( ) academic organization that provides communication education resources. covid- and health care's digital revolution health resources & services administration (hrsa) helping hospitals deliver cost-effective care. american hospital association issue brief pandemic creates opportunity for telehealth to catch on, wbur news dean of stanford medicine: how virtual care can make medicine even more human the transition from reimagining to recreating health care is now tele-trust: what is telemedicine's impact on the physician-patient relationship? telemedicine transforms response to covid- pandemic in disease epicenter. sciencedaily. nyu langone health / nyu school of medicine tele-trust: what is telemedicine's impact on the physician-patient relationship? human connections and their roles in the occupational well-being of healthcare professionals: a study on loneliness and empathy healthcare providers versus patients' understanding of health beliefs and values medicine: how virtual care can make medicine even more human free tools to help you through the coronavirus pandemic online learning during covid- : tips to help med students succeed american academy of family physicians caring for our caregivers during covid- covid- : video on quick tips to connect. academy of communication in healthcare mental disorders as risk factors: assessing the evidence for the global burden of disease study the closing moments of the medical visit soliciting the patient's agenda: have we improved? clues to patients' explanations and concerns about their illnesses. a call for active listening a study of patient clues and physician responses in primary care and surgical settings communication rx: transforming healthcare through relationship-centered communication key: cord- -kap tdiy authors: srinivasan, malathi; phadke, anuradha jayant; zulman, donna; israni, sonoo thadaney; madill, evan samuel; savage, thomas robert; downing, norman lance; nelligan, ian; artandi, maja; sharp, christopher title: enhancing patient engagement during virtual care: a conceptual model and rapid implementation at an academic medical center date: - - journal: nejm catal innov care deliv doi: . /cat. . sha: doc_id: cord_uid: kap tdiy stanford healthcare shares the lessons learned during its rapid deployment of virtual visits during the covid- pandemic. stanford primary care and population health clinics comprise thirteen clinical groups including general primary care, senior care, urgent care, employer-based clinics, concierge medicine, and coordinated care. during the first two months of virtual health roll-out, our stanford primary care providers conducted over , video and , telephone visits. virtual health encompassed virtual visits and all of the clinical activities surrounding the clinical care which were no longer conducted in person. within four weeks after initiating the virtual health program, we conducted more than interviews with staff and providers (physicians, advanced practice providers, medical assistants [mas] ) in stanford primary care to understand their experiences around virtual health. despite high provider and patient satisfaction, technical limitations and system readiness challenges hindered visit quality, and from the provider viewpoint, left some patients unprepared for virtual visits. providers observed that patients with cognitive impairment, language barriers, or technology access concerns experienced disproportionate challenges. providers struggled with platform connectivity, the provider-directed patient self-exam, and establishing an emotional connection with patients. some medical assistants (mas) felt unfulfilled, with less direct patient contact. providers observed that patients with cognitive impairment, language barriers, or technology access concerns experienced disproportionate challenges. providers struggled with platform connectivity, the provider-directed patient self-exam, and establishing an emotional connection with patients." the next six weeks saw a period of creativity, led by clinic mas who spontaneously formed improvement teams to address identified challenges. these were later brought together centrally to coordinate clinic improvement efforts. at ten weeks, we surveyed all primary care providers system-wide to identify general issues relating to provider burnout. we re-conceptualized our engagement strategy and identified new areas for growth. the virtual health program delivered extremely variable quality of care, for several reasons. in virtual health, more responsibility is placed on patients to prepare for the visit, to examine themselves and to generate their own health data, while providers are expected to make sound decisions with a very different set of data. given the circumstances of the transition, many patients became highly activated, whereas others were left behind. our prior systems were optimized for in-person care, and were not as suitable for virtual health care delivery. several factors were difficult or in some cases impossible to adapt to virtual health. in-person visits relied on our medical staff to obtain in-person patient updates, vital signs, and " perform detailed follow-up. patients had time to prepare for their visits while in the waiting area, center, and develop their visit agenda. provider exams, routine imaging and procedures occurred immediately on-site. rapid, direct communication around patient encounters by providers and medical assistants enhanced care follow-up and continuity, while informal face-to-face communication with colleagues and specialists supported clinical decision-making. we developed a virtual health patient engagement model that incorporated principles of the nam quintuple aim, which evolved from the nam triple aim (quality of care, cost, patient experience) to include patient equity and inclusion, and prevention of provider burnout. drawing from the wellmd model, we considered factors to support patient engagement in virtual health, including system/technology support, support by clinical teams, and customized support for self-care ( figure ). a foundational step to building the infrastructure for virtual health was to convert key elements of the in-person visit to the virtual experience. this included developing processes for virtual rooming, virtual waiting room, virtual visit, virtual check-out, and continuous virtual care & support ( figure ). providers and mas quickly recognized that many patients were unprepared for their video visit. at several primary care sites, care teams met to develop and pilot independent solutions for pre-visit preparation. mas experimented with virtual rooming strategies, depending on their resources, ranging from low touch (secure patient portal message with written rooming questions/screenings) to medium touch ( - minutes phone calls with chief complaint and health maintenance review) to high touch ( -minute phone or video visits for comprehensive agenda setting, health maintenance review, behavioral health screening, and medication review). after three weeks of experimentation, mas and clinic leadership had division-wide meetings to share and adopt best practices and develop new workflows around health maintenance (hedis and mips measures). two weeks later, about % of patients had a virtual rooming visit with a ma. providers reported that patients undergoing virtual rooming were generally more prepared for and more engaged in their video visit. patients were asked to log on to the patient video portal - minutes in advance of their provider visit, to ensure that they didn't have videovisit access problems, to verify medications, and to help the clinic keep running on schedule. when patients logged on, they could complete questionnaires, prepare for their visit, or watch videos related to their health (chf only, at this writing, with expansion plans). based on provider/patient feedback, we have begun plans for an interactive virtual clinic platform to maximize the utility of this waiting time. teams were concerned that critical issues in scheduling/follow-up would fall through the cracks with virtual health implementation. employer-based clinics and coordinated care recognized that many patients did not want to discuss health maintenance when they had acute issues. to address this gap, mas called patients after video visits to help with scheduling procedures and labs, and also conducted appropriate health maintenance screening for depression, tobacco cessation, and more. positives screens in the after-visit setting triggered actions such as behavioral health follow-up. mas called patients after video visits to help with scheduling procedures and labs, and also conducted appropriate health maintenance screening for depression, tobacco cessation, and more." during program evaluation, providers reported wide variation with establishing patient rapport and conducting the virtual physical examination. two education teams began working on engagement and physical examination best practices. to help providers achieve meaningful connection with virtual health patients, the stanford presence group developed and distributed five best practices for telepresence communication : • prepare with intention (pause, refresh, focus, prepare) " • listen intently and completely (remain visible on screen, lean in, maintain eye contact, communicate through facial expressions, avoid interruptions) • agree on what matters most (establish a virtual visit agenda, incorporate patient priorities/ goals) • connect with the patient's story (engage virtually with the patient's home environment and social support) • explore emotional cues (look for/validate emotional cues in facial expressions, body language, changes in verbal tone/volume). the provider-directed patient self-exam recast the patient's role from examinee to both examiner and examinee. "exam coach" was added to the provider's role. based on provider feedback, we developed "practical tips" videos for the most useful outpatient problem-focused examination sets, including: • common concerns: upper respiratory tract infection, shoulder pain, back pain, knee pain, • critical conditions: screening stroke exam, congestive heart failure/cardiovascular exam, pulmonary exam • sensitive examinations: male and female genitourinary exams. an initial video to teach providers how to coach self-exams on upper respiratory tract, low back pain and shoulder pain was viewed , times on youtube within a few weeks. research has begun on validating these measures, and developing additional exam videos for both providers and patients. to address the need for targeted support for patient self-care, including education and integrated home monitoring, we developed and have begun to build out the following resources. over two months, we strengthened the virtual support programs that provided longitudinal health monitoring and support for goals of care. we launched a digital lending library to send internet of things (iot) devices to appropriate patients, allowing for home-monitoring of parameters such as blood pressure, weight, and pulse, with these data streamed to our electronic health record system (ehr). we have several hundred devices available, funded by grants. technology/ai-enabled care within a month of launching virtual health, several care teams converted their in-person programs to virtual programs, adding new offerings to support self-care. chronic disease management and group education teams converted existing diabetes, weight management, intensive behavioral health, and depression programs to virtual programs, adding both group classes and one-on-one support. psychologists at one site offered new virtual support groups for stress management. to address covid- health concerns, we provided advanced care planning large (> person) and small ( person) group classes. in the two months since near universal virtual health program implementation at stanford, we developed new models and processes to drive patient engagement in the virtual setting. central to our implementation was a combination of individual program innovation, robust rapid program evaluation, centralized program development, and a willingness to foster creativity at every level. this transformation took thousands of hours to develop and hundreds of people to deploy, and, we hope, has positively impacted our larger community. while we believe that elements of virtual health are here to stay, virtual health has not yet been proven to achieve the quintuple aim, including improving equity in care, promoting joy in practice, and bending the cost curve." we are still building out our virtual health programs. the future of post-pandemic virtual health is unclear. while we believe that elements of virtual health are here to stay, virtual health has not yet been proven to achieve the quintuple aim, including improving equity in care, promoting joy in practice, and bending the cost curve. during this rapid program growth, we learned valuable lessons which will inform our future work in virtual health. • equity and justice as core virtual health principles:while virtual health may increase health care access for many patients, it may exacerbate equity-related issues for those with limited access to advanced technologies or limited technology literacy. we should carefully evaluate the technology gap in our patient populations and augment with alternatives where needed. for example, some patients may not have smartphones, but may still be able to interact with care teams via sms. • rapid evaluation, rapid change: rapid qualitative assessment was critical to making mid-course corrections, to gain a deeper understanding of participant experiences. to do so, we used highefficiency qualitative evaluation rather than traditional longer form qualitative evaluation. • change-makers as interviewers: unlike traditional third-party qualitative interviews, many interviewers were qualitative research trained faculty who were involved in program development and implementation. for instance, population health leads heard firsthand about mas' concerns regarding their lack of patient contact. in response, they expanded the virtual rooming project to increase high quality interactions between patients and mas. • empowering creativity: improving patient engagement was not a "top down" process: all individuals within the health system were encouraged to innovate, in a coordinated manner. for instance, each clinic experimented with ways to address patient needs for visit preparation, layering on additional components as new needs emerged. • highest level of the license: the foundation of many health systems, including ours, is medical assistants. , these well-trained, compassionate personnel are often overlooked as sources of innovation. yet, their deep connection to patients, and understanding as a bridge between patients and providers gives them a unique vantage point as innovators. for instance, the technology access program start began as one bilingual ma reached out to help her spanish language patients navigate the virtual health app and ensure their comfort with the technology. • patient as partner: patient engagement is critical to the success of health care endeavors to improve quality of care. - with the initial press of virtual health implementation behind us, we can now partner more deeply with patients and our existing patient advisory groups to develop and test future engagement strategies. while devastating, the covid- pandemic has created an opportunity to re-think the very core of care delivery. the future of health care will likely involve a balance of in-person and virtual care, with the integration and strategic use of different technologies playing a vital role. , as the health care community collectively innovates, we are asking fundamental questions regarding the way in which we practice medicine. we are considering what patients really need from our health care system, the role of the clinical encounter, and the unique advantages/issues of providing care in the digital sphere. while these questions may not be fully answerable now, if virtual health is to be a significant part of post-pandemic health care, we need to begin to address these issues from the patient's perspective. rapid system transformation to more than % primary care video visits within three weeks at stanford: response to public safety crisis during a pandemic virtually perfect? telemedicine for covid- engaging patients to improve quality of care: a systematic review tele-presence : a ritual of connection for virtual visits -stanford center for continuing medical education -continuing education (ce) addressing equity in telemedicine for chronic disease management during the covid- pandemic comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the veterans health administration the expanding role of the medical assistant. pop health mat new roles for medical assistants in innovative primary care practices a multilevel analysis of patient engagement and patient-reported outcomes in primary care practices of accountable care organizations the association between patient engagement hit functionalities and quality of care: does more mean better? what the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs rapidly converting to "virtual practices": outpatient care in the era of covid- key: cord- -f uf kvf authors: demaria, lauren n.; tran, ann q.; tooley, andrea a.; lisman, richard d.; belinsky, irina; kim, eleanore t. title: oculoplastics education in the coronavirus pandemic with virtual suturing curriculum date: - - journal: ophthalmic plast reconstr surg doi: . /iop. sha: doc_id: cord_uid: f uf kvf nan ophthalmology training has been critically affected by the covid- pandemic, particularly in new york city. with elective surgical cases canceled, clinics closed, and residents re-deployed, residency programs in surgical specialties have redirected their educational focus to virtual platforms to maintain surgical confidence amongst residents. virtual education has permeated every facet of the residency experience. telemedicine and teleconferencing have been rapidly adapted by ophthalmology departments to maintain a high level of patient care and residency education during the crisis. resident lectures, grand rounds, journal clubs, and departmental and nationwide conferences have transitioned to virtual meetings via zoom (zoom video communications, inc, san jose, ca, u.s.a.) or cisco webex (san jose, ca, u.s.a.) video conferencing. virtual wet lab curriculums have been created, and virtual reality surgical simulators utilized. alternative methods of oculoplastic surgical training have also been developed in the pandemic setting. notably, the department of ophthalmology and visual sciences of the chinese university of hong kong created surgical simulations using goat eyes with eyelids, incorporating hands-on practice with individualized supervision for trainees. in order to provide our residents with suturing experience during the pandemic, the oculoplastics team at new york university created a virtual suture training wet lab curriculum; this didactic incorporates elements of the in-person suturing didactics at bascom palmer eye institute. a flipped classroom methodology was utilized. prior to the first suturing session, our pgy- ophthalmology residents were provided pre-work consisting of review of an introductory powerpoint presentation with surgical videos on basic suture techniques (simple interrupted, buried, running, running locking, horizontal mattress, vertical mattress). residents were provided a home suture kit that included a -blade, . mm toothed forceps, castroviejo needle holder, wescott scissors, - nylon sutures, and foam boards. raw chicken breasts with skin were individually purchased by the residents to approximate eyelid skin. the residents had two virtual training sessions which included group discussion and wet lab breakout rooms with a : or : attending to resident ratio using the zoom video platform. the residents prepared their personal surgical station with the above instruments and focused the video camera of their smartphone or tablet on either themselves during group discussions or on their chicken breasts during the wet lab. the oculoplastics attendings ensured clear visualization of the residents' hands and chicken prior to commencing each break-out session. the residents were encouraged to practice at home in between sessions and in preparation for the final performance evaluation. an optional virtual suturing office hour was provided for residents who missed any of the suturing sessions or who desired additional instruction. residents were given a survey regarding their subjective comfort level, knowledge, anxiety, and efficiency in performing suture techniques, as well as the effectiveness of the virtual training structure. residents were additionally graded on suturing technique prior to instruction and at the final performance evaluation (table) overall surgical confidence faculty members of the new york university ophthalmology department; the resident with the highest point total received recognition. the effectiveness of the virtual suture course will be assessed by the improvement in the residents' objective performance as well as their subjective confidence in independently repairing eyelid lacerations using basic suture techniques. also, the level of comfort of the oculoplastics team in continuing as virtual surgical instructors will be considered. our introductory experience with virtual wet labs has shown that virtual suture instruction can be an effective and viable mode of oculoplastics education for junior residents mastering basic suturing techniques. similar to other novel methods of virtual education for residents, we foresee the utility of this platform in our residency curriculum beyond the pandemic. extenuating circumstances have pushed residency programs to use flexibility and innovation to create new curricula. virtual surgical education in oculoplastics and ophthalmology has the potential to enhance existing modes of surgical training for residents. our hope is that residency programs will be encouraged to utilize virtual surgical training in ophthalmology education in this new era of telehealth. virtual surgical training during covid- : operating room simulation platforms accessible from home virtual learning during the covid- pandemic: a disruptive technology in graduate medical education academic ophthalmology training during and after the covid- pandemic oculoplastic surgery practice during the covid- novel coronavirus pandemic: experience sharing from hong kong this research was supported by the nyu research to prevent blindness grant.the authors have no financial or conflicts of interest to disclose.the authors alone are responsible for the content and writing of the article. key: cord- -gud dow authors: kalpokas, ignas title: problematising reality: the promises and perils of synthetic media date: - - journal: sn soc sci doi: . /s - - - sha: doc_id: cord_uid: gud dow this commentary article focuses on the emergence of synthetic media—computer-generated content that is created by employing artificial intelligence (ai) technologies. it discusses three of the most notable current forms of this emerging form of content: deepfakes, virtual influencers, and augmented and virtual reality (collectively known as extended reality). their key features are introduced, and the main challenges and opportunities associated with the technologies are analysed. in all cases, a crucial change is underway: reality (or, at least, the perception thereof) is seen as increasingly less stable, and potential for manipulation is on the rise. in fact, it transpires that personalisation of (perceived) reality is the likely outcome, with increasing societal fragmentation as a result. mediatisation is used as a broad-ranging metatheory that explains the permeation by media of everyday affairs to explain the degree of impact that synthetic media have on the society. in this context, it is suggested that we search for new and alternative criteria for reality that would be capable of accounting for the changing nature of agency and impact in today’s world. for assessing the reality of objects and phenomena still hold and whether reality in the general sense must be reconsidered. adopting a perspective tentatively affirmative of such a switch, this article explores ways in which the new, synthetic, media can affect human thinking and behaviour without dealing with anything conventionally real. although the assertion that the media now play an increasingly central role in everyday life has become ubiquitous, the changing nature of the media themselves is commonly overlooked. while discussions would often focus on issues of framing, misrepresentation, or underrepresentation, it is becoming crucial to also focus on the media's generative capacity. the latter refers to the capacity to create synthetic likenesses, personalities, and entire environments solely by way of digital technologies. therefore, the reality we experience and use as a baseline for future decisions and life plans can easily have no physical counterpart and might be even unique to our own personal experience. to provide at least a tentative account of the transformations pertaining to synthetic media, mediatisation theory is briefly overviewed as a metatheory for conceptualising the media's growing influence. the analysis then focuses on synthetic media, first engaging with the capacity to create synthetic likenesses (deepfakes), then moving onto synthetic personalities (virtual influencers) and synthetic worlds (extended reality). this article thereby demonstrates the growing challenges faced by traditional accounts of reality that are biased in favour of physical tangibility. the contention is that the reality of something must, instead, be measured primarily through affective capacity. according to an influential definition, mediatisation refers to the condition whence the media 'have become an integral part of other institutions' operations, while they also have achieved a degree of self-determination and authority that forces other institutions […] to submit to their logic' (hjarvard , p. ) . the matter here is, essentially, one of the media's ever-presence, permeating 'all aspects of private, social, political, cultural, and economic life, from the micro (individual) to the meso (organisational) to the macro (societal) level' (giaxoglou and döveling , p. ). in the same vein, the social world of today is 'changed in its dynamics and structure by the role that media continuously (indeed recursively) play in its construction' (couldry and hepp , p. ). hence, the media no longer mediate between the world and the experience of it but increasingly generate that experience. simultaneously, while previously individuals were confined to their physical location, now one can be immersed in a number of digital worlds and interact with a number of individuals regardless of distance (couldry and hepp , p. ) . likewise, the media must be seen as constituting 'a realm of shared experience' by offering 'a continuous presentation and interpretation of "the way things are"' and thereby contributing to 'the development of a sense of identity and of community' (hjarvard , p. ) , thereby determining the functioning of social relations (nowak-teter , p. ). of course, the media have always played a community-building and community-integrating role. however, the key difference is this: while previously the media used to perform a somewhat supplementary role, building onto the 'real' world and conveying or explaining it, with varying degrees of fidelity, the current condition is characterised by the media hosting and creating the world that they purport to merely represent (kalpokas et al. ) . no less importantly, mediatisation also implies a certain delegation of agency as 'collectivities [are] created by automated calculation based on the "digital traces" that individuals leave online' (couldry and hepp , p. ) . in this sense, as boler and davis ( , pp. - ) assert, algorithms inherent in today's dominant media platforms 'define the spaces of our information encounters, encounters with others, and the status of knowledge'. simultaneously, attention becomes the scarcest of resources-individuals simply no longer have sufficient means to pay enough of it (citton , p. ) . when coupled with algorithmic analysis of trends and user behaviour, attention becomes its own magnet: 'attention attracts attention', i.e. the more people interact with a digital object, the more it rises in the algorithmic pecking order, thereby becoming more visible to others; therefore, even 'looking at an object represents a labour which increases the value of that object', leaving pleasure and labour inextricably entwined (citton , pp. - , ) . it then also becomes obvious that whatever maximises audience attention, becomes an attractive proposition for content providers-audience captivation becomes more important than truthfulness, 'reality' in the conventional sense of the term, or any other considerations (kalpokas ) . that also implies a great degree of malleability and adaptability of the social world, as strict adherence to the tangible no longer is a must: for as long as social occurrences can be created and sustained within media ecosystems, they can and should be seen as sufficiently real, leading towards 'primacy of anticipation over content' (marcinkowski , p. ) . such anticipation refers to both the communicators (anticipation of particular audience expectations to be satisfied) and their audiences (anticipation of being satisfied); in this situation, neither side is likely to give the substance of content priority-whatever satisfies expectations, is good enough. and no less importantly, technology now affords increasingly sophisticated ways of decoupling satisfaction of expectations from conventional considerations of reality by producing high-fidelity synthetic reality. deepfakes are digital content, generated using a deep learning technique known as a generative adversarial network (gan). the production process involves the simultaneous use of two algorithms: one, typically referred to as 'the generator', is tasked with creating artificial content while the second, called 'the discriminator', tries to find fault in the newly-generated content; once such a fault is found, the generator learns from its own mistakes and creates an improved version to be scrutinised by the discriminator, and so on (chesney and citron , p. ; giles et al. , p. )-this is where the adversarial element of gan comes from. the end product is arrived at when the pair of algorithms can no longer make any improvements through mutual learning. one of the main fears pertaining to deepfakes is that they can purport to represent events or insinuate behaviours that never took place in order to destroy the reputations of featured individuals (for both political manipulation and private harassment) or potentially even sway the results of elections (chesney and citron , p. ); alternatively, they can lead to an environment of distrust, whereby even 'hard' evidence of crimes or misdemeanours can be easily dismissed as mere deepfakes (woolley , p. ) . deepfakes can also potentially be used for blackmail and extortion, either for financial gain or to manipulate decisionmakers (hall , p. ) . likewise, whereas the creation of simulated public opinion currently requires armies of trolls, deepfakes can automate the process, generating custom-made content coming from custom-generated profiles etc. (giles et al. , p. ) . crucially, deepfakes are democratic in nature: the only things needed are training material for the algorithms and computing power; in contrast to traditional photo or video editing software, no specialist skill is necessary as the process is automated, meaning that even a relative amateur can produce high-quality synthetic content (chesney and citron , p. ) . currently, the primary use of deepfakes is for synthetic pornography, as in transposing the faces of celebrities or former partners onto the bodies of performers in pornographic videos; however, there are clear threats coming from improvements in the technology itself, such as reducing the quantity of necessary input and increasing the quality of output, and from its pairing with other techniques, including big data-based precision targeting to identify those most susceptible to believing the synthetic content (paul and posard ) . although deepfakes can usually still be identified it is only a matter of time until technology catches up with human perception; moreover, as human response to audio-visual content is often visceral and immediate, people will, nevertheless, believe their eyes and ears 'even if all signs suggest that the video and audio content is fake' (charlet and citron ) . simultaneously, as communication, particularly online, is turning more and more towards the visual, the capacity to manipulate content in this dominant mode of expression can become a notable source of power (vaccari and chadwick , p. ) . nevertheless, due to the aforementioned democratic nature of deepfakes, it is unlikely that this power would be concentrated in the hands of a few actors only. a much more likely outcome is dizzying excess, in which it becomes increasingly difficult for information consumers to make up their minds. the net result might be 'a climate of indeterminacy' whereby people have low levels of trust beyond their bubbles (vaccari and chadwick , p. ) . moreover, this indeterminacy is likely to extend even further, including in domains where objective veracity is prized. one such example would be the legal process, whereby the authenticity of even video evidence will become hard to determine (see e.g. maras and alexandrou ), thereby further contributing to the undermining of trust. in particular, deepfakes may prove to be dangerous in the runup to elections, as parts of e.g. a smear campaign against an opponent. while unlikely to feature in isolation, they are likely to form an integral part of broader cyber operations, perpetrated by domestic or foreign actors (whyte ) . extant research already indicates that if deepfakes are targeted precisely, they can considerably reduce the image of an unfavourably depicted politician in the eyes of the target population (see dobber et al. ) . certainly, the precision-targeting necessary for such an effect necessitates large sets of audience data, which might up the ante for those willing to enter the political manipulation game. nevertheless, for well-resourced political campaigns and, even more so, for hostile nation-states targeted deepfakes will, in all likelihood, become a new addition to their arsenal. still, even for the less-resourced, deepfakes may prove to be a viable tool, for example in trying to harass activists of the opposite camp by placing their images in pornographic videos or other types of content that the victims would likely find unpleasant and disturbing (see e.g. maddocks ). for those reasons, it is extremely likely that deepfakes will feature, in some capacity, in the elections to come. simultaneously, though, the problematisation of reality wrought about by deepfakes extends much further than manipulation or other nefarious uses. for example, as kietzmann et al. ( , p. ) asserts, 'we may soon enjoy injecting ourselves into hollywood movies and becoming the hero(ine) in the games we play' while shopping is going to be transformed by a capacity to create personal deepfake avatars to model different outfits, leading to 'ultimate personalization'. indeed, deep personalisation is likely to be the next big thing in digital consumer-oriented products more broadly, a continuation of the current drive to put as much personal touch into services as possible. there are also further opportunities for businesses: while data-driven targeting and programmatic ad buying are already de rigueur; the next step would be employing gans to deepfake segments in anything from news broadcasts to films in real time to deliver targeted advertising and personalised product placement to every viewer. nevertheless, this ability to place oneself (or be placed) at the centre of the universe and to subject perceived reality to one's interests or tastes (or tasks at hand) clearly points towards an impending future of 'reality' that, instead of being stable and capable of providing a common point of reference, becomes personally tailored and, simultaneously, only personally meaningful, leading to personalised experience cocoons. ultimately, such synthetic media are going to 'challenge public opinion and what we know as reality in basically all sectors of culture and society' (woolley , p. ) . hence, individuals will be faced with a broad variety of largely (or, at least, immediately) indiscernible truth candidates only to default to their pre-existing opinions, partisan bubbles, or influencers. however, the latter are also becoming synthetic. recent developments in today's media also involve the creation of synthetic personalities, primarily as virtual influencers (vis). like their human counterparts, these are personalities geared for maximum audience impact. however, due to their synthetic nature, vis provide an unprecedented degree of flexibility and targeting. hence, it is typical for creators to provide vis with 'a composite personality based on market research', and then use machine learning-based social listening to adapt to target audiences as effectively as possible (bradley a) . in contrast to a human influencer, all of the virtual one's characteristics, including 'age, gender, tone of voice and aesthetics' can be tailored to match audience expectations (bradley a). therefore, as bergendorff ( ) similarly to what has been observed in relation to deepfakes, the synthetic nature of these influencers opens up potential for manipulation, particularly because they can be made so impactful. campaigners already warn of adverse consequences on matters ranging from body image and a sense of inferiority in comparison to virtual personalities' computer-generated accomplishments to virtual influencers taking a political stance (booth ; yocom and acevedo ) . and while in case of most, if not all, of the currently popular virtual influencers such concerns are more of a side effect, it is not too difficult to imagine a virtual influencer intentionally created for manipulative purposes; having been created specifically with appeal to a target audience's preferences in mind and specifically designed to evoke trust from that particular segment of the population, virtual influencers could the conceivably become trusted purveyors of information held in high esteem by their followers (yocom and acevedo ) . while they would be unlikely to develop independent persuasive power in the short or mid-term, virtual influencers could conceivably assist efforts to wrap target audiences within a cocoon of misinformation and this amplify existing campaigns. for brands, vis offer the usual combination of advertising and audience engagement, but with total control of content and behaviour, unlike the often-erratic antics of real-life influencers (bradley a) . moreover, a vi tends to generate around three times more engagement than a human one and acquires followers at a significantly higher rate (leighton ) , possibly as a result of their meticulous tailoring. an additional benefit of vis is their independence from real-world context: for example, while coronavirus lockdowns issued by governments have significantly constrained opportunities (travel, public appearances etc.) for human influencers, virtual ones can continue regardless (deighton ). the preceding can leave brands wondering why hire a human 'when you can create the ideal brand ambassador from sctratch' (hsu ) . from a societal perspective, however, the situation might be somewhat suboptimal because vis are less regulated than their human counterparts, leaving brands more leeway in constructing their campaigns; moreover, vis endorsing products they claim to have tried (which is, of course, impossible) likely contains more than a hint of manipulation (hsu ; cook ) . this problem also extends beyond products and brands as the persuasive power of vis can also be used for promoting political actors and agendas (deighton ). crucially, the synthetic nature of vis might be somewhat liberating: while social media have been used by humans to perform their fake selves, vis are at least authentically fake (hsu ). nevertheless, this authenticity can be easily lost. one reason is the interactive capacity of vis. making vis interact both among themselves and with real-life humans allows for storytelling opportunities and manufactured events that can be carefully orchestrated to generate publicity (sokolov ) and captivate audiences through 'emotional storytelling and empathy' (luthera ) . this captivation might preclude followers from maintaining the necessary distance. the second reason, meanwhile, concerns those followers who do retain that distance: here, the creators of vis may be facing an emotive storytelling gap in talking about specifically human experience while simultaneously being open about not being human (bradley b) . that might drive the creators of some vis to be at best ambiguous about the nature of their creations. after all, around % of millennials and gen z social media users follow or have followed vis without realising their artificial nature (cook ). the next step in dissolving the boundary between the real and the synthetic will be true ai generation of vis without requiring major human input (bergendorff ) . once vis cease being painstakingly human-made and, instead, become interactively and automatically generated, they will not only become ubiquitous but will also become even more irresistible by automatically adapting to their audiences. and as their impact increases, the question of whether they are human or virtual will become increasingly irrelevant. a further step towards the problematisation of reality is the capacity for immersion in a synthetic environment through augmented and virtual reality technologies, typically referred to collectively as extended reality (er). the problematisation of reality is made particularly acute by the fact that er is only effective if it causes an illusion of presence (i.e. the loss of awareness of technological mediation) and an illusion of plausibility, whereby a user's experience responds personally to their actions (pan and de hamilton , pp. - ) . for full immersion, users must also be provided with an 'experiencescape', i.e. a package of 'people, products, and a physical environment' (hudson et al. , p. ) . in that way, er becomes a self-contained world that stands in for 'normal' everyday experience. moreover, the merging of er and social media is likely to offer 'far more immersive experiences and the possibility of sharing more of our lives online', affording an even more effective refuge from the physical world (marr ) . thus far, the primary uses of er are for gaming and educational purposes, but new and emerging uses involve e.g. virtual attendance of real concerts and sporting events (rubin ), potentially even allowing a band to perform in their studio while their sound is put into a completely virtual concert performed by their avatars-particularly attractive in times of distancing and travel restrictions. additionally, there is increasing use of er meeting spaces for both commercial and private use, standing in for travel (rubin ) . in other words, er can literally offer a (synthetic) world of experience within the confines of one's home. however, virtual co-presence also comes with its own dangers, such as virtual abuse, which can have psychological effects as bad as the 'real' thing (rubin ). moreover, there also is a threat of manipulation as er can cause attitude change through experiencing a place, a brand, or a person (tussyadiah ) . in fact, social engineering on er is already a thing, although the applications currently available (at least those open about their aims) are primarily concerned with empathy, social responsibility etc. (marx ) . nevertheless, there is no guarantee that such techniques will not be (or are not already) also employed for nefarious purposes. an important sticking point is that er allows much more extensive data collection (particularly biometric data) than any other type of media (braun ) . these data can also be matched with a record of everything the user sees or hears while the device is on (marr ) . the result is not only potentially detrimental privacy invasion but also unprecedented capacity to tailor the experienced environment by predicting the most visceral of our responses (hall and takahashi ) . that tailoring might tilt users towards prioritising er over the non-user-centric physical environment, thus further contributing to the problematisation of reality. furthermore, the er of the near future 'will be aware, data-rich, contextual, and interactive' courtesy to the development of both g and cloud-based representations of the physical environment, allowing data to be overlaid on the physical world in real time; the net result will be not only a richer experience but also a shift of er from an add-on to the operating system of everyday life (koetsier ) , particularly as haptic technologies mature. as with the other types of synthetic media discussed above, manipulative potential is rather clear. in the case of er, this relates not only to the capacity of generating artificial experiences but also its immersive quality that might have serious ramifications. as audiences experience content much more vividly and are, therefore, less immune to the messages promoted, fake news on er are likely to be more impactful than their broadcast or online forms (pavlik ) . a further issue to be kept in mind is the disappearance of authorship: whereas in traditional content it is easier for the audience to remain conscious of the constructed nature of what they encounter, immersiveness is likely to lead to over-ascribed authenticity (johnson ) . in this way, borders between different versions of reality are likely to blur, thereby completing the slide towards epistemological anarchy. finally, as the adoption of er accelerates, that will further affect the perception of the self, not least through the development of digital avatars into effective standins (marr ) , thereby diminishing the importance of the physical self. concurrently, in line with the development of synthetic persons, it will be increasingly difficult to tell whether one is interacting with an avatar of a human or with an artificial agent (pan and de hamilton , p. ) , thus further stripping reality of its tangible and verifiable character. as shown in this article, the issue of reality has become less straightforward than ever. as we move towards the construction of synthetic likenesses, persons, and entire worlds, that which is real (at least in terms of affecting understanding and causing decisions) might become intangible and personalised. certainly, people have always had divergent interpretations of the world, including many opinions that were false. however, the present condition simultaneously allows the creation of increasingly realistic synthetic objects and environments and is likely to ensure survival even of those who fundamentally misperceive some of the basic physical characteristics of the world. nevertheless, the change goes even deeper as we seem set to lose the awareness of-or, indeed, interest in-the source of lived reality while lacking the time, resources, or motivation to assess the exact nature of what is driving us towards certain beliefs, actions, or decisions. hence, it is advisable that we move towards an affective criterion of reality: an artefact's or an environment's reality to an individual is directly proportionate to the power of affect exerted onto that individual (kalpokas ) . while that might, at first sight, come across as a highly relativist solution, it nevertheless adheres closely to the problematisation of reality discussed above. the net result would be a partly synthetic life that only abides by the conventions of the physical world to a limited extent. data availability there is no data associated with this article. why i'd invest in a robot teenager: an investor's perspective on cgi influencers the affective politics of the 'post-truth' era: feeling rules and networked subjectivity fake online influencers a danger to children, say campaigners. the guardian even better than the real thing? meet the virtual influencers taking over your feeds. the drum can virtual influencers build real connections with audiences? the drum security, privacy, virtual reality: how hacking might affect vr and ar. iot tech trends campaigns must prepare for deepfakes: this is what their plan should look like. carnegie endowment for international peace deepfakes and the new disinformation war: the coming of age of posttruth geopolitics brands are building their own virtual influencers. are their posts legal? huffpost the mediated construction of reality. polity, cambridge deighton k ( ) why use virtual influencers? raconteur do (microtargeted) deepfakes have real effects on political attitudes? mediatization of emotion on social media: forms and norms in digital mourning practices the role of deepfakes in malign influence campaigns deepfake videos: when seeing isn't believing augmented and virtual reality: the promise and peril of immersive technologies the mediatization of society: a theory of the media as agents of social and cultural change these influencers aren't flesh and blood, yet millions follow them. the new york times with or without you? interaction and immersion in a virtual reality experience promises and perils in immersive journalism london kalpokas i ( ) towards an affective philosophy of the digital: posthumanism, hybrid agglomerations, and spinoza creating students' algorithmic selves: shedding light on social media's representational affordances deepfakes: trick or treat augmented reality is the operating system of the future. ar cloud is how we get there what it means for virtual instagram influencers' popularity rising the dark side of deepfake artificial intelligence and virtual influencers a deepfake porn plot intended to silence me': exploring continuities between pornographic and 'political'. deep fakes porn stud determining authenticity of video evidence in the age of artificial intelligence and in the wake of deepfake videos mediatisation of politics: reflections on the state of the concept the important risks and dangers of virtual and augmented reality taking virtual reality for a test drive mediatization: conceptual developments and research domains. sociol compass why and how to use virtual reality to study human social interaction: the challenges of exploring a new research landscape artificial intelligence and the manufacturing of reality. the rand blog journalism in the age of virtual reality: how experiential media are transforming news virtual influencer trends: an overview of the industry. the drum virtual reality, presence, and attitude change: empirical evidence from tourism deepfakes and disinformation: exploring the impact of synthetic political video on deception, uncertainty, and trust in news deepfake news: ai-enabled disinformation as a multi-level public policy challenge the reality game: how the next wave of technology will break the truth and what we can do about it this social media influencer is a robot-but how could this influence the future? the globe post conflict of interest the author has reported no conflict of interests. key: cord- - mk authors: maheshwari, kavish; hindocha, sandip; yousif, ali title: virtual clinics: need of the hour, a way forward in the future. adapting practice during a healthcare crisis. date: - - journal: j plast reconstr aesthet surg doi: . /j.bjps. . . sha: doc_id: cord_uid: mk nan virtual clinics: need of the hour, a way forward in the future. adapting practice during a healthcare crisis. there are no conflicts of interest virtual clinics: need of the hour, a way forward in the future. adapting practice during a healthcare crisis. the whole world is gripped by the novel coronavirus pandemic, with huge pressures on the health services globally. within the coming days, this is only going to increase the pressure on the health care services and needs robust planning and preparedness for this unprecedented situation, lest the whole system may cripple and we may see unimaginable mortalities and suffering . the whole concept of social distancing and keeping people in self isolation has reduced footfall to the hospitals but this is affecting delivery of routine care to patients for other illnesses in the hospital and telehealth is an upcoming way to reduce the risk of cross contamination as well as reduce close contact without affecting the quality of health care delivered . at the bedford hospital nhs trust, for the past one year we have been running a virtual clinic for our skin cancer suspect patients, where in after a particular biopsy if the clinical suspicion of a malignancy was low, these patients were not given a follow up clinic appointment and instead they were informed of the biopsy result through post, sent both to their gp and themselves. most patients encouraged this model to not have to come back to an appointment and this took significant pressure off our clinics. in the event we needed to see a patient, they were informed via a telephonic conversation to attend a particular clinic appointment. from an administration standpoint, this resulted in less unnecessary follow up appointments in our skin cancer follow up clinics, which could then be offered to our regular skin cancer follow up patients as per the recommended guidelines, without having to struggle with appointments. virtual clinics have previously shown to be safe and cost effective alternatives to the out patient visits in surgical departments like urology and orthopedics . they improved performance as well as improved economic output , . we have increased the use of these virtual clinics, with the onset of the novel coronavirus pandemic, in order to reduce the patient footfall to our clinics. most patients voluntarily chose not to turn up and with the risk being highest amongst the elderly, it was logical to keep them away from hospitals as far as possible. in order to achieve this, we have started virtual clinics for nearly all patients in order to triage patients that can do without having to come to the hospital for now. the world of telemedicine is the way forward in nearly all aspects of medical practice and this pandemic situation might just be the right time to establish such methods. we propose setting up of more such clinics in as many subspecialties of plastic surgery, which not only will help in the current crises situation, but will also be useful in the future to take pressure of our health care services. conflicts of interest: none declared ethical approval: not required who declares covid- a pandemic covid- : uk starts social distancing after new model points to potential deaths telehealth for global emergencies: implications for coronavirus disease (covid- ) prospective evaluation of a virtual urology outpatient clinic virtual fracture clinic delivers british orthopaedic association compliance key: cord- -ee s pjs authors: ofek, eyal; grubert, jens; pahud, michel; phillips, mark; kristensson, per ola title: towards a practical virtual office for mobile knowledge workers date: - - journal: nan doi: nan sha: doc_id: cord_uid: ee s pjs as more people work from home or during travel, new opportunities and challenges arise around mobile office work. on one hand, people may work at flexible hours, independent of traffic limitations, but on the other hand, they may need to work at makeshift spaces, with less than optimal working conditions and decoupled from co-workers. virtual reality (vr) has the potential to change the way information workers work: it enables personal bespoke working environments even on the go and allows new collaboration approaches that can help mitigate the effects of physical distance. in this paper, we investigate opportunities and challenges for realizing a mobile vr offices environments and discuss implications from recent findings of mixing standard off-the-shelf equipment, such as tablets, laptops or desktops, with vr to enable effective, efficient, ergonomic, and rewarding mobile knowledge work. further, we investigate the role of conceptual and physical spaces in a mobile vr office. the concept of the office as we know it is changing and this notion has only accelerated with the covid- pandemic and the resulting wide-scale lock-downs that has suddenly forced millions of workers to carry out their work tasks in home environments that may be ill-suited for prolonged office work. the covid- crisis has also highlighted the challenges in supporting effective collaborative environments and given rise to new problems, such as as "zoom fatigue" , the phenomenon that extended videoconferencing tends to exhaust workers. in general, more people are working in locations far from physical office building or while on the move. while this transition can induce many positive effects, such as enabling flexible hours, reducing time spent in traffic and enable workers to live in far away locations, it does require workers to be able to carry out productive work in environments that might be less than optimal. the worker may need to use a small home office, or a makeshift work-space on the go, crumbed in an airplane seat, surrounded by a crowd of people with no privacy, or using a small desk in a hotel room. furthermore, working from afar may strain collaboration with co-workers. another major change is the plurality of devices that users employ today. while in the past, most of the information work was done on stationary desktop pcs or relative mobile laptops that enabled a few hours of work but using limited input and a fixed small screen. nowadays, user may carry ultra-mobile phones and tablets that can be used in small spaces but are limited in their input space and display sizes, as well as larger devices whenever there is more space or accessibility to power and wifi. cloud tools, enable to easily transfer data and documents between the devices, yet editing capabilities varies drastically between devices. in recent years, vr technology has been progressed by leaps and bounds. head-mounted devices (hmds) have become light, cheap, supporting high-resolution displays that are on par with available screens (such as hp reverb's x display), they may use inside-out optical tracking, which requires no special setups of the user's environment, enable optical hand tracking for controller-less interaction, support video pass-through for occasional interaction with the external world and be driven by existing laptops and tablets. while much of the hype around vr has focused on immersive gaming and entertainment, in this work, we focus on the use of mobile vr headset as a solution for many of the problems raised before. past works such as the office of the future by raskar et al. [ ] , looked how to support immersive and fluid collaborative knowledge work. they utilized projection systems that increased the display area seen by the user and enabled the transition between different work stations. building on this idea, without the need of instrumenting the user's environment, research has proposed to user consumer-oriented hmds to extend the display space and mold a unified work space using multitude common devices, such as laptops and tablets [ ] . we suggest a novel immersive work-space that enables the user to work in a similar fashion at a large variance of real physical environments. we direct our design space at the use of large display space but at the same time, small physical space that limits the input to the physical devices used by the user such as a tablet and their immediate vicinity. furthermore, the sensing of vr hmds enables extended collaboration than available by the devices alone. beside sharing documents between co-workers and enabling co-edit of them, it is possible to render the reference space between multiple users for better collaborations [ ] , that is unlimited by physical limitations exist in real environments. there has been different works that relate to the mobile vr office work presented in this paper, mostly in the areas of mixed reality (mr), information windows in spatial environments; and spatial interaction. early work on supporting knowledge workers using mr investigated the instrumentation of the office by projection systems to extend the interaction space in the office, e.g. [ ] [ ] [ ] . later, research begun exploring mr for similar uses but focusing on the use of hmds [ , , ] . different tasks, such as text entry (e.g., [ ] , system control [ , ] and visual analytics [ ] have been the focus of research. those works were mostly looking at people working on a desktop pc, using the large interaction space of vr [ ] with controllers or hand gestures [ ] , which do not fit the requirements for small interaction space of uncontrolled physical environment. the large display space of vr attracted researchers looking at organizing information around the user [ , ] . from head and world references windows [ ] , arranging displays in a cylinder around the user [ ] , to different coordinates system referring to the user's environment, and object, user's body or head [ ] . past works looked at fast access to virtual items [ , ] , multitasking [ ] and visual analytics [ ] . while vr enables large display space in any physical environment, most past works did not addressed the limitation of small input space that may be available for the user. we are looking at different ways in which we may increased the expressiveness of the user without using large gestures. while current devices such as tablets and phones enable only d display and touch input, we are looking at extending the information display and interaction in the depth direction too, displaying different layers of information, and use the interaction space only or near the tablet in order to support interaction in constrained physical spaces [ , , , ] . we draw on these rich sources of interaction ideas [ , , , , ] and adopt techniques in the context of vr interaction with touchscreens for mobile knowledge workers. our work complements multimodal techniques combining touch and mid-air [ , ] , gaze-based techniques [ , ] and ideas for combining hmds with touchscreens [ , ] through novel techniques for accessing virtual windows around or behind a physical touchscreen. vr headsets can decouple workers from their physical environments and transport them the virtual environment, thereby allowing the user to work in a private virtual office controlled by them. the system may map limited input space to full control of the large display space (see figure left). it may enable collaboration between far away workers in a way that is not possible in a physical space. in the following subsections we will describe these advantages. as described by grubert et al. [ ] , the available work environment for the worker on the go may be sub-optimal, including obstacles for interaction in the vicinity of the user, lack of good illumination, a multitude visual and audio disturbances, lack of privacy and more. using vr hmds, users can generate their familiar ideal environments of their liking reducing to adapt to new context, layout around them, masking them for external visual and audio disturbances. while many virtual application use a large input space and enable people to roam inside a virtual space and operate using the full reach of their arms, in this paper we are focusing on using small input space and in particular use input spaces of devices such as a tablet, due to the following reasons: the use of large input gestures comes at the price of the amount of energy invested by the users [ ] , and there are situations such as in an airplane or touchdown spaces where there is not enough room to do ample movements. to enable the user to work a full work day and reduce the exhaustion, we expect the user to do small gestures using supported hands, very similar to the gestures she would have done near her desk at the office. in fact, in the virtual world, which may not adhere to the physical laws of reality, small user gestures may reduce the amount of work users are needed to do today, such as locomotion, reaching toward far objects. also, while the virtual display space maybe as large as we wish, interaction space may be limited by the physical environment. by designing interaction for a small input space, the user may be able to keep his familiar working gestures and muscle memory in many different physical environments. one critical design aspect for vr office workers situated in uncontrolled environments, such as shared office spaces, trains, airplanes, cafes or public spaces, is preventing eavesdropping of at least highly sensitive information, such as passwords. while vr hmds are inherently personal and do not expose the displays to people around the user, the input gestures of the user are exposed to the public around her. schneider et al. [ ] addressed the use of standard keyboards while working in vr. by augmenting the arrangement of the keyboards as seen in the vr space they obfuscate the entry of passwords by the user . in a similar fashion, the use of private display space that can be rearranged without the knowledge of an external viewer to hide the semantics of inputs such as stylus strokes or soft keyboards to protect sensitive data input. when using vr hmds in public spaces, one also needs to consider the social acceptability of those interactions [ ] . for example, schwind et al. [ ] indicated, that vr hmds are accepted to be used in public spaces, but only when social interaction between physical present people is not expected. for example, users acceptance of vr hmds in settings such as public transportation (trains or busses) was significantly higher than in a public cafe. williamson et al. [ ] , highlighted the need for allowing for transitioning between physical and virtual worlds to allow to accommodate dealing with interruptions when using vr hmds on airplanes. eghbali et al. [ ] , put forward design recommendations for socially acceptable use of vr in public spaces, again recommending to be able to interact with the physical space and users in vr and ideas how to achieve this have been proposed [ , , ] . information worker uses a slew of input devices, some of them have little changed over tens of years. for example, the physical keyboard is still the most known and preferred input device for text entry. the use of a vr hmd obscure the view of the keyboard from the user, and the application renders a virtual view of the keyboard. since the virtual environment is not bound the limitation of the physical world, it is possible to change the look and functionally of the device according to application needs [ ] . figure shows two different dimensions in which a physical keyboard may be augmented for different use in vr. the output mapping, or the way the keyboard is rendered in vr can change the functionalities of keys on the keyboard. some keys may not be displayed to direct the user to specific keys, some keys may be rendered as one big key for easier selection, or just changing the functionalities of keys. another option is to use a small portable keyboard, and change it's keys functionality according to need to simulate a full size keyboard. the input dimension changes the understanding of a signal from the keyboard. while the default semantics is that each key has a unique input signal, it is also possible to combine several keys to one big key or even use the full keyboard to sense d location of a press. the same type of augmentation may be used on other devices, whether it is a mouse or track pad a touch screen or a stylus. for example, adding new semantics for mouse buttons, wheel or movement directions, or a stylus that represents it's functionality. the limited input space may not allow for comfortable viewing. for example, when interacting with a tablet laying on a tray of an airplane seat, it may not be easy to tilt the hmd down to look at the tablet and the hands around it. following the work of grubert et al. [ ] , the display of the tablet and the user hands may be retargeted from their physical space to lie in the user's field of view, see figure . grubert et al [ ] found that if the user is typing on a physical keyboard there is no performance penalty in such retargeting, and when using a soft keyboard that lacks of haptic feedback, there is a minor speed penalty, but it enables much improved ergonomics for the user's head. such a difference between the input space and it's corresponding display may enable better utilization of the physical affordances of the user's environment, regardless of the display space. for example, changing a continuous parameter, such as audio volume, can be achieved by moving a slider on a tablet. however, this requires the user to target their finger to the slider and visually determine the new position for the slider. the extended sensing of the hmds may allow for tracking users' fingers while they are away from the tablet, and reappropriate natural physical landmarks, such as a handle of a chair or the side edge of a tablet or a tray, to guide the finger as it moves the slider. when people collaborate in physical environments, we can define different spaces of collaboration [ ] : task space is where the work appears. for the information worker this is usually a set of documents such as spreadsheets, text documents, shared whiteboard, etc.. most modern applications let multiple people edit the same document concurrently online. the user may see the locations of the other people edits, send comments between users and so on. person space are where verbal and facial cues are used for expression. video and audio chat applications can be used to realize this level of communication. however, in physical environment, people also use reference space where remote parties can use body language, such as pointing, to refer to the work, organize the separation of work to different participants and more. figure , middle, shows an office that has these three spaces with a local participant a and remote participants b and c. figure right, shows the same office virtually created when user a wears a hmd. the use of vr hmds opens up several opportunities for communication of the reference space, some even beyond the collaboration in a physical environment. for example, the pointing direction of users hands or gaze can be visualized for highlighting relevant objects and facilitating collaboraiton in vr [ , , , ] . tang et al. [ ] looked at different arrangements for collaborators around a table task space. they found that if people sitting around the document as they tend to do in a physical environment are visualized, it is easy to associate the gestures with people, however each person sees the document from a different direction. they also tried to render all users hands as if they all sit in one locations, but associating the hands with different users proved to be confusing. vr hmds enable new arrangements, where all collaborators may see the task space from the same point of view, but translating their avatars and hand gestures, as if they are sitting around the task space for easy associations. further, as people tend to work from a far, there is a starting option of virtual room mates: people that are rendered as working in the user's vicinity, and if the user is moving her body toward a virtual neighbour it can originate conversations and ad-hoc collaborations. if on the other hand the user is concentrating on a specific problem, it may fade out the neighbours to help the user concentration. while vr has a long tradition of being used as design tool for constructing architectural spaces [ ] , designing purely virtual worlds for productive use from an architectural perspective has not seen detailed attention, yet. often, virtual office environments have been modelled to be replicas from physical rooms [ ] , or abstract office spaces [ , ] . only recently, researchers have begun to investigate the effects of virtual space and place on office work. for example, ruvimova et al. [ ] indicated that vr environments (like working on a virtual beach) can outperform work done in a physical open office in terms of flow and performance. guo et al. [ ] were inspired by insights on the positive effects of elements of nature on workers well-being [ ] and used a naturalistic environment for studying long term work in a vr office. still, a number of research questions remain to fully utilize the power of well designed vr spaces for mobile knowledge workers such as: how much congruence between physical and virtual space do office workers need to work productively, safely, healthy and enjoyably? when working in a physical environment, co-located with other users, questions about awareness in vr office environments rise [ , , ] . also, transitions between physical and virtual world have been studied , e.g., in terms of presence [ , , , , ] . however, the effects of awareness and transition techniques on flow and productivity of knowledge workers have just begun to be explored [ , ] . also, it remains an open challenge, how spatial design can support communication both with physically co-located and remote users. what is the impact of architectural design on virtual office environments? large it companies have invested substantial resources to design and build physical office buildings such as amazon spheres, facebook menlo park, apple park or google mountain view. aspects such as spatial dimensions, visibility, materials and lighting or the soundscape of an environment have seen great attention to facilitate chance encounters and physical meetings and still allow workers to focus on individual tasks, if needed. this has partly been done due to the observations that architectural design can support collaboration, productivity and creativity [ , , , ] . however, with recent trends to increase work from the home office, even with its positive effects on workers [ ] , these goals are at stake. groupware tools such as slack, microsoft teams or workplace by facebook focus at productivity and hardly replace planed or chance personal interactions. it remains an open question if properly spatially design virtual office environments can have similar effects on collaboration as physical office environments. to this end, studies are needed which carefully compare effects of architectural and virtual space. this is especially challenging, as potential confounds such as technology artefacts [ ] or user embodiment [ ] have to be considered as well. another open question to study is related to how a virtual environment could create opportunities and motivate participants to have unscheduled casual meetings such as hallway conversations, which can be a great contribution to a project, reinforce the bounds between colleagues, and decrease the isolation factor for remote workers. hallway conversations could also encompass side discussions between team members next to the conference room that happen just after a meeting. experiences such as having a virtual hallway nearby the virtual office could be interesting to study. as an increasing number of people work away from the offer there is an opportunity to use vr to enhance they way we work and collaborate. vr can, for example, disconnect the worker from disturbances, allow the office worker to virtually recreate a familiar working environment, and enable new collaborative ways of working to improve efficiency and mitigate the effect of people working at a distance. in this paper, we have reported on recent findings in this emerging area and discussed design aspects that need to be taken into account to realize a practical mobile virtual office: work environment control, privacy and social acceptability, re-appropriation of input devices, retargeting visuals of input space, sharing reference spaces and architectural space. through this we hope to spark further research in this rapidly expanding field. why we need more nature at work: effects of natural elements and sunlight on employee mental health and work attitudes a survey of d object selection techniques for virtual environments breaking the screen: interaction across touchscreen boundaries in virtual reality for mobile knowledge workers wearable devices: new ways to manage information virtual reality: how much immersion is enough? using office design to increase productivity cross-device taxonomy: survey, opportunities and challenges of interactions spanning across multiple devices interaction for immersive analytics extending a mobile devices interaction space through body-centric interaction commission for architecture and the built environment and british council for offices social acceptability of virtual reality in public spaces: experiential factors and design recommendations the personal cockpit: a spatial interface for effective task switching on head-worn displays spatial analytic interfaces: spatial user interfaces for in situ visual analytics windows on the world: d windows for d augmented reality pen-based interaction with spreadsheets in mobile virtual reality notifivr: exploring interruptions and notifications in virtual reality the mixed reality book: a new multimedia reading experience challenges in mobile multi-device ecosystems. mux the office of the future: virtual, portable, and global effects of hand representations for typing in virtual reality text entry in immersive head-mounted display-based virtual reality using standard keyboards challenges using head-mounted displays in shared and social spaces sharevr: enabling co-located experiences for virtual reality between hmd and non-hmd users mixed reality office system based on maslowâȂŹs hierarchy of needs: towards the long-term immersion in virtual environments realitycheck: blending virtual environments with situated physical reality does it matter where you work? a comparison of how three work venues (traditional office, virtual office, and home office) influence aspects of work and personal/family life interactions in the air: adding further depth to interactive tabletops consumed endurance: a metric to quantify arm fatigue of mid-air interactions a design space for gaze interaction on head-mounted displays improving virtual reality safety precautions with depth sensing judith friedl, and clemens nylandsted klokmose. d user interfaces: theory and practice in limbo: the effect of gradual visual transition between real and virtual on virtual body ownership illusion and presence obstacle avoidance method in real space for virtual reality immersion transition between virtual environment and workstation environment with projective head mounted display physical keyboards in virtual reality: analysis of typing performance and effects of avatar hands enhanceddesk: integrating paper documents and digital documents handnavigator: hands-on interaction for desktop virtual reality the effect of avatar realism in immersive social virtual realities virtual shelves: interactions with orientation aware devices a dose of reality: overcoming usability challenges in vr head-mounted displays expanding the bounds of seated virtual workspaces a survey on d virtual object manipulation: from the desktop to immersive virtual environments mirrortouch: combining touch and mid-air gestures for public displays enlarging a smartphone with ar to create a handheld vesad (virtually extended screen-aligned display) conversational pointing gestures for virtual reality interaction: implications from an empirical study gaze+ pinch interaction in virtual reality the everywhere displays projector: a device to create ubiquitous graphical interfaces the effects of sharing awareness cues in collaborative mixed reality the office of the future: a unified approach to image-based modeling and spatially immersive displays transport me away": fostering flow in open offices through virtual reality notification in vr: the effect of notification placement, task and environment correspondence and non-correspondence: using office accommodation to calculate an organisation's propensity for new ideas visualizing focus of attention in mixed reality community space reconviguration: reconfiguring physical keyboards in virtual reality virtual reality on the go? a study on social acceptance of vr glasses gradual transitions and their effects on presence and distance estimation does a gradual transition to the virtual world increase presence? three's company: understanding communication channels in three-way distributed collaboration smooth immersion: the benefits of making the transition to virtual environments a continuous process workspaces that move people virtualdesk: a comfortable and efficient immersive information visualization approach mixed reality in architecture, design, and construction head pointer or eye gaze: which helps more in mr remote collaboration interacting with paper on the digitaldesk planevr: social acceptability of virtual reality for aeroplane passengers menus on the desk? system control in deskvr passive haptic menus for desk-based and hmd-projected virtual reality key: cord- -ryyokrdx authors: baron, lauren; cohn, brian; barmaki, roghayeh title: when virtual therapy and art meet: a case study of creative drawing game in virtual environments date: - - journal: nan doi: nan sha: doc_id: cord_uid: ryyokrdx there have been a resurge lately on virtual therapy and other virtual- and tele-medicine services due to the new normal of practicing 'shelter at home'. in this paper, we propose a creative drawing game for virtual therapy and investigate user's comfort and movement freedom in a pilot study. in a mixed-design study, healthy participants (n= , females) completed one of the easy or hard trajectories of the virtual therapy game in standing and seated arrangements using a virtual-reality headset. the results from participants' movement accuracy, task completion time, and usability questionnaires indicate that participants had significant performance differences on two levels of the game based on its difficulty (between-subjects factor), but no difference in seated and standing configurations (within-subjects factor). also, the hard mode was more favorable among participants. this work offers implications on virtual reality and d-interactive systems, with specific contributions to virtual therapy, and serious games for healthcare applications. virtual reality (vr) is a computer-generated simulation of a d environment that users can immerse themselves into and interact with via hardware (headset, controllers, joystick, treadmill, etc.). given that most people in the world are experiencing stressful life changes under the covid- pandemic crisis, we investigate how to integrate vr into at-home therapy. vr has been successfully used within rehabilitation settings for motor learning, impaired cognition, obesity, and overall health and wellness [ ] . in this paper, we introduce a creative drawing game for virtual therapy and investigate user's comfort, range of motion and movement in multiple scenarios and configurations in a pilot study. this game allows the user to be fully engaged in both the physical stimulation and the mental stimulation. figure demonstrates an overview of the game with a user performing one of the therapeutic tasks while standing. the game encourages broad arm motions while still being entertaining as the user strives to connect the dots of the drawing. a creative drawing game modelled like connect the dots allows for familiarity and ease while playing -users are not overwhelmed with a game that feels foreign to them. the working hypothesis of this study was that our creative drawing vr game would be effective when integrated into therapy by analyzing improved task completion time (tct), accuracy based on lower number of the mistakes, and user experience (ux). more specifically, research questions to inspire the study were: does the vr therapy game improve user's range of motion and reach? is there any difference between the complexities of the easy/hard levels in the game based on tct and accuracy? how about and differences on tct and accuracy based on game configurations of seated and standing? do our users enjoy playing the game and recommend it to their peers? if so, which configurations are the most popular ones? figure : overview of a user playing the creative vr therapy game. though vr started out as a form of entertainment, it has grown to have implications in the medical field, from simulating surgery for surgeons [ ] to attenuating patient pain during chemotherapy [ ] . one of the industries vr is advancing is physical therapy. vr is preferred in rehabilitation because of its portability so that patients can take the therapy home, its ability to attenuate pain, its independence from external pressures and distractions, and its game-like characteristics that engage users. for example, vr was proven to be better at reducing phantom limb pain than other distraction methods [ ] . because the patients used vr exercise imagery, it stimulated the same brain regions that are responsible for actual movement. therefore, pain was reduced due to pain distraction and punctually activated brain regions involved in the pain matrix network [ ] . another example is how stroke patients report physical pain and an inability to concentrate during their rehabilitation without vr [ , ] . not only does vr make therapy movements not as painful, but it also helps patients regain movement that was lost (i.e. after a stroke) and extend their range of movement. by transforming rehabilitation into an entertaining game, the intense, repetitive, task-oriented arm exercises become more engaging and provide a more positive experience for both the patient and their therapist [ ] . vr improves movement range and pain in the upper extremities (ue). our paper looks at the difference between seated and standing vr regarding the dynamics of movement and comfort in a creative vr therapy game. the pros and cons of seated vr and standing vr have been studied closely, yet still stimulate further research and discussion [ ] . there are many reasons why people chose seated vr over standing vr and vice versa. some users prefer to be seated at a desk because they can have an interactive surface (desk) to perform their task on [ ] ; it is more comfortable and less prone to fatigue to be seated than walking around during long durations [ ] ; it is more suitable for those with a sedentary lifestyle or mobility-impairments [ ] ; it reduces the risk of injuries due to falls, motion sickness, or hitting other objects [ ] ; and it makes them users feel less vulnerable and more acceptable to use vr [ ] . however, standing vr gives users better range for full-body gestures, better performance, and better interactions and locomotion within the d environment [ ] . in addition, developers lean towards seated vr because hand/object tracking can be easier when the user's overall movements are restricted in space [ ] ; many leading vr products appear to be designed for seated configuration [ ] ; it is more suitable for small or cluttered spaces [ ] ; and it is less likely for users to be entangled in the chords/cables [ ] . there are many numerous hardware and layout configurations for vr, and there is still a lot of progress to be made towards best practices of user comfort, and movement assessment of users in seated vr, particularly in virtual therapy. we aim to evaluate what configuration is best for virtual therapy for ue mobility by measuring accuracy and tct, visualizing their movements through data tracking, and evaluating their responses to the exit survey. investigating the best practices for vr therapy is in high demand. the coronavirus (covid- ) pandemic is a global health emergency currently involving countries with > , , infections confirmed and > , deaths worldwide [ ] . however, covid- has affected nearly every person mentally and emotionally. the impact on mental health concerns not only medical staff, who are working nonstop in a highstress and high-risk health environment, but also millions of people forced into isolation/quarantine [ , ] . availability of physical therapy services in the community-even for urgent concerns-has decreased during the covid- pandemic, as opinions about whether home-and community-based physical therapy (pt) should remain open are mixed [ ] . because of stay-at-home mandates, patients must choose to take their pt home or risk exposure going to one of the scarce pt services that are open amidst the pandemic. by continuing their pt at home, patients reduce the risk of hospitalization or other forms of care-both essential public health goals during a viral pandemic that is currently overwhelming hospital and nursing home capacity [ ] . it is necessary to increase remote access to care while preserving scarce resources, including personal protective equipment [ ] . without integrating remote rehabilitation options, such as vr, telehealth services, and digital practices, practitioners may disproportionately harm the most vulnerable patients, send a troubling message to the general public about the value of physical therapists, or worsen the potential short-term and long-term mental health consequences related to this global emergency [ , ] . we address the problem of how configuration contributes to user performance and range of motion in the vr environment. our studies were inspired by several previous experiments that investigated the significance of body position while using vr. there are several vr systems based on different user body configurations: seated [ ] , leaning while seated [ ] , standing [ ] , leaning while standing [ ] , walking in place [ ] , etc. kruijff et al. studied how leaning configurations affect vr performance [ ] . they tested both static leaning (keeping a tilted posture throughout the whole trial) and dynamic leaning (their upper-body inclination changes dynamically throughout the trial) with the leaning angles of forward, upright, and backwards. while the dynamic leaning data did not produce substantial results, the static leaning showed that leaning does improve accuracy, tct, and range of movement. their conclusions were based off the positive effect that leaning while seated had on self-motion perception. self-motion perception is how users use sensory cues to be immersed in their vr environment; it increases task performance because users feel part of the virtual environment and perceive cues that anchor them to the real world [ , ] . range of motion while using vr is important to study because if we can find the best configuration for users to move freely in, their user performance and comfortability while completing the task will improve. also, being able to use your body to navigate within the virtual environment allows your hands to be free to complete tasks. for instance, using d devices (joystick, keyboard, etc.) to move around is not practical. in most applications of vr, ground navigation is not the primary action the user has to perform, so the system should keep users' hands available to use for tasks other than ground navigation [ ] . by moving in the virtual environment using other body parts, the user's hands, eyes, and local head orientation are completely free and available for other physical or social interactions. lazynav looked at how moving both the upper and lower extremities affected user performance [ ] . participants tested combinations of these motions while standing: bend bust, lean bust, rotate shoulders, rotate hips, bend hips, bend knees, take a step. one-way anova tests showed that there were significant differences of all the motion pairs when they measured their movement distance, tct, and accuracy. with their quantitative and qualitative data, they were able to suggest which general body motions were easier to perform and more comfortable for their "lazy" vr design. this shows how a user's range of motion affects how they perform in their task and how easy/comfortable they perceive the game. when we evaluate how seated versus standing configurations, we will measure both user performance and user range of motion with quantitative (movement distance, tct, accuracy, exit survey data) and qualitative data (user suggestions). from gathering data on what configuration allows for the best range of motion during a vr game, we can propose the best configuration a patient should be in for vr physical therapy. one of the biggest advantages of using vr for pt is that it is portable; patients can take their therapy home to do it frequently at their convenience [ ] . a virtual reality therapy home-based system (vrt-home) was developed for children with hemiplegic cerebral palsy (cp) to practice hemiplegic hand and arm movements; children with cp have a brain injury in the motor cortex that impairs the opposite ue [ ] . their results showed that the system successfully targeted hand/arm movements of the hemiplegic ue, especially reaching activities that involve the shoulder and elbow. additionally, the child participants reported "[having] lots of fun" and "would like to take the games practice therapy activities home to play". patients enjoy using vr in their pt for their upper limbs; it is effective, enjoyable, and portable. however, this study only used seated configurations for their participants. we look at seated and standing configurations for a therapy game that works primarily on ue rehabilitation. we also consider how the therapy game will be received as a remote therapy tool during the covid- pandemic and "shelter at home". the secret garden is a -minute self-help vr protocol made to reduce the burden of the coronavirus [ ] . vr is an effective tool for the prevention and treatment of stress-related psychopathological symptoms and ptsd, with therapeutic benefits [ , ] . in this simulation, each user has a partner to discuss their emotions/reflections and they perform different tasks related to personal identity and interpersonal relationships. it provides the sense of community that was taken away due to isolation and quarantine and provides an outlet to manage one's stress. its biggest takeaways were the flexible use, high level of autonomy, and lower costs. gao et al. explores how physical activity vr programs reduce stress and promote health and wellbeing in older adults [ ] . our creative drawing game combines ue movements with a creative release to enhance user experience and health. the goal of this study is to compare two configurations of seated versus standing vr in body movements, userfriendliness, comfort and immersion during a creative drawing vr therapy game. our creative drawing game was coded in c# and through unity game engine. our game is compatible with several vr head-mounted displays (hmds), but we have chosen windows mr for our study as a more portable candidate in comparison to other consumer-level hmds. another motivation for choosing windows mr is its easy setup which will be extremely important in the future for tele-rehabilitation use of the game at homes by ordinary, first-time vr users. in our animal drawing game, the user can choose whether they want to participate in the easy level or hard level. the goal is to connect the dots of an outline drawing of either a fish (easy level) or a chicken (hard level) with a virtual paint brush. the background is a simple, serene mountain scape with a blue sky and clouds, allowing the user to focus on their task in a relaxing, distraction-free environment. when each dot is hit, it turns green from red, and a positive audio feedback sound is played to the user. when all the dots are green, meaning the user successfully connected all the dots of the drawing, they are celebrated by visually exciting animations. a walkthrough of each of the levels, based on their completion state is provided in figure . the game performance is flexible; the user can switch controllers to draw with either their left or right hand. the controller that is not drawing can be used to adjust the d dots model to the height or position the user feels most comfortable and allows this game to be played both seated and standing. no matter where they adjust the task to be, they are still reaching and moving their body to complete their drawing. we want to compare how much the range users can reach and how accurate their movements are while seated and while standing. using qualtrics, we developed pre-and post-questionnaires. in the pre-questionnaire, all the participants were asked about their demographics, prior vr and video game experience, level of education, past injuries, and fitness level. after the participants completed their tasks, they were given their individualized link to the postquestionnaire based on what testing group they were in. we chose to use a five-point likert scale for our questions because it is one of the most fundamental and frequently used psychometric tools for research [ ] . they were all asked to rate their discomfort level, movement restrictions, and ease of completing the task using the likert scale. we then asked a variety of questions about their ux. some of our post-questionnaire questions were derived from a validated and unified ux questionnaire for immersive virtual environments [ ] . the pre-questionnaire allowed us to collect demographics and background data on our participant pool. we asked about demographics: age, gender, height, weight, ethnicity, and education level. this data helps us understand how diverse and representative the group we are collecting data from is. participants were also questioned for vr usability: how often do you play video games; how much do you enjoy playing video games; have you ever used virtual reality headsets before. for those who have experience with vr, we then asked: what is the reason you used vr; did you enjoy using vr. this information indicates how receptive users will be to use a vr game for therapeutic activities. we also asked questions about user fitness: how frequently do you exercise a minimum of minutes per session; have you had a severe upper body injury, either due to sports or other accidents. data about users' fitness tells us how well users' performances will be in our therapy game that targets the upper body. users who have had previous rehabilitation experience would be able to provide more insight on how our therapy game compares in its effectiveness and entertainment. the post-questionnaire provides insight on vr usability/ux. users were asked how strongly they agree to the following statements: it was easy to compete the virtual drawing task; i felt comfortable while completing the task; i felt my movement was restricted while completing the task; using the vr drawing activity, i did stretch my body more than i normally do; i enjoyed playing the creative drawing game. this data gives us a better sense of how well our game will be perceived as a creative therapy game for users with little vr experience. we also asked about presence and cybersickness to ensure the users were not distracted by external stimuli while completing the task in the vr environment: the sense of moving around inside the virtual environment was compelling; my interactions with the virtual environment seemed natural; i was completely captivated by the virtual environment; i still paid attention to the real environment; i suffered from fatigue, headaches, nausea, or eyestrain during my interaction with the virtual environment. learning that the user was immersed in the vr environment and was not distracted by external factors helps us eliminate that confounding variables contributed to their tct and number of mistakes while playing. we can also assess how engaged users were with their therapeutic activities. finally, we asked users how likely they were to recommend this creative therapy game to friends of family members as a therapeutic exercise, particularly amidst covid- . we also collected text entries from participants, asking for thoughts on how to improve this activity for future use and their preferences for being seated vs. standing. a unique id was generated by each participant and was repeatedly used in completion of the questionnaires to assist us keep track of their pre-, post, and main intervention data while preserving their anonymity. design we chose to use a x counter-balanced mixed-design to test seated vr vs. standing vr and easy level vs. hard level. we used a within-subject design for the seated vs standing configuration because it allows us to see how the same person responds differently given the different conditions of seated vs. standing, and used a between-subject design for the level complexities because it reduces confounding variables due to exposure of multiple treatments. the four testing groups following the mixed design that participants were randomly assigned to were as follows: users test the easy level seated first then standing; users test the easy level standing first then seated; users test the hard level seated first then standing; users test the hard level standing first then seated. procedure the study was approved by the institutional review board (protocol #: xxxxxx). after consent, participants were randomly assigned to one of the four study conditions. we carefully instructed each participant what to do and after they expressed that they fully understood, they were guided to a chair or the middle of the room to stand depending on their conditions. we then gave them the headset to put on and their hand controllers and were started on either the easy or hard level using their dominant hands (figure ). we manually recorded how many times they made a mistake in their continuous drawing stroke (when a dot doesn't turn green because they missed it) and their task completion time. they were then asked to complete the post-questionnaire for the configuration they just tested and repeated the task in the other configuration. after all their trials were completed, each participant filled out the exit survey about their experience using the game. we used stata software and rstudio to perform the setst and visualize the findings. we performed one-way anova tests to find a significant difference between the easy and hard levels based on our dependent variables of task completion time (tct) and number of mistakes. we also performed tests to find out any significant differences between the seated and standing configurations using the tct, number of mistakes, and postquestionnaire data. we also used a python program to collect data on the hand controller position, which we visualized it using rstudio. the d visualization allows us to visually assess how accurate was a drawing compared to the provided outline. it also visualizes the range of their movements from how far they could reach to draw their drawings so that we can see what areas they struggled to reach. for example, in figure d , the visualization shows that the user was shakiest in the upper left corner of the fish and overlapping lines in the upper left corner of the chicken; we can speculate that the user's range of motion is not as strong on the upper left side. the quantitative and qualitative data we collected from the questionnaires help us determine if their performance was affected by any confounding variables, such as distractions or cybersickness, and helps us understand their impressions about the game. the results from participants ( females) took part in the pilot study is reported here. a significant difference between the game's level of complexity for easy level (fish drawing) and the hard level (chicken drawing) with task completion time (f( , )= . , p< . ), and number of mistakes was observed (f( , )= . , p< . ). overall, the chicken model was more challenging, and harder to complete, but yet entertaining; users also spent more time to complete it, and have more mistakes while performing the task. no significant difference was observed on study configurations of seated and standing based on tct nor mistakes in any of the easy or hard levels of the game. figures and presents a summary of these results in four smaller conditions, and also for larger levels of the game based on tct and mistakes. "i prefer standing. it was a lot easier to move. when i was sitting i had to reach more and wanted to lift myself off the chair a bit to get to the highest parts of the chicken. but since i couldn't i had to really stretch my arm and controller out to hit the dots." in summary, seated configuration was reported to be more comfortable, it was recognized to facilitate more stretching/reaching because they could not move lower body towards dots, and it had more accommodates to medical conditions. besides, standing configuration was preferred by some of the participants because it was easier to reach while standing, especially for short participants. another reason for seated is that some participants felt they had to be more weary of hitting things in the real world while standing because they were not grounded on a chair. to evaluate the functionality of our portable creative therapy game, we tested our game in the apartment of a lab member, following covid- guidelines. this setting strengthens our evidence that our therapy game is compatible with remote therapy and the shelter-at-home mandate. with our well-defined study design, we managed to conduct a relatively comprehensive data collection. however, similar to any study, there was some limitations to our pilot study. this was our preliminary study to objectively evaluate our vr therapy game and thus, we tested it with convenience sampling and our pool of participants was young, healthy college students. we anticipate testing the creative therapy game with actual patients in need of upper extremity therapy in the future. this project contributes not only to upper limb rehabilitation, but to therapy of all disciplines. if we can effectively integrate vr into pt, patients will be more comfortable and more engaged in their recovery. intensive, repetitive, task-oriented effective recovery tasks that are proven to be the most effective form of pt can be in the form of an entertaining, immersive vr game, from creative drawing for the upper body to versions of soccer to work on footwork [ , , ] . our project provides evidence that we can make a simple, familiar, portable game that is also helpful, encouraging, and distraction-free for remote therapy. due to "stay at home" orders and need to socially distance in response to covid- , portable physical therapy is necessary. the demand for remote rehabilitation is high, as meeting with a physical therapist would increase the chance of infection and hospitalization [ ] . not to mention, those not suffering from ue mobility inhibitions are now feeling an increase of depression, stress, and anxiety from the global emergency [ ] . our proposed therapy game allows users to do their therapy at the comfort of their homes, helping both physical and emotional health of the individuals. the immediate next steps of this project are to conduct studies with larger-scaled, and representative participant pools to validate our findings. because this game would be targeted to ue patients, we would need participants with upper limb impairments to collect data from. from a technical point of view, the therapy game and data-collection software need to be more user-friendly for patients with no technical background to easily use at home. it would benefit the patient if they could receive real time feedback on their performance and compare it to previous performances on one easy-to-use interface. also, using a creative physical therapy game requires the user to play the levels multiple times a day for the therapy to be truly effective [ ] . therefore, we need to add more levels so that the game stays challenging, engaging and entertaining for the user. more levels would also allow us to address the needs of multiple patients and market to not just stroke, parkinson's disease or cp patients, but to all patients with upper extremity impairments. in this article, a creative virtual therapy game was introduced and tested with a preliminary participant pool of students. the results from participants' movement accuracy, task completion time and usability questionnaires indicate that participants had significant performance differences on two levels of the game based on its difficulty (between-subjects factor), but no difference was observed in seated and standing configurations (withinsubjects factor). it means that both of these configurations can be used interchangeably, for instance in future clinical applications with some further considerations; without introducing the risk of lowered performance or accuracy due to study configuration. also hard mode was more popular among participants. these findings suggest great potential for its future applications in remote physical therapy for upper-extremity mobility during the covid- shelter-at-home reality. we would like to acknowledge and thank all members in of the research team at the affiliated university. we also wish to express our gratitude to the participants who kindly participated in our study. we wish to acknowledge our gratitude for the 'sponsor' program for sponsoring this project, with a grant from the 'grantsponsor'. any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the sponsors. haptic retargeting: dynamic repurposing of passive haptics for enhanced virtual reality experiences training intensity affects motor rehabilitation efficacy following unilateral ischemic insult of the sensorimotor cortex in c bl/ virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability d user interfaces: theory and practice influence of virtual reality soccer game on walking performance in robotic assisted gait training for children experimental methods: between-subject and within-subject design exploratory findings with virtual reality for phantom limb pain; from stump motion to agency and analgesia the essential role of home-and community-based physical therapists during the covid- pandemic virtual reality exercise as a coping strategy for health and wellness promotion in older adults during the covid- pandemic effects of virtual reality-based exercise imagery on pain in healthy individuals self-administered, home-based smart (sensorimotor active rehabilitation training) arm training: a single-case report global storm of stress-related psychopathological symptoms: a brief overview on the usefulness of virtual reality in facing the mental health impact of covid- likert scale: explored and explained upper body leaning can affect forward self-motion perception in virtual environments covid- and the advancement of digital physical therapist practice and telehealth virtual reality and pain management: current trends and future directions the development of a home-based virtual reality therapy system to promote upper extremity movement for children with hemiplegic cerebral palsy virtual reality in psychiatric disorders: a systematic review of reviews extended lazynav: virtual d ground navigation for large displays and head-mounted displays taking steps: the influence of a walking technique on presence in virtual reality surgical navigation inside a body. us a proposition and validation of a questionnaire to measure the user experience in immersive virtual environments unfulfilled rehabilitation needs and dissatisfaction with care months after a stroke: an explorative observational study experiences of upper limb somatosensory retraining in persons with stroke: an interpretative phenomenological analysis results and guidelines from a repeated-measures design experiment comparing standing and seated full-body gesture-based immersive virtual reality exergames: within-subjects evaluation standing in vr: towards a systematic classification of challenges and (dis)advantages remain seated: towards fully-immersive desktop vr key: cord- - ktt zw authors: hardcastle, lorian; ogbogu, ubaka title: virtual care: enhancing access or harming care? date: - - journal: healthc manage forum doi: . / sha: doc_id: cord_uid: ktt zw covid- has catalyzed the adoption of virtual medical care in canada. virtual care can improve access to healthcare services, particularly for those in remote locations or with health conditions that make seeing a doctor in person difficult or unsafe. however, virtual walk-in clinic models that do not connect patients with their own doctors can lead to fragmented, lower quality care. although virtual walk-in clinics can be helpful for those who temporarily lack access to a family doctor, they should not be relied on as a long-term substitute to an established relationship with a primary care provider. virtual care also raises significant privacy issues that policy-makers must address prior to implementing these models. patients should be cautious of the artificial intelligence recommendations generated by some virtual care applications, which have been linked to quality of care concerns. covid- fast-tracked the adoption of virtual medical care in canada. with recommendations that individuals stay home and health professionals minimize face-to-face interactions with patients, provinces looked to virtual care as a means of facilitating safe access to health services. in this article, we analyze virtual care models in canada and argue that although they can improve access to health services, policy-makers must approach them with caution due to quality of care and privacy issues. this is particularly important as provinces transition from the virtual models adopted in response to covid- to those that will be relied on as permanent features of the health delivery system. there are two main models of virtual care in canada. the first facilitates communication between patients and their own physicians, while the second is a virtual walk-in clinic. some provinces employ both models. in response to covid- , provinces modified existing billing codes or created new ones to enable virtual communications within existing clinical relationships. , depending on the province, these billing codes allow doctors to consult with their patients via phone, an app designed specifically for medical consultations, or a general videoconferencing app like zoom. self-regulatory bodies or provincial governments may recommend or require the use of particular platforms to facilitate virtual visits. some provinces have also opted to pay for virtual walk-in clinic visits, whereby patients log into an app and are matched with a licensed physician with whom they do not have a preexisting clinical relationship. in this regard, british columbia, alberta, and ontario reimburse physician visits through babylon by telus health, while saskatchewan insures lumeca consultations. in addition to publicly funded virtual providers, there are various virtual providers that charge patients directly, such as maple. when technology is used to support communications between patients and their own doctors, virtual options may enhance quality of care. for example, patients who have contagious illnesses or compromised immune systems can consult with physicians without the risk of transmission. virtual options may also improve access for patients with mobility issues or those who live in remote areas. rural access could be further enhanced if provincial colleges collaborate on telemedicine, so that licensing rules do not act as a barrier to the cross-provincial practice of medicine. prior to covid- , patients expressed a desire for expanded virtual options, with a canada health infoway survey finding that while % of canadians wanted virtual visits with their provider, only % of family doctors offered this option. however, virtual care requires access to the requisite technology and an ability to use that technology, which certain patient populations may struggle with. furthermore, virtual care may be inappropriately distant for some encounters such as sharing a cancer diagnosis with a patient or conducting certain mental health consultations. the canadian medical association lists additional symptoms that are not amenable to virtual care: ear pain, cough, abdominal/gastrointestinal symptoms, musculoskeletal issues, most neurological symptoms, and congestive heart failure. when technology is used as a virtual walk-in clinic rather than a means of communicating with one's own doctor, quality of care may suffer. there is a significant body of literature exploring the impact of continuity of care on patient outcomes. one crucial element of continuity is an ongoing relationship with a primary care provider, particularly for patients with chronic or complex medical conditions. for example, studies link continuity of care to improved health outcomes, reductions in emergency department visits, and fewer hospitalizations. , continuity of care may also suffer due to limits on access to health information. virtual walk-in clinic physicians may have access to some medical records (by virtue of being licensed in that jurisdiction and thus able to log onto the provincial electronic medical record system), but these records may not include notes made by family physicians or other reports. in addition, notes from virtual consults via babylon are not shared with the patient's regular doctor unless the patient requests this. several physician groups have expressed concerns with virtual walk-in clinics. for example, the president of the alberta medical association noted problems with babylon's focus on "episodic care." she noted that patients access a "small number of doctors who work in rotation" rather than their own family physicians and there is "no mechanism to assign patients to a consistent babylon physician in order to maintain continuity." the college of physicians and surgeons of british columbia has received several allegations of deficient care provided by virtual walk-in clinics, with the inquiry committee concluding that it is "almost impossible for physicians to meet expected standards for the majority of patients presenting with episodic concerns in this fashion." virtual walk-in clinics may also drive up healthcare costs and raise equity concerns. for example, a uk study found that patients used babylon consultations "more than would be expected given their age and health status," although the authors could not determine whether this was driven by the accessibility of the service, supply-induced demand, or unmet medical need. this study found that the vast majority of babylon patients were younger, healthier, and lived in wealthier areas, suggesting that virtual care may facilitate inequitable access to physicians. policy-makers should collect comprehensive canadian data on the divide between those who access virtual care and those who see doctors in person as medical practices re-open following covid- , so that they can address inequities. while some provinces insure virtual visits provided through certain apps, others require patients to pay for consultations. maple, one popular platform, charges patients $ for weekday visits, $ for weekend visits, and $ for overnight visits. this raises equity concerns because it allows wealthier people (who, on average, tend to be healthier ) to jump the queue and purchase quick access to medical care, which may be delivered by doctors who would otherwise spend their time treating patients in the public system according to need rather than ability to pay. one possible benefit of the virtual walk-in clinic model is improved access to care for patients who do not have family physicians or who live in remote areas without doctors. however, if patients do not have established relationships with family physicians, these apps should not become their primary point-of-contact with the healthcare system. instead, virtual walk-in clinics should be a temporary, stop-gap measure and governments must prioritize policies that ensure that all canadians have an established relationship with a primary care provider. because of these concerns, it is problematic for governments to encourage the use of this model of care as they have done in some provinces, or for telus to send emails to its customers advertising babylon, given that this may prompt patients who have family physicians to use more convenient, but also more fragmented, virtual options. regardless of the mode of delivery, virtual care must comply with privacy laws. in most provinces and territories, the relevant laws include health information statutes and, in some provinces, privacy legislation that applies to the private sector. the federal personal information and protection of electronic documents act (pipeda), which governs personal information collected, used or disclosed by privatesector organizations in the course of commercial activities, can also apply. this legislation applies to personal information that crosses provincial/territorial and national borders and is especially relevant to regulating virtual care provided by outof-province or foreign healthcare professionals and businesses. similarly, providers operating within canada who move health information across borders are subject to pipeda. although the impact of privacy laws on virtual care systems will become clearer as these systems mature, several privacyrelated concerns have emerged. these include questions surrounding custodianship and ownership of virtual care health information, broad authorization for unspecified use and sharing of patient health information, and data security. when patients virtually consult their own doctors, custodianship and ownership of health information is likely not an issue. generally, persons or entities designated as custodians can collect and share health information under health information protection statutes. physicians delivering virtual care to their existing patients are health information custodians and are bound by routine rules regarding the collection, use, and disclosure of health information. based on applicable legal doctrine, health information collected at point of care belongs to the patient who provided it. with the virtual walk-in clinic model, more vexing considerations arise. while a physician who delivers care under this model is a custodian under the health information statute of the jurisdiction where he or she is licensed, the status of companies that operate virtual walk-in clinics is less clear. for example, babylon has not been designated as a custodian under alberta's health information regulation or equivalent british columbia and ontario rules. this means that the company is potentially not bound by alberta's health information act. since these companies will inevitably have access to patient health information-babylon's terms of service stipulate such access-it is concerning that they may escape regulatory reach. rules regarding ownership of health information may be difficult to implement or enforce where virtual walk-in companies are domiciled in or operate outside a province or outside canada. babylon's privacy policy states, for example, that patient data may be "processed, stored, or accessed" by babylon and its service providers (both within and outside canada) or accessed by foreign governments under applicable law. given the implications of such widespread use and sharing of a patient's health information, companies like babylon ought to be clearly designated custodians under applicable provincial laws. a related concern is the use of terms of service or clickthrough agreements to obtain consent from users of virtual care apps. these agreements typically ask patients to consent to the retention, use, and disclosure of collected health information for purposes that are not clearly specified or which are unrelated to providing medical care. putting aside issues with lay comprehension of the often verbose legalese in these agreements, consent is assumed from "clicking-through" regardless of whether the user actually read or understood the agreement. for example, babylon's privacy policy asks users to consent to sharing their health data with other companies and foreign governments. under applicable federal and provincial legislation, health information can be used, retained or disclosed only for purposes authorized by patients, or, absent such authorization, for specified purposes. pipeda requires that organizations generally seek "express consent when the information is likely to be considered sensitive." given the sensitive nature of health information, authorization obtained for broad, unspecified use, disclosure, or retention of health information is likely to be legally problematic. ensuring data security is arguably the most challenging aspect of virtual care. with the explosion of communication technologies, there are many reliable and affordable options available to both physicians and patients. for virtual consultations with their own patients, doctors often rely on phones and popular, consumer friendly conferencing software such as zoom, skype, and facetime. , however, these software are notoriously insecure and vulnerable to security breaches. for example, zoom and skype have recently faced breaches, including hacking, cyberattacks, leaks of private information, and unconsented sharing of user data with advertisers. , privacy experts are also concerned with the encryption used by zoom. standalone platforms designed specifically for virtual medicine may attract less attention from cyberattackers, at least until they gain widespread use. it is presently unclear if medical apps are designed to withstand security attacks because these technologies were introduced without the completion of privacy impact assessments. saskatchewan's information and privacy commissioner recently cautioned health professionals and patients to "be careful what you sign up for." alberta's commissioner similarly noted "concerns" with babylon and launched an investigation into the app. she encouraged "physicians or patients with concerns about this app to remain opted out of using it," while her office reviews its compliance with privacy laws. concerns with ai symptom checkers some virtual platforms include additional features, the most problematic of which use artificial intelligence (ai) technology to provide medical recommendations to users. the algorithms that produce these recommendations have not been subject to rigorous independent scrutiny and, given their proprietary nature, this oversight may never occur. there is also a lack of regulatory oversight over these technologies. , numerous concerns have already been reported with the accuracy of babylon's symptom-checker. for example, it recommended that patients seek emergency care for conditions that could be managed in the community (at a time when patients were avoiding unnecessary hospital visits), and according to a complaint to the uk's medical device regulator, it misdiagnosed a heart attack as a panic attack. although the app cautions that its recommendations should not be substituted for medical advice, individuals may not view recommendations with sufficient skepticism given the app's promotion by government and the fact that consultations with actual doctors are integrated into the same platform. although babylon claims that its symptom checker performs better than doctors, fraser et al. conclude that "babylon's study does not offer convincing evidence that its babylon diagnostic and triage system can perform better than doctors in any realistic situation, and there is a possibility that it might perform significantly worse." although virtual care was rapidly adopted in response to covid- , policy-makers now have an opportunity to reevaluate before it becomes entrenched as a permanent feature of the healthcare delivery system. we make three recommendations that will help mitigate the concerns with virtual care. first, given the uncertain custodianship and ownership of the data generated under these models, the use of broad authorization for use and sharing of information, and data security issues, it is essential that policy-makers wait for privacy impact assessments before proceeding with virtual care so that it is implemented in a manner that complies with privacy laws. although health providers adopted various ways of communicating electronically with their patients during covid- , governments and professional self-regulatory bodies must develop guidance on the permanent adoption of virtual care to ensure that they are meeting their obligations as custodians of health information. second, because of the convenience of virtual care (and the resulting incentive for some patients to prefer it over in-person consultations), policy-makers should prioritize virtual models that facilitate electronic access to one's own doctor over virtual walk-in clinic doctors with whom patients do not have an established relationship. given that continuity of care is linked to better patient outcomes, it is essential for governments to implement policies ensuring that all canadians have access to a consistent primary care provider, rather than relying on virtual walk-in clinics as anyone's main point of contact with the healthcare system. policy-makers must also address the fact that virtual models will naturally exclude some groups, such as those without access to the requisite hardware and a reliable internet connection. third, policy-makers must ensure the public understands the significant limitations on ai-generated health recommendations. for example, they may consider not adopting virtual care models that integrate medical recommendations, given that patients may overestimate the reliability of recommendations that come from the same platform they use to consult with doctors. health canada must also ensure that its regulatory approach keeps pace with these emerging technologies. while virtual care can enhance access to health services, policy-makers must address significant concerns before forging ahead with its permanent implementation in order to preserve quality of care and protect privacy. with the public's considerable appetite for virtual care and prime minister trudeau's recent announcement of $ . million to "develop, expand, and launch virtual care and mental health tools," it seems virtual care is here to stay. lorian hardcastle https://orcid.org/ - - - virtual visit tariffs. . accessed government of alberta. new app helps albertans access health care what's the hold up on national licensing for doctors? cmaj news virtual care in canada: discussion paper virtual care playbook continuity of care with doctors-a matter of life and death? a systematic review of continuity of care and mortality continuity of care with family medicine physicians: why it matters setting the record straight. . accessed telemedicine as a stand-alone, episodic care service rarely meets expected standards available at: www.hammersmithfulhamccg.nhs.uk/ media/ /evaluation-of-babylon-gp-at-hand-final income inequality and health: what does the literature tell us? personal information and protection of electronic documents act law for healthcare providers. lexisnexis virtual care patient faq telemedicine and virtual care guidelines (and other clinical resources for covid- ). . accessed skype audio graded by workers in china with "no security measures". the guardian zoombombing": when video conferences go wrong move fast and roll your own crypto: a quick look at the confidentiality of zoom meetings advisory from the office of the information and privacy commissioner of saskatchewan on apps that offer health care consultations office of the information and privacy commissioner of alberta. commissioner investigating babylon by telus health app. . accessed rise of medical ai poses new legal risks for doctors row over babylon's chatbot shows lack of regulation ai doctor app babylon fails to diagnose heart attack, complaint alleges. the telegraph safety of patient-facing digital symptom checkers virtual visits and patientcentered care: results of a patient survey and observational study prime minister announces virtual care and mental health tools for canadians key: cord- - ynduijm authors: turner, sandra; pham, trang; robledo, kristy; turner, sara; brown, chris; sundaresan, purnima title: rapid adaptation of cancer education in response to the covid- pandemic: evaluation of a live virtual statistics and research skills workshop for oncology trainees date: - - journal: j cancer educ doi: . /s - - - sha: doc_id: cord_uid: ynduijm due to covid- , an annual interactive statistics and research methodology workshop for radiation oncology trainees was adapted at short notice into a live virtual format. this study aimed to evaluate trainee opinions around the educational value of the workshop, logistical aspects and impact on interactivity. a post-course on-line survey was completed by / trainee attendees (response rate %). for five pre-specified learning outcomes (lo), to % of trainees agreed that the lo was completely or largely met (likert scores and on a scale = not met at all; = completely met). all trainees felt that logistical aspects of the workshop including organisation, accessibility to the platform and sound/image quality were good or excellent. with regard to opportunities for interaction and suitability for small-group ‘break-out’ sessions, the majority felt that interaction could be adequately maintained whilst just under a quarter felt the delivery method was not fit for the purpose. networking/social engagement with peers and teachers was the factor most impaired using the live virtual delivery format. over three-quarters of trainees replied they would favour the current event or other educational sessions being offered (at least as an option) in a virtual format in the future. cost and convenience were given as the major non-covid- –related benefits of virtual on-line learning. these preliminary findings provide valuable feedback to help adapt or develop further on-line educational and training initiatives that will be necessary in the covid- pandemic period and beyond. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. the far-reaching consequences of the covid- pandemic are playing out currently across all spheres of life in all parts of the world [ , ] . the enormity of the community health and economic impact of the novel coronavirus infection is clearly of paramount significance. however, there will be countless ramifications that permanently alter elements of our work and personal lives, some of these for the better. in this way, the current dire situation offers opportunities for innovation over the longer term. for cancer patients undergoing radiation therapy and systemic treatments and for staff looking after them, there are a special set of complex considerations in maintaining good quality clinical care during the pandemic [ , ] . other core departmental functions such as quality assurance, research activity, and professional training and education need to continue in some form despite additional challenges. such a crisis draws into sharp focus where efficiencies and alternative practices need to be investigated as a priority both in the realm of clinical care and across other domains. electronic supplementary material the online version of this article (https://doi.org/ . /s - - - ) contains supplementary material, which is available to authorized users. the smart workshop is a full-day interactive education session designed to enhance trainee knowledge and skills in statistical methods, critical appraisal of medical literature and research methodology [ , ] . it is a mandatory component of training in radiation oncology in australia and new zealand under the auspices of the royal australian and new zealand college of radiologists and is run each year in association with the trans-tasman radiation oncology group (trog) annual scientific meeting. five days before the edition of the smart workshop, a decision was made to convert it to a live virtual format. this brief article describes trainee-reported outcomes on educational value and logistical and social aspects of the rapidly implemented real-time virtual delivery format. forty-three trainees within the australian and new zealand radiation oncology (ro) training program had registered to attend the smart workshop in march . workshop learning outcomes (lo) are that (after the workshop) trainees are able to: (i) describe features of different trial study designs, (ii) describe study outcome measures/endpoints, (iii) justify selection of suitable endpoints, (iv) apply new knowledge for the purposes of critically appraising the literature and (v) consider ways in which they might participate in research. several weeks prior to the decision to adapt the workshop format, trainees had been sent the usual 'homework' pack including select research methodology questions to consider in relation to three published ro trials, provided as learning prompts. five days before the workshop, trainees were informed by e-mail of the change to a live virtual format. forty-eight hours before the workshop, trainees and faculty were sent an e-mail with login instructions to access the video-conferencing platform. the smart workshop program is composed largely of short didactic lectures given by the biostatisticians to align with learning outcomes, followed by highly interactive small-group sessions led by the radiation oncologist facilitators [ ] . this year, several key faculty including the convenor, two biostatisticians, one of seven facilitators and a support officer met in a single location in sydney respecting covid- social distancing requirements at the time. the other six facilitators, two biostatisticians and (of registered) trainees logged into the video-conferencing platform externally from across six australia states and both islands of new zealand. a technical support officer and the conference event manager also connected from remote locations to assist with logistics and troubleshooting. the entire original content of the smart workshop was delivered via the live virtual format. however, the 'small'group sizes were increased compared to the usual in-person workshop due to unfamiliarity with the as yet untested technical aspects of running the virtual breakout sessions. during the small-group sessions, trainees were divided and directed into four distinct digital 'rooms' in which around ten residents were tutored by one or two radiation oncologists and a biostatistician. interactivity was enabled through all participants knowing, usually seeing, who was on-line and each having access to a microphone. trainees could also use the text chat window to ask questions or comment. just like the usual workshop model, after each breakout group session, the whole cohort came back to one virtual conference room to present their group's responses and for a debrief. two international guest speaker talks were retained in the program. as usual, they were invited to provide inspiration to trainees to engage in research. speakers, one presenting virtually in real-time and one recorded, were located in new zealand and the uk, respectively due to travel restrictions. only the lunchtime and post-workshop networking events were cancelled. three days following the workshop, all participating trainees were invited to provide feedback via a surveymonkey® questionnaire (see supplementary material). due to the short time-line, formal institutional ethics approval was not sought. trainees were assured that responses were anonymous and neither individual nor collated responses would be linked to training progression. demographic questions related to level of training and prior smart workshop attendance. trainees were asked their views on the educational value of the workshop components (didactic and interactive) and to rate their experience against the pre-prescribed los. opinions around the logistical, technical and networking/social aspects of the virtual delivery format were sought as well thoughts about digital delivery methods for future educational activities. responses were collected using five-and seven-item likert scales with freehand text answers encouraged, focusing on areas for improvement. quantitative data were analysed using percentages and means. twenty-seven of ro trainees completed the first section of the survey after two reminder e-mails, giving a response rate of . %. forty-four per cent ( / ) were in their first years of training, % ( / ) in their third year and the remainder in the last years of a minimum -year training program. one trainee skipped all questions beyond demographics leaving full input from / trainees (response rate %). with respect to the perceived suitability of the level of teaching, taking all workshop components into consideration, % ( / ) of trainees felt that the level was not optimal for them. judging from the open-ended comments that followed, trainees were divided as to whether the level was too sophisticated or too basic. correlation of these findings with year of training and/or previous attendance was not possible due to the anonymity of responses. all trainees responding to the survey felt that logistical aspects of the workshop including organisation, accessibility of the video-conferencing platform and sound and image quality were good or excellent. with regard to the 'opportunity for participant interaction' and 'suitability for small-group breakout sessions', % ( / ) and % ( / ) of trainees, reported the delivery method as not being fit for purpose. figure shows trainees' ratings around logistical aspects of the virtual live workshop and views on suitability of the format for interactive group work in particular. over three-quarters of responding trainees indicated they favoured the smart workshop and/or other (un-named) educational sessions being available via an online platform as part of their future ro training. the survey included the question: 'in your view, how much did being able to see (i.e. on video) other participants and teachers enhance the ability to interact?' to which % ( / ) trainees answered in the affirmative; % felt this factor was 'very-' or 'extremely important'. figure shows responses relating to the impact of the virtual delivery format on their ability to network with others at the workshop (teachers, peers and invited speakers) as well as other ro researchers attending the subsequent trog scientific meeting, also delivered online for the first time [ ] . between and % of trainees felt there was 'no impact' or 'a little impact' on their ability to network with other groups linked to the workshop (listed above). the vast majority (up to % for interaction with peers) indicated that the virtual format impacted 'quite a lot' or 'very much' in this domain. a rigorous qualitative thematic analysis was beyond the scope of this study. however, open-ended comments solicited around workshop los and suggested improvements, revealed some common opinions. one strong message was trainees' recognition of the short turn-around time and appreciation of not missing out on core learning. only one trainee felt the smart workshop should have been cancelled. most favoured aspects were the small-group interactive sessions, having access to biostatisticians' expertise and the value of basing learning on publications of real ro research. main areas suggested for 'improvement' were having access to a virtual workshop as a standard training option and ensuring input from all participants in small-group sessions. reduced cost and travel time were the most common reasons trainees favoured having the option of ongoing virtual meetings, especially those training in non-metropolitan centres. equally, many trainees stressed the value of in-person interactions. a typical example quote was: 'there are benefits of meeting virtually, and this was so important in these covid times, however ultimately nothing can replace the engagement and community that come with face to face meetings.' an annual statistics and research methods workshop for australian and new zealand ro trainees was rapidly converted into a live virtual experience. the response rate to an evaluation survey sent to participants was remarkably high ( %) considering the pressure trainees were under soon after the outbreak of the coronavirus epidemic in these countries. with escalating changes within workplaces, including the threat of hospital redeployment, it would be totally understandable if trainees had chosen to ignore an optional survey. on-line training methods for education within the medical setting have received increasing attention in recent years [ , ] , including within the field of ro [ ] [ ] [ ] [ ] . similarly, virtual reality tools have huge scope for ro professional [ , ] and patient [ ] education. there is far less evidence, if any, around the feasibility and value of adapting face-to-face interactive education into a mirrored live virtual format. this report provides some considerations for the delivery of existing curriculum elements fig. impact on ability to network with others via real-time virtual methods going forward, both during the pandemic and beyond. despite the rapid turnaround time, the workshop logistics were viewed favourably by the vast majority. it is noteworthy that no trainee dropped out after log-in. similarly, despite the lack of familiarity with interactive meeting software platforms in early march, navigation through the on-line workshop 'rooms' for the various groups was pleasingly smooth, albeit assisted by professional technical support. limitations of the current study are that views of the responding trainees may not necessarily reflect those of the whole group. the overall number of respondents was quite small despite a reasonable response rate for a voluntary survey. the survey format may have favoured trainees more au fait with electronic learning methods leading to bias. generalisability across other geographical regions cannot be assumed. our countries represent high-income training environments in which trainees are typically well supported to attend educational sessions and are well resourced with regard to modern computer technologies. trainees were not asked specifically about challenges of participation from home such as having privacy or competing childcare/home schooling responsibilities. the findings from this study will clearly not be applicable to all types of learning necessary for oncology training, particularly where the clinical and workplace contexts are central to learning. however, for 'non-medical expert' or 'intrinsic' skills [ ] , such as professionalism, quality improvement, leadership/management and scholar/research skills, as well as for more didactic clinical teaching, live virtual and other digital formats may offer a useful substitute for face-to-face and on-the-job teaching. of special interest was the impact of the virtual format on learner/teacher and learner/learner interactivity, a key feature of the workshop design founded on theoretical constructs for effective learning [ ] . most trainees felt that interactivity was still achieved though hindered to some extent. previous research supports that student interactivity can be successfully achieved for real-time virtual teaching methods [ ] . if future virtual versions of this workshop or other activities are convened, focus on maximising interactivity would be important. strategies might be to request that cameras were always turned on during smallgroup sessions and having access to participant photos and names. bandwidth issues requiring that video be turned off to improve the speed of connection might be an impediment in some situations. user proficiency across numerous on-line platforms has quickly developed over the months since the workshop both for learners and teachers. it is probable that if the workshop had been scheduled, a few weeks or months later, interactivity would have been more effortless for all involved. not surprisingly, networking and social engagement aspects of the workshop were hardest hit by the change of format. interaction with peers and mentorship by senior researchers have been reported as strong factors in trainee engagement in research within our countries [ ] . one trainee commented that s/he and peers had used mobile phone group messaging to network 'behind the scenes' as a substitute for in-person chatting, especially during lunchtime. it is hard to imagine, however, that an adequate replacement for constructive mingling and building of research-oriented networks in the one location could be achieved in an on-line space. findings of this study do suggest that live virtual formats for education might offer a useful supplement or alternative mode of delivery for some curriculum content and for some learners. the expansion of 'blended learning' i.e. mixed digital and in-person methods, in health care education, including for ro offer promise [ , , ] . on-line learning, whether real-time or not, can have major cost and convenience savings as well as being more climate-friendly. for trainees living in regional areas, the benefits of increasing live virtual education offerings, still allowing interaction with peers, are self-evident. for parents (likely more women) balancing child-care responsibilities, these formats could be particularly attractive. in oncology, as for other specialities, we will continue adapting much of our traditional teaching to online formats. this process, accelerated by the pandemic, was already in train to improve efficiency and accessibility for learners. the findings of the current study support the feasibility of live virtual formats for education delivered to moderately large groups of trainees. feedback from learners participating in a cancer-specific statistics and research methods workshop gives a taste of the acceptability and educational value of the virtual approach in delivering some components of training. furthermore, the results of this evaluation are instructive in directing faculty, supervisors and training bodies to areas where strategies for improvement, such as optimising interactivity and 'networking' between participants, might be focused going forward. who declares covid- a pandemic clinical features of patients infected with novel coronavirus in covid- : global consequences for oncology reduced fractionation in lung cancer patients treated with curative-intent radiotherapy during the covid- pandemic promoting a research culture amongst junior radiation oncologists: outcomes from the introduction of the ranzcr research requirement in training engaging future clinical oncology researchers: an initiative to integrate teaching of biostatistics and research methodology into specialty training adapting to a global pandemic through live virtual delivery of a cancer collaborative trial group conference: the trog experience reinventing medical teaching and learning for the st century: blended and flipped strategies blended learning for postgraduates; an interactive experience postgraduate education in radiation oncology in low-and middle-income countries distance learning in the applied sciences of oncology development and impact evaluation of an elearning radiation oncology module can radiation oncologists learn to be better leaders? outcomes of a pilot foundations of leadership in radiation oncology program for trainees delivered via personal electronic devices vert, a virtual clinical environment, enhances understanding of radiation therapy planning concepts augmented and virtual reality: exploring a future role in radiation oncology education and training patient education using virtual reality increases knowledge and positive experience for breast cancer patients undergoing radiation therapy canmeds physician competency framework. royal college of physicians and surgeons of canada adult learning theories: implications for learning and teaching in medical education: amee guide no when to talk, when to chat: student interactions in live virtual classrooms blended learning: an institutional approach for enhancing students' learning experience perspectives on medical education in radiation oncology and the role of the estro school publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the royal australian and new zealand college of radiologists has given permission for the use of the smart postworkshop survey data to be used for the purposes of this publication. key: cord- -hox m mv authors: anderi, emilyn; sherman, latoya; saymuah, sara; ayers, eric; kromrei, heidi t title: learning communities engage medical students: a covid- virtual conversation series date: - - journal: cureus doi: . /cureus. sha: doc_id: cord_uid: hox m mv context challenges to medical education have been pervasive during the covid- pandemic, and medical students, in particular, have faced numerous obstacles as a result. one of the greatest losses for medical students was the inability to gather with their peers and a lost sense of community. the learning community (lc) program at wayne state university school of medicine (wsu som) expanded our offerings through the use of the zoom platform to increase a sense of connectedness among medical students. the first initiative of its kind at wsu som, the virtual conversation series enabled students to share their pandemic challenges while also connecting with physicians on the covid- frontlines. students were offered eight online sessions with physicians and residents who were able to share insight regarding ( ) how to succeed as a medical student on rotation during covid- , ( ) potential implications of the pandemic on residency applications, ( ) the utility of telemedicine, ( ) tips for patient encounters, and ( ) realities of serving as a physician during a global health crisis. methods residents and clinical physicians on the covid- frontlines participated in -minute discussions with wsu som students through zoom. electronic qualtrics surveys were distributed to medical student attendees of the virtual conversation series and responses were received via likert scale, open text, and ranking questions. results qualtrics results demonstrated % of medical students (n= ) reported they learned new information about the covid- pandemic from the perspective of physicians. additionally, % of medical students described the virtual conversation series as ‘extremely useful’. conclusion the virtual conversation series emphasizing different medical aspects of covid- provided a unique benefit to medical students’ understanding of the current landscape of healthcare, the anticipation of their future roles as physicians, connectedness with their community, and opportunity to practice flexibility as they begin to apply online learning with real-world situations in the health system. qualtrics results demonstrated % of medical students (n= ) reported they learned new information about the covid- pandemic from the perspective of physicians. additionally, % of medical students described the virtual conversation series as 'extremely useful'. the virtual conversation series emphasizing different medical aspects of covid- provided a unique benefit to medical students' understanding of the current landscape of healthcare, the anticipation of their future roles as physicians, connectedness with their community, and opportunity to practice flexibility as they begin to apply online learning with real-world situations in the health system. remote learning has emerged to the forefront of academic content delivery, posing a unique challenge to building community and rapport among peers in academic programs. over the past few years, medical schools have been moving away from the traditional lecture-style education model and moving towards more small-group learning experiences, as well as experiential learning activities [ ] . instructional strategies such as case-based learning sessions, laboratory sessions, and earlier clinical encounters are expanding. as the covid- pandemic evolved and social distancing measures were put into place, medical students faced numerous obstacles relating to their education such as the inability to gather with peers, lost sense of community, inadequate opportunities to practice crucial clinical skills, uncertainties of their roles in rotations, as well as individually grappling with virtual delivery of rigorous and difficult academic content while in quarantine [ , ] . the loss of these collective experiences poses a huge threat to the unity of the student body that medical schools and students have worked so hard to build. there are numerous examples of schools utilizing virtual teleconferencing platforms to increase engagement during the covid- pandemic [ , ] . faculty members adjusted their lectures for both pre-clerkship and clerkship curriculum to allow for optimal delivery over an online platform. many small-group case-based learning sessions are being facilitated online, and some schools have even been successful at providing clinical skills instructional experiences virtually [ ] . the ramifications of social distancing measures and pause in medical education have also taken a toll on medical student's psychological wellbeing. cao et al. utilized the -item generalized anxiety disorder scale (gad- ) to assess the mental health of medical students in china during the covid- outbreak [ ] . it was found that . % of medical students experienced anxiety and of these students, . %, . %, and . % of students experienced severe, moderate, and mild levels of anxiety, respectively. students identified that much of their anxiety was due to stressors such as economic hardships, changes to daily life, and academic delays; whereas students who had strong social support reported lower levels of anxiety. medical schools have been exploring the implementation of different strategies to help cope with the mental and emotional issues faced by medical students during this pandemic. the shiraz university of medical sciences developed a social media platform to offer peer mentoring services to medical students [ ] . their platform provided the opportunity for senior medical students to act as peer mentors to junior medical students and assist them in coping with the anxiety and stress brought on by the covid- pandemic. not only did students report satisfaction with the program and a significant impact on their mental wellbeing, but it also provided them with an opportunity for professional growth. prior to the pandemic, maintaining a sense of support and community amongst medical students has always been a challenge faced by schools across the country. wayne state university school of medicine (wsu som) has worked at encouraging the engagement of students through the introduction of learning communities (lcs). here, students are divided into one of eight lcs, each with - students per class year, and each with a student elected to serve as an lc coordinator (lcc) for each medical class. working with the lc program manager, lccs take on the duty of encouraging students within his/her cohort to engage students through mentorship, social and unifying activities, scholarship, and community service. as the covid- pandemic evolved, the lccs were inspired to find creative ways to maintain connections with their peers and community members. the lc program at wsu som expanded their programming to increase the sense of connectedness among the student body and promote integral exposure to the realities of covid- for medical students through a virtual conversation series. to our knowledge, this is the first initiative of its kind, which enabled students in the som to share their experiences during a pandemic while simultaneously connecting with physicians on the covid- frontlines. although many medical students have volunteered in the fight against covid- , they do not know what to expect in their roles as future physicians in the constantly evolving health care landscape. herein, we discuss the topics offered through this virtual conversation series, and their effectiveness in promoting student engagement during the covid- pandemic. the virtual conversation series initiative involved lccs individually reaching out to an array of residents and clinical physicians selected from the network of office of student affairs director of mentoring and student engagement. essential frontline physicians were handpicked based on specialty and range of experience. lccs contacted each physician by email, with an invitation to co-host a virtual conversation alongside a second or third-year medical student lcc facilitator. the physicians immediately began accepting the invitations by scheduling the virtual conversations over the first three-weeks of april . social media announcements and email invitations were then sent to the lc members by their respective lccs. details regarding the eight -minute virtual conversations included the name of the hosting lc and physician, conversation topic, date and time, as well as the zoom link to join. conversation topics included ( ) utilizing telemedicine, ( ) serving on the frontlines from a resident's perspective, ( ) physician experience managing a pandemic versus natural disasters, ( ) being an intern in the medical intensive care unit (micu), ( ) leading community resources, ( ) leading and rounding, ( ) an epidemiologist's perspective, and ( ) unique barriers faced by homeless and lesbian, gay, bisexual, transgender and queer or questioning (lgbtq)+ adolescents during the pandemic. the decision to use zoom as the platform for the series was based on the rapid transformation to online learning and the preference to continue the uninterrupted duties and engagement of the lcs. zoom was the chosen platform for the series as students were familiar with the interface and had regularly utilized it during the transition to remote learning through wsu som. a survey link was emailed to the attendees within one hour of concluding the conversations to collect the data needed to measure the series objectives. afterwards, a composite of all the surveys was used to qualitatively analyze the data. the virtual conversation series primarily aimed to inform the wsu som medical students who are anticipating their new roles serving on the frontlines. a likert scale ( =extremely dissatisfied, =slightly dissatisfied, =neither satisfied/dissatisfied, =slightly satisfied, =extremely satisfied), open text, and ranking questions (extremely useful, very useful, useful, somewhat useful, not at all useful) were used to collect response. a likert scale and ranking questions were used to standardize responses for comparison, and open text responses were included to illicit more specific feedback from attendees. without utilizing identifying information, evidence was gathered using the qualtrics survey tool to evaluate each of the presentations. wsu som used the survey responses to identify, measure, and appropriately address shortcomings, introduce specific covid- pandemic-related curriculum, and prepare students, faculty, and staff accordingly. the eight lcs hosted a unique student experience through the virtual conversation series. one hundred percent of the respondents (n= ) from each conversation of the series reported that the presentations were useful, with open text responses demonstrating % of students felt the topics directly covered student experiences in clinical rotations during a global health crisis, as well as student futures as physicians in the covid- landscape. students interacted with and questioned the panelists about health systems' preparedness and vigorously changing safety protocols, the roles of medical students during the global health crisis, and more. when asked to rate the usefulness of the virtual conversation series, % of medical students selected 'extremely useful' and % selected 'very useful'. % of medical students selected 'not at all useful' (figure ). qualitative text analysis was performed by two individual researchers, and any relevant discrepancies were discussed and resolved. results of the analysis identified new information medical students learned through the virtual conversation series categorized according to the following: ( ) reflections on patient experiences, ( ) resource shortages, ( ) medical student roles during the covid- pandemic, ( ) covid- perspectives from frontliners, ( ) mental health exacerbations of clinical providers during the pandemic, and ( ) the impact of covid- on lgbtq+ populations. % of medical students reported they learned something new about the covid- pandemic from the perspective of frontliners (figure ). when asked, "how satisfied are you with zoom for this type of online session?" responses indicated the use of zoom as a platform for the series was highly received by a wide margin. six percent of the attendees were extremely dissatisfied with the platform but did not state why. four percent of students were neither satisfied nor dissatisfied. contrarily, % of the responses ranged from slightly satisfied to extremely satisfied ( figure ). students were also asked for suggestions of future topics in the interest of another installment of the virtual conversation series. twenty-one students responded with suggestions among which % reported wanting to hear more about physicians' perspectives from the front lines of the covid- pandemic, % were interested in hearing more about managing covid- patients, and % hoped to learn more about the roles of medical students and residents during this time. the remaining % were interested in various topics such as managing mental health as a patient care provider, the health system's preparedness for the pandemic, and financial management as a physician. the virtual conversation series was influenced by covid- to bring awareness of the realities of the pandemic to wsu som lc medical students. the objective was to provide peer connectedness while educating students on the medical concerns surrounding the pandemic by using residents and physicians to engage directly with students. conversation topics included ( ) utilizing telemedicine, ( ) serving on the frontlines from a resident's perspective, ( ) physician experience managing a pandemic versus natural disasters, ( ) being an intern in the micu, ( ) leading community resources, ( ) leading and rounding, ( ) an epidemiologist's perspective, and ( ) unique barriers faced by homeless and lgbtq+ adolescents during the pandemic. students were asked "what did you learn about the covid- pandemic that you didn't already know?", and two individual researchers performed qualitative text analysis to identify response themes. results indicated topics such as mental health and burnout concerns affecting inexperienced residents, intensive care units (icus) quickly meeting capacity, the importance and rationale behind telemedicine, and adaptation and preparedness for pandemics are similar to that of natural disasters. the virtual conversation series feedback survey was used to measure and appropriately address shortcomings, introduce specific pandemic related curriculum, and prepare students, faculty, and staff accordingly. limitations include student sample size; although there was a total of participants, only students responded to the survey. however, the majority of students who responded agreed on the utility and importance of the initiative. the virtual conversations series allowed the wsu som lc program to provide an opportunity for engagement and mentorship of students while promoting and following social distancing measures. many students were able to network with the presenting residents and physicians and proposed topics for future installments of the series. the majority of student responses indicated that future directions of the virtual conversation series should focus on medical student concerns and questions regarding the covid- pandemic such as managing covid- patients and the roles of medical students and residents during this time. the virtual conversation series provided a unique benefit to medical students' exposure of the realities of covid- , the current landscape of healthcare, anticipation of their future roles as physicians, connectedness with their community, and opportunity to practice flexibility as they begin to apply online learning to real-world situations in the health system. medical students who are training to serve in their roles as frontliners have been provided with an opportunity to connect with their peers already on the frontlines, which has bolstered their preparation. with a desire for expansion of the topics presented in this virtual conversation series, as well as other topics that pertain to medical students' professional development, it is recommended this initiative be incorporated into a more longitudinal component of the medical school curriculum to increase student connectedness with their peers through lcs and physician colleagues. is lecture dead? a preliminary study of medical student' evaluation of teaching methods in the preclinical curriculum medical student education in the time of covid- the role of medical students during the covid- pandemic daily medical education for confined students during covid- pandemic: a simple videoconference solution ophthalmic clinical skills teaching in the time of covid- : a crisis and opportunity the psychological impact of the covid- epidemic on college students in china peer mentoring for medical students during covid- pandemic via a social media platform we would like to acknowledge the help of the wayne warrior learning community student coordinators, as well as the residents and physician panelists who made this opportunity possible. human subjects: consent was obtained by all participants in this study. animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. key: cord- -prp hiz authors: beck, dennis; beasley, jennifer title: identifying the differentiation practices of virtual school teachers date: - - journal: educ inf technol (dordr) doi: . /s - - -y sha: doc_id: cord_uid: prp hiz despite a large increase in enrollments of students in online courses at the k- level, there is very little research on the use of differentiation in fully online (called “virtual”) schools. this study asked virtual teachers from two different types of schools to discuss their differentiation practices, and compared differentiation practices of teachers across these schools. nineteen focus groups consisting of teachers were conducted. data were analyzed using tomlinson’s differentiation framework. results showed that the large majority of teacher comments about differentiation definitions, assessments, curriculum, grouping and strategies fell in the novice category, and that newer virtual school teachers may struggle in developing skills in differentiation in an online environment. teachers use the principles of differentiation to make decisions that are responsive to the needs of all students (tomlinson, (tomlinson, , . unfortunately, there is very little research on the use of differentiation in fully online (called "virtual") schools. this is important, because districts employing online education courses have increased enrollments from % to %, with rural districts making the most growth (gemin and pape ) . in recent times, a global pandemic forced many educators to teach remotely. in addition, students accessing this technology are more diverse than ever. enrollment of english language learners (ell) was higher in - ( . %) than in the previous ten years (u.s. department of education, office of special education programs, individuals with disabilities education act (idea) ). this has resulted in larger online classrooms with more diversity of students. although there is much research on the effectiveness of differentiation in the brick and mortar k- classroom (baumgartner et al. ; doubet ; valiandes ) and on the best practices of how teachers define and enact differentiation (archambault et al. ; westberg and daoust ) , there are few studies found on the use of differentiation in virtual schools. one study found that teachers struggle to find ways to differentiate instruction (beasley & beak, ) , but beyond that, no research compares differentiation practices of teachers across different types of virtual schools. in order to begin to explore the differentiation practices of virtual teachers, this research will ask the following research questions: . how do virtual school (vs) teachers differentiate teaching practices in an online classroom? . how do the differentiation practices of vs teachers compare across diverse kinds of online schools? literature review a differentiated approach to instruction is informed by principles that include providing high quality curriculum, utilizing flexible grouping, and administering ongoing assessments within a community that respects learning activities that are challenging for all students (tomlinson, ; . differentiation has often been confused with the term "personalized learning" and for the purposes of this study, it is important to distinguish between the two. dewaters ( ) stated, "personalized learning occurs when teachers and students work together to develop a personalized pathway to student learning" (p. ). dewaters ( ) claimed personalized learning diverges with differentiation in its highlighting of student interests, needs, readiness, and motivation. this global definition can encompass many instructional methods. in practice, many virtual schools use this term to promote learning that is student selected and student guided. in contrast, differentiated instruction is facilitated by the teacher working in partnership with the student needs. at times, a differentiated lesson may take on the aspects of a personalized learning assignment, but ultimately the learning experiences are guided by learning goals with the teacher facilitating the process (tomlinson b) . the literature has defined differentiation in practice primarily through research in the traditional face-to-face classroom (tomlinson, ; turner and solis ) . when observing classrooms, teachers who exhibit fidelity to the model of differentiation a) gather information to tailor instruction to student interest and learning profile as well as readiness to learn the topic or state standard, b) foster classroom community, c) group students flexibly, and d) utilize formative assessment for learning (doubet ) . these noted classroom indicators are supported by research in cognitive learning (bransford et al. ) . a successful learning community is knowledge-centered (bransford et al. ; miller & hudson, ) , learner-centered (ainley, hidi, & berndorff, ; bransford et al. ; tomlinson et al. ) , as well as assessmentcentered (bransford et al. ; glaser, chudowsky, pellegrino, ) . differentiated instruction has been shown to have a positive impact on student achievement (baumgartner et al. ; doubet ) . the best practices of teachers who differentiate instruction involve (a) the collection of information about student interests, learning profiles, and student readiness; (b) cultivation of a community in the classroom, (c) distribution of students into groups that can be easily changed based on the activity, and (d) use of formative assessment for learning (doubet ) . in differentiated classrooms, community is strengthened through the use of formative assessments that teachers use to determine student readiness, interest and learning profile to access a student's knowledge, skill, and/or understanding during a learning experience. however, there is little research or literature on what differentiation looks like in the virtual school classroom. how do teachers in virtual schools differentiate their instruction, and what does it look like across different types of virtual schools? during the covid- crisis, many schools required teachers to transition to online instruction (borup, jensen, archambeault, short, & graham, ) . however, online education has been growing even before this recent crisis, making it important to uncover best practices of differentiation in virtual schools. key aspects of teaching in a face-to-face classroom may look different online, but it will always be important for teachers to meet the needs of all students (bransford et al. ) . in this section we will briefly discuss online education and best practices in online teaching. forty-four of states reported online learning opportunities for k- students. virtual schools have grown both in numbers and in scope of offerings (gemin and pape ) . a virtual school refers to k- online learning programs offered fully online by an educational organization where students can earn credit toward graduation or promotion to the next grade level. despite this growth, evidence for achievement gains in virtual schools is poor (woodworth, raymond, chirbas, gonzalez, negassi, snow, & van donge, ; cremata, davis, dickey, lawyer, negassi, raymond, & woodworth, ) . most research focusing on student achievement in virtual schools has found them to be significantly less effective than brick and mortar schools (minnesota office of the legislative evaluator, ; woodworth et al., ) , though at least two studies found greater academic gains than in brick and mortar peers (wang & woodworth, ) . with that said, low student achievement is very common in virtual schools. over four years, colorado online schools yielded three times more dropouts than graduates. additionally, the scores of virtual school students' on state tests were, on average, to percentage points below the state average in reading, writing and math (hubbard& mitchell, ) . researchers in ohio examined achievement trends by students' achievement in their prior, comprehensive public school (cps) and found that students in virtual schools are performing worse on standardized assessments than their peers in traditional charter and traditional public schools (ahn and mceachin ; also tucker et al. ) . technology may offer great promise for the future of education, but the data is not showing that it isn't necessarily benefiting virtual schools. virtual schools do have potential advantages, such as accommodating schedules and a broader span of courses than may be offered locally. virtual schools can also serve disabled students who have difficulties attending in-person classes on a regular basis (miron and gulosino ) . some of the reported benefits of virtual schools include offering convenient lessons that fit a learner's schedule, enabling students who have other obligations during the daytime hours to finish their educational goals, and providing additional time periods for learning. virtual schools may also act as a shelter for cps students who have experienced bullying. these advantages may be some of the reasons why virtual schools receive high levels of student, parent and teacher satisfaction. teaching with a student's needs in mind is at the center of the philosophy of differentiation, which is explained in the next section. in this study, three virtual schools located in the mid-southern united states participated in focus group interviews over the course of the - academic year. ninety-two teachers were interviewed using a focus group protocol that was designed to gather information specifically in five categories: ) definition; ) curriculum; ) assessments; ) grouping; and ) strategies. approximately students attended four virtual schools in this mid-southern u.s. state during the - school year. three of the schools chose to participate in this study -two charters and one district-based. teachers from these schools were interviewed in focus groups to find out more about their differentiation practices. table represents the schools included in the study, pseudonyms are used for schools and individual teachers. the research questions for this study were: how do the differentiation practices of vs teachers compare across diverse kinds of online schools? a total of virtual classroom teachers were interviewed from three virtual schools located in the mid-southern united states (table ) . of those teachers interviewed, % of the participants self-identified as female and % of the participants self-identified as male. % of the participants reported to have or less years of teaching experience, % reported to have - years of teaching experience and % reported having or more years of teaching experience. % reported to have less than years of experience teaching online. a total of focus groups were collected over the course of a year. participants were contacted through the virtual school administration in september , researchers contacted each virtual school and asked permission to interview teachers either face-to-face or online. after obtaining institutional permission, administrators from each school provided dates and times for focus group settings. both researchers conducted focus groups for all three schools, with a maximum of teachers per group. for this study, teachers from the three schools participated in the focus groups (table ) focus groups were held with teachers in each school according to their academic subject area or specialty in late february, . the focus group protocol consisted of questions based on results of a previous survey of virtual school teachers' beliefs about differentiation. researchers chose focus group protocol as a way to verify the results of the survey used in the previous research study. as opposed to an interview, in a focus group discussion, researchers adopt the role of a "facilitator" or a "moderator." this allows the researcher to facilitate or moderate a group discussion between participants and not between the researcher and the participants. unlike interviews, the researcher thereby takes a peripheral, rather than a center-stage role in a focus group (bloor et al. ( ) ; johnson ( ) . after transcription, researchers examined focus group transcripts and code them based on tomlinson's differentiation work ( a). the interview protocol consisted of questions based on the teachers' responses at the focus group. an interview protocol was created by the researchers in response to findings from a previous study (beasley & beak, ) . this research revealed that ) online teachers understood the importance of getting to know their learners, but their practice contradicted that belief, ) online teachers report that they need to differentiate content, product, and process, and ) there was little mention of using assessment to inform instruction. this study built upon the findings of the previous work by focusing on further defining what teachers are doing to differentiate in the classroom, and comparing these practices across types of virtual schools. questions were centered on the three findings of the previous research (table ). the questions were also aligned with the principles of differentiation as defined by the previous research and literature review. this alignment to previous research and literature were important in order to build upon the findings by both the authors and experts in the field. of particular interest was finding out how virtual teachers are using assessment in their online classroom. the questions were kept purposefully open ended in order to facilitate discussion. data analysis of focus group transcripts occurred in two phases. first, a grounded theory approach (strauss and corbin, ) was used to code the data set. developing an initial codebook included the code, a definition of the code, and guidelines for using the code. afterwards, the researchers used those codes as they analyzed for themes finding respectful tasks* *based upon the work of tomlinson ( a tomlinson ( , b from the participants' responses. the goal was to reach categorical saturation (lincoln & guba, ) . a confirmatory analysis was also conducted through the use of a second coder. we then adapted hedrick's "ascending levels of intellectual demand ( ) for differentiation as a coding scheme for understanding how novices transition to apprentice, practitioner, and expert levels. hedrick's ( ) original framework looked at ways that educators grow in their understanding and application of differentiation in brick and mortar classrooms and this was considered as we identified ways teachers spoke about their use of differentiation in virtual classrooms (fig. ) . due to the lack of literature when it comes to how differentiation is being applied and defined in k- vss, the researchers applied the ascending levels of intellectual demand (aid) to participant responses. for this study, novices were noted by their lack of clarity of definition and application of differentiation. they tended to teach as if the whole class were the same. apprentices were more likely to tolerate some ambiguity and begin to see groups of students with similar needs. practitioners were able to apply the principles of differentiation in multiple ways fig. ascending levels of intellectual demand: differentiation and begin to utilize assessment data to change assignments for varying groups of students. finally, experts were able to begin to see students individually and plan proactively on a consistent basis. further characteristics are discussed for each level (e.g. "unsettled by the ambiguous nature of differentiation" in novice level) and thus developed a coding scheme that described how each of these descriptions looked in a vs. focus group transcripts were coded using this scheme. results on research question : how do vs teachers differentiate teaching practices in an online classroom? the interviews resulted in findings that were categorized by levels of differentiation but also allowed researchers to hear about the practices of virtual teachers. salient quotes were identified to communicate the findings in the area of ) defining differentiation, ) curriculum, ) grouping, ) teaching strategies, and ) assessment. similar to the initial research, vs teachers' definitions were more novice in nature. vs teachers spoke about differentiation being "different for different students" (novice, item ). a quote by one teacher exemplified this, "...differentiation to me, i think it's about the root word...to be different. if you are differentiating you're cooking outdoors, then you make changes to your cooking that make it look different than cooking in a kitchen" (vs , creative school). a more expert level response was demonstrated by two vs teachers, "...differentiating is based a lot on the relationships you build with the students. we learn about their past educational experiences, what their goals are for the future, and what obstacles might be in their path so that you can modify and adjust the way that you present material and help them to engage" (vs , creative school). many of the responses to curriculum in a differentiated classroom sought solutions that were already a part of their existing repertoire (novice, item ). very few vs teachers made connections across disciplines or saw ways to modify content, process, or product. one teacher from filmore virtual school noted, "i differentiate my lesson by changing the number of examples i give students who are farther along in the lesson. i also reduce the number of answers in a multiple choice for struggling students." a more practitioner level response demonstrated, "i look at my curriculum and see where students are both content wise, but also engagement wise. i try to engage student personal interests -and that looks different in different disciplines" (vs , filmore school). in the area of grouping, there were fewer comments than other categories. of the distinct quotes examined as a part of this study, directly correlated to grouping. this may be that many of the school lms systems did not allow many types of grouping strategies, or it could have been due to the fewer number of students in the "live sessions." as with other categories, the majority of vs teachers situated themselves within the novice level, primarily item that focuses on challenges instead of benefits. one example was, "i don't necessarily group, but i do allow them to chat with one another through our social discussion groups" (vs , filmore school). another identified this as an area for improvement, "if they don't call in, they don't show up, so they're not part of any grouping. i think this is my downfall" (vs , creative school). teaching strategies noted by the teachers were typically categorized by what they did when they were brick and mortar teachers (novice, item ). an example of this was by a teacher from the valentine school, "...sometimes you just revert back to some of the tools that you had when you were in a face-to-face classroom -like i would put a math problem up on the whiteboard and discuss the answer." one vs teacher had a more expert level answer (one that models differentiation with flexibility and fluency): "i really set out to gamify my class and it has done a world of good. my students have made so many gains both in engagement and academically" (vs filmore school). the area of assessment was more informative than in our last research study (beasley & beak, ) , representing % of the quotes being analyzed. previously, we found that very few vs teachers spoke about how they used assessment in a differentiated classroom. however, during this study's focus groups, one teacher noted "...sometimes we have to dig a little deeper -it's not exactly what it says when you first look at data-you have to start to talk with kiddos to find out what they need in our classroom" (vs , creative school). another answer that identified at a more practitioner level (item ) was: "i would say that most of the time (assessment) helps me to understand that a student may have to show me their answer in more than one way -not just a written answer" (vs , creative school). results for research question : how do the differentiation practices of vs teachers compare across diverse kinds of online schools? the results of the comparison of differentiation practices using these levels of differentiation are presented in table . the numbers in each cell represent the number of times that teachers in each school mentioned something that was coded as a definition, assessment, grouping, or strategy, and at which level. for all three virtual schools, the vast majority of teacher comments about differentiation definitions, assessments, curriculum, grouping and strategies fell in the novice category. teachers who made these statements showed evidence of being new or inexperienced to differentiated instruction. also, all three schools show a reduced, but still robust presence of comments in the apprentice column. this means that these teachers shared comments that showed that they knew more about differentiation of instruction and practiced it more than did novices, but still fell short of regular practice and expertise. an interesting contrast is found when comparing filmore virtual (district-based charter school) teachers' responses to that of the other schools at the practitioner or expert level for definitions, assessments, grouping, and strategies. filmore teachers had % of their responses coded at the practitioner and expert levels, while create and valentine virtual schools had higher levels of differentiation. however, filmore virtual school did show evidence of differentiation in the curriculum category at the practitioner and expert levels. another item that stands out in the data is that valentine virtual school appears to have much more expertise in their definitions of differentiation, which you might expect from the oldest statewide virtual school. also of note is that create virtual school appeared to have the most evenly spread distribution of comments about differentiation across the apprentice, practitioner, and expert levels of differentiation in all of the categories of differentiation. comparing differentiated instruction practices across schools by category is helpful in terms of considering some of the larger impacts of different types of virtual schools, but it does little to provide information on the more granular differentiated instruction practices of virtual school teachers. discussion on research question : how do vs teachers differentiate teaching practices in an online classroom? as stated previously, the large majority of teacher comments about differentiation definitions, assessments, curriculum, grouping and strategies fell in the novice category. also, all three schools show a reduced, but still robust presence of comments in the apprentice column. this falls in line with current statistics showing that virtual schools have grown both in numbers and in scope of offerings (gemin and pape ) . such large growth would most likely result in a large number of teachers who are untrained in online instruction. this also confirms research by kennedy and archambeault ( ) about the lack of teacher training to teach online, as well as the lack of training in how to lead and administrate instruction online. as seen in this study, this lack of confidence to differentiate is also in line with literature in the field. the most recent u.s. survey on preparation (bowsher, sparks, and hoyer, ) reported that % of teachers in their first year of teaching felt unprepared to differentiate instruction in the classroom. this same report noted that early career teachers need common planning times and regular support in order to increase in expertise. unless time is given for virtual teachers to receive professional development in differentiation, movement towards expertise may be impeded. many of the virtual school teachers' responses to curriculum in a differentiated classroom sought solutions that were already a part of their existing repertoire and had difficulty flexibly grouping. this confirms research by dixon, yssel, mcconnell & hardin ( ) that when adopting new strategies and techniques, teachers need multiple experiences to build efficacy. this literature suggests that novice teachers start by adopting new routines before working on more high preparation strategies or adjusting curriculum. it also supports research from the diffusion of innovations field that discusses the sometimes lengthy process that most people go through before they fully adopt an innovation as paradigm-shifting as the differentiation process (rogers ) . flexibility of instruction is another obstacle that is prevalent in the literature on differentiation (doubet ; tomlinson ; tomlinson et al. ) . in this study, vs teachers struggled to think of grouping strategies within the confines of their classroom. this study provided a look into the use of assessment in the differentiated classroom. it was revealing here to focus on what the few teachers who identified at a practitioner or expert level said about assessment. they focused on finding multiple means to assess student understanding and digging deeper to determine student needs. this corroborates research by tomlinson and moon ( ) that stresses assessment as imperative to differentiation. without knowing where students are, it is impossible to chart a personalized course for each student to reach the lesson's goals. although vs teachers were not utilizing assessment in the same way, all identified it as fundamental to differentiating instruction. discussion on research question : how do the differentiation practices of vs teachers compare across diverse kinds of online schools? a result that was mentioned previously was the comparison of filmore virtual (districtbased charter school) teachers' responses to that of the other schools at the practitioner or expert level for definitions, assessments, grouping, and strategies. this confirms previous research with virtual school teachers in the area of assessment (beasley & beak, ) . filmore teachers had % of their responses coded at the practitioner and expert levels, while create and valentine virtual schools had higher levels of differentiation. recalling that filmore virtual's is a new virtual school may help interpret this data. as a new virtual school that is district based, filmore virtual has used its own brick and mortar teachers as online course instructors. as a result, the relative inexperience of filmore's teachers with online learning may be the reason that they showed no evidence of differentiation at the practitioner or expert levels. however, filmore virtual did show evidence of differentiation in the curriculum category at the practitioner and expert levels. this may be due to a widespread belief among virtual school administrators that when a school first begins to provide online courses, there is overreliance on the online courses to differentiate instruction. this may also be due to research in differentiation that indicates that the act of differentiating is a highly nuanced skill that requires embedded training. tomlinson ( ) states: "for all its promise … effective differentiation is complex to use and thus difficult to promote in schools. moving toward differentiation is a long-term change process" (p. ). as a result, filmore virtual school teachers may be experiencing this long-term change process that tomlinson describes. to help move novice teachers along the continuum towards expertise, teachers may need to learn more about the strengths of virtual schools in finding ways to respond to student needs. in the beginning, virtual school teachers will need to know about and help students to take advantage of such things as accommodating schedules and a broader span of courses than other schools can potentially increase student engagement by pairing students with courses that are a good match for them while allowing them to take them at their own pace. they can also equip disabled students who have frequent medical appointments to attend virtual school classes and complete assignments on time. as teachers grow in their knowledge of differentiation, they can begin to learn more about how the community of virtual schools can act as a shelter for cps students who have experienced bullying. virtual school teachers can begin to weave community building, curriculum and assessment with flexible instructional decisions to accommodate for student differences. these advantages may be some of the reasons why virtual schools receive high levels of student, parent and teacher satisfaction compared to cps. another result mentioned that valentine virtual school appears to have much more expertise in their definitions of differentiation, which you might expect from the oldest statewide virtual school. many of the larger virtual school providers have defined programs of professional development for their teachers, and valentine virtual is included in this program (gemin and pape ) . they have a professional development (pd) program for all teachers that includes their own approach to best practices for online teaching. this pd program appears to have been successful in helping teachers understand the definition of differentiated instruction. this confirms what tomlinson and allan ( ) have suggested, that an educational leader may first want to assist teachers in defining differentiation as a first step to understanding what it is and is not. as virtual teachers begin to grow, leaders need to ensure that a common definition is identified. however, according to our data, this experience and training has apparently only been implemented successfully in the grouping category, but not in assessments, curriculum or strategy. although it is promising that valentine virtual teachers possess expertise in defining differentiation and in grouping, it is concerning that it hasn't impacted assessments, curriculum, or strategy, particularly because of these areas' proven impact on student achievement (baumgartner, lipowski, & rush, ; doubet ) , and particularly on student performance on standardized assessments (ahn and mceachin ; also tucker et al. ) . in the study, create virtual school appeared to have the most evenly spread distribution of comments about differentiation across the apprentice, practitioner, and expert levels of differentiation in all of the categories of differentiation. there may be many reasons for this even distribution, but one could be due to the hiring practices at create virtual school, which appear to focus on hiring more experienced teachers regardless of whether they have online experience. this hiring practice may have resulted in create virtual school teachers who are experienced with differentiating instruction in brick and mortar environments and who are learning to apply similar principles in online learning environments. it could also point to the ability to transfer differentiation skills across different kinds of learning environments, something that could increase quality of instruction in online schools, which is sorely needed (woodworth et al., ; cremata et al., ) . comparing differentiated instruction practices across schools by category is helpful in terms of considering some of the larger impacts of different types of virtual schools, but it does little to provide information on the more granular differentiated instruction practices of virtual school teachers. in this study, there were limitations that may have impacted the results. the small sample size of virtual classroom teachers does not allow the researchers to generalize across all contexts. another limitation was the instrument used to identify novices to experts in differentiation. the subjectivity of the aid when analyzing participant responses may have resulted in errors. finally, the lack of research in the topic does not allow for corroboration with other experts in the field. increasing the number of participants in the future may enhance the generalizability of the findings. research on the practice of differentiation is ongoing, both in the brick and mortar school as well as the virtual school. this research helped to reveal the differentiation practices of teachers across different types of virtual schools. it also made clearer some of the differences between the differentiation practices of expert online teachers and those who are less than expert. this is significant because little research has been done to discover the expert differentiation practices of online teachers. discovery of these practices should help to create professional development for all online teachers that is focused on building teachers skills in differentiation specific to the online learning environment. continued research on professional development in differentiation can reveal the connection between differentiation and increased online teacher efficacy (dixon et al. ) . previous research in virtual schools has found that teachers struggle to find ways to differentiate instruction. for example, it has shown that online teachers report that they need to differentiate content, product, and process, and also comprehend the importance of learner profiles. however, their practice contradicts their beliefs. actual practice shows that they do not use learner profiles as part of differentiation, and there is little mention of the use of assessment to inform instruction. the current study showed that newer virtual schools may struggle to acquire teachers who differentiate instruction at the practitioner and expert level. this points to a need to further investigate the instructional practices of the teachers who were practitioners and experts in the different categories of differentiation. future research should explore these expert and practitioner practices and seek to develop professional development interventions that are effective in helping teachers to differentiate instruction at these higher levels. a follow up study is planned where teachers whose responses demonstrated practitioner or expert levels of differentiation (tomlinson a (tomlinson , b will be invited to participate in a follow up interview that focuses on better understanding their expertise in differentiating instruction in a virtual school. the current study also showed that even experienced virtual schools may be effective in one area of differentiated instruction yet fail to deliver in others. other research has shown that obstacles to differentiation may be technological, instructional, administrative, and organizational in nature (aldossari ; doubet ) . future research should investigate what kind of obstacles may be hindering application of differentiated instruction in the areas of assessment, curriculum, and strategies, as well as considering potential solutions to overcome these obstacles. if curricular or technological obstacles to differentiation of instruction exist, curriculum and software designers should consider how to remove those obstacles while maintaining other development priorities. additionally, future research can examine how schools can partner with designers and developers of online curriculum to allow for maximum differentiation. student enrollment patterns and achievement in ohio's online charter schools interest, learning, and the psychological processes that mediate their relationship the challenges of using the differentiated instruction strategy: a case study in the general education stages in saudi arabia regular classroom practices with gifted students: results of a national survey of classroom teachers increasing reading achievement of primary and middle school students through differentiated instruction defining differentiation in cyber schools: what online teachers say supporting students during covid- : developing and leveraging academic communities of engagement in a time of crisis society for information technology & teacher education preparation and support for teachers in public schools: reflections on the first year of teaching supporting students during covid- : developing and leveraging academic communities of engagement in a time of crisis how people learn: brain, mind, experience, and school national charter school study: research report getting personalization right. the reading teacher differentiated instruction, professional development, and teacher efficacy teacher fidelity and student response to a model of differentiation as implemented in one high school (order no. ) keeping pace with k- online learning knowing what students know. the science and design of educational assessment ascending levels of intellectual demand within and beyond the parallel curriculum model troubling questions about online education. colorado: ednews. education and information technologies designing and implementing mathematics instruction for students with diverse learning needs it is good to talk': the focus group and the sociological imagination minnesota office of the legislative auditor virtual schools report the diffusion of innovation leadership for differentiated classrooms how to differentiate instruction in academically diverse classrooms let's celebrate personalization: but not too fast how to differentiate instruction in mixed-ability classrooms an educator's guide to differentiating instruction differentiating instruction in response to student readiness, interest, and learning profile in academically diverse classrooms: a review of literature assessment and student success in a differentiated classroom ohio e-schools: learning from their experience the misnomers of differentiating instruction in large classes individuals with disabilities education act (idea) database evaluating the impact of differentiated instruction on literacy and reading in mixed ability classrooms: quality and equity dimensions of education effectiveness evaluation of rocketship education's use of dreambox learning's online mathematics program the results of the replication of the classroom practices survey in two states online charter school study key: cord- -ehrww uu authors: bender, andreas; jenkins, jeremy l.; li, qingliang; adams, sam e.; cannon, edward o.; glen, robert c. title: chapter molecular similarity: advances in methods, applications and validations in virtual screening and qsar date: - - journal: annu rep comput chem doi: . /s - ( ) - sha: doc_id: cord_uid: ehrww uu this chapter discusses recent developments in some of the areas that exploit the molecular similarity principle, novel approaches to capture molecular properties by the use of novel descriptors, focuses on a crucial aspect of computational models—their validity, and discusses additional ways to examine data available, such as those from high-throughput screening (hts) campaigns and to gain more knowledge from this data. the chapter also presents some of the recent applications of methods discussed focusing on the successes of virtual screening applications, database clustering and comparisons (such as drug- and in-house-likeness), and the recent large-scale validations of docking and scoring programs. while a great number of descriptors and modeling methods has been proposed until today, the recent trend toward proper model validation is very much appreciated. although some of their limitations are surely because of underlying principles and limitations of fundamental concepts, others will certainly be eliminated in the future. molecular similarity [ ] [ ] [ ] [ ] follows, in principle, a simple idea: molecules which are similar to each other exhibit similar properties more often than dissimilar pairs of molecules. this is often written as the relationship which leaves open two major questions: . how to represent molecular structure (the connectivity table or the coordinates of atoms are not per se suitable choices)? . what is the functional form between structure (or rather structural representation) and the property under consideration so that we can derive an empirical measure of similarity? in order to explicitly include both challenges mentioned one can reformulate to give mðpropertyÞ ¼ f ðgðstructureÞÞ where m is the measurement outcome of a molecular property concept (such as log p as a surrogate measure of 'lipophilicity'), g represents the transformation of a molecular structure into a 'descriptor' which is amenable to a statistical analysis or machine-learning treatment and f connects experimental measurement and structural representation. both steps are generally independent of each other, although some combinations of molecular representation and model generation technique are more sensible than others. the problem in establishing a suitable function g, which translates a molecular structure into a descriptor representation, is that it is usually not known a priori which molecular features contribute to a certain property. for example, some functional groups in ligand-receptor binding will establish ligand-receptor interactions, while others simply point into bulk solvent. often a large number of descriptors need to be calculated in order to (hopefully) capture the relevant factors for a certain molecular property, since often no direct experimental observation is known. the problem in establishing a function f, which correlates descriptor representation and property is that its functional form is also usually not known. again, no underlying theory exists and its character can vary between two extremes. linear regression, for example, represents a simple functional form between input and output variables with the advantage of a very small number of free parameters -and following occam's razor it should be applied in cases where there is a sound physical reason to believe in an underlying linear relationship between input and output variables. at the other end, neural networks are able to model any (also nonlinear) relationships between input and output variables. however, they depend on a large number of variables, which may lead to spurious correlations. often the choice of a functional form, in the absence of physical laws, is governed simply by trial-and-error. the problems in establishing the optimal choice of f and g are increased by the fact that the relationship between structure and measured property (the only relationship available from experimental data!) is rarely given over a large region of chemical space. data are sparse -estimations of the size of the chemical space for typical drug molecules [ ] (up to heavy atoms) are in the region of , experimental datasets on a property of interest are rarely available for more than compounds and are often considerably smaller. a solution to the problem of identifying the 'best' molecular descriptor will never be fully established -for both practical reasons (the limited size of datasets) and theoretical reasons. a wide variety of different features are important for each property and the functional forms between descriptor representation and property can usually not be established from physical laws (and thus cannot be optimized analytically). still, we can establish empirical measures of molecular similarity to predict some particular properties better than others, tested on some of the more or less restricted datasets available. this review deals with both novel molecular representations, function g from above, as well as novel model generation and machine learning methods, function f from above. as soon as a relationship between molecular representation and a particular property's values is established a crucial question arises: how good are predictions for novel molecules? ideally, all of chemical space would be covered with zero error. limits in descriptor generation as well as in experimentally available data clearly prevent us from reaching this goal. still, in order to establish confidence in models in practical settings, this requirement can be replaced by the question: which area of chemical space is covered with acceptable error? different methods (best known among them are approaches like crossvalidation), attempt to provide empirical answers to this question. intuitively one might guess that for the question which region is covered by a given model, the distance of compounds from the training set to the novel compounds whose properties are to be predicted is relevant. this is indeed the case, as has been established in recent articles (see section ) . the question of how good predictions for novel compounds are is often established by cross-validation, where portions of the available datasets are, in turn, taken as an external test set, while the remainder of the dataset is used for training purposes. the test set thus attempts to simulate a novel set of molecules, unknown to the training phase of the model and root-mean-square errors (rmse) or cross-validated correlation coefficients (q ) on the test set are often reported as a measure of the generalizability of models. recently, it has emerged that cross-validation actually shows merely that a model is internally consistent, but not necessarily predictive for new compounds. the question of how reliability of models can be assured is also discussed in section , and indeed several recent publications propose approaches to determine the 'domain' of models (the area in which they are applicable, see section for details). conventionally, enrichment over random selection is often cited, giving an estimate of how many more active compounds are retrieved from a database than by pure chance. while this measure is correct in the way it is calculated, more recently the performance of 'sophisticated' fingerprints has been compared to trivial features, namely counts of atoms by element, without any structural information [ ] . the performance ratio of 'state-of-the-art' methods (i.e., circular fingerprints and unity fingerprints) to those 'dumb' descriptors can then be interpreted as the 'added value' of more sophisticated methods. soberingly, on many datasets of actives 'real' fingerprints do not perform significantly better than atom counts (see fig. ). this also relates to the suitability of current databases employed for retrospective virtual screening runs, which are often derived from the mddr [ , ] . while on the one hand, multiple activity classes are present, those datasets still possess two major disadvantages; first, no information about definite inactivity of compounds is contained in the database. still, if experimental data for retrieved hits are subsequently obtained, many of the 'false-positive' predictions may well be active. second, following bioisosteric considerations in combination with 'fast follower' approaches to synthesis, it should be noted that this database contains a large number of close analogues. the hit rates obtained on this dataset may thus be overly optimistic compared to real-world libraries employed for virtual screening. still, the two databases referenced above, which are both subsets of the mddr, were very important as they enabled comparison of similarity searching approaches on multiple, identical datasets. we would also like to emphasize that more suitable datasets are too often -unfortunatelyunavailable from the pharmaceutical and biotechnology companies. in the following sections, we will also cover other recent developments in some of the areas, which exploit the 'molecular similarity principle'. section will present novel approaches to capture molecular properties by the use of novel 'descriptors'. since molecular descriptors and the methods used to analyze the data they represent cannot be separated easily, the second part of this section also covers novel data analysis methods. section focuses on a crucial aspect of computational models -their validity. in the previous few years, about two dozen publications that focused on 'model validation' have appeared, an area which shall be summarized in this review. finally, sections and turn to the application of the methods described earlier. in section , we discuss additional ways to examine data available such as those from high-throughput screening (hts) campaigns and to gain more knowledge from this data. section describes some of the recent applications of methods described in the preceding sections, focusing on successes of virtual screening applications, database clustering and comparisons (such as drug-and in-house-likeness) and recent large-scale validations of docking and scoring programs. we will now describe some of the recent developments in the calculation of molecular descriptors. pot-dmc [ ] (short for potency-scaled dynamic mapping of consensus positions) takes not only the (binary) activity of a compound into consideration for virtual screening applications, but also the quantitative activity of a structure. accordingly, each bit of the descriptor vector (which consists of a combination of one-, two-and three-dimensional ( d, d and d) features) is multiplied depending on the ic value of the compound. scaled bits are summed and normalized at each position. afterward, the descriptor can be used for virtual screening. when applied to a database of ccr chemokine receptor antagonists, serotonin receptor agonists and gonadotropin-releasing hormone agonists, the method overall did not retrieve a larger number of structures -but those which were retrieved were, as intended, of higher activity than in cases where no scaling according to activity was applied. the fepops [ ] (feature points of pharmacophores) descriptor aims to exploit a (relative) advantage of d descriptors, the ability to discover novel scaffolds against a given target, based on active sample structures. after generation of tautomers and conformers, k-means clustering of atomic coordinates is performed. thus, no knowledge about the active conformation of a structure is necessary. interaction types are assigned to characteristic 'feature points' in a subsequent step, and are again subject to k-medoids clustering to reduce redundant conformer coverage. cluster representatives can now be used for similarity searching. validations are presented using both mddr (cox- , hiv-rt and ht a inhibitors and ligands, respectively) and in-house datasets. in addition, it was shown that inhibitors can be identified from a database, based simply on endogenous ligands (for dopamine and retinoic acid). a completely different path is followed by the lingo [ ] approach, which is based on a textual representation of molecules. based on the smiles string of a structure, and without time-consuming conversion and descriptor generation, a molecule is represented by a set of overlapping 'lingos', each of which represents a substring of the complete smiles structure. while being a straightforward concept (in the best possible sense), favorable performance is presented on log p and solubility datasets, where cross-validated rms errors are . and . log units, respectively. the descriptor also shows applicability to bioactivity, where significant discrimination between bioisosteres and random functional groups can be observed. reduced graph descriptors have been the subject of interest for a considerable time, and recently further work was performed in this area with success. earlier comparison algorithms of reduced graphs represent the graph as a binary fingerprint, sometimes leading to molecules perceived as similar by the algorithm, which are not similar to the eyes of most chemists. this problem was recently addressed [ ] by applying 'edit distance' measures to the similarity of compounds -the number of operations needed to transform one reduced graph structure of a molecule into another. through this emphasis of not only the fragments present in reduced graphs, but also the way in which they are connected, better agreement with the human perception of 'molecular similarity' could be achieved. molecular binding can be thought of as being mediated by complementary shapes and matching properties -where, due to solvation and other effects, 'matching' does not only mean complementarity. accordingly, a 'shape fingerprint' method has recently been presented [ ] which implements shape similarity measures akin to volume overlap methods, but which, due to the employment of database-derived reference shapes, is several orders of magnitude faster. (note of course that shape also plays an important role in other areas of science [ ] .) employing gaussian descriptions of molecular shape, about shape comparisons can be performed per second and the resulting shape similarity was shown to be useful in virtual screening applications. only some parts of a ligand bound to its target will actually interact with the target, other parts will just be pointing into the bulk solvent. by analyzing the variability of ligands' regions, features which correspond to each of the regions can be inferred -molecular features which are involved in ligand-target interactions will be more highly conserved than those which point into the solvent, due to the stricter requirements imposed on them. the 'weighted probe interaction energy (wep) method' [ ] exploits exactly this principle, and can be used to derive ligand-based receptor models. this was applied to the steroid dataset (which is well known from comfa studies) a set of dihydrofolate reductase (dhfr) inhibitors as well as hydrophobic chlorinated dibenzofurans. in particular, the dhfr model was able to elucidate interactions relevant to binding which very closely resemble the target-derived model complex. previously applied to the calculation of inter-substituent similarities, which might be exploited for the identification of bioisosteric groups [ ] , the r-group descriptor (rgd) was more recently also the subject of qsar investigations [ ] . the rgd describes the distribution of atomic properties at a distance of n bonds (n ¼ , , y) away from a core that is common to a series of compounds. in combination with partial least squares the descriptor was applied to several datasets for qsar studies, comprising of benzodiazepin- -ones active at gaba a , triazines exhibiting anticoccidal activity and a set of tropanes active at serine, dopamine and norepinephrine transporters. rgdss in combination with pls showed comparable performance overall to hqsar and eva models in a cross-validation study, in some cases outperforming the other qsar approaches. another alignment-free method for the time-efficient generation of qsar models is fingal [ ] (a short and straightforward acronym for 'fingerprint algorithm'). unlike rgds, a hashed fingerprint is generated which encodes structural features of the molecule, where distances may be measured either topologically or by employing spatial information between atoms. applied to d ligands, the d version of fingal, in particular, was able to outperform comfa-and comsia-based approaches. for estrogen ligands, performance was highly dependent on the structural class of compounds, not only for fingal but also for models based on comfa, hqsar, fred/skeys (fast random elimination of descriptors/substructure keys) and dragon descriptors. in subsets such as a pesticide subset, no model was obtained via comfa (correlation coefficient of zero), whereas fingal gave correlation coefficients as high as . in a cross-validation study. the grid force field [ ] has been the basis of a number of descriptors developed recently, among the best-known ones being the grind descriptor [ ] . some extensions of the descriptor have been presented recently, which include the incorporation of shape [ ] into the descriptor. it was recognized that molecular shape is a major factor determining ligand-receptor binding, a property that was previously not emphasized enough by the original grind descriptors. this was due to the fact that only maximum products of interactions are incorporated into the descriptor, omitting large lipophilic features which do not contribute significantly to calculated interaction energies with probes, but might still have profound influence on binding through steric effects. introducing the new 'tip' probe (which is not a probe in the traditional sense but a measure of curvature of the molecular surface) led to significant improvements in qsar studies of adenosine receptor antagonists (of the xanthine structural class) and plasmodium falciparum plasmepsin inhibitors being observed. interestingly, tip-tip correlations were also found to be the most significant descriptors in case of a antagonists, showing the importance of the shape descriptor on this class. the second development was the 'anchor-grind' approach [ ] , which focuses on user-defined features to calculate a distribution of interaction points relative to it, thereby incorporating pre-existing biological knowledge about a target. models are found to be both of better quality and easier to interpret on congeneric series of hepatitis c virus ns protease and of acetylcholinesterase inhibitors, as well as more discriminatory between factor xa inhibitors of both high and low affinity. a virtual screening methodology also based on the grid force field was developed recently [ ] . this method was validated on a large dataset containing thrombin inhibitors and also showed potential to select suitable replacements for scaffolds typically encountered in the lead optimization stage. a molecular 'descriptor' which actually does not employ an explicit transformation of the molecular structure into descriptor space was recently presented [ ] . it employs a graph kernel description of the structure in combination with support vector machines (svms) for regression analysis. the computational burden is alleviated through employing a morgan index process as well as the definition of a second-order markov model for random walks on d structures. the method was then validated on two mutagenicity datasets. while already exhibiting the ability to capture molecular features responsible for bioactivity (here mutagenicity) in its current form, future developments might include more abstract representations of the molecular scaffold such as some form of reduced graph representation. while the bioinformatics area has a multitude of methods which can be applied to the analysis on d representations of protein sequences and dna, due to branching and cyclization the case is far more difficult for small molecules. one of the few d representations of molecules [ ] , based on multidimensional scaling of the structure from d into d space, has more recently been extended to allow for the alignment of multiple structures [ ] . applied to skc kinase ligands as well as herg channel blockers, significant improvement in retrieval rates could be observed in a retrospective study if multiple (in this case ) ligands were used for screening. the concept of feature trees was also recently extended to allow for the incorporation of knowledge derived from multiple ligands into a single query [ ] , and retrospective screening results on ace inhibitors as well as adrenergic a a receptor ligands showed considerable improvements over searches using single queries, both in terms of enrichments as well as the diversity of structures identified. when structures are encoded in a discrete fashion, 'binning' is often employed in order to convert real-valued distance ranges into binary presence/absence features. this approach is followed in, for example, the cats autocorrelation descriptor in its d version (cats d) [ ] . however, binning borders may introduce artifacts such that feature distances close to each other but on opposites sides of bin borders being perceived to be as different from each other (simply since features do not match) as much more distant features. accordingly, a related descriptor termed 'squid' was recently introduced which incorporates a variable degree of fuzziness [ ] . applied to cox- ligands considerable retrieval improvement was observed, with best performance at intermediate degrees of fuzziness. using cox- ligands as well as thrombin inhibitors in combination with graph-based potential pharmacophore point triangles, typed according to interaction types, features responsible for ligand-target binding could be identified [ ] . in addition, prospective screening was performed and a benzimidazole identified as a potent cox- inhibitor was experimentally found to be active in a cellular assay with high affinity (ic ¼ nm). the ultimate descriptor, in the realm of virtual screening, is the response of the biological system. while structure-derived descriptors are quick and (usually) easy to calculate, they are not the final goal -it is the effect that the compound has in a 'real world' setting. using those biological effects as descriptors, namely percent inhibition values across a range of targets for a number of molecules, the 'biospectra similarity' (the similarity of effects on the respective targets) was established via hierarchical clustering [ ] . it was found that biospectra similarity provides a solid descriptor for forecasting activities of novel compounds and this was validated by removal of some important target classes after which clustering of compounds was overall still very stable. while the response of single targets is already a step toward biology, protein readouts of cell cultures [ ] also incorporate cell signaling networks, thus stepping even closer to whole organism systems (of course at the price of increased complexity and cost involved). also based on biological response data (phenotypic screening) a 'class scoring' technique was recently developed [ ] , which does not assign binary (hit/non-hit) activities to individual compounds but to classes of compounds instead. this way, more robust assignments are achieved as well as a lower number of false-positive predictions. svms have been previously used for distinguishing, for example, between drug-and non-drug-like structures [ ] and recently have been applied in virtual screening [ , ] . using dragon descriptors and a modification of the traditional svm to rank molecules (instead of just classifying them), performance was in this study [ ] validated on inhibitors (or ligands) of cyclin-dependent kinase , cyclooxygenase , factor xa, phosphodiesterase- and of the a a adrenoceptor. compared to methods such as binary kernel discrimination in combination with jchem fingerprints the new approach was found to be superior. the ability of lead hopping was also demonstrated recently through the combination of svms with d pharmacophore fingerprints (defined as smarts queries) [ ] . there is a trend in the recent cheminformatics literature toward ensemble methods, i.e., methods where multiple models (instead of a single model) are generated and used together (as an ensemble) to make either qualitative or quantitative predictions about new instances. random forests [ ] are an ensemble of unpruned classification or regression trees created by bootstrapping of the training data and random feature selection during tree induction. prediction is then made by majority vote or averaging the predictions of the ensemble. on a set of diverse datasets (blood-brain-barrier penetration, estrogen-binding, p-glycoprotein-activity, multidrug-resistance reversal-activity and activity against cox- and dopamine receptors) superior results to methods such as decision trees and pls were reported. more recently, 'boosting' was applied to the same (and additional) datasets [ ] , and as a general rule this new method seems to be slightly superior in large regression tasks, whereas random forests are claimed to excel in classification problems. additionally, employing k-nearest neighbor classifiers, svms and ridge regression in an ensemble approach [ ] gave significant improvement over single classifiers on a 'frequent hitter' dataset. most models derived in qsar studies, for example, ordinary and partial least-squares regression or principal components regression, employ a linear parametric part and a random error part, the latter of which is assumed to show independent random distributions for each descriptor. however, since molecular descriptors never capture 'complete' information about a molecule, this independence assumption is often not valid. kriging [ ] has replaced the independent errors by, for example, gaussian processes. applied to a boiling point dataset and compared to other regression methods (ordinary and partial least-squares and principal component regression) improved performance could be observed. alongside model generation, feature selection is also an important step in many studies. since no perfect descriptors of the molecular system are known, often a multitude of descriptors (often several thousands) are calculated and it is hoped that they capture information, which is relevant to the respective classification or regression task. a comparative study of feature selection methods in drug design appeared recently [ ] , which compares information gain, mutual information, w -test, odds ratio and the gss coefficient (named after the authors, galavotti, sebastiani and simi; a simplified version of the w -test) in combination with the naı¨ve bayes classifier as well as svms. while svms were found overall to perform favorably in higher-dimensional feature spaces (and do not benefit much from feature selection), feature selection is found to be a crucial step for the bayes classifier. (note that this has at the same time been shown empirically in virtual screening experiments [ , ] .) some of the methods, namely mutual information and genetic programing, have also been evaluated separately for their use in qsar studies [ ] with respect to a dataset which showed some (typical) problems present in the area, such as a very different sizes of 'active' vs. 'inactive' data subsets. the problem that structure-activity relationships are rarely linear has been addressed previously through the application of nonlinear methods [ , ] such as k-nearest neighbor approaches [ , ] . more recently, k-nn has also been combined with a comfa-like approach, termed k-nn mfa, to predict bioactivity of a compound based on its k-nearest neighbors in 'field space' [ ] . as discussed by the authors, some of the disadvantages of comfa such as alignment problems are retained; nonetheless, multiple models are produced in each run, giving more room for appropriate model selection. removing limitations of the statistical model is possible using non-parametric models which have recently been used in qsar studies [ ] and were shown to improve results over more conventional regressiontype models. also bayesian regularized networks have been found to be of interest in recent qsar studies [ ] [ ] [ ] . those networks possess inherent advantages including that they run less risk of being overtrained than non-bayesian networks (since more complex models are punished by default). the effect of binary representations of fingerprints has been known for some time, such as combinatorial preferences [ ] and size effects [ ] (depending on the similarity coefficient used). more recently, another aspect of the binary representation of features in a fingerprint has been analyzed [ ] . integer or real-valued representations of feature vectors were calculated for activity classes and employed cats d and cats d autocorrelation descriptors as well as ghose and crippen fragment descriptors. afterward, retrospective virtual screening calculations were performed for both the original (quantitative) representations and the binary (presence/absence) fingerprints. surprisingly, in only out of the cases did significantly different numbers of actives get retrieved (defined as more than % difference). in addition, the retrieved actives showed, depending on the activity class, very different overlap, between % and %, indicating some orthogonality of the same descriptor, differing by its representation (integer/real-values vs. binary format). exploiting the 'molecular similarity principle' by not only looking for neighbors of an active compound and assuming they are active (as is usually done in virtual screening) but also using this knowledge further to improve the model, has recently been exploited in a method called 'turbo similarity searching' [ ] . by feeding back information about the nearest neighbors of an active compound into the model generation step, an increased number of active compounds can be retrieved in a subsequent step. this is analogous to the re-use of hot air in turbo chargers in cars, where the output (hot gas, nearest neighbor in this case) is fed back into the loop to improve performance. a number of publications have appeared recently focusing on the validation of qsar models. a wealth of parameters exist here, such as training/ test/validation set splits, the dimensionality of descriptors used in relation to the number of degrees of freedom of a model, or the way selection of features is performed. while it has been recognized for some time that a larger number of descriptors increases the likelihood of chance correlations [ ] , more recently a discussion of the validity of statistical significance tests, such as the f test, has appeared [ ] which puts the number of features considered into relation to the significance of a model. this study cautions in agreement with earlier work that one needs to be very careful when judging the statistical significance of correlation models if feature selection is applied -and that statistically 'significant' models can hardly be 'avoided' if too large a variable pool is chosen to select features in the first place. since datasets are generally limited in size, a suitable split into training and test set(s) is crucial in order to achieve sufficient training examples on the one hand, and as high as possible a predictivity of the model on the other. often, leave-one-out cross-validation has been used to judge model performance -where the compound 'left out' was supposed to be a novel compound found for which property predictions had to be made. unfortunately this is, according to recent studies, not a suitable validation method [ , ] . in the case of leave-one-out cross-validation, where features are selected from a wider range, the tendency exists in every case to select those features which perform best on a particular compound -thus decreasing generalizability of the model. results were summarized in a simple statement: 'beware of q !', where specifically the cross-validated correlation coefficient of a leave-one-out cross-validation is alluded to. in addition, general guidelines for developing robust qsar models were developed, namely a high cross-validated correlation coefficient and a regression, which shows slope close to and no significant bias. using theoretical considerations as well as empirical evaluations the question of leave-one-out vs. separate test sets was recently considered in detail [ ] . performing repeated cross-validations of both types on a large qsar dataset, the conclusion was drawn that in the case of smaller datasets, separate test sets are wasteful, but in case of larger datasets (at least large three-digit numbers of data points) it is recommended. this partly contradicts the above conclusion, that separate test sets should always be used. the discrepancy was explained by the fact that in the earlier work only small separate test sets were used (containing compounds), which was not able to provide a sufficiently reliable performance measure. the finding that cross-validation often overestimates model performance was corroborated in a recent related study [ ] , in particular, in cases where strong model selection such as variable selection is applied. the main influence on quality overestimation was found to be a (small) dataset size; other factors are the size of the variable pool considered, the objectto-variable-ratio, the variable selection method, and the correlation structure of the underlying data matrix. while in case of conventional stepwise variable selection overconfidence is commonly encountered, as a remedy lasso (least absolute shrinking and selection operator) selection is proposed, as well as the utilization of ensemble averaging. both techniques give more reliable estimates of the quality of the developed model. given that the latter was shown to improve performance in many cases on its own the generation of reliable performance measures is an additional advantage of ensemble techniques. overfitting is a problem which describes good model performance on a training set but much worse performance on subsequent data, and thus, mediocre generalizability of the model (the model is not robust). a recent discussion of this problem, with many accessible examples, gives similar guidelines to those above, such as that leave-one-out cross-validation is not sufficient [ ] . it also emphasizes the recommendation of multiple training/test set splits even in the case of very large dataset sizes and of performing cross-validation across classes of compounds in the case of close analogues (instead of molecule-by-molecule splits). in order to have some measure of overfitting, the use of 'benchmark models' such as partial least squares is recommended (depending on the particular problem) in order to determine whether there might be simpler models appropriate to the task (indicating that the more complex model overfits the data). using a toxicity dataset of phenols against tetrahymena pyriformis [ ] the conclusion that q is not a sufficient predictor for the applicability of a qsar model to unseen compounds is corroborated, and suggests using the rms error of prediction (rmsep) instead. this guideline is presented along with additional important points: that outliers should not necessarily be deleted since this step reduces the chemical space covered by the model, that the number of descriptors in a multivariate model needs to be chosen carefully and finally that an 'appropriate' number of dimensions is required for pls modeling. in addition, the influence of the number of variables on predictive performance for training and test sets is investigated. several recent publications have attempted to investigate what the actual scope of a qsar model is -and attempted to develop guidelines to assess the applicability of a model to a novel compound whose properties are to be predicted [ , ] . two measures for applicability are proposed: the similarity of the novel molecule to the nearest molecule in the training set and the number of neighbors of the novel compound within the training set with a similarity greater than a certain cutoff. as expected, molecules with the highest similarity are best predicted, and this was found to be true across datasets as well as across methods. the applicability measures described above can also be used numerically to derive error bars for estimations of how likely the prediction of a specific model is within a certain error threshold. the issue of model validity was also briefly reviewed from a regulatory viewpoint [ ] . in a similar vein, a 'classification approach' has been presented for determining the validity of a qsar model for predicting properties of a novel compound [ ] . focusing on linear models (though the underlying concept is more generally applicable), the predictions made for compounds within the initial training set are differentiated between 'good residuals' and 'bad residuals'. using three different datasets (an artemisinin dataset as well as two boiling point datasets) machine-learning methods were employed to predict whether a novel compound belongs to the 'good' or 'bad' class of residuals, thereby making predictions as to whether its properties can be predicted -with a success rate of between % and %. a stepwise approach for determining model applicability [ ] considers physicochemical properties, structural properties, a mechanistic understanding of the phenomenon and, if applicable, the reliability of simulated metabolism in a step-by-step manner. with several qsar datasets, it could be shown that for substances that are well covered by the training set improved predictions can be made for novel compounds, in agreement with the conclusions stated above. the performance of similarity searching methods varies widely, comprising both target-and ligand-based approaches. while large enrichment factors (often in the hundreds) are reported, the question arises of how much 'added value' more sophisticated methods actually provide, compared to very simple approaches, and where the gain-to-cost ratio actually shows an optimum. a recent study illustrated that simple 'atom count descriptors' (which do not capture any structural knowledge but represent a molecule by a set of integers which represent the number of atoms of each element) are able to have comparable performance to state-of-the-art fingerprints [ ] . thus, when averaged over multiple target classes, the added value of virtual screening approaches is probably closer to two (compared to trivial descriptors) than in the region of often published double-digit numbers (compared to random selection). it should be added that performance of 'dumb' and more sophisticated descriptors varied widely, between virtually no difference in performance up to high single-digit performance improvements of state-of-the-art fingerprints (which are, with respect to retrieval rate and on a mddr-dataset, circular fingerprint descriptors). hts results are notorious for the amount of noise they contain and methods such as multiple screening runs are routinely applied to alleviate the problem. still, additional experiments are required. an alternative method was recently presented [ ] which, applying purely computational methods, is able to predict truly active compounds with improved reliability in screenings where multiple compounds are screened per well. using scitegic circular fingerprints [ ] , similarities between molecules in wells containing compounds predicted as being active (which may be true positives or, often, just noise) are calculated. the compounds most similar to active compounds are more likely to be active themselves; by predicting (across wells) those compounds which are similar to each other and at the same time are located in wells showing activity, the active compounds out of the mixtures can be estimated. this way, between % and % of the active compounds could be retrieved in the top % of the sorted compounds. another approach which attempts to improve knowledge derived from hts campaigns was recently proposed [ ] ; the conventional selection of a fixed number of compounds showing activity in a primary screen is replaced for secondary screens ('top x approach'). alternatively, methods based on partitioning are frequently employed. in the approach presented here, an ontology-based pattern identification method is employed, which originated from bioinformatics methods (the prediction of gene function based on microarray data). taking scaffold diversity into account and also applying the 'molecular similarity principle', the overall probability of selecting active compounds from different clusters is maximized. based on earlier hts data, significant improvement of hit confirmation rates was demonstrated, compared to a conventional 'top x' approach. related work was recently also performed with a focus on scaffold clustering [ ] . as discussed below, scoring functions are not yet able to predict binding affinities sufficiently well across the board of target proteins. still, the identification of active ligands was shown to be improved by a second data post-processing step. first, ligands are docked to the target. subsequently, predicted active and inactive compounds are subject to model generation via a naı¨ve bayesian model [ ] based on circular fingerprints. applied to protein kinase b and protein-tyrosine phosphatase b, significant performance improvements could be observed in combination with dock, flexx as well as glide scores on protein-tyrosine phosphatase b. on the other hand, results on protein kinase b results were not improved, which was attributed to the fact that the predicted actives used to train the model were % false positives. understandably, performance cannot be improved if the initial enrichments are not able to identify true positive binders. more recently, another step was introduced between scoring and selecting active and inactive compounds for training the bayes classifier [ ] , which is one of the available consensus scoring methods. since consensus scoring is often able to rescue docking results in cases where a specific scoring function fails, rank-by-median consensus scoring was shown to improve results for protein kinase b considerably. other consensus approaches (rank-by-mean, and rank-by-vote) did not perform as well. this was attributed to their sensitivity to cases where one of the scoring functions performs badly. (the median of a set of numbers is less sensitive to outliers than its mean.) an alternative method for post-processing docking scores is the post-dock approach whose final goal is the elimination of false-positive predictions and their discrimination from artifacts [ ] . based on a ligandtarget database, derived descriptors (dock score, empirical scoring and buried solvent accessible surface area) and models from machine-learning methods were derived to identify false-positive predictions. validating the method on structurally diverse targets (plus the same number of decoy complexes), of binding and only of complexes were predicted to be of true-positive nature. compared to purely docking-based methods, dock and chemscore achieve enrichments on the order of five to seven, depending upon the database used, while the method presented here claims to obtain about -fold enrichment. consensus prediction of docking scores is often able to improve results over single functions and multiple ways have been proposed to combine scores from different functions such as rank-by-rank, rank-by-vote or rankby-number [ ] . performance improvement could not be observed in every case and a theoretical study [ ] to elucidate the way in which consensus scoring improves results, concluded that this was due to the simple reason that multiple samplings of a distribution are closer to its true mean than single samplings. assumptions made by the study, such as the performance of each individual scoring function is comparable, have led to the work later being criticized [ ] , and it has been concluded that consensus scoring can improve results but that it is not true in every case (as observed in practice). more recently, it was demonstrated [ ] that two criteria are important if consensus scoring is to be successful: first, each individual scoring function has to be of high quality, and second, the scoring functions need to be distinctive. even if no training data are available to judge those points, rank-vs.-score plots were proposed to gauge the success of target-based virtual screening against a particular target. while consensus predictions for ligand-based virtual screening have been known for some time, a more recent study extended the descriptors employed to include structural, d pharmacophore and property-based fingerprints as well as bcut descriptors and d pharmacophores [ ] . logistic regression and rank-by-sum consensus approaches were found to be most advantageous due to repeated samplings, better clustering of actives (since multiple sampling will recover more actives than inactives) and agreement of methods to predict actives but less so inactives. in addition, more stable performance across a range of targets was observed. if multiple active compounds are known in a virtual screening setting, the question arises of how to combine the retrieved lists of individual compounds. applied to different activity classes from the mdl drug data report as well as the natural products database [ ] it was recently found that the rank-by-max method generally outperforms the rank-by-sum method, while concluding that the tanimoto coefficient is superior to other similarity coefficients considered. as to the applicability of consensus approaches, it is found that more dissimilar activity classes profit more than more homogeneous classes, where best retrieval performance is already obtained using lower numbers of query structures (which are then already able to cover the 'activity island' inhabited by the particular class of compounds). while many applications of virtual screening tools have appeared in the literature, only some examples can be given here. a phosphodiesterase- (pde ) inhibitor recently has been optimized through the application of small combinatorial libraries [ ] . affinity was increased by three orders of magnitude by screening only compounds after prioritization by flexx docking. following the recent sars scare, a virtual screening procedure via docking (dock program) was able to find inhibitors of sars coronavirus c-like proteinase with binding affinities of k i ¼ mm out of compounds tested [ ] . virtual screening based on a homology model of the neurokinin- (nk ) receptor led to the discovery of submicromolar ligands [ ] , while even nanomolar binding compounds against checkpoint kinase (chk ) could be discovered [ ] by applying successive filtering for physicochemical properties, pharmacophore filters and docking stages. ligand-based pharmacophore models generated by catalyst [ ] were used to discover nanomolar ligands of erg , emopamil-binding protein (ebp), and the sigma- receptor (s ) [ ] . out of compounds tested, exhibited affinities of less than nm. high levels of biliary elimination of a cck antagonist led to the quest for novel compounds, which retained activity and selectivity while improving half-life. using field points derived from xed charges [ ] , novel heterocycles were proposed [ ] (switching from an indole to pyrrole and imidazole series), which decreased molecular weight and polarity and achieved the desired scaffold hop. apart from this list of applications against particular targets, only two further applications shall be described here (since the field is simply too large to capture it in its entirety). first, ligand-and target-based approaches were recently compared in their abilities to identify ligands for g-protein coupled receptors [ ] . evaluating docking into homology models, ligand-based pharmacophore models and feature trees, d similarity searches as well as models built on d descriptors, all ligand-based techniques were shown to outperform the docking-based approaches. however, docking also provided significant enrichment. second, the 'hts data mining and docking competition' presented its results recently [ ] [ ] [ ] . duplicate residual activities of , compounds against escherichia coli dhfr in primary screening were released in late [ ] , upon which groups submitted activity predictions for a test set of the same size (but with unknown activity). approaches employed ranged from docking [ , ] to purely ligandbased methods [ , ] . overall, none of them was able to predict actives from the test set reliably. while this was partly due to difference in chemical composition of the training and test sets, an additional problem was posed by the test set which did not contain real 'actives' (showing proper dose-response curves in secondary assays), thus making predictions difficult. several novel clustering algorithms have been presented recently, each of which extends previous approaches in its own way. a combination of fingerprint and maximum common substructure (mcs) descriptors [ ] speed up clustering (compared to purely mcs methods) enabling its application to large datasets, and the method was shown to be able to identify the most frequent scaffolds in databases, to select analogues of screening hits and to prioritize chemical vendor libraries. a modification of k-means clustering also showed a considerable speed increase to be possible when processing large libraries [ ] , as demonstrated on a dataset containing about , compounds derived from the mddr. the desired speed-up was observed along with favorable enrichment of activity classes within the clusters. by introducing fuzziness into the clustering process [ ] , superior results can be obtained compared to the original (non-fuzzy or 'crisp') approaches to k-means and ward clustering, depending on the particular dataset and the property one attempts to predict. fuzzy clustering assigns partial memberships to multiple classes (instead of binary values); with a log p dataset the best fuzzy parameterization was shown to clearly outperform the best crisp clustering. in addition, partial class memberships were shown to capture the 'chemical character' of a compound more satisfyingly than conventional (crisp) class assignments. while the concept of 'drug-likeness' has to be applied with care (and one needs to be aware of its limitations) it has nonetheless received considerable attention in recent years, based on datasets derived from the available chemicals directory (acd) and the world drug index (wdi). first applications employed ghose/crippen descriptors in combination with neural networks for classification, and correct classification was achieved for % of the acd and % of the wdi, respectively [ ] . later, the application of svms was not able to improve overall performance significantly, but the new method was able to correctly classify compounds that were misclassified by the ann-based technique [ ] . very recently a further analysis of the drug/non-drug dataset appeared, which analyzed svm performance (as well as that of other machine-learning methods) in more detail [ ] . it was found that, in spite of problems with the dataset (some descriptor representations of compounds were, for example, identical in the drug and non-drug dataset) performance could be improved considerably to about % misclassified compounds by optimizing the kernel dimensions employed. an application using 'humanunderstandable' descriptors of drug-vs. non-drug-like properties has also been presented [ ] recently, and was able to distinguish between both datasets with the most important descriptors being proper saturation level and the heteroatom-to-carbon ratio of the molecule. the concept of database comparison is also more generally applicable, as was shown recently when the question of how 'in-house like' external databases are was addressed in order to help to decide whether they should be acquired or not [ ] . a number of validations of docking programs have appeared recently, and it is interesting to observe that they grow in size in every respect -including the number of docking and scoring functions considered as well as the number and diversity of ligand-target complexes employed for their evaluation. using dock, gold and glide in order to evaluate the performance of docking programs in target-based virtual screening on five targets (hiv protease, protein tyrosine phosphatase b, thrombin, urokinase plasminogen activator and the human homologue of the mouse double minute oncoprotein), it was concluded that performance is both target-and method-dependent [ ] . performance varied widely, between near-perfect behavior (for example, gold in combination with protein tyrosine phosphatase b) to negative enrichment (for example, gold with hiv protease). employing fred, dock and surflex, and adopting the algorithm to the particular binding pocket, it was found that target-based virtual screening is successful in some cases [ ] , with surflex probably performing the best overall. investigating phosphodiesterase b [ ] and a set of known inhibitors with decoys, the scoring functions pmf, jain, plp , ligscore and dockscore were compared with respect to their ability to enrich known ligands. it was found that pmf and jain showed high-enrichment factors (greater than four-fold) alone, while a rank-based consensusscoring scheme employing pmf and jain in combination with either dockscore or plp showed more robust results. in what is probably one of the most extensive studies yet, scoring functions in combination with protein-ligand complexes from the pdbbind database have been compared for evaluation [ ] . the scoring functions compared were x-score and drugscore, five scoring functions implemented in sybyl (chemscore, d-, f-and g-score and pmf-score), four implemented in cerius (ligscore, ludi, plp and pmf) as well as two scoring functions implemented in gold (goldscore and chemscore) as well as the hint function. performance was assessed by their ability predicting affinity (k i /k d values). overall, x-score, drugscore, sybyl with chemscore and cerius with plp performed better than the other combinations, giving standard deviations in the range of . - . log units. another very comprehensive evaluation [ ] employed docking programs in combination with scoring functions against eight proteins of seven types. three criteria were used for assessment, namely the ability to predict binding modes, to predict ligands with high affinity and to correctly rank-order ligands by affinity. while nearly all programs were able to generate crystallographic ligand-target complexes, the identification of the correct structure by the scoring function was found to be considerably more error-prone. averaged over all targets, none of the programs was able to predict more than % of the ligands within an rmsd of equal to or less than Å . while active compounds were correctly identified, activity prediction was more difficult -to the extent that 'for the eight proteins of seven evolutionarily diverse target types studied in this evaluation, no statistically significant relationship existed between docking scores and ligand affinity' [ ] . similar results were obtained on five datasets (serine, aspartic and metalloproteinases, sugar-binding proteins and a 'miscellaneous' set) using the scoring functions bleep, pmf, gold and chemscore [ ] , where across all complexes on average no function returned a better correlation than r ¼ . . interestingly, another recent study drew quite different conclusions from similar observations [ ] . docking endogenous ligands into a panel of proteins it was concluded that proteins are often very promiscuous and do not interact with only a single clearly defined small molecule. while this is surely possible, given the limitations of today's scoring functions it might well be the case that predictions are just not yet good enough. while a great number of descriptors and modeling methods has been proposed until today, the recent trend toward proper model validation is very much appreciated. applications of the 'molecular similarity principle' do not yet show the power one would like them to have -and although some of their limitations are surely due to underlying principles and limitations of fundamental concepts, others will certainly be eliminated in the future. concepts and applications of molecular similarity chemical similarity searching approaches to measure chemical similarity -a review molecular similarity: a key technique in molecular informatics the art and practice of structurebased drug design: a molecular modeling perspective a discussion of measures of enrichment in virtual screening: comparing the information content of descriptors with increasing levels of sophistication in vitro and in silico affinity fingerprints: finding similarities beyond structural classes comparison of fingerprint-based methods for virtual screening using multiple bioactive reference structures pot-dmc: a virtual screening method for the identification of potent hits a d similarity method for scaffold hopping from the known drugs or natural ligands to new chemotypes lingo, an efficient holographic text based method to calculate biophysical properties and intermolecular similarities the reduced graph descriptor in virtual screening and data-driven clustering of high-throughput screening data small molecule shapefingerprints extracting the three-dimensional shape of live pigs using stereo photogrammetry novel receptor surface approach for d-qsar: the weighted probe interaction energy method calculation of intersubstituent similarity using r-group descriptors use of the r-group descriptor for alignment-free qsar fingal: a novel approach to geometric fingerprinting and a comparative study of its application to d-qsar modelling a computational procedure for determining energetically favorable binding sites on biologically important macromolecules grid-independent descriptors (grind): a novel class of alignment-independent three-dimensional molecular descriptors incorporating molecular shape into the alignment-free grid-independent descriptors anchor-grind: filling the gap between standard d qsar and the grid-independent descriptors virtual screening and scaffold hopping based on grid molecular interaction fields graph kernels for molecular structure-activity relationship analysis with support vector machines one-dimensional molecular representations and similarity calculations: methodology and validation fast small molecule similarity searching with multiple alignment profiles of molecules represented in one-dimension multiple-ligand-based virtual screening: methods and applications of the mtree approach comparison of correlation vector methods for ligand-based similarity searching fuzzy pharmacophore models from molecular alignments for correlation-vector-based virtual screening extraction and visualization of potential pharmacophore points using support vector machines: application to ligand-based virtual screening for cox- inhibitors biospectra analysis: model proteome characterizations for linking molecular structure and biological response can cell systems biology rescue drug discovery? identifying biologically active compound classes using phenotypic screening data and sampling statistics comparison of support vector machine and artificial neural network systems for drug/nondrug classification virtual screening of molecular databases using a support vector machine lead hopping using svm and d pharmacophore fingerprints random forest: a classification and regression tool for compound classification and qsar modeling boosting: an ensemble learning tool for compound classification and qsar modeling ensemble methods for classification in cheminformatics new approach by kriging models to problems in qsar a comparative study on feature selection methods for drug discovery molecular similarity searching using atom environments, information-based feature selection, and a naive bayesian classifier similarity searching of chemical databases using atom environment descriptors (molprint d): evaluation of performance evaluation of mutual information and genetic programming for feature selection in qsar nonlinear prediction of quantitative structure-activity relationships nonlinear quantitative structure-activity relationship for the inhibition of dihydrofolate reductase by pyrimidines novel variable selection quantitative structure-property relationship approach based on the k-nearest-neighbor principle development and validation of k-nearest-neighbor qspr models of metabolic stability of drug candidates three-dimensional qsar using the knearest neighbor method and its interpretation application of non-parametric regression to quantitative structure-activity relationships robust qsar models using bayesian regularized neural networks predictive bayesian neural network models of mhc class ii peptide binding an in silico approach for screening flavonoids as p-glycoprotein inhibitors based on a bayesian-regularized neural network combinatorial preferences affect molecular similarity/diversity calculations using binary fingerprints and tanimoto coefficients analysis and display of the size dependence of chemical similarity coefficients comparison of three holographic fingerprint descriptors and their binary counterparts enhancing the effectiveness of similarity-based virtual screening using nearest-neighbor information chance factors in studies of quantitative structureactivity relationships judging the significance of multiple linear regression models rational selection of training and test sets for the development of validated qsar models beware of q ! assessing model fit by cross-validation chance correlation in variable subset regression: influence of the objective function, the selection mechanism, and ensemble averaging the problem of overfitting the better predictive model: high q( ) for the training set or low root mean square error of prediction for the test set? assessing the reliability of a qsar model's predictions similarity to molecules in the training set is a good discriminator for prediction accuracy in qsar improving opportunities for regulatory acceptance of qsars: the importance of model domain, uncertainty, validity and predictability determining the validity of a qsar model -a classification approach a stepwise approach for defining the applicability domain of sar and qsar models prioritization of high throughput screening data of compound mixtures using molecular similarity novel statistical approach for primary high-throughput screening hit selection hiers: hierarchical scaffold clustering using topological chemical graphs finding more needles in the haystack: a simple and efficient method for improving high-throughput docking results combination of a naive bayes classifier with consensus scoring improves enrichment of high-throughput docking results postdock: a structural, empirical approach to scoring protein ligand complexes consensus scoring: a method for obtaining improved hit rates from docking databases of three-dimensional structures into proteins how does consensus scoring work for virtual library screening? an idealized computer experiment virtual screening using protein-ligand docking: avoiding artificial enrichment consensus scoring criteria for improving enrichment in virtual screening the use of consensus scoring in ligand-based virtual screening enhancing the effectiveness of virtual screening by fusing nearest neighbor lists: a comparison of similarity coefficients design of small-sized libraries by combinatorial assembly of linkers and functional groups to a given scaffold: application to the structure-based optimization of a phosphodiesterase inhibitor virtual screening of novel noncovalent inhibitors for sars-cov c-like proteinase successful virtual screening for a submicromolar antagonist of the neurokinin- receptor based on a ligand-supported homology model identification of compounds with nanomolar binding affinity for checkpoint kinase- using knowledge-based virtual screening pharmacophore modeling and three-dimensional database searching for drug design using catalyst discovery of high-affinity ligands of sigma receptor, erg , and emopamil binding protein by pharmacophore modeling and virtual screening scaffold hopping with molecular field points: identification of a cholecystokinin- (cck( )) receptor pharmacophore and its use in the design of a prototypical series of pyrrole-and imidazole-based cck( ) antagonists virtual screening of biogenic amine-binding g-protein coupled receptors: comparative evaluation of protein-and ligand-based virtual screening protocols mcmaster university data-mining and docking competition -computational models on the catwalk experimental screening of dihydrofolate reductase yields a ''test set'' of , small molecules for a computational data-mining and docking competition evaluating the highthroughput screening computations high throughput screening identifies novel inhibitors of e. coli dihydrofolate reductase that are competitive with dihydrofolate here be dragons: docking and screening in an uncharted region of chemical space virtual ligand screening against e. coli dihydrofolate reductase: improving docking enrichment using physics-based methods using extended-connectivity fingerprints with laplacian-modified bayesian analysis in high-throughput screening follow-up screening for dihydrofolate reductase inhibitors using molprint d, a fast fragment-based method employing the naive bayesian classifier: limitations of the descriptor and the importance of balanced chemistry in training and test sets database clustering with a combination of fingerprint and maximum common substructure methods a hierarchical clustering approach for large compound libraries clustering files of chemical structures using the fuzzy k-means clustering method a scoring scheme for discriminating between drugs and nondrugs classifying 'drug-likeness' with kernel-based learning methods a new rapid and effective chemistry space filter in recognizing a druglike database in-house likeness'': comparison of large compound collections using artificial neural networks comparison of automated docking programs as virtual screening tools fast structure-based virtual ligand screening combining fred, dock, and surflex retrospective docking study of pde b ligands and an analysis of the behavior of selected scoring functions an extensive test of scoring functions using the pdb bind refined set of protein-ligand complexes a critical assessment of docking programs and scoring functions predicting protein-ligand binding affinities: a low scoring game? ligand selectivity and competition between enzymes in silico key: cord- -wqgq ci authors: sutzko, danielle c.; martin, colin a.; chu, daniel i. title: development and implementation of virtual grand rounds in surgery date: - - journal: am j surg doi: . /j.amjsurg. . . sha: doc_id: cord_uid: wqgq ci nan from the halls of johns hopkins in the late th century with sir william osler to present day auditoriums, grand rounds have remained a hallowed tradition of academic medicine. and like any tradition, grands rounds has evolved with the times from the osler era, which featured actual patients, to present-day powerpoint-heavy presentations. through all these changes, challenges have persisted with delivering effective grand rounds including poor attendance, inconvenient times/locations, uninteresting subject matters, high costs and ineffective teaching styles. the unprecedented covid- pandemic has further challenged this tradition through restrictions on large gatherings, institutional bans on travel and major budgetary constraints. at our institution, surgical grand rounds were cancelled for two months (march-april ) with the withdrawal of many visiting professors. given the uncertainty of the duration of these restrictions, our department created a virtual grand rounds system to overcome these challenges and to continue the long-standing tradition of grand rounds. over the last decade the advancement and widespread adoption of technology and immersive virtual reality (ivr) has challenged traditional learning methods. within the virtual reality realm, medical curriculums have evolved to include virtual didactics and have now expanded to even using the virtual environment for surgical procedural training. virtual meetings using the internet have been well-described before the covid- pandemic. sine qua non for most institutions and organizations, the covid- pandemic has forced a reckoning of the traditional way of running meetings. as a result, these restrictions have accelerated the adoption, adaptation and application of modern internet-based technologies to all professional meetings including grand rounds. in this manuscript, we aim to share our institutional experience with development and implementation of a virtual grand rounds. specifically, we will detail the setup for a virtual grand rounds program, describe its step-wise implementation and review its advantages/disadvantage. while every institution will have its own unique system, resources and culture, we aim to provide a broad framework to guide the continued evolution of grand rounds. the setup and implementation for a successful virtual grand rounds is based on three principles: use of a versatile internet-based technology platform, ensuring security and effective moderating (figure ). while several technology platforms exist, our institution is licensed to use zoom (zoom video communications, inc., san jose, ca), a cloud-based peer-to-peer software platform that provides videotelephony and online chat services. use of zoom has grown significantly during the covid- pandemic going from million daily users in december to over million daily meeting participants by april . our institution provides a professional license which permits up to unique attendees, unlimited time and important features including share screens, chat boxes and recording. the platform is versatile, easy-to-use and well-suited to host speakers and audiences from around the world as it permits one-click entry into sessions, screen-sharing and several levels of communication including direct audiovideo and chat boxes for questions. for security, our virtual grand rounds requires pre-meeting registration, which registers the attendee and then provides a unique link for one-click login to the meeting. the pre-meeting registration link is embedded in calendar invites to the grand rounds, available on the department website and easily shareable. on login after registration, all attendees are automatically muted with capability to turn on their video. because we use the pre-registration function, our department does not utilize the waiting room feature of zoom, which provides another option for security by requiring a host/co-host to allow entry of every participant into the session. as the grand rounds audience is large, it would be onerous and resource-intensive to require manual entry for every participant based on their name. importantly, the pre-meeting registration also allows tracking of all participants which is useful for recording attendance, assigning cme credits and having the ability for faculty to logon and complete an online quiz for maintenance of certification (moc) part ii credit from american board of surgery following the grand rounds presentation. while unwelcome participants could technically register and login (e.g., zoom-bombing), another layer of security is provided by the "co-host" assignments (given only to the moderator, administrator and speaker) which gives only the co-hosts the ability to share screens and to mute/disable audio and video. to ensure a successful virtual grand rounds, the role of the moderator has become increasingly important. given the lack of audience feedback and physical interactions in virtual meetings, the moderator is essential to keeping everyone on-schedule, overcoming technological glitches and guiding all virtual interactions. as large audiences are usually muted and often have their videos off, the combined silence and empty screens can be disconcerting. it is in that space, however, that the moderator should aim to start grand rounds on-time, introduce the speaker and ensure sharing of the speaker's screen. on occasion, there will be technological glitches such as an inability to share screens (e.g., make sure to enable co-host role for speakers on zoom) and poor audio-video. we have minimized many of these glitches by running a "test" session -hrs before the actual virtual grand rounds with speakers to go over screen sharing and schedules. in this test run the speaker, on the day of grand rounds, once the speaker is introduced and beginning the presentation, the moderator should be scanning the chat box (where questions are often placed), observing the participant list for any alerts (such as raised virtual hands) and monitoring the time. on conclusion of the talk, the moderator should begin the discussion. we have often experienced delays in questions from participants and therefore the moderator should be prepared to ask the first question. we have also observed that most participants prefer to ask questions in the chat box and in this case the moderator should repeat the questions aloud for those who are in the meeting by audio-only. on conclusion of the session, the moderator should end the virtual meeting for all participants. virtual grand rounds sessions have several advantages. first, we have found that attendance has sharply increased since changing to a virtual format secondary to the need for social distancing. figure demonstrates our average pre ( attendees) and post ( attendees) virtual grand rounds attendance (p <. ). this significant increase likely results from the flexibility of attending grand rounds from any physical location, the ability to advertise to a wider audience and opportunities to easily ask questions. in fact, a recent study on burnout interventions in surgery by lebares et al, found residents to be increasingly stressed when they could not attend didactics because of their clinical duties. during the semi-structured interviews conducted with the trainees, an operationalized/practical step suggested was a summer hiatus from grand rounds. with the virtual platform, this added stress could be decreased with trainees and faculty able to tune in to the grand rounds remotely and decrease the time away from necessary clinical duties. for some participants, walking - minutes across campus for grand rounds can be a barrier. traveling to the hospital may also be difficult for emeritus faculty and alumni in the region. the virtual option allows them to participate in a meaningful way from their office or from the convenience of their home. second, there is an economic advantage to having virtual grand rounds. an in-person traditional visiting professorship often includes transportation, lodging, and a social gathering. in addition, the visiting professor steps away from clinical duties for - days which is a potential loss of clinical revenue. the virtual format saves on these costs and travel times. to maintain the personal and professional gains from a visiting professorship, however, we have incorporated one-on-one and small group virtual meetings into the agenda of all our visiting speakers to meet our faculty, trainees and staff. third and finally, the virtual format allows for new partnerships within the institution and between institutions. many of our virtual grand rounds have created unique opportunities for other institutional departments and centers to share their work. similarly, virtual grand rounds has created a mechanism through which we can now more easily join with other institutions across the country to share clinical expertise, experiences and research. although there are many advantages to the virtual grand rounds platform, this format comes with some disadvantages. one of the most significant disadvantages is the lost in-person experience during grand rounds presentations and immediately following the lecture for the question and answer session. the lack of in-person experience affects both the presenter and attendees. from the presenter perspective, the virtual format makes engaging the attendees in an interactive fashion, with few to no visual cues, increasingly difficulty. techniques including live polls of the audience by raising their hands or asking the attendees in the audience to turn to their neighbor for a quick discussion on a certain topic are not easily executed on this platform. on the other hand, the ability for the attendee to ask the presenter a question directly from the audience is a much different, more personal experience in-person compared to when your question is read out loud by the moderator from a chat box. this being said, we do give the option for attendees during the virtual format to ask the question themselves which would bring their video screen to the presenter once the audio of the attendee is activated, but this option is seldom utilized and can be more arduous for the moderator. not only do the attendees have a different experience asking questions of the grand rounds presenter, but they also miss out on the downtime following the dismissal of the auditorium where they could have a one-on-one conversation with the speaker about further details or their presentation or research niche. these one-on-one conversations could be starting points for networking with the individual, and even opening doors for future opportunities including research projects or national committee opportunities. furthermore, our grand rounds speakers are usually scheduled a complete - day itinerary before and after their talks. during this time, they meet with multiple faculty in various stages of their academic careers who may have an overlapping interest. these meetings are again lost on the virtual format. although our committee has now adapted our virtual grand rounds to include an open "zoom" session where the grand rounds presenter will stay in a single zoom session with a shortened itinerary to attempt to resemble the one-on-one interviews that would have otherwise traditionally taken place. as we continue through these unprecedented times with the covid- pandemic and phases of gradual reopening of our hospital and university campus, it is unclear when the return of traditional in-person grand rounds will resume. however, with the many advantages and conveniences afforded by the new virtual platform, we believe that the new "normal" will likely include a hybrid format that can be viewed either in-person or virtually for participants that are unable to attend. this hybrid format will allow for greater flexibility for attendance, while still providing an in-person interactive session for those on-site. can we make grand rounds "grand" again? immersive virtual reality in surgery and medical education: diving into the future medical conference by computer virtual congresses zoom grows to million meeting participants despite security backlash key factors for implementing mindfulness-based burnout interventions in surgery key: cord- -ig i authors: philippe, stéphanie; souchet, alexis d.; lameras, petros; petridis, panagiotis; caporal, julien; coldeboeuf, gildas; duzan, hadrien title: multimodal teaching, learning and training in virtual reality: a review and case study date: - - journal: virtual reality & intelligent hardware doi: . /j.vrih. . . sha: doc_id: cord_uid: ig i it is becoming increasingly prevalent in digital learning research to encompass an array of different meanings, spaces, processes, and teaching strategies for discerning a global perspective on constructing the student learning experience. multimodality is an emergent phenomenon that may influence how digital learning is designed, especially when employed in highly interactive and immersive learning environments such as virtual reality (vr). vr environments may aid students' efforts to be active learners through consciously attending to, and reflecting on, critique leveraging reflexivity and novel meaning-making most likely to lead to a conceptual change. this paper employs eleven industrial case-studies to highlight the application of multimodal vr-based teaching and training as a pedagogically rich strategy that may be designed, mapped and visualized through distinct vr-design elements and features. the outcomes of the use cases contribute to discern in-vr multimodal teaching as an emerging discourse that couples system design-based paradigms with embodied, situated and reflective praxis in spatial, emotional and temporal vr learning environments. digital teaching and learning embrace active pedagogy and learner-centred approaches. the basic assumption is that learners are unique and therefore learning should be personalized. as argued by reigeluth et al. [ ] , learner's centred activities value intrinsic motivation [ , ] as well as metacognition [ ] for a more personalized and meaningful learning process. for achieving an active, situated and embodied learning experience, meta-cognitive knowledge seems to enhance learning [ ] . in line with this assumption, one can consider specific pedagogical methods such as active learning, learning by doing, collaborative learning, problem-based learning and game-based learning. prince indicates for instance that active learning has a positive but weak effect on students' academic achievement [ ] . vernon and blakes metaanalysis indicates that problem-based learning may yield metacognitive learning over traditional methods [ ] . this is also supported by dochy et al. meta-analysis that concludes for robust positive effects on student's skills without studies reporting negative effects [ ] . those conclusions are also in line with walker and leary's meta-analysis [ ] . based on previous meta-analysis and systematic reviews [ ] [ ] [ ] [ ] [ ] [ ] , serious games [ ] may also be efficient in various contexts, if combined with informed learning instructions. in line with the idea of "active pedagogy" and "learner-centred approaches" the concept of "multimodality", was developed in the early s [ , ] . multimodality refers to "multiple" modes of representation, with combined elements of print, visual images and design. this shift from paper-based education to multimodal education involves rethinking the way in which teaching, and learning are designed, approached and practiced. this promotes the way in which pedagogies, content and technology are designed and used to enable multimodality to take place in a variety of contexts and social relationships [ ] . whether digital tools are employed to scaffold new ways of learning or they are just reproducing traditional modes of teaching and learning is still an open research question [ ] . digital tools are at least as efficient as non-digital tools, when integrated into a consistent pedagogic strategy, with clearly defined training objectives and instructions. therefore, the purpose is not to replace traditional methods by digital tools. rather, one should consider digital tools for the actual value they can bring, for instance regarding the personalization of the content, in combination to non-digital tools and methods. digital tools are part of the toolbox available for the trainers and they can contribute to the development of multimodal, active and learner-centred approach. in this context, virtual reality (vr) was recently introduced to the consumer market [ ] and deployed in digital educational interventions [ ] . education and training are pointed out as promising fields of vr implementation [ ] . the advent of immersive and high-fidelity digital technologies such as virtual reality may supplement or enhance analogue learning spaces as modes of expression. for example, Öman and hashemi suggested that technology may be used to increase students' communicative and collaborative skills instead of focusing on how to use the technology from a technical perspective [ ] . vr is shown to offer self-regulated and multiple learning choices compared to other learning platforms which lead to high quality of experience and retention [ ] [ ] [ ] [ ] [ ] . however, the use of vr in the context of multimodality for teaching and learning has not been investigated yet. as an example, a search using the terms vr and multimodality and teaching or learning for any peer reviewed article published between and on science direct (elsevier) led to hit. the ieee database only retrieved articles. the first one relates to the use of listening strategies by learners in second life vr environment [ ] . a second one relates to multimodality in vr but without teaching and learning purpose [ ] . the three other papers are totally unrelated to the topic of interest [ ] [ ] [ ] . this shows that virtual reality and multimodality are rarely tackled scientifically as a connected issue. we propose that multimodality may be investigated as a teaching and learning process in terms of ways of enacting it within a vr's semiotic domain as a design space that affords constructivist and activity-based learning. multimodality may be viewed as the vehicle for students to design and orchestrate their own modes of learning that are meaningful to them in the form of multimodal ensembles and semiotic resource [ ] . such multimodal ensembles may include images and language along with more static modalities resembling frozen actions [ ] such as classroom objects and equipment incorporating desks, tables, displays, chairs, books and chalkboards. there is a plethora of evidence on how multimodality may be deployed in traditional learning environments [ ] [ ] [ ] , in blended learning spaces [ ] [ ] [ ] and online learning spaces [ ] [ ] [ ] . there are constellations of evidence on employing multimodality as means to experience teaching and learning in digital and analogue semiotic domains. yet, there is infrequent substantiation on how meanings of words, images, communication processes, teaching strategies, roles and learning activities may be situated in a vr semiotic domain. this paper attempts to illuminate the application of multimodal teaching and learning as a pedagogically rich strategy that blends, couples and combines constructivist-led practice. such strategy constitutes distinct ways of thinking, acting and interacting. essentially, it allows to experience teaching and learning in unique ways. in section hereafter, we present an overview of the literature supporting how vr may be used in learning and teaching as means to increase learning efficiency, based on recent developments in designing and representing learning content and activities through vr. in section , we propose a methodology for integration of vr into multimodal learning path and we illustrate this methodology in section with eleven different vr case-studies resembling different design approaches to map multimodal learning with vr features and components. finally, in section , we evaluate this proposition considering the current situation of the pandemic and how vr and emerging xr (extended reality) technologies can contribute to reshaping the learning and teaching fields while physical distancing tends to be normalized. digital learning technologies aim to help learners increase their capacity for innovation, leadership, multiand inter-disciplinary collaboration, emotional intelligence, critical skills, collective problem identification and solving skills, in a participatory environment [ ] . multimedia resources and tools in these environments include, e. g.: videos, interactive images, recorded presentations, online quizzes, discussion forums (synchronous and asynchronous), visual representations of learner data to describe progress (summative analysis) and what learners are doing to learn [ ] . the increasing use of multimedia in education and training offers the possibility of presenting content in multiple representations (text, images, video, audio, ubiquitous media) to accommodate different teaching and training strategies, learning outcomes, assessment methods and feedback mechanisms. key aspects are the use of a range of tools, resources and services in a pedagogical manner to enhance the students' experience. the integration of multimedia learning into different modes of learning seems to encourage learners to develop a more flexible approach based on inquiry and information retrieval. hazari [ ] and mayer et al. [ ] argue that student learning is deeper and more meaningful when a range of interactive tools and resources are deployed rather than using text alone. shah and freedman [ ] list the benefits of using visualizations in learning, such as ( ) external representation of information, ( ) deeper learning, ( ) triggering learners' attention and concentration by making information more complete, thus simplifying ill-defined concepts and ideas. these tools can be serious games, and virtual reality. these technologies allow us to go beyond standard forms of written and spoken language [ ] . vr environments are being envisaged as a medium that aid learners' efforts to be active. learners consciously attend to, and reflect on, critique leveraging reflexivity and novel meaning-making leading to a conceptual change. there is an enlightening research spectrum on measuring the instructional effectiveness of immersive virtual reality [ ] [ ] [ ] , understanding trainers' conceptions of teaching in vr [ , ] , students' attitudes towards vr [ , ] and trainer professional development using vr [ ] [ ] [ ] . there are also studies that investigate associations between specific pedagogies and theories with vr [ , ] embroiling constructivist models of learning with the premise to individually and collaboratively construct knowledge and experience through critical learning and thinking. in summary, these previous works indicate that learners respond to the environment with an interaction-reaction opposition: they build their own knowledge and social interactions are primordial to that building [ ] . the advent of vr head-mounted displays has encouraged the development of an array of vr environments particularly used for augmenting the student learning experience [ ] . in this context, vr may be broadly described as an experience in which students interact within a d dimensional world with body and gestural movement, experiencing interactive content such as images and sounds [ ] . a distinctive characteristic of a vr system is that students can interact and manipulate objects by emulating how objects are manipulated in the real-life [ ] . commentators and researchers alike have attempted, through metaanalyses and systematic reviews, to discern the processes, strategies and methods that are most likely to be aligned with vr tools, elements and features (e.g. for language learning) [ ] . there is consensus that vr may promote activity based and student-centred learning, as proliferated in the constructivist learning paradigm, whilst attaining student motivation, self-regulation and self-assessment. a key advantage of learning using vr is that students can view objects and content from multiple perspectives and thereby situating learning in line with subject contexts. for example, vr allows rich learning environments such as factories or real-life like working spaces, particle physics events and brain anatomy. it affords opportunities to learn through interacting with virtual objects leading to creating new cognitive schemata tied to situated learning instances. in conjunction to this, spatial perception and cognition such as acquiring navigation and localization skills within a vr environment may be codified and represented as thirdperson symbolic experiences increasingly supporting and amplifying a sense of social and selfpresence [ , ] . cooper and thong highlights four distinctive elements of vr as an educational tool: ( ) experiencing as the ability of students to respond physically and emotionally to a range of stimuli, ( ) engagement as the multisensory experience that may enhance student's engagement, ( ) equitability as ways of responding to sameness and differences in schools and ( ) everywhere as offering exciting possibilities in relation to location, timeliness and how the learning process emerge [ ] . usual vr advantages listed in the literature are embodying, acting, repeating [ ] , and increasing motivation while learning compared to other media [ , ] . yet, leaners' acceptance and learning instructions' creation are still restraining large adoption [ , ] . in education and training this can be explained by lack of on-campus experiments [ , ] . globally, previous meta-analyses ( studies), systematic reviews ( study) and reviews ( studies) documented vr efficiency for learning [ , , , , ] . but, according to lanier et al. experimental quality in vr is sometimes questionable due to the methodological challenges faced on the study design, data analysis reporting and disseminating the knowledge gained [ ] . within the issue of learning with vr in the context of a multimodal path, the ability to create efficient teaching and learning environments as well as strong experimental proofs depends on design principles that are applied. despite the considerable uptake of vr for learning and teaching, there is little, if any, evidence on designfocused studies that illuminate in-vr elements and features that focus on the affordances and constraints as well as the dynamics perpetuated to support multimodal teaching using vr. an early study from dickey [ ] investigated the potential of a vr to support activity-based multimodal teaching and learning through an evaluative case study. vr elements that afforded an activity-based and multimodal approach to teaching included an in-vr chat tool as the primary means for presenting a concept for discussion. responsive feedback and interaction with the students were the main learning affordances along with multimodal information presented as visual illustrations. another affordance was granting unique names for students to establish unique virtual identities for maintaining control over the learning environment. such virtual identities were inextricably connected with avatar representations [ ] . pre-selecting, modifying or creating new avatars helped students to distinguish their virtual appearance and learning about and coming to appreciate design in their efforts to apply design principles for creating their avatars by manipulating avatar objects, shapes, colours and attributes. kinesthetics and point-of-view aspects for avatars to interact with objects, within the virtual learning space were directly linked with the provision of an 'avatar' mode for individual and collaborative activities. an integrated web-browser was also viewed as a feature that can instigate multimodal learning especially when connected to in-vr learning objects via sensors for allowing students to make relationships between the vr object and its underlying information found on the web. this inter-connection between in-vr objects and information about them on the web alludes to the employment of distinct semiotic principle [ ] . learning occurs through interrelations within and across multiple sign systems (symbols, objects, images, facts, information) as an inter-related and connected knowledge from different semiotic domains. more recently, doumanis et al. investigated the impact of a multimodal learning interaction of gamified tasks in a collaborative virtual world [ ] . multimodal interactions within the vr seemed to improve learning in comparison to the non-multimodal control group. specifically, the multimodal interactions observed improved students' ability to generate ideas thus facilitated a sense of presence and immersion with the vr condition. doumanis et al. triggered three types of immersion (e. g. spatial, emotional and temporal) aligned with vr features. navigation in the vr world with speech control and virtual representation with an avatar along with access to information, user grouping, textual communication and dialogue log were central features for encouraging active, multimodal and critical, as opposed to passive and unimodal, learning. principles of active learning were embedded in the use of the vr features creating certain dynamics and controlling essential features. for example, teachers should have full control of the vr classroom in terms of controlling student navigation or a "proxy option" to temporarily take control of a student's avatar as means to facilitate their effort to learn the system or grouping students for collaborative in-vr projects having students working in teams and taking on assigned roles. therefore, vr allows more interaction opportunities for learners with peers, content (e. g. information) and objects (digital assets). designing in-vr group dialogic learning experiences enables for distributed knowledge and collaborative problem-solving, encouraging perception of thinking and reasoning as inherently social processes. designing vr elements creates learning situations for students to think with others by using and manipulating vr tools and places emphasis on the distributed knowledge product generated by a web of students working for resolving a common problem. innocenti et al. developed a virtual environment for learning how to play musical instruments [ ] . similarly, to dickey [ ] and doumanis et al. [ ] , navigation elements is a key multimodal feature as means to provide spatial orientation cues for learning and usability aspects. for example, to mitigate vr sickness while students are interacting and manipulating d objects for designing a prototype or researching an object, a virtual locomotion technique [ ] may be induced to offer natural, usable and efficient ways for multimodal driven activities to be navigated through and enacted in the vr environment. navigation elements need to be tied to in-vr collaborative scenarios for aiding students to perform tasks, set by the teachers or by peers, for practicing the intended learning outcomes. collaborative scenarios may encompass pre-determined designs of the vp-space such as scaffold for helping the students to move within the vr environment, progressively learning how to interact with objects, making the in-vr goals clear and distinguishable and encouraging exploration, inquiry and observation of how the different modes reveal intended meanings. vr is a semiotic domain that triggers students to learn in different ways, applying an array of developmental skills and competencies as they move from one vr scenario to the next. the role of the teacher and the student within the vr space are changing depending on the scenario, as the general premise is that there is no single master of knowledge. rather each member takes roles with associated skills to master such as being the researcher, developer, designer or project manager in different settings. in that way, people with varied skillsets and dexterities have the possibility to exchange their roles and learn from each other. as opposed to designing unimodal online learning environments (e.g. creating a moodle page for students to download content, developed by the teacher), vr scenarios may be designed in a way that afford both a change in practice but also a change in identity [ ] . this can be done by distributing and re-distributing students into diverse vr groups, switching different roles interchangeably and sharing knowledge mastered from participating in previous vr groups through employing reciprocal problem-based in-vr learning scenarios. the premise is that there is no 'master' of knowledge in the sense that knowledge construction and especially knowledge building is a collaborative process through a network of people that distributes pervasive multimodal information, roles and responsibilities. multimodality as a context-based and situated learning instantiation may be designed for and represented through collaborative vr, as part of xr. the most common collaborative vr features are: ( ) focusing attention, ( ) connecting learners to the learning materiel [ ] . collaborative vr [ ] may encourage multiple perspectives on a given phenomenon through conversation and interaction and joint construction of knowledge [ ] (it echoes the four pillars of learning [ ] ) by providing feedback to facilitate the adoption of learning reflexes [ ] and monitoring of scenario development; allowing distant learning [ ] . such collaborative practices in vr may encourage the formation of social identities and viewing knowledge as a social construct developed through a network of individuals having common goals and interests [ ] . by employing collaborative vr teachers may design virtual places that afford collaborative learning processes that take social interactions into account offering a more diverse and richer forms of dialogue that would be challenging to design or construct in other learning environments [ ] . individually or collaboratively, vr allows for learning instances to be embodied (to be represented by an avatar) [ ] . such embodiment gives a unique dimension illuminating a learning by doing orientation rather than only passively memorising and acquiring information [ ] . this offers richer and more diverse forms of dialogue and interaction between students and contextualized learning objects for vicarious forms of learning [ ] . being immersed in vr creates a sense of presence, it allows learning from each other and adapting performance in response to meaningful pseudo-natural feedback [ ] generated from interactions with dobjects. reflecting on this pseudo-natural-occurring feedback may cause to transform a daunting learning experience to a harmonious learning situation [ ] which can improve learning effectiveness compared to other modalities [ ] . vr allows unique teaching and learning experiences which, by design, makes it interesting to implement in existing multimodal paths. currently, the industry may not always seize the opportunity to apply such design principles, yet vr is starting to be introduced in multimodal paths across different subject areas and disciplines. the purpose of this section is to illustrate the variability of vr application into existing learning paths with examples coming from the field, schools, universities and companies in france and singapore. some were implemented in france, others in singapore, or both and in other countries as well. accordingly, the games are available in several languages, as illustrated in the following figures to . each example, connected to a general purpose, is described according to certain in-vr teaching and learning goals: knowledge transmission, practicing, feedback, evaluation. for each goal, we identify the activity which can be implemented. we distinguish the paths according to the nature of the vr experience that is integrated: serious games, simulations, collaborative vr (see table ). ( ) serious game [ ] section: we describe several use cases integrating a serious game in vr, single player, including feedback to the player. the user is facing a situation with a non-playing character, embodied with an avatar or only a voice. feedback are provided immediately during the game as well as at the end of the game and help the user to improve. such application is particularly relevant to train soft skills, such as how to behave with a client, a patient, a colleague. ( ) simulation [ ] section: we describe several use cases integrating simulation in vr, which purpose is to provide a relevant representation in vr of a target system to be learned (a machine, an organ, a network, etc.). such a tool is relevant to train users to interact with said system and learn procedural sequences or gestures. ( ) collaborative vr [ ] section: we describe several use cases integrating collaborative vr, i. e. a virtual environment where participants can join and are embodied with a personalized photorealistic avatar. participants can be distant or in the same room. they can share immersive content, such as interactive d models, °videos or role-playing game. such paths, embedding vr experiences along with other activity-oriented multimodal activities, could infer specific in-vr features, representations and visualizations mapped with intended learning outcomes. in addition, the association of multimodal activity-based teaching strategies would enable both individual and collaborative practices in the wider semiotic vr domain within which they occur. such deployments are being evaluated through quality of experience in order to collect user's state with such apparatuses [ ] . the vr tool is proposed as a practicing activity opening a seminar to foster equality behaviour by managers, regarding gender, disability and diversity. in gender awareness scenarios, the user can play whether a man or a woman. the game points discrimination and stereotypes through dialogue choices the learner must complete. it is part of a general company awareness policy regarding gender inequalities, aiming at understanding how many stereotypes about women drive once thoughts in the work environment, and how much these stereotypes influence our choices when it comes to promoting women. other scenarios relate to physical and cognitive disabilities as well as sexual orientation. figure illustrates situations and the options that are offered to the player, following the last statement of the non-playing character (npc), in english, as deployed in singaporian company. in this example, we aim at generating empathy by playing the role of some else, a woman or a disabled person. using the same approach, we propose another application, which will be integrated as part of a medical and dentistry and resulting from a french-singapore partnership. the purpose is to play the role of a child in the medical environment to better understand his.her point of view and anticipate his.her fear and anxieties. this application will be used for practicing. figure illustrates the point of view of the child as a patient in different situations: on the dentistry chair (left) and during a discussion with the doctor and a parent (right). clues in the field of view support the role of the child, such as the view of the child body (figure , left) . the vr tool is proposed as a practicing activity opening a course in a business school to train students to customer relationship management in a shop. the vr game, including an individual feedback, is played in the classroom and followed by a general discussion with the teacher. then evaluation takes place using traditional paper and pen methods, in the classroom. this program organization is very close to the previous one, although it takes place at school. figure illustrates the overall view of the shop (right figure single user serious game in vr for social norms and behaviour changes relating to discriminations. picture) and a zoom on a particular shop area, juice machine, where actions are required from the player (left). the vr tool is proposed as a practicing exercise on top of other applied exercises of a one-week training program for future shop managers. learners play one half of a day a serious game training them to the management of costumers' satisfaction. the purpose is to be able to answer questions for the best customer service experience possible. the game allows learners to memorize typical issues customers can encounter in respect with companies wording and policy. figure illustrates the shop where the game takes place (left) and the client npc the player is interacting with during the game (right). the red dot represents the player gaze direction allowing the interaction with the environment, such as the selection of answers. the vr tool is proposed as a practicing exercise embedded in a path for developing skills for front desk employees in the hospitality industry. the overall program also includes several individual debriefing sessions with a trainer, who can be distant from the trainee, flashcards to contribute to the retention. the entire path is validated through an assessment quiz certifying learning (retention). figure illustrates several situations of the game: with client npcs and possible answers from which the player has to select (left, in english) and a single client npc (right, in french). a "pause" button is shown as well as the score, showing the player progression in the game. this score contributes to immediate feedback to the player, indicating whether the selected answers are good or not regarding the quality of the customer relationship management. the vr tool is proposed as a practicing and evaluating activity, used as a closing applied exercise. the serious game consists in playing a thief trying to steal sensitive and confidential information from pcs, usb memory device but also paper notes. the purpose, as a player, is to steal as many information as possible during a short period of time. learners' identify sensitive information unprotection behaviours. the game also provides feedback and an evaluation of the player. in this context, the vr game is added to a face-to-face (physical) training program for any worker in companies for them to learn cybersecurity rules. figure illustrates some objects the player can interact with to determine those that can present a risk regarding cybersecurity, these objects are identified with yellow circles. this learning scenario is implemented in france, in singapore and other countries. the vr tool is provided as a practicing and evaluating activity among multiple applied exercises in a training program for operators on production line in pharmaceutical industry. the vr consists in a simulation of a true machine with the actual procedure for performing assembly task. each step is written and an agent (a voice) is guiding the player step by step through the process. the purpose is to allow learners to get confronted with the actual machine and pieces before doing it in real life. several modes allow progressive learning: a guided and a semi-guided mode for practicing and non-assisted mode for evaluation. the training program also includes several activities, collective and individual. figure shows game interface elements: the different steps of the game are presented on the left picture, showing the player is currently playing step , instructions are presented to guide the player (here "take the grease tube and grease the joints"), the objects required for the action are highlighted with blue halo (here the joints and the grease tube), on the right picture the player can see his/her hand manipulating the spanner. the vr tool is proposed as a practicing exercise for two players integrated into a training program for developing skills communication skills along an inter-job process. in two different vr environments, one learner is driving the train while the other learner is communicating at distance from the control place to give indications to the driver. during that time, the trainer is supervising the simulation without intervene. the trainer is annotating the scenario so he can do a debriefing of specific points with learners after the simulation. the purpose is to make learners memorize procedures while communicating and driving a train. figure illustrates the game environment. the vr tool is provided as a practicing tool, which can be used by neurosurgeon students to get used to brain anatomy and d manipulation. vr is added to help student to improve their d navigation skills, it consists in merged neuroimaging from patients' brain, with addition of artefact mimicking tumours. students have to identify their precise localization and size. a collaborative mode allows teachers and students to use the application collectively. such application contributes to downing and replacing part of real brain tumour surgery training. figure shows the user interface with a measurement tool (left) and the control panel to set the various display parameters (right). the controllers are represented in the virtual environment to facilitate the manipulation and interactions. the collaborative vr tool is provided for knowledge transmission as an innovative medium to share contents relating to process engineering in a common virtual environment, with students and teacher located in the same classroom. the course takes place in an engineering school. the vr is added as a new mode of the pedagogical multimodal path, integrated with traditional lecture, group assignment, and pen and paper evaluation. figure shows the setup of the students in the classroom (left) and the setup in the virtual classroom (right). virtual reality & intelligent hardware vol issue ： - the collaborative tool is provided for knowledge transmission as a new mode of the pedagogical multimodal path, allowing to share immersive content ( d interactive models and °videos and pictures). the purpose of using vr is to allow students to better understand the actual dimensions of equipment used in particle physics (i.e. colliders) and have a more realistic representation of the experimentation site, without physically visiting switzerland. during a regular session, high-school students follow introductory courses to particle physics in the morning, then individually sit in front of a computer to identify and sort real particle-collision events. they finish by sharing and piling up their results (together and with other classes around the world), to reach and experience the statistical methods and thresholds of particle discovery. vr is used to lecture students about the real size and lay-out of the gigantic apparatus that allow particle discoveries: an interactive d sketch of the cms (compact muon solenoid) detector (the lecturer and students are teleported to scale on the cms detector) with particle collision events and then °images and video to show the "real" images. the main advantage is to show an environment that cannot be illustrated in a regular classroom, because of its size and inaccessibility. figure shows the setup of the students in the classroom (left) and the setup in the virtual classroom (right). a view of the virtual environment is shown on the screen in the physical classroom for non-vr participants. the d model is shown at real scale, so that the students can better measure it. the collaborative vr tool is added at different time points for knowledge transmission, practicing and providing feedback as a communication tool in a multimodal path. the general purpose of the training program is to promote learners' leadership skills. it is implemented in an international company with managers from several countries. the use of vr allows participants to connect more easily and regularly without needs for traveling. the trainer can control participants' audio, allowing everyone to hear each other or isolating tables from each other for specific activities. this program has notably been implemented with an international company with managers from countries in asia-pacific area, including singapore. figure illustrates the view of the virtual environment from the desktop interface of the trainer. it shows the participant list and allows the management of the participants groups (the "tables"). in this paper, we highlight the connection between vr learning and multimodality and the instruction concepts related to it. this paper concentrates on vr but new hardware allow varying degree of "virtuality" [ ] . new generations of vr hmds also offer ar modules with a "see-through" capability for rapid switch from computer generated environment to real environment and any mixture thereof. tracking, voice tracking and body tracking. haptics and brain computing are also fields undergoing rapid progress and will be launched soon. all these technologies enable natural user interface [ ] . this comes along with deployment of g networks and possibility for streaming and cloud-based application architectures. this is already used for gaming, this will soon benefit to vr. shadow, a cloud gaming platform, is launching what it calls a "vr exploration program", i.e. a closed beta test for vr streaming [ ] . these new generations of hmds combined with opportunities of beyond- g networks will allow the development of genuine mixed reality experiences with fully natural interactions. changing the habits may take time, said alvin graylin, ceo of htc china, but for the benefit of users. hardware companies' strategies thus strongly impact the design of learning and teaching solutions that can be developed in france, in singapore and globally. this paper concentrates on learning and teaching but in the covid- crises context, other uses of xr are wildly discussed. prior to that crisis, vr was still emerging in some sectors. several factors are limiting the adoption, including the cost of equipment and complexity of implementation. from a business point of view, these limitations to adoption may be observed both in france and in singapore. in contrast, adoption of mobile technologies is much more significant, in line with the smartphone mobile equipment rate. while the future of vr was highly associated with entertainment and gaming in some recent market studies [ ] , one may expect that these trends will be impacted by the current context of physical distancing and climate issues. therefore, it could be assumed that the evolution of the vr and xr technologies will support the development of new experiences for remote working, authentic and content rich mediated learning and healthcare contexts. limiting people travels is a key aspect of the strategy to control pandemics, such as constraints as an opportunity and proposed a virtual version of the event. it has been the case of the v ec , the virtual vive ecosystem conference that was planned by htc in china in march [ ] and laval virtual planned in france in april [ ] . these are in line with preliminary attempts such as the idc conference hold in the netherlands in september , with the ibc live system initiated by tiledmedia and intel to live stream the five-day ibc conference globally in k, °virtual reality [ ] . of note, the use of vr for remote interaction, as described in use case # allows to significantly reduce traveling costs. as a consequence, the initial investment for individual equipment can be rapidly amortized. the impact of sanitary constraints has been significant, and it may last for to months more from now at a certain level. this will induce deep changes in habits notably with the support of technologies precluding a return to what the world was before covid. some describe a fully digital world, where xr technology will be the must-have, that's the position of alvin graylin, htc china ceo. at least for the coming years, an adoption phase will be characterised by coexistence in hybrid systems, for instance with organisation of physical events with virtual version, increased use of home office and flex office, blended learning with on-campus and remote learning, etc. more than % of the world's students' population have been impacted by the pandemic and the closures of schools, estimates unesco [ ] . the next school year may also be significantly impacted. this situation has revealed strong inequalities among teaching systems regarding their digital maturity and their capacity to ensure pedagogical continuity. although digital tools can bring significant advantages, for remote learning context as well as with the personalisation of education that undoubtedly bring support to students in difficulties, a strong private-public partnership will be essential to design and transform the education system, says marie-christine levet, ceo of educapital, the first european edtech vc fund [ ] . this transformation will require support and training of the teachers and parallel adaptation of the technologies to their specific needs and requirements. additionally, to hold the promise of a digital society, for learning, working and any other activities, xr technologies must be fully inclusive, and ensure accessibility to everyone, despite disabilities, would they be cognitive or physical. in this context, experimentation is the key to evaluate how technologies can be integrated into the teaching practice, especially in a multimodal perspective. this paper stipulated a review on designing and using vr for multimodal teaching, learning and training. vr and xr are highly versatile tools, which can be used for collaborative or individual activities, with distant or physically related participants at any step of the learning process: knowledge transmission, practicing, feedback and evaluation. we have described three main types of tools based on vr: serious games, mostly for soft skills training, simulation, mostly for procedural learning and collaborative vr for immersion with innovative content and to facilitate interactions between distant participants. these are only a few examples and the advent of technologies will allow to combine them more easily (e. g. collaborative serious game and simulation). the concept of adaptive learning and deep learning are also progressing along which will allow to create even more personalized and interactive learning experience as well as to provide indicators of individual progression to the trainer. however, we also identify a lack of robust evaluation framework to evaluate how these tools can be used in an optimized way and generate relevant synergies with existing tools, for the benefit of users: trainers and trainees. our purpose is therefore to increase researchers' attention in terms of designing vr experimentations that could be inspired by the use cases we have described. moreover, insights from this paper motivate us to list a certain number of research issues that need to be tackle. they are particularly aiming to apply scientific findings to the filed by pushing specific matters: -how to design learning in vr based on a multimodal strategy? -how to collect and analyse user data obtained in vr to discern a multimodal path? -how to determine whether a vr system should replace or complement an existing multimodal teaching and learning intervention enacted in the classroom? -what learning taxonomies may be mapped as means to enable in-vr multimodal teaching and learning for hybrid or purely online and distance forms of teaching and learning? a gap seems to be prevalent between scientific knowledge and industrial practices when vr is deployed in multimodal learning paths. communicating about use cases and choices that have been made might help to create a framework facilitating the process of mapping multimodality to in-vr features and components. the authors declare no competing financial interest. instructional-design theories and models. the learner-centered paradigm of education intrinsic motivation toward a tripartite model of intrinsic motivation metacognition and learning: conceptual and methodological considerations. metacognition and learning effectiveness of learning strategy instruction on academic performance: a meta-analysis does active learning work? a review of the research does problem-based learning work? a meta-analysis of evaluative research effects of problem-based learning: a meta-analysis. learning and instruction a problem based learning meta analysis: differences across problem types, implementation types, disciplines, and assessment levels serious game-based and nongame-based online courses: learning experiences and outcomes a serious game for amplifying awareness on multimodal teaching: game design and usability study from visual simulation to virtual reality to games digital games, design, and learning: a systematic review and metaanalysis serious games: mechanisms and effects origins of serious games multimodality and literacy in school classrooms multimodal discourse: the modes and media of contemporary communication theories and practices of multimodal education: the instructional dynamics of picture books and primary classrooms. the reading teacher visual fatigue impacts on learning via serious game in virtual reality reality-creating technologies as a global phenomenon state of the art of virtual reality technology new applications design and redesign of a multimodal classroom task -implications for teaching and learning virtual reality training in laparoscopic surgery: a systematic review & metaanalysis a literature review on immersive virtual reality in education-state of the art and perspectives a systematic review of virtual reality in education educational virtual environments: a ten-year review of empirical research enhancing our lives with immersive virtual reality listening strategy applications by learners under the context of multimodality multimodal interface for temporal pattern based interactive large volumetric visualization multi-modality behavioral influence analysis for personalized recommendations in health social media environment deep multimodality learning for uav video aesthetic quality assessment what video games have to teach us about learning and literacy modal density and modal configurations teaching poetry through collaborative art: an analysis of multimodal ensembles for transformative learning the effect of multimodal learning models on language teaching and learning. theory and practice in language studies implications of multimodal learning models for foreign language teaching and learning a literacy pedagogy for multimodal composing: transforming learning and teaching application of multimodal learning in online english teaching engaging literature through digital video composing: a teacher′s journey to"meaning that matters creating meaning through multimodality: multiliteracies assessment and photo projects for online portfolios. die unterrichtspraxis/teaching german the distance learning of foreign languages: a research agenda authentic assessment in online learning: moving beyond text to celebrate multimodal measures of student achievement learning, teaching, and scholarship in a digital age web . and classroom research: what path should we take now? educational researcher innovating pedagogy : open university innovation report journal of information systems education. investigating pedagogical value of wiki technology learning science in immersive virtual reality investigating the effectiveness of desktop virtual reality for teaching and learning of electrical/electronics technology in universities virtual health education: scaling practice to transform student learning: using virtual reality learning environments in healthcare education to bridge the theory/practice gap and improve patient safety teachers′ conceptions and their approaches to teaching in virtual reality and simulation-based learning environments. teachers and teaching teacher perceptions of learning affordances of multi-user virtual environments teaching with virtual reality: crafting a lesson and student response. (report) investigating learners′ attitudes toward virtual reality learning environments: based on a constructivist approach improving teaching and learning of computer programming through the use of the second life virtual world teaching training in a mixed-reality integrated learning environment fostering learning through interprofessional virtual reality simulation development a constructivist approach to virtual reality for experiential learning. e-learning and digital media emboldened by embodiment: six precepts for research on embodied learning and mixed reality learning theories and educational paradigms understanding virtual reality: interface, application, and design. presence: teleoperators and virtual environments a review of the use of virtual reality head-mounted displays in education and training. education and information technologies language learning in virtual reality environments: past, present, and future. educational technology & musical genre learning in primary education first-and third-person perspectives in immersive virtual environments: presence and performance analysis of embodied users implementing virtual reality in the classroom: envisaging possibilities in stem education enhancing our lives with immersive virtual reality a systematic review of virtual reality in education virtual reality challenges in education and training effects of virtual presence and learning outcome using low-end virtual reality systems integration of virtual reality in secondary stem education educational virtual environments: a ten-year review of empirical research virtual reality training in laparoscopic surgery: a systematic review & metaanalysis virtual reality check: statistical power, reported results, and the validity of research on the psychology of virtual reality and immersive environments teaching in d: pedagogical affordances and constraints of d virtual worlds for synchronous distance learning the impact of multimodal collaborative virtual environments on learning: a gamified online debate virtual locomotion: a survey situated learning: legitimate peripheral participation teachyverse: collaborative elearning in virtual reality lecture halls collaborative virtual environments: an introductory review of issues and systems virtual reality applications to work the state of immersive technology research: a literature analysis a literature review on immersive virtual reality in education: state of the art and perspectives. in: elearning and software for education (else) implicit learning through embodiment in immersive virtual reality a taxonomy of virtual worlds usage in education virtual reality headsets-a theoretical and pragmatic approach how immersive is enough? a meta-analysis of the effect of immersive technology on user presence the effectiveness of training in virtual environments a meta-analysis with examination of moderators of student cognition, affect, and learning outcomes while using serious educational games, serious games, and simulations an analysis of vr technology used in immersive simulations with a serious game perspective affordances of virtual reality for collaborative learning virtual classroom ' s quality of experience: a collaborative vr platform tested augmented reality: a class of displays on the reality-virtuality continuum brave nui world: designing natural user interfaces for touch and gesture marché des technologies immersives (vr/ar/mr) htc conducts its first virtual "vive ecosystem conference" (v²ec) fully in vr allowing global attendees to join virtual sessions laval virtual key: cord- - b wn j authors: barsoum, zakaria title: covid- pandemic: personal view to a new model of pediatric practice date: - - journal: world j pediatr doi: . /s - - - sha: doc_id: cord_uid: b wn j nan the coronavirus pandemic is an unprecedented challenge to health care professionals. central in its management remain social distancing, personal hygiene and wearing proper personal protective equipments. distant medical practising is alien to clinicians. virtual consultations deploying recent technology have now replaced the normal practice of routine clinics. virtual consultations minimise the risk of covid- transmission, promote public protection and reduce the backlog of waiting lists during this time of testing. many clinicians may feel uncomfortable with this new model of practice where the gold standard rule in medical practice is direct contact with patients. face to face consultations help build up rapport between doctors and patients. face to face clinical practice enables clinicians to better identify clinical problems and provide meticulous clinical assessment. uplifting patient safety and sound clinical judgement are a top priority for physicians. virtual clinics are useful tools at the time of covid- pandemic when health care demands are pressing. clinicians are at the front door in this battle and subsequently are at increased risks of contracting disease and transmitting it to their close contacts and loved ones, placing physicians under immense emotional pressures. children with allergy such as food allergy are a special cohort that may benefit well from virtual consultations. the preponderance of them are well and parents can provide a detailed allergy focused clinical history guided by clinicians during virtual consultations. the quality of video recording can provide clues about various allergic skin manifestations. obtaining allergy focused clinical history is a quality statement [ ] . in our unit, paediatric allergy team had forethought to launch virtual clinics before recent recommendations from the british society for allergy and clinical immunology (bsaci) justified this model [ ] . service started on march , , eight clinics were run and patients reviewed. no adverse events were reported and patient perception of the new service was encouraging. adjustments were made related to specific allergy investigations such as skin prick tests, congruent with bsaci recommendations, those tests can be deferred during covid- pandemic [ ] . in brief, virtual clinics are useful at times of pandemics although they lack direct clinical relationship with patients. virtual consultations deploy recent technology in medicine and are recommended by professional bodies. although clinical confidence and appropriateness of use may vary in various aspects of clinical care, our experience in paediatric allergy is satisfactory. author contributions bz wrote, revised and approved the final version of the manuscript. funding none. the national institute for health and care excellence (nice). nice report bsaci report covid- : pandemic contingency planning for the allergy and immunology clinic ethical approval not needed. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.* zakaria barsoum doctorzakaria@yahoo.com key: cord- -frfui a authors: feitosa, jennifer; salas, eduardo title: today's virtual teams: adapting lessons learned to the pandemic context date: - - journal: organ dyn doi: . /j.orgdyn. . sha: doc_id: cord_uid: frfui a nan wake up, roll out of bed. no need to change from your pajamas. make an extra strong coffee. change the kids and get breakfast ready. take the trash out. check your calendar to make sure you can first skim the news. while checking linkedin, another status update from a colleague that has been furloughed. change your zoom background to something fun since your first meeting is just a check-in with your small team. mute your microphone because your dog starts barking. unmute to provide some insight to show you are still connected. stop your video, so you can answer your kid's math question. finally, start going down your long list of emails, in order, to avoid answering unnecessary emails. you have gotten the most pressing emails out of the way and the video conference ended. oh! your next meeting is not for another minutes. maybe it's time to shower. wow! it's only : am. another long day ahead. this is a typical start to the day of your now virtual team member. covid- has dramatically changed organizations, family dynamics, and teamwork. according to gallup, the number of americans working remotely jumped from . % who were part-time in the beginning of this year to now % full-time remote workers, all by the first week of april. can we still apply what we know about virtual teams? probably not. researchers have highlighted five main challenges that ordinary virtual teams face. considering the current situation, we will revisit these original challenges to contextualize them with the goal of helping managers better navigate these unprecedented times. table summarizes these takeaways while providing action items for managers under these circumstances. trust matters, particularly in virtual teams. however, the emphasis in virtual teams has been on establishing trust. current teams already have an established level of team trust, but are now asked to work together with a heightened level of virtuality. rather than worrying about building trust, current organizations have to worry about maintaining and monitoring team trust with decreased opportunity for observation. accordingly, indicators of team trust will also change. team members' lack of responsiveness or their discrediting of coworkers' messages can be signs of trust violations, or psychological breach. companies, such as appirio, have established communication policies where team members are required to respond to each other within hours. to monitor team trust, managers need to pay attention to how team members are connecting, responding to one another, and more importantly maintaining their shared tasks. this allows them to promptly identify when episodes of trust violation occur in order to stop teams from permanently destroying their originally established team trust. updated guideline # : rather than the original concern about establishing trust, monitor team trust to catch any violation early on by checking in with team members and being mindful of their interactions. generally, team process gains include team coordination, cooperation, and communication. these are all parts of the synergy that effective teams have in common. how can synergy be created when employees are worried about their health, their job security, and life events? employees can no longer walk up to co-workers to bounce ideas off of one another, ask for help, or start promising collaborations. nevertheless, people are resilient and can learn informally along the way. this is crucial, considering that the best way to avoid process loss in virtual teams is to provide extensive team training, and not many teams have had time for extensive team training while adjusting to covid- circumstances. information sharing is the most hindered team process when in high virtuality. appen, global leader in speech and search technology services, has invested in clear and precise communication, including e-learning training. furthermore, interpersonal processes can be boosted when teams communicate through virtual mediums if the right conditions are in place. managers can engender these conditions by setting new norms, being transparent about decision making, and empowering employees to participate. in turn, this can speed up the formation of virtual synergy and offer stability during these uncertain times. updated guideline # : rather than the focus on groupprocess losses associated with virtual teams, the focus should be on process gains (e.g., communication) by providing direct channels for information sharing. inclusion is the feeling of belonging in someone else's space. how can you foster such an environment virtually? most of the ways to create an inclusive culture require at the very least occasional face-to-face interactions. current teams have to deal with a huge level of discrepancy in each member's local context, from different home situations to internet reliability, all the while ensuring that everyone's voices are heard. peoples' transition to working from home and their likelihood to press the unmute button to participate in a meeting will differ, and recognizing this can go a long way toward fostering inclusiveness. isolation and detachment are common challenges, and are exacerbated by the current situation. fostering a psychologically safe environment can bridge the gap in virtual teams. concepts as simple as having team members think about the pros and cons of all ideas can help workers understand other team members' perspectives. therefore, teams should find situational commonalities with their co-workers (e.g., ensuring everyone is safe and healthy) while facing different constraints (e.g., boredom, housework, childcare, time zone, internet reliability) to allow for a sense of belonging despite differences. for instance, envato market records all the large meetings so everyone has access wherever, whenever. managers should provide a safe environment, get to know each other, and draw from technological tools to make this happen. updated guideline # : rather than creating a virtual environment of inclusiveness and involvement through occasional face-to-face interactions, maximize the benefits of virtual teams by learning more about each other at a deeper level in the current platform. a main concern for those leading virtual teams is how to monitor team members' performance. however, with the fear of salary reduction or job loss, it is likely that employees are performing at their maximum capacity. accordingly, ask everyone to think about pros and cons of all ideas, including their own understand others' constraints (e.g., personal challenges) set aside time dedicated to each member in order to make sure each team member gets adequate opportunity to speak assess teamwork often provide feedback to your team members often follow up to ensure communication still flowing among team members allocate time for peer evaluations and debriefing sessions focus on results rather than hours worked taskwork is important, but what will really set effective virtual teams apart right now are teamwork skills. how can team members continue to orchestrate their work without being able to get approval from colleagues in a different department? unfortunately, people are more likely to ignore requests and delay responses when going virtual. hence, assessing team members' teamwork behaviors, providing continuous feedback that highlights any problem areas, and ensuring that employees feel heard will maintain the appropriate collaborations strong. combining the virtual team challenges of balancing taskwork and teamwork with its accurate assessment, we urge current teams to focus on teamwork and continuous feedback. organizations can draw from goal setting and debriefing methods to keep team members engaged instead of micromanaging during these unprecedented times. as an illustration of assessment, stack overflow focuses on results rather than how many hours team members work. the most essential workers will be those who can connect the dots and help other team members complete their tasks well. these core team players that are going above and beyond need to be supported, encouraged, and recognized. updated guideline # : rather than focusing on a balance of teamwork and taskwork, really make a point to recognize teamwork often by assessing their collaborative behaviors and providing constructive feedback to the team. in summary, the key takeaways for virtual teams in the pandemic include: ( ) monitor trust, ( ) focus on process gains, ( ) foster inclusion through psychological safety, and ( ) assess teamwork often. although the current context adds another layer of complexity, there are ways to continue to be productive in an innovative but yet humane way. managers that are most likely to succeed during this time are those that can adapt, understand differences, and serve as the glue between team members. today's virtual teams: adapting lessons learned to the pandemic context does trust matter more in virtual teams? a meta-analysis of trust and team effectiveness considering virtuality and documentation as moderators debunking key assumptions about teams: the role of culture unpacking the concept of virtuality: the effects of geographic dispersion, electronic dependence, dynamic structure, and national diversity on team innovation trust and temporary virtual teams: alternative explanations and dramaturgical relationships this work was partially supported by nasa grants nnx ab g, nnx ap g and national science foundation grant # to rice university. key: cord- -echy ks authors: schwamm, lee h.; erskine, alistair; licurse, adam title: a digital embrace to blunt the curve of covid pandemic date: - - journal: npj digit med doi: . /s - - - sha: doc_id: cord_uid: echy ks digital health, virtual care, telehealth, and telemedicine are all terms often used interchangeably to refer to the practice of care delivered from a distance. because virtual care collapses the barriers of time and distance, it is ideal for providing care that is patient-centered, lower cost, more convenient and at greater productivity. all these factors make virtual care tools indispensable elements in the covid response. in this perspective, we offer implementation guidance and policy insights relevant to the use of virtual care tools to meet the challenges of the covid pandemic. to-consumer, fee-for-service model, but these services contribute to fragmentation of care and do not allow for documentation in the electronic medical record of the patient's principle site of healthcare, and are not amenable to big data and natural language approaches to mapping the surges of care and load balancing across health systems. these companies of course should play a role in the covid response and should consider offering their clinical services at a significant discount, and their software to providers who wish to rapidly deploy. medical licensure areas need to be defined more generously during this crisis. we strongly agree with action by federal and regional authorities to temporarily remove or suspend restrictions related to the need for medical licensure in the jurisdiction where the patient is located, and recommend broad extensions of malpractice insurance to cover virtual care when delivered in a clinically appropriate manner, expansion of scope of practice for all healthcare providers and staff. in addition, coverage and payment parity for virtual care should be applied to all outpatient, inpatient, and critical care encounters should be authorized for all payors for all providers. insurance companies should deploy their increased revenue from decrease elective care utilization to increase coverage of all those providing care specific to this emergency. at our large, academic, integrated healthcare delivery system in new england, partners healthcare, we have taken a virtual-first approach and are expanding our existing portfolio of highly effective virtual care solutions and retooling them to deal with many of the challenges in this pandemic. our core principles are ( ) patients first, ( ) focus our provider time on delivering care, ( ) keep distance whenever possible, and ( ) use the simplest means possible (e.g. telephone or asynchronous messaging) when clinically appropriate. it is vital that in implementing virtual care we do not create a new social determinant of health in the form of lack of access to virtual care technology or affordability, that those with limited english proficiency be afforded the opportunity for medical interpretation, and that the visually impaired or disabled are still able to access care. for this reason, extensive use of telephonic communication may be best suited for some patients. we have identified and are implementing five priority virtual care initiatives to respond to the needs of our patients, and strongly recommend other health systems to consider these tactics as they plan their responses, now and in the future. we will offer the details of our solutions and approaches to any health system peers who request them. . virtual visits: video-enabled, provider-to-patient virtual visits will minimize in-person encounters at sites for ambulatory care for patients who would otherwise come in-person for care. this allows both providers and patients to conduct visits from their homes. this workflow is designed for patients without suspected covid- , and who are either at high risk of serious complications if infected, or who have ongoing medical conditions that will predictably deteriorate if unattended. while we have a currently active program which includes between and providers performing these virtual visits in a framework that is tightly integrated into our electronic health record (epic systems corporation), this model is unsuitable for our rapid expansion in the coming weeks to over , providers, both fully employed by our system and private practice providers affiliated with our hospitals. for this jump in scale, we will use a standalone option outside of the immediate ehr workflow that will allow for visits to occur in a parallel channel that can be conducted on almost any device while still being secure, private, centrally managed and supported across all providers and patients. this process will also allow providers who are assigned to home quarantine due to possible exposures to continue working if they are not disabled by illness. the effort to stand up such a rapid deployment will be substantial. in our early scaled efforts these past weeks, we have seen virtual visit volume at one of our academic centers grow roughly % when compared to the same period the year prior, and are seeing over % weekly program volume growth. we expect this level of growth to continue across the system in the near future. . in-room "video intercom": this virtual solution will reduce clinical staff contact with patients who have confirmed or suspected covid- illness by allowing a major reduction in the time spent in the room by providers who do not need to be providing direct care, including all staff and visitors. no patient training or device operation is needed, and the provider can connect to the patient room at any time using a standard hospital laptop or personal device. we believe this intervention will help reduce the risk of nosocomial spread as well as the rate of ppe consumption. to date, we have enabled over hospital rooms and will continue to rapidly scale as covid cases increase and our equipment supplies allow. . virtual urgent care: video-enabled brief urgent care visits will alleviate office visits and ambulatory surge clinics when patients cannot be adequately be triaged by phone alone, to assess illness severity and need for hospitalization, provide further reassurance, and to meet other minor healthcare needs. all encounters will be documented in our electronic health record. . virtual consults: this solution supports provider-to-provider expert consultation to an existing network of community hospitals in new england affiliated with our health system to receive services, such as telestroke, allowing upwards of % of patients to remain in the community site rather than be transferred to our academic medical centers which may soon be over-capacity. we will leverage this solution to provide expert consultative care across all specialties and provider types (e.g., physicians, nurses, respiratory therapists, imaging technicians) especially critical care services that are likely going to be in high demand. . automating the covid- screening process: a new webbased automatic screening process leveraging a microsoft robotic process automation tool (sometimes called a "chatbot") and currently in use at other health systems, is being modified and implemented for use by patients and providers to help properly evaluate and classify risk of covid- infection, and provide guidance on next steps in disposition. this asynchronous tool will be widely promoted to help alleviate pressure on live telephone requests to our nurse led covid hotline. it will also allow for near instantaneous modification of the clinical algorithms hardwired across the system by a central update to the robotic process automation tool, which is critical in a crisis management where written and telephonic communication systems are easily overwhelmed. the week of april th, individuals have launched our automated health bot which is more than double the number of calls to our covid- nursing triage hotline. of individuals who completed the health bot, % were classified as having positive symptoms and were triaged by the bot to the nurse hotline, home quarantine, dedicated covid- respiraory illness clinic or an emergency department. longer-term, as we expect a sustained response will be needed over the next year, our next wave of interventions will include provider-to-device, or remote patient monitoring at home for homebound patients currently under our care and those who are self-quarantined and at risk of deterioration, development of more robust asynchronous tools, such as structured clinical questionnaires offered via our patient portal, and enhanced remote specialty support via our large econsult program. we firmly believe that virtual care tools, if implemented quickly and reliably, can help blunt the curve of covid infection, and allow for our brick and mortar system to deliver care over more time without exceeding its capacity limits. this last point is particularly important as reported covid- mortality has ranged between . % and % in part based on healthcare delivery capacity. two centuries ago in , drs. john collins warren and james jackson called on the boston's gentry to help establish massachusetts general hospital as the state's first public general hospital with these words, "when in distress every man becomes our neighbor, not only if he be of the household of faith, but even though his misfortunes have been induced by transgressing the rules both of reason and religion." to meet the urgent need posed by covid , providers, payers, licensing boards, medicolegal carriers, and technology companies will need to break from traditional silos, realign their incentives for the common good, and deliver on our promise to our neighbors and patients to provide patientcentered, safe, and reliable healthcare during this crisis. several guidelines and reviews have called for broader adoption of virtual care into mainstream care delivery, but beyond telestroke systems of care large-scale uptake has been scant [ ] [ ] [ ] [ ] [ ] [ ] . now more than ever we need all providers to become rapidly proficient in delivering care virtually, rather than confining the practice of a small group of specialists . one of the few silver linings to this health crisis is that it will transform our antiquated methods of healthcare delivery and show us new ways in which more evolved technology can truly add value to healthcare for all. received: march ; accepted: april ; telehealth: seven strategies to successfully implement disruptive technology and transform health care patient and clinician experiences with telehealth for patient follow-up care virtual telestroke support for the emergency department evaluation of acute stroke role for telemedicine in acute stroke. feasibility and reliability of remote administration of the nih stroke scale virtual visits partially replaced in-person visits in an aco-based medical specialty practice experience with telemedicine in a multi-disciplinary als clinic virtually perfect? telemedicine for covid- the role of telehealth in the medical response to disasters challenges and opportunities faced by large health systems implementing telehealth establishment of an internationally agreed minimum data set for acute telestroke teleneurology and mobile technologies: the future of neurological care teleneurology consultations for prognostication and brain death diagnosis digital health strategies to improve care and continuity within stroke systems of care in the united states recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the american heart association recommendations for the implementation of telehealth in cardiovascular and stroke care: a policy statement from the american heart association virtual care as a specialty all authors dr. schwamm reports serving as a paid scientific consultant regarding user interface design and usability to lifeimage (a privately held teleradiology company correspondence and requests for materials should be addressed to l.h.s.reprints and permission information is available at http://www.nature.com/ reprintspublisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons. org/licenses/by/ . /. key: cord- - w lpn authors: dewar, shenbagam; lee, pearl g.; suh, theodore t.; min, lillian title: uptake of virtual visits in a geriatric primary care clinic during the covid‐ pandemic date: - - journal: j am geriatr soc doi: . /jgs. sha: doc_id: cord_uid: w lpn nan to the editor: the novel coronavirus or severe acute respiratory syndrome coronavirus pandemic called for a rapid adoption of telehealth service across all health systems in the united states to limit virus exposure to patients and health providers. as our colleagues at other institutions are also transforming the traditional in-person visits to virtual visits, we would like to share our experience and begin a national dialogue for what a high-quality virtual visit would entail. herein, we share our experience in providing telehealth for patients in a geriatric primary care clinic. we provide an overview of features we implemented to enhance the visit experience. our multisite geriatric clinic, which provides more than primary and geriatric specialty visits weekly within an academic healthcare system, moved quickly to transform most of in-person clinical appointments to virtual care format. in the course of weeks, by eliminating nonurgent in-person visits and rapid implementation of virtual care, we ramped up from zero to % of total geriatric primary and outpatient specialty care visits ( figure ). virtual care transformation was made possible by institutional commitment, as well as efforts by individual physicians, office staff, information technology specialist, and patients and caregivers. first, within geriatrics, we identified videoconferencing platforms available to our providers. before the coronavirus disease (covid- ) epidemic, our healthcare system had adopted epic as its electronic health record (ehr) system, which allows for health insurance portability and accountability act (hipaa)-compliant video visits. the epic integrated video visits involve several requirements: ( ) providers must set up specific applications on apple branded smartphone or tablets and ( ) patients are required to have online patient portal account through epic and download the health patient portal application; many patients had not completed either one or both of these steps. to address these limitations, the healthcare system quickly deployed epic "superusers" to help physicians set up the application for video visits. each physician reviewed his/her patients scheduled for clinic visits to weeks in advance and designated the need for each visit as nonurgent (reschedule), urgent virtual, or urgent in-person visit. the initial goal in the third week of march was to eliminate in-person visits simply by rescheduling. but by april, we encouraged providers to convert to virtual visits and clinic staff contacted all the patients to offer virtual visits. we quickly learned ways to telecommunicate with staff in real-time for scheduling virtual visits, and physicians were able to self-schedule virtual visits due to a newly upgraded feature in the ehr. by mid-april, the epic platform enabled providers to launch virtual care even from non-apple devices. for patients, we have expanded to a hipaa-compliant chatroom format, zoom health, which entails only clicking on a web link and can accommodate multiple family members joining from remote locations. our administrative staff and medical assistants shared responsibility to assist patients with the technology and to collect previsit clinical information. initially, most of our patients were reluctant to install video-capable applications onto their smartphones and tablets; thus, our patientsʼ preference of telephone visits over video visits is not surprising, given that nearly % of adults aged to years surveyed in a national sample expressed concern for difficulty using the technology for telehealth. anecdotally, the chatroom format facilitated family and caregivers to help the patients log on at the designated time. we recognized that the leading concern about telehealth visits among older adults is that healthcare figure increasing use of telephone and video virtual care after michigan shelter-in-place order. weekly trends in geriatric outpatient visits, by in-person vs virtual formats, showing a steep increase in telephone virtual care vs a slower uptake in video visits. the baseline proportion before the michigan state order to shelter in place on march , (black vertical dashed line), is indicated by the blue horizontal line at % for in-person visits, and maroon and green dashed lines for virtual formats at %. the x axis indicates the week (beginning date) and the total number of visits in parentheses. the % confidence intervals are indicated around each proportion and were obtained using the three-part categorical outcome for type of visit with week as the only categorical predictor (stata . ). providers would not be able to do a system-based physical examination ( % in a national survey). we have summarized our adaptation of the virtual examination (table ) , using the four basic components: inspection, palpation, percussion, and auscultation. several strategies facilitated our visits: ( ) patient or caregiver involvement. before the visit, our staff asked if patients could self-measure home blood pressure (bp), pulse, body weight, temperature, and fingerstick glucose, if appropriate. with virtual visits scaling up, the health system realized the importance of bp monitoring and has adopted bp drive-through visits. for telephone visits, patients who have skin lesions were prompted to send images via the patient portal if enrolled. during the visit, caregivers can hold the camera to help perform inspection and/or palpation of the concerned areas. ( ) previsit medication review. our pharmacy technologist or medical assistant performed medication reconciliation with patients before the virtual visit via telephone calls. alternatively, the physician can perform medication reconciliation during the visit if patients have their medications readily available. ( ) previsit distribution of forms. patient health questionnaire- , fall screening, social history, and physical and cognitive functional assessment. ( ) detailed history taking. this results in over % of the diagnostic yield in outpatient clinic visits (ie, without examination, laboratory tests, or studies). ( ) cognitive assessment. montreal cognitive assessment (moca) has issued recommendations on how to use abbreviated or full version of moca for telephone visits or audiovisual visits. we are grateful for the close collaboration and generous spirit among the healthcare providers, staff, medical assistants, information technology specialists, and our patients and their caregivers. in the future, we will obtain quality of care data, which is a leading concern of older adults on telehealth. infrastructure to monitor our performance in virtual care. for example, we can track the volume of virtual visits related to distance in miles saved. in the first weeks, over , travel miles have been saved, with an average of miles per virtual visit. such information will help optimization of care delivery in the future. during this extraordinary period of social isolation and loneliness, it gave us a tremendous opportunity to provide virtual care widely, even among patients whom we doubted would adapt to the change. our clinicians have turned their skepticism over the feasibility of providing virtual visits to older adults, embracing the emerging healthcare technology. future studies will need to assess how this change in healthcare delivery affects patient care, outcomes, patient satisfaction, and clinicianʼs sense of completeness in caring for the geriatric patients. medicare telemedicine health care provider fact sheet university of michigan national poll on healthy aging moca montreal cognitive assessment assessing depression in primary care with the phq- : can it be carried out over the telephone? relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients the authors affirm that we have listed everyone who contributed significantly to the work and no other contributors other than the authors. we thank julie bynum, md, for her advice during the manuscript preparation. conflict of interest: each author declares no personal or financial conflicts and declare "the authors have no conflicts."author contributions: authorsʼ listed were involved in the data, analysis and interpretation of data, and preparation of manuscript.sponsorʼs role: no sponsor involvement. key: cord- -h j f xq authors: dooley, anjali b.; houssaye, nadia de la; baum, neil title: use of telemedicine for sexual medicine patients date: - - journal: sex med rev doi: . /j.sxmr. . . sha: doc_id: cord_uid: h j f xq introduction: telemedicine (tm) will play a significant role in contemporary practices that diagnose and treat sexual medicine patients. although only a small percentage of urologists, sex therapists, social workers, psychiatrists, gynecologists, and urogynecologists currently use tm, many more practices are going to embrace this technology in the near future. this article will discuss the process for implementing tm in sexual medicine with minimal time, energy, effort, and expense. we will also examine compliance and legal issues associated with implementing tm in practice and how to code for tm services based on regulatory guidelines. objectives: the purpose of this article is to improve the understanding of the concept and the trends of using tm to provide care for sexual medicine patients. methods: the study involves a literature review focussing on the new centers for medicare and medicaid services guidelines including the relaxation of the health insurance portability and accountability act requirements. results: covid- has changed the doctor-patient relationship especially in the area of sexual medicine. there are many patients with sexual medicine conditions that are amenable to the use of tm methods. conclusion: virtual visit utilizing audiovisual telecommunications is a very attractive approach for sexual medicine patients. many patients with sexual medicine problems are no longer going to accept the antiquated method of healthcare involving making an appointment, visiting a brick-and-mortar facility, and the requirement of having a physical examination. the new normal will be communicating with patients by utilizing tm. dooley ab, houssaye n de la, baum n. use of telemedicine for sexual medicine patients. sex med rev ;xx:xxx–xxx. objectives telemedicine (tm) is a new approach to treating sexual medicine patients. the purpose of this article is to share the advantages of tm and how to implement such a program in any practice managing patients with sexual problems and conditions. we also want to use this article to educate sexual medicine practitioners on the legal guidelines for using tm. finally, no article on tm would be complete without a discussion on the importance of documentation and coding for a virtual visit. as wayne gretzky, one of the greatest hockey players, advised "a good hockey player plays where the puck is. a great hockey player plays where the puck is going to be." and in this covid- era, the proverbial puck is going to be communicating with patients using tm. whether they know it or not, healthcare professionals caring for sexual medicine patients have for long practiced a form of tm-only without the video component. by taking phone calls from patients asking for medication refills or responding to patients after hours and on evenings and weekends, professionals have already availed themselves of a form of tm. in the face of such patient demands, sexual medicine professionals either acquiesce and call pharmacies to refill the medications, or they deny requests and suggest that patients make an appointment and receive a new prescription. while the latter action will probably not endear patients to a sexual medicine provider, providers who acquiesce to patients' phone requests to have prescriptions filled or otherwise seek free medical advice should keep in mind that they are not being compensated for providing these services. not only are physicians legally responsible for their actions, by rewarding patients with a prescription or advice, but may also be inadvertently motivating them to continue to seek free medical guidance without making follow-up appointments. as the legal landscape and regulations for reimbursement are changing to adopt tm more readily-particularly during the coronavirus (covid- ) pandemic-tm is increasingly being used to handle rising demands on healthcare professionals and to reduce the spread of the disease. there is potential for tm to improve efficiency, reduce healthcare costs, and improve patient satisfaction. it is important to consult with a healthcare attorney who understands the technology, state-by-state regulatory challenges, and reimbursement challenges. whether such advice comes from a competent legal counsel or a tm implementation company with its own in-house legal professional, the message is clear: guidance in this rapidly changing arena is imperative. failure to do so-and the potential consequences of such inaction-do not make for good medicine. on the upside, improvements in technology have changed the landscape of the entire healthcare industry and modern tm can be an important adjunct to a high-functioning sexual medicine practice. among other benefits, sexual health professionals can be compensated for their text, phone, or video interactions with patients while practicing good medicine. tm can provide an electronic record of phone interactions and a seamless method of billing the patient or the insurance company for the virtual visit. as providers for patients with sexual health problems, we are now able to leverage the advances in digital technology using tm while directly addressing some of tm's risks. the proper use of tm can lower the cost of healthcare for patients and providers. professionals who harness tm will magnify their competitive advantage exponentially as they are now able to connect with their existing sexual medicine patients and attract new patients. using tm, professionals will be able to reach patients in a larger geographic radius, rather than depending exclusively on time-honored word-of-mouth marketing to promote their practices. it is increasingly imperative that we embrace technologies that will make our practices more attractive to our patients. initially, tm's best use was for rural areas, where there were few physicians, especially urologists or sexual medicine professionals, and reimbursement was available for all specialists. as recently as , an american urological association census showed that . % of counties in the united states have no urologists. the same report also noted that from to , telehealth service use increased substantially, especially in rural areas ( %) of the country as compared to the somewhat slower ( %) growth in urban areas. now there is a trend toward more urban medical practices embracing tm. currently, urban usage of tm has grown to match and even surpass rural usage. between and , urban areas saw a jump from % to more than % use, while rural growth increased from % in to % in . kaiser permanente chief executive officer bernard tyson indicated that % of the more than million annual encounters with kaiser doctors took place remotely using tm. american well (amwell), a for-profit organization that has set the standard for online care, estimated that by , between , and , u.s. physicians would be using telehealth to see patients. nearly all healthcare providers including non-physicians now recognize the demand for and the importance of using tm to care for patients. the number of physicians and non-urologists using tm continues to increase by about % per year and is likely to grow at an even faster rate in the near term. that coincides with the growth in tm patient visits, which increased annually by % between and . the healthcare profession's primary mission is to diagnose and treat diseases and to do no harm. tm can solve several healthcare challenges: improved outcomes, reduced cost of care, and increased patient satisfaction. in other words, tm helps achieve a triple aim. conducting a tm doesn't require any additional staff to accomplish the session, thus reducing the cost of care. also, patients don't have to be moved from the reception area to the examination room and then to the checkout counter, thus improving the efficiency of the practice and allowing the providers to see more patients. in particular, tm can increase efficiency and reduce expenses of caring for sexual medicine patients. it is possible for sexual medicine physicians to implement a tm program by starting with a smartphone or a tablet device with no requirement to purchase additional hardware or software. tm enhances traditional face-to-face interactions between the patient and the sexual medicine professional. a strong doctorpatient relationship is the foundation of a model that has worked since the time of hippocrates and which almost always begins with a face-to-face encounter between a patient and a healthcare provider. as such, tm should support, not replace, traditional care delivery. with tm care, providers can continue to provide care for patients in-person while offering to them the flexibility and convenience of being seen remotely for follow-up visits and check-ups and dispensing education for their sexual medicine conditions. tm also offers providers an opportunity to attract new patients. today, patients are looking for more convenient ways to access their providers and receive immediate care without going to an emergency room or an urgent care center. there are large numbers of patients who appreciate convenience, flexibility, and real-time care with their providers and such patients often have busy schedules and lifestyles that are similar to those of their providers. patients who are employed are less willing to waste their time traveling to the office or the clinic and waiting to be seen by the provider. this makes tm very attractive to anyone in the workforce. seen from another perspective, the healthcare profession today is increasingly challenging and stressful. more physicians than ever are retiring early or experiencing burnout, which is now at an epidemic proportion of % of all physicians. unfortunately, urologists have one of the highest burnout rates of all physician specialties. with more than % of practicing urologists over the age of years and nearing retirement, coupled with the rising demand for urological care from aging patient populations, urologists are facing increased pressure to see more patients and spend less time with each one of them. telehealth can bridge the gap between physician supply and patient demand. tm can improve job satisfaction by making it easier to interact with patients. providers can use tm to make it easier to balance their work and family life and perhaps decrease the risk of physician burnout. sexual medicine patients often seek a provider who is up-todate with the latest in diagnostic and therapeutic methods of treating sexual medicine diseases. patients are also interested in providers who are on the leading edge of technology in their practices and whose use of such technology can reduce healthcare expenses. % of consumers who have used telehealth say that it has lowered their healthcare costs. on the other hand, people's biggest concerns about using telehealth services are cost, privacy, and loss of the personal relationship with their doctor. this understanding of what patients look for and seek to avoid in their patient-provider relationships can help identify those for whom tm might provide an attractive alternative. many sexual medicine patients are going to be easily managed using tm. even patients with sensitive health issues, including erectile dysfunction in men, are potential patients to be managed with tm. among the best advantages, many of the patients that are typically seen in the office in a face-to-face setting can easily be managed using tm. table provides a list of patients who can be easily and safely managed using tm. the guidelines for seeing new patients using tm have not been well-defined. the american medical association confirms that tm may be used for all patient visits including initial evaluations in order to establish a provider-patient relationship. the best and safest advice is provided to the patient once in a face-to-face visit or if the provider is consulted by another physician and has received an in-person evaluation by the referring doctor, then the consulting physician can provide care using tm. it is noteworthy that some postoperative patients will also be amenable for follow-up using tm. viers et al reported that post-radical prostatectomy patients were followed up using a video visit compared to post-prostatectomy patients followed up in the traditional office visit. the study showed that there were no significant differences in patient safety, confidentiality, efficiency, or overall patient satisfaction. the tm visits incurred lower costs, with a similar level of urologist satisfaction for video visits ( %) and office visits ( %). if post-prostatectomy patients can be safely cared for in the postoperative period, then perhaps vasectomy patients, vas reversals, penile prosthesis, and post-artificial urinary sphincter patients might also be monitored using tm. conditions that are not suitable for tm are those for which an in-person visit is required to evaluate the patient due to the severity of the problem, the necessity of a physical examination, the need for protocol-driven procedures, or the need for aggressive interventions, such as patients requiring an injection, implantation of testosterone pellets, or in-office procedures. other patients for whom tm may not be suitable for medical care include those with cognitive disorders, intoxicated patients, language barriers, emergency situations that warrant an office visit or a visit to the emergency room, or who do not have the required technology to conduct a virtual visit. late adopters often express an assumption that face-to-face visits are the preference of the patients. also, many practices table . sexual medicine patients followed using telemedicine erectile dysfunction hypogonadism (low t and estrogen deficiency) premature ejaculation peyronie's disease follow-up or after intralesional injection male infertility lower urinary tract symptoms (bph) follow-up stds discuss reports and imaging studies (psa, serum testosterone level) certain postoperative patients follow-up visits to annual examination new patient interview prior to an in-office visit rural patients living at a great distance from the sexual medicine professional existing patients who are at a great distance from the brick-andmortar office bph ¼ benign prostatic hyperplasia; psa ¼ prostate-specific antigen; stds ¼ sexually transmitted diseases; t ¼ testosterone. sex med rev ;-: e are concerned about implementing tm due to the perceived legal and compliance barriers. however, many patients prefer the convenience of a virtual visit. given the tremendous growth of tm, we are seeing a critical number of patients who will expect that their provider(s) will be able to conduct virtual visits. practices that don't offer tm are likely to find that patients will seek out a provider who does offer this service. already, nearly two-thirds of healthcare professionals expect their commitment to tm to increase significantly in the next years. of those providers who have not adopted tm, nearly % expect to implement tm in the near future. from to , the adoption of virtual visits has increased in healthcare by %. of course, there is some understandable concern about the cost and the complexity of implementing the tm technology. unfortunately, the implementation of electronic medical records (emrs) has left a bitter taste amongst the healthcare communities. emrs were complicated, expensive, and often resulted in loss of productivity because the learning curve was so steep that doctors had to decrease the number of patients seen before becoming comfortable with the conversion from paper to electronic records. there are going to be practices and providers who will find that using tm will disrupt their workflow or the methodology of managing patients. implementing tm will require an adjustment on the part of the providers. providers will have to designate a segment of time that is dedicated to tm and make every effort to be on time for those virtual visits with their patients. of course, the largest hurdle for most physicians will be providing care and not touching or examining the patient. however, tm implementation is much less onerous and much less expensive. tm is available as a cloud-based platform that requires less it support and lower levels of hardware and software management. the technology required for patients to participate in tm is nearly ubiquitous. according to pew research center, % of americans own a smartphone and more than half ( %) own a tablet. in essence, the basic requirement to connect patients to providers electronically is already in place. from the provider perspective, the basic requirements for implementing a tm program include a computer with video and audio capabilities, and a broadband internet connection with sufficient bandwidth and speed to view the majority of video encounters in high quality. depending on the magnitude of the program, computer technology assistance may be needed to implement tm into practice. it will also be helpful if the tm program is interoperable with the practice's emr and the practice billing program; if not, double and triple entry will erase the efficiencies provided by conducting a virtual visit. like any other aspect of providing patient care, obtaining and documenting informed consent should be practiced with all tm patients. not only is getting informed patient consent a recommended best practice by the american telemedicine association, it is a requirement in many states and/or a requirement for reimbursement, depending on the payer. a sample consent for tm is shown in figure . the national telehealth policy resource center provides a state-level map that provides information on the consent requirements in each u.s. state. some states have no requirements regarding consent for a virtual visit. others require verbal consent. in any case, it is a good policy to obtain consent (either verbal or written) and document in the patient's record that a consent was obtained before initiating a virtual visit. the consent should also include the practice's policies regarding billing, scheduling, and cancellations for tm visits. since tm is a new way of receiving care for many patients, practitioners and staff must teach patients how the processes and technologies work. such information should include explanations of patient confidentiality and privacy in the context of virtual doctor visits, the kinds of technical equipment needed for a virtual visit, and the above-mentioned expectations in terms of scheduling, canceling, and billing policies. another barrier that must be considered is liability insurance for conducting a virtual visit with a patient. professionals who are going to offer tm care for patients should request proof in writing that the liability insurance policies cover tm malpractice and that the coverage extends to other states, should the patient be physically located in a state different from the state where the provider holds a license. those who provide tm care also should check with liability insurers for requirements of and limitations on conducting virtual visits with their patients and document such requirements or limitations. for example, a policy may require that the doctor keep a record (either written or recorded) in the emr of the visit. consequently, using tools such as skype, facebook, or google, which do not include such documentation for the virtual visit, would make those programs less attractive since they do not comply with malpractice liability requirements. perhaps the biggest barrier to virtual health adoption is the compensation for the tm visit. the good news is that legislation by most states is quickly embracing virtual health visits (see legal landmines to consider section). finally, a focus on privacy and health insurance portability and accountability act (hipaa) compliance is mission-critical to the success of a tm program. unfortunately, healthcare has the dubious distinction of being one of the industry's most vulnerable to data breaches and a particular target for hackers. therefore, it is understandable that, especially in the area of sexual health, professionals are concerned with data privacy, security, and compliance. it is important to recognize that a virtual visit in an office setting or in the home environment could allow fellow employees or family members to overhear the conversations between the healthcare professional and the patient (see additional analysis in the legal landmines to consider section). the legal and regulatory landscape for the use of tm includes federal and state-specific laws and requirements. it is important to be aware of the laws in each state in which a provider's patients are located, and practice according to the requirements of these laws. note that this web of requirements is changing rapidly, in real time and as a result of the covid- pandemic. beyond current challenges and opportunities-taking a longer view, in other words-tm is becoming more established, and compensation and accountability protocols are being created that reward doctors for care delivered remotely and that align physician responsibility (and potential exposure and liability) with that of other more traditional methods of patient counseling and treatment. physicians are also better positioned to receive compensation commensurate with the services they provide via tm. providers treating sexual medicine patients are, in particular, prime candidates to maximize the potential of this technology. to ensure a smooth transition to or expansion of tm services, physicians and healthcare providers should seek the guidance of legal counsel. a knowledgeable healthcare and tm attorney can help practitioners make the best decisions on the following: . corporate practice laws. these laws require that your practice be governed by a healthcare professional, not someone with a non-medical background. this becomes important if one is looking to provide virtual practice in another state. . collaborative agreement requirements. these laws require physician supervision of nurse practitioners and physician assistants and may limit the number of allied healthcare providers that a physician may supervise. this is an issue that must be considered, especially if the practice significantly relies on the services of nurses, such as advanced practice registered nurses, who have a broad scope of practice and may be very qualified to care for sexual medicine patients. . interstate licensing laws. certain states may allow for the transfer of practice licenses, or reciprocity, between states; however, there are a number of states that do not, meaning that a provider may need to consider obtaining a license in that state. . state prescription drug monitoring laws. every state (except for missouri) has some form of a prescription drug monitoring program. if you plan to prescribe, you will need to look at that state's requirements for registering in and checking that state's prescription drug monitoring program. . physician-patient relationship and prescription drug laws. drug monitoring laws have expanded to define when you may prescribe controlled substances to a patient. although state laws may differ, the ryan haight act implemented a requirement that physicians have at least one in-person, faceto-face visit with the patients before prescribing them a controlled substance for the first time. state laws may vary, however; it may be best to consult with an attorney to understand your state's requirements for prescribing controlled substances to new patients. on march and , , the u.s. substance abuse and mental health services administration published updated guidance temporarily waiving certain requirements for the treatment of substance abuse, including opioid use disorder and alcohol or benzodiazepine withdrawal. for example, the u.s. substance abuse and mental health services administration is no longer requiring providers to conduct an in-person evaluation of patients treated with buprenorphine if a program physician has determined that an adequate evaluation can be conducted via tm. (this waiver does not apply to new patients being treated with methadone.) these and other steps have been taken in order to facilitate treatment and reduce infection during the covid- crisis and will likely be terminated once the national public health emergency is suspended. . telehealth reimbursement. reimbursement policies vary by state, region, and payor, and can lead to a very patchwork practice. however, this will likely change over time as payors become accustomed to the demands for telehealth and centers for medicare and medicaid services (cms) continues to push for virtual communication with patients. practices will need to prepare to address the changes in coding and reimbursement changes that are sure to occur. . data privacy and security. from a content perspective, healthcare data and personally identifiable information are extremely important-which makes electronic health records, or the digital form of patients' medical histories and other data, particularly tempting targets for hackers and cyber criminals. in the first quarter of alone, more than data breaches-involving the health information of more than individuals per event and often numbering in hundreds of thousands of patients per breach-were reported to the u.s. department of health and human services (hhs), as required by the federal health information technology for economic and clinical health act. to ensure compliance with hipaa requirements, providers must establish robust protocols, policies, and processes for handling sensitive information. more recent federal and state laws, such as the california consumer privacy act and the illinois biometric information privacy act, also have specific requirements that may implicate healthcare providers and expose them to liability for failure to adequately safeguard protected data, particularly when data are being transmitted, used, and discussed across a wide range of web-based tools, including hardware, software, and applications. . hipaa compliance. generally-and certainly under normal circumstances-tm is subject to the same rules governing protected health information (phi) as any other technology and process used in physician practices. the hipaa security rule includes guidelines on tm and stipulates that only authorized users should have access to the patient's electronic phi, that a system of secure communication must be established to protect the security of electronic phi, and that a system to monitor communications must be maintained, among other requirements. third parties that provide tm, data storage, and other services, with a few exceptions, must have a business associate agreement (baa) with a covered entity. such an agreement should include specific language that ensures compliance with hipaa requirements. during the covid- pandemic, however, certain hipaa restrictions relating to tm have been temporarily waived by hhs. more specifically, hhs secretary alex azar has exercised his authority to waive sanctions against covered hospitals for non-compliance with rules governing requirements to obtain a patient's agreement to speak with family members or friends involved in the patient's care, to distribute a notice of privacy practices, to request privacy restrictions, to request confidential communications, and the use of non-public facing audio and video communications products, among others. these are temporary measures only; at such time when the national public health emergency is lifted or when the hhs secretary decides, based on new developments, this position on discretionary nonenforcement will end. identifying and implementing an effective, robust tm solution is as important as any other technology decision. a key step in this process is finding a reliable tm vendor-an effort that requires time and due diligence. one of the best ways to select a vendor is to ask colleagues who have implemented tm and "kick the tires" of their program. it is important to receive feedback from similar practices and find out their experience with the technology. ask the vendors for referrals from other sexual medicine professionals who have used the program. speak to doctors and staff, and, if possible, ask for permission to speak to a few of their patients to learn more about their experience with the technology. the tm program should be interoperable and have a seamless connection between the tm program and the emr. such sophisticated programs are more costly but are, in the long run, more efficient and productive than an off-the-shelf tool that functions parallel to or alongside the emr. the newest programs also have an automated "rules engine" that checks the eligibility of every patient specifically for tm reimbursement as soon as the visit is scheduled. by using a rules engine, if a claim is ever denied and the tm visit was previously approved, the tm reimbursement experts resolve the problem and obtain reimbursement. essentially, the company ensures a clean tm submission to the payer. if possible, test the product to ensure ease of use and accessibility on mobile devices, laptops, or home computers. products today should have a tm app that offers full mobile compatibility, which allows sexual medicine professionals to quickly schedule patients, check patient records, access payment information, and correspond with patients in real time. arrange a live demo with several vendors so that a clear comparison between programs can be made. reputable vendors will have a baa in place to protect private information. their software should also be health information trust alliance certified and hipaa compliant to meet certain industry standards. finally, look for a company that offers reliable customer support. tech support will be very important, especially when launching the tm program, as all types of issues and questions will occur when installing a new system. ask about the vendor's customer service and the it support teams that are available to assist practice, before, during, and after initiating the new technology. ask the vendor and its previous clients about the promptness of returned phone calls and the page at which they can solve technical problems. ideally, customer support and information technology teams should be available round the clock. be sure your tm vendor provides a baa. a baa is a written agreement between a healthcare provider and a contractor/ vendor. a provider enters into a baa with a contractor or other vendor when that vendor might receive access to phi. a final key point about vendor and solution selection: tm programs are not one-size-fits-all solutions. a platform that works in one practice may not be applicable to another similar practice. understand practice needs, processes, and the people who will have some interaction with or responsibility for the tool, look for a telehealth partner who will work with the practice to ensure a program meets all of the requirements, and make decisions accordingly. perhaps, the main obstacle to widespread tm adoption for sexual medicine practitioners has been the complexity around reimbursement. commercial payers and cms have been slow to enact formal policies for tm reimbursement. because of this, it is a common misconception that providers cannot be reimbursed for tm appointments, or that compensation is provided at a reduced rate. this makes tm appear economically unappealing to sexual medicine providers. beginning march , , tm services are no longer considered "optional" coverage in medicare advantage plans for which the patient will be required to pay an additional fee. instead, the cms now allows tm as a standard, covered benefit in all plans, enabling beneficiaries to seek care in their homes rather than requiring them to go to a healthcare facility. in the past, tm was restricted for use in rural areas or when patients were at a great distance from their providers. starting march , and for the duration of the covid- public health emergency, medicare will make payments for professional services furnished to beneficiaries in all areas of the country in all settings, regardless of the location or the distance between the patient and the doctor. the intention is to offer medical services to patients who may have been exposed to coronavirus or have symptoms of covid- while avoiding the need for such patients to visit brick-and-mortar offices and risk spreading the disease to staff and other patients. with the expansion of tm services, providers will now be reimbursed for virtual care at the same rate they are for in-person visits. there are also state parity laws that require commercial payers and cms to reimburse for tm, often at the same rate as a comparable in-person service. under the new guidelines noted above, reimbursement parity laws are now in place for every state and the district of columbia. the center for connected health policy and the advisory board primer are valuable resources that can help providers stay abreast of state-by-state changes in virtual health reimbursement. as for coding, in particular, as long as the provider performs and documents the elements of history and decision making, including the time spent counseling, and documents the visit as if a face-to-face visit occurred, the providers have a billable evaluation and management visit. the main types of virtual services that can be provided to medicare patients include medicare telehealth visits, virtual check-ins, and e-visits. currently, medicare patients may use telecommunication technology for any services that were previously rendered as an inperson communication. the provider must use an interactive audio and video telecommunications system that permits real-time communication between the doctor and the patient at home. during the current public health emergency, it is imperative that patients with or suspected of having covid- avoid travel, when possible, to physicians' offices where they could risk their own or others' exposure to further illness. the patient must also have a prior established relationship with a provider; however, the new guidelines indicate that hhs will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. established medicare patients may have a brief communication service with sexual medicine providers using a telephone or a live video discussion. these brief virtual services, usually e minutes in duration, are initiated by the patient. the time required for a virtual visit must be documented in the medical record. these virtual check-ins are for patients with an established (or existing) relationship with a physician where the communication is not related to a medical visit within the previous days and does not lead to a medical visit within the next hours. the purpose of the "virtual check-in" is to determine if an office visit or a test or procedure is indicated. medicare pays for these virtual check-ins (or brief communication technology-based services) for patients to communicate with their doctors and avoid unnecessary trips to the doctor's office. these brief virtual check-ins are only for established patients. if, for example, an existing patient contacts a sexual medicine professional for a brief virtual visit to ask a question or to ask if an office visit is necessary, the provider may bill for these brief ( e minutes) virtual check-in services, conducted via telephone or other telecommunication devices, using codes g in order to answer a brief question, to determine if an office visit is necessary, or to recommend another service. established medicare patients may have non-face-to-face patient-initiated communications with their provider without going to the doctor's office. these services can only be reported when the billing practice has an established relationship with the patient. the services may be billed using cpt codes e . the coding for these visits is determined by the amount of time the provider spends online with the patient: : online digital evaluation and management service, for an established patient for e minutes spent on the virtual visit; : e minutes; : or more minutes. given today's circumstances, many doctors will want to immediately start the communication process with their patients and will avail themselves of the free video communication offered by applications such as google hangouts, skype, facetime, and facebook messenger. since march , , with the relaxation of the hipaa restrictions for tm, it is now possible to have a virtual visit with a patient using one of these and other free, non-hipaa compliant connections. the logic behind this change is that such communication methods are no different than the telephone call that has been conducted for decades without any video component. using these free technologies, a sexual medicine provider can have an asynchronous visit referred to as a store and forward method of sending information or medical images, which takes place in one direction with no opportunity for interaction with the patient-a video text message left for the patient can be considered an example of an asynchronous visit. on the other hand, a synchronous or real-time video visit with a patient is a way communication that provides medical care without the necessity to examine the patient. however, there are some downsides to this method of using what we deem "telemedicine-lite" and the free applications that have grown in use quite recently. first, it must be noted that these virtual visits on skype, facetime, and other non-hipaa compliant or secure methods are not conducted on an encrypted website. second, no documentation is prepared for the doctor-patient relationship or interaction. finally, unless the doctor keeps a record of these virtual visits and submits the interactions to the practice coders, there will be no billing and no reimbursements for the visit. thus, doctors are not only legally responsible for their decision making, prescription writing, and medical advice, but may also fail to receive compensation for their efforts. a sample documentation form that can be used to record the documentation of the visit that took place is provided in figure . there are work-arounds that support use of the free programs, protect the doctor, and allow the provider to receive compensation for the virtual visit. one such method is "triangulation" of the virtual visit, which includes necessary parties: (i) the doctor, (ii) the patient, and (iii) the scribe or medical assistant who will record the visit. before initiating the virtual visit using triangulation, it is imperative to ask the patient for their permission to allow the medical assistant (or any other person in the office who functions as a scribe) to listen to the conversation. in so doing, it is important to provide the reason that a third party is participating in the visit, noting that this person will take notes regarding the visit and then ensure that the notes are entered into the emr that confirms the documentation process. the scribe or assistant will also record the time, date, and the duration of the visit (documentation requirements for billing purposes) and will then code the visit properly and enter it into the practice management system so that a bill is submitted to the insurance company. at the end of this process, the provider will have documentation that consent was obtained, that the visit took place, that notes were made, and that the patient's insurance company should be billed for the visit. triangulation can offer legal protection, should physicians choose to use one of the free, non-hipaa compliant solutions, and provides an opportunity to capture all of the reimbursements that would be owed-generating increased efficiencies and productivity (figure provides a sample documentation form). a good rule of thumb for the use of cpt codes is to use the same codes that would be used for an in-person appointment. for tm services in general, one would code as for any regular outpatient, face-to-face visit, using cpt codes e for an established patient visit and e for a new patient visit. these are the most common cpt codes for outpatient office visits either in a face-to-face or a synchronous virtual visit, that is, via a real-time interactive audio and video telecommunications system. as an example, for a sexual medicine encounter using tm, the reimbursement for ranges from $ to $ . the challenge is to achieve the complexity requirements for a level office visit without a physical examination. the documentation for these encounters, whether they are face-to-face or virtual visits, requires of of the following components: pharmacy, and spends minutes on communicating with the patient, this visit meets the complexity requirements for . since level and office visits ( and ) require a comprehensive physical examination, it is necessary to document the time spent with the patient, that is, requires e minutes of consultation and requires or more minutes. it should be noted that, as a direct result of the coronavirus pandemic, new telehealth codes have been added temporarily, along with expanded billing and coding. however, we do not believe that all of these changes will be made permanent before or at the point at which the national health emergency is declared to be over. in the interim, we believe that it is best practice to follow the coding indications as described in this article. it is also imperative to contact a healthcare attorney well versed in coding issues to ensure that billing and coding compliance is maintained. irrespective of the tm service used, it is important to confirm the tm billing guidelines before engaging patients with tm visits. consider starting the call to the payer and confirm that the payer provides parity between tm visits and face-to-face visits. then ask which specific billing codes should be used. until physicians and their practices become comfortable with tm-and while developing the necessary experience with coding and billing for tm service-we recommend that practices use a tm platform that includes a rules engine that offers recommendations for each tm visit based on past claims data. such rules engines help sexual health providers determine which cpt code is to be used and identify the appropriate modifiers for the various insurance companies. the value of a rules engine is that it supports submission of a clean claim that is less likely to be denied and very likely will be paid. there are some vendors who are so confident that their rules engine will match the service with the proper cpt code and proper modifier, that the vendor guarantees full private payer reimbursement for tm visits, or the vendor will reimburse the claim. we suggest that providers consider a pilot trial with a few patients and staff in order to become comfortable with the new technology and then expand usage based on the feedback they provide. if possible, a face-to-face visit should precede a tm visit which should include a comprehensive physical examination. ultimately, tm is here to stay. those professionals who do not communicate with patients using tm may find that their practices are antiquated and might suffer an attrition of existing patients. we believe that the traditional face-to-face interactions with sexual medicine patients are not going to completely disappear. nothing can replace the supreme importance of an in-person face-to-face visit with a trustworthy, well-respected physician. however, we hope to have demonstrated that there is going to be a seismic shift from face-to-face to face to computer-assisted encounters in the immediate future. contemporary sexual medicine practices must consider the implementation of tm. failure to do so will likely see an erosion of patients, many of whom will migrate to practices that offer tm. in spite of insurance and government interference, there has been a steady-and, at present, explosive-rise of tm. there are significant numbers of patients who want to consult sexual medicine professionals via ubiquitous communication technologies such as teleconferencing and email. sexual medicine is one of the areas of healthcare that is primed for the incorporation of tm into practice. the "proverbial puck" of sexual medicine patients is going to be in the hands and the computers. of the professionals who embrace tm. american urological association web site research shows telehealth service use on the rise kaiser permanente ceo reports strong use of telehealth telehealth index: physician survey telemedicine is poised to grow as its popularity increases among physicians and patients. healthcare finance the triple aim: care, health, and cost addressing physician burnout: the way forward the advisory board company healthmine digital health report: state and impact of digital health tools telemedicine concerns and how to overcome them modeling patients' acceptance of provider-delivered e-health available at: https:// mhealthintelligence.com/news/telehealth-offers-a-platformfor-discussing-sensitive-health-issues -state survey: establishing of a patient-physician relationship via telemedicine efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial virtual visits in a general medicine practice: a pilot study patient preferences for direct-to-consumer telemedicine services: a nationwide survey acceptance and resistance of telehealth: the perspective of dual-factor concepts in technology adoption virtual visits-confronting the challenges of telemedicine productivity and cost implications of implementing electronic medical records into an ambulatory surgical subspecialty clinic available at: www. hipaajournal.com/category/hipaa-breach-news sweeping regulatory changes to help u.s. healthcare system address covid- patient surge medicare telemedicine health care provider fact sheet key: cord- -pjg t g authors: dunkerley, sarah; thelwall, claire; omiawele, joshua; smith, adam; deo, sunny; lowdon, ian title: patient care modifications and hospital regulations during the covid- crisis created inequality and functional hazard for patients with orthopaedic trauma date: - - journal: int orthop doi: . /s - - -x sha: doc_id: cord_uid: pjg t g purpose: the covid pandemic has decreased orthopaedic fracture operative intervention and follow-up and increased the use of virtual telemedicine clinics. we assessed the implications of this management on future orthopaedic practice. we also surveyed patient satisfaction of our virtual fracture follow-up clinics. method: we prospectively analysed patients during two weeks of ‘lockdown’ assessing their management. we surveyed virtual fracture clinic follow-up patients for satisfaction, time off work and travel. results: forty-nine percent of patients had decisions affected by covid. twelve percent of patients were discharged at diagnosis having potentially unstable fractures. these were all upper limb fractures which may go onto mal-union. twenty-nine percent of patients were discharged who would have normally had clinal or radiological follow-up. no patients had any long-term union follow-up. virtual telemedicine clinics have been incredibly successful. the average satisfaction was . / . in only % of cases, the clinician felt a further face-to-face evaluation was required. eighty-nine percent of patients would have chosen virtual follow-up under normal conditions. conclusion: lessons for the future include potentially large numbers of upper limb mal-unions which may be symptomatic. the non-union rate is likely to be the same, but these patients are unknown due to lack of late imaging. telemedicine certainly has a role in future orthopaedic management as it is well tolerated and efficient and provides economic and environmental benefits to both clinicians and patients. the coronavirus pandemic has had huge implications for the whole of the medical profession. orthopaedics has been affected by the limitation of resources (particularly theatre capacity) and the need to additionally consider patient and clinical safety in terms of virus transmission. fracture management in the uk has altered with higher rates of conservative management fractures and a reduction in the amount of follow-up, particularly face to face. the boast 'management of orthopaedic outpatient fracture management during covid- ' set up a pragmatic way of managing patients with fractures [ ] . the great western hospital in swindon is a large district general hospital in the uk with inpatient beds. in the orthopaedic department, we have adapted to the coronavirus pandemic through the increase in virtual fracture clinic followups using a combination of video and telephone clinics. we discuss the implications for orthopaedic surgeons in the future based on this treatment. we also address the lessons learnt from virtual fracture and how they may be usefully developed for the future. great western hospital was an early adopter of the new patient 'virtual fracture clinic' (vfc). there is a large amount of evidence in the literature that virtual fracture clinics are a cost-efficient and cost-effective way of triaging trauma [ ] [ ] [ ] [ ] . all new patients are initially reviewed virtually, based on information from emergency departments. they receive a telephone call from the trauma nurse team with advice and their management decision. the changes to this structure since the coronavirus pandemic were merely organisational. two doctors ran the clinic every day remotely. management decisions were based on the british orthopaedic association standards for trauma and orthopaedics (boast) guidelines for the management of orthopaedic outpatient management [ ] . there was reduced operative capacity due to reduced theatre capacity, primarily due to redeployment of ventilators, time for ppe and decontamination. patient face-to-face appointments were minimised for patient and staff safety. removable immobilisation was utilised and no late clinical imaging was undertaken. new virtual follow-up fracture clinics reduced patient face-to-face appointments. anonymised telephone calls and video calls via fleming 'accurx' system were used. we prospectively analysed the outcomes of virtual fracture clinic patients from the th to the th of april, during peak lockdown. one hundred fifty-four patients were reviewed. decisions were classified as 'normal' or 'covid-related' decisions. fiftyone percent of the decisions were as normal and % were affected by the coronavirus pandemic. of those, ( %) patients were brought into hospital, ( %) patients were given a patient-initiated follow-up (pifu) and ( %) were given a virtual follow-up telemedicine clinic. all the patients brought into hospital were 'normal' decisions and all those in the virtual fracture clinic review clinic were 'covid' due to lack of normal face-to-face interaction. the pifu patients were subdivided into groups: 'normal' decisions, 'covid' decisions based on lack of clinical review or follow-up, and 'covid' decisions based on potential mal-unions (see fig. ). brought into hospital ( patients, %) of these patients, five required operative intervention, five had manipulations in clinic, five needed nurse led clinic for wound issues and four needed further clinical review and imaging. virtual clinic follow-up ( patients, %) of these patients, of them attended the hospital prior to the appointment for an xray. twenty-three patients were then given a pifu as a result of the appointment, one was brought in for a face-to-face appointment due to clinical need and three were sent for further imaging. pifu: covid lack of follow-up ( patients, %) these patients were not brought back for any formal review. they lacked further imaging and clinical examination. most ( patients) sustained upper limb injuries. pifu: potential mal-union ( patients, %) these sustained fractures were unstable and could potentially collapse in the future. they were not followed up but could be corrected by a late osteotomy if required. these were all upper limb injuries and the majority of them were in elderly patients. ten patients had distal radius fractures, five had shoulder injuries, three hand injuries and one sustained an elbow injury. nineteen patients had unstable fractures which may lead to symptomatic mal-union. extrapolating this over weeks of lockdown, with increasing patient numbers, leads to a conservative estimate of over in this group. mal-union can lead to impaired function and pain [ , ] . even if % of them went on to symptomatic mal-union requiring surgery, this equates to fifty correctional osteotomies on top of a strained elective upper limb service. the rate of non-union is unlikely to be affected, but due to the lack of late imaging, we are unable to identify these patients. there should be no increase in surgical intervention, but patients may present later or with more profound complications. there has been a paradigm shift in the attitude towards telemedicine in the general public. virtual meetings and working remotely have been widely adopted throughout the public and private sector [ ] . technology has rapidly expanded to enable continuation of services [ ] . telemedicine clinics have advantages and disadvantages compared with face-to-face evaluation, which will always remain the gold standard to clinical evaluation. we will discuss the advantages, the disadvantages and implications for the future. advantages for clinicians, telemedicine provides a wide variety of advantages. they can be done remotely from the hospital, do not require any physical infrastructure such as access to clinic rooms and require less staff namely a receptionist or clinic nurse. they generally involve quicker appointments (although if video conferencing is used in addition, this can take some time to set up). all this leads to increased costeffectiveness. clinics can be easily screened by consultants and effective triaging can take place. training is also easily adapted into clinics. clinicians can video call each other, share screens and use a continuous 'chat' system so communication can occur throughout the consultations. in the current situation, they also decrease potential viral transmission. for patients, there is also plethora of advantages. the time to appointment is quicker due to increased capacity in clinic. there is no travel time or inconvenience to the patient, including travel and car parking costs. they are particularly helpful to patients who are working as they do not require any time off work. there is a less waiting and time taken out of the patient's day. there is also a greater degree of flexibility with virtual clinics not being tied to a set rota timetable. if imaging is required, this can be done at the patient's convenience rather than in pre-designated slots. environmentally, virtual clinics can save a great deal of travel time, road congestion and petrol consumption. disadvantages and limitations there are some considerable disadvantages to telemedicine. telephone communication requires a better understanding of english as a spoken language and in some patient groups this is much more challenging than face-to-face conversations. patients with hearing impairments or those who use lip reading as an adjunct suffer particular communication difficulties. video conference requires a certain level of technological ability and equipment which may limit certain population groups, especially the elderly. non-verbal communication, which is extremely important in communication, is totally removed if just the telephone is used. clinical examination can be adapted for telemedicine, but there are limitations to it. lack of palpation is inevitable and can lead to significant impairment in clinical ability. certain examinations including range of movement can be assessed relatively easily and clinical examinations in the extremities, particularly the upper limb, are considerably easier than other assessments. there are also some potential security risks over the telephone with a lack of the person being identified. issues such as coercion particularly in child protection issues and vulnerable adults are much harder to identify which is a huge concern. even in a video call, there is no knowing who is behind the camera. a face-to-face assessment of a patient will always provide a wider picture of the whole situation. pre-requisites for a successful virtual clinic in order for a virtual clinic to be successful, there has to be fluid communication and transition between virtual and face-to-face assessment. patients who have been assessed virtually and require face-to-face clinical assessment need quick access to appointments in order not to be disadvantaged. ideally, this needs to be across a wide variety of subspecialists to allow the best assessment and management options. there also needs to be adequate technological infrastructure in order for virtual clinics to work reliably. contact details, electronic records and dependable remote access are fundamental. in order to assess the effectiveness of our virtual clinics, we needed to consider not only the clinician and hospital experience but also the patient experience. we asked patients what they thought of virtual clinics. we focussed on patient satisfaction, working status, time off work and travel time. we surveyed patients from the th of june to the th of july. at the time of their appointment, we asked them where they were, if they worked, if they had taken any time off work for the virtual appointment, how much time they would have taken off work if it had been a hospital appointment, their travel time if they didn't work and if they would be amenable to a follow-up call. they then received a second phone call some days later from a different member of the orthopaedic team, asking them for a satisfaction score out of five and whether under normal circumstances they would have preferred the appointment in hospital or a virtual clinic appointment. we have full responses from patients. twenty-seven patients were contacted by a consultant-level doctor and by two senior registrars (st and st ). seventy-five had been discharged from clinic, needed a further face-to-face follow-up, required further virtual assessment and one required an injection. thirty-six patients were working on the day we phoned, nine were actively employed but not working that day, were off sick due to their injury and of people were not employed. sixteen people were at work at the time of the call and were at home (a proportion of people worked from home). in the working group, nobody had taken any time off work for a virtual clinic appointment but if it had been a hospital appointment, an average of minutes of working time would have been taken off (range - minutes). this totalled . hours of working time for one clinic over six weeks. in the non-working that day group, the travelling time averaged minutes (range - minutes). this totalled . hours of travelling time. the average satisfaction score was . / (range - ). the number of people who under normal circumstances who would have preferred to have been reviewed in a hospital setting was (with people preferring a telephone/video call). both the satisfaction scores and the preference of appointment were broken down for each clinician and there was no significant difference between the three doctors. of the people who would have preferred a hospital appointment, the satisfaction score was . (range [ ] [ ] . there was no significant difference in age of the patients, type of injuries or working status or travel time. of the patients who were brought back for a face-to-face follow-up, five were due to future appointments to have a cast removed and six were due to the clinician deciding they needed a clinical assessment in hospital (thus a repeat appointment). in five of these six cases, this was due to the clinician deciding they needed a more detailed clinical examination. the remaining patient was brought in due to an english language communication barrier. interestingly, these patients still had a satisfaction score of . and only one of these patients ( %) would have preferred their appointment to have been in the hospital initially, which was unexpected. we have therefore concluded that patients were pleased with our virtual fracture clinic service. there was no particular group that was highlighted as being dissatisfied or where the clinician was unable to effectively assess the patient. virtual fracture clinics have huge benefits both in terms of cost-effectiveness, flexibility and efficiency of fracture clinic management. patient satisfaction is high among our population group. the economic impact in terms of time off work and the environmental impact of travel is significant. we hope to make virtual follow-up fracture clinics part of standard orthopaedic practice in the future. reviews following on call admission or assessment (for instance a limping child or cellulitis) work particularly well as a phone call. follow-up imaging review such as in suspected scaphoid fractures or postmanipulation cases is significantly more efficient. immediate post-operative checks can be done with a wound review via video and discussion regarding normal recovery. this can also be translated to an elective service; for instance, long-term follow-up after arthroplasty can easily be done with a prearranged x-ray and outcome scores. covid- has had a profound impact on the outpatient orthopaedic management of fractures, but we have highlighted three particular aspects of potential change. our first consideration is to the group of patients who have been discharged with potential mal-unions who may need assessing and a corrective osteotomy in the future. in our hospital, this is likely to be over patients with upper limb fractures. these patients may also have worse outcomes following their fracture. this may well impact the already stretched elective upper limb service after covid, requiring significant operative time. these patients have been identified and we will report back on these patients after a one year follow-up. the second group of patients that are yet to be identified is those with any fracture who are developing non-union. the rate of non-union is unlikely to have changed, but these patients have not been followed up, so their presentation may be significantly later than normal. the third consideration is that virtual clinics were developed out of necessity but have proven to be very successful. patient satisfaction is high ( . / ) and the rate of conversion to hospital appointment due to the clinician feeling that inadequate assessment was made was low ( %). the economic advantage to lack of lost working time and the environmental impact on saved journeys was significant. they are now being integrated into our standard fracture pathways. covid- will have many implications throughout the health sector and to the whole of society. we hope to utilise the learning from the challenges that it has provided to design a more efficient and effective orthopaedic department in the future. management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic ( ) www.boa.ac.uk version - virtual fracture clinic delivers british orthopaedic association compliance adopting and sustaining a virtual fracture clinic model in the district hospital setting -a quality improvement approach the clinical and cost effectiveness of a virtual fracture clinic service: an interrupted time series analysis and before-and-after comparison fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care distal radius malunion distal radius malunion j hand surg keep calm and log on: telemedicine for covid- pandemic response virtual health care in the era of covid- publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors would like to acknowledge the whole orthopaedic department at the great western hospital in swindon for their hard work during this busy and challenging period. conflict of interest the authors declare that there are no conflicts of interest. key: cord- - fws authors: rios, izabel cristina; de carvalho, ricardo tavares; ruffini, vitor maia teles; montal, amanda cardoso; harima, leila suemi; crispim, douglas henrique; arai, lilian; perondi, beatriz; morais, anna miethke; de andrade, andrea janaina; bonfa, eloisa silva dutra de oliveira title: virtual visits to inpatients by their loved ones during covid- date: - - journal: clinics (sao paulo) doi: . /clinics/ /e sha: doc_id: cord_uid: fws nan as a consequence of the sars-cov- pandemic, social contact among people has undergone significant changes. to slow the spread of the virus, social distancing measures, such as isolation and the maintenance of distance between individuals, which includes changing the manner in which people greet each other, are in place, demonstrating responsible health practices. the lack of physical contact with other human beings is a major challenge during this highly contagious pandemic. to protect vulnerable people, hospitals have discontinued all visitations; so, from the moment a patient is admitted to the hospital, he or she is alone. covid- is a painful disease because in addition to the intense physical suffering, there is an added, unprecedented, emotional strain because patients cannot receive support from their families. this separation leads to feelings of solitary agony and helplessness, not only for patients but also for their family members ( ) . across the world, healthcare providers have tried to diminish the loneliness of patients and families by enabling the use of remote communication devices ( ) . as many patients are elderly, or incapacitated, they are unable to use the equipment themselves, and so nurses and doctors have developed the idea of virtual visits ( ) . virtual visits are meetings between patients and their family members using technological communication means. the importance of this process was emphasized by the claims of healthcare providers that although a medical visit ( ) was essential to keep families informed about the clinical status of their relatives who were admitted to the hospital requests were often made to see and talk to the patients and that even a very short visit brought significant comfort to the patients. moved by compassion, healthcare providers initially used their own devices to bring patients closer to their loved ones; subsequently, this became an institutional practice of care. it was observed that patients and families shared more than just information during these visits-they received encouragement from and supported each other to help cope with the suffering and disease ( , ) . despite the benefits of the virtual visit for patients and their relatives, its implementation is not easy as healthcare staff is usually overburdened during a pandemic and thus is under stress and is more focused on medical treatment than on care. to overcome this problem, in the hospital das clínicas, school of medicine of the university of são paulo, we initiated a model to implement virtual visits with a team of volunteers not directly involved in patient care. this strategy allowed us to enable virtual visits to our patients in the wards as part of integral assistance during the hospitalization period without overburdening the healthcare staff dedicated to providing medical treatment and assistance. such virtual visits have demonstrated very good outcomes for patients, families, and volunteers. the first obstacle for implementing virtual visits was the lack of a sufficient number of devices for the wards, including emergency rooms and intensive care units. we chose to use tablets because of the following advantages: allows the viewing of larger and more accurate images, allows the participation of more than one family member, and allows making videocalls to family members via whatsapp, the most widely used communication resource in brazil. all devices were donated by one communications technology company. another major concern was the risk of the disease spreading to the volunteers. to overcome this problem, the blood pressure monitor floor stand model was altered to create a metal stand support with wheels, and the tablet was attached onto this modified device. this solution enabled a reduction in the exposure of the volunteers to the virus as they can place this modified stand with the tablet in front of the patient and then move away from the bed. figure shows the tablet support device. the challenge involved in engaging a team of volunteers was solved by online dissemination of the project to medical students, who had the right mindset for this task. twentyeight current and former medical students joined the virtual visit team (vvt). they were trained in family and patient communication skills, and they also received orientation regarding covid- safety protocols. the humanization group (hg) of the hospital da clínicas led the virtual visits project. although virtual visits are a doi: . /clinics/ /e copyright & clinics -this is an open access article distributed under the terms of the creative commons license (http://creativecommons.org/licenses/by/ . /) which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited. no potential conflict of interest was reported. relatively simple idea, the operational logistics involved in connecting patients with families requires attention to various details. herein, we present the step-by-step routine to be followed: . the healthcare team selects patients who will participate in the virtual visit by videocall or by audio or video recording, prioritizing those who are too incapacitated to use their own device. videocalls are more suitable for patients to be able to speak and interact with their families. audio or video recordings are preferred when patients are unconscious or cannot communicate. the healthcare team asks patients for their consent to be involved in the virtual visit. . the healthcare team adds the patients' data in a spreadsheet, which is shared with the hg. . members of the hg team contact the patients' families by telephone to explain to them how the virtual visits will work and also list the rules to be followed: they do not have permission to photograph or record the visit; patient health information will be not provided during this procedure (this was because the healthcare team would schedule a daily call, providing updates regarding the clinical status of the patients), and the volunteer will stay near the patient during the conversation. if these conditions were agreed to, further steps were considered. . the hg team receives the volunteer schedule for the day and gives the volunteers instructions about the patients scheduled for virtual visits. then, the volunteers head for the wards. each volunteer carries out his/her task in or wards, visiting about to patients. . in the ward, the volunteer collects the tablet and finishes the safety procedures required for the area. . in the patient's rooms, the volunteer confirms the patient's willingness to participate in the virtual visit, then connects the call via whatsapp. the rules of the virtual visit are explained once more, and then the volunteer allows the patient to speak for minutes with his/her family. after this time has passed, the volunteer asks if there are any doubts, says goodbye and ends the call. then, the volunteer blocks the cell phone number called for avoiding the inadequate use by family. . at the end of day, the volunteers clean the equipment and return it to the wards. . the volunteers register the visit in an electronic medical record and a control data spreadsheet. figures and illustrate the virtual visit. over the course of one month, the vvt undertook virtual visits. the patients, families, and volunteers perceived the virtual visits as beneficial. the patients and their families were reported to be appreciative of the chance to see and communicate with each other. the virtual visit allows for the meeting between loved ones, which enhances the health of the patient, provides emotional comfort and a form of contact, and increases the hope of healing. as virtual visits promote emotional well-being, they will soon become part of a set of measures geared toward improving the quality of healthcare during the covid- pandemic. the volunteers also reported a positive impact and felt personal satisfaction from their contribution. in addition, the virtual visit constitutes an innovation that can be adopted by healthcare organizations for any other situation in which patients cannot physically meet their loved ones. finally, the following list provides some tips to help develop virtual visits in a healthcare service: -for safety reasons, only hospital devices are recommended for use. -wireless connection may be a problem, and assuring its good performance is essential. -logistical support is needed by the vvt, in addition to leaders who can monitor the process and be reached at all times. -exceptionally patients and families have conflicts between them during the virtual visit. in this case, volunteers must be prepared to facilitate the end of the visit. -debriefing sessions for exchanging experiences among vvt members are essential for empowerment and for the volunteers to remain motivated to continue participating in the project. notwithstanding the hard work that the development of virtual visits requires, we provide here a concrete example of the use of technology in parallel with compassion that together make patient care more compassionate and effective. the authors are grateful to césar augusto martins pereira from the biomechanics laboratory (lim- ) for creating and making the tablet support device. social isolation in covid- : the impact of loneliness virtual health care in the era of covid- video-calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research telemedicine in the era of covid- compassion in a time of covid- not dying alone -modern compassionate care in the covid- pandemic figure -virtual visit. photo by key: cord- - bgavlam authors: twogood, rory; hares, elly; wyatt, matthew; cuff, andrew title: rapid implementation and improvement of a virtual student placement model in response to the covid- pandemic date: - - journal: bmj open qual doi: . /bmjoq- - sha: doc_id: cord_uid: bgavlam practice-based learning via clinical placement is a core part of a physiotherapy degree with the chartered society of physiotherapy requiring completion of placement hours over a preregistration degree programme. in april , as a result of the covid- pandemic and subsequent lockdown connect health had to cancel student placements as we transitioned to virtual consultations for all clinics. this cancellation of student placements was replicated across the nation with many higher education institutes reporting a backlog of student placements. without the requisite placement hours students are unable to progress into the next academic year or are unable to graduate. this then reduces the flow of new-graduate physiotherapists into the workforce at a time when there is a plan to grow the physiotherapy workforce to meet primary care demand. in response to this problem a novel placement model to facilitate virtual student placements (‘virtual placements’) was developed, tested and then rolled out across connect health using the plan-do-study-act quality improvement methodology. the model combines shadowing a broad range of virtual clinics with delivery of patient-facing online exercise classes via the facebook live platform and completion of virtual projects to support knowledge consolidation. this virtual student placement model enabled an increase in student capacity of over % compared with – with students starting between may and august . the model runs using widely available technology, requires no additional investment and has enabled these students to continue their studies and progress towards qualifying as physiotherapists. connect health ('connect') is the largest, independent provider of integrated community musculoskeletal (msk) and physiotherapy services in the uk, serving over national health service (nhs) patients per year across clinical commissioning groups and over businesses. connect consists of over clinicians on a national basis and is diverse in terms of range of professional roles. connect health serves a broad patient population and have specialist services to accommodate this which includes persistent pain, rheumatology, orthopaedics, podiatry and msk physiotherapy. connect actively supports higher education institutes (hei's) as a placement provider, accommodating an average of physiotherapy undergraduate student practice placements nationally per year. ten undergraduate students, from two hei's, were due to commence their msk practice placement within connect in april . however, traditional physiotherapy student placement models are heavily reliant on face-to-face care delivery and clinical mentorship. therefore, with the novel covid- pandemic resulting in 'lockdown' in the uk, the traditional model of student placements became redundant. this generated a need to develop a new, innovative model for undergraduate student placement provision. the covid- virus is transmitted primarily through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. who on march , declared the covid- outbreak a global pandemic, and the uk went into 'lockdown' on the march . national lockdown and social distancing regulations consequentially resulted in placement providers having to cancel student placements due to a shift to virtual working, redeployment of staff and the increased of students contracting covid- on practicebased placements practice-based learning is a global mechanism for hei's to provide students with experiential learning to bridge the gap between their academic present and their professional future, providing practical opportunity to apply their taught knowledge into skill acquisition. there are over hei's in the uk who provide physiotherapy preregistration programmes. the provision of clinical open access practice placements for students are fundamental to physiotherapy education and the chartered society of physiotherapy (csp) stipulates that each student must complete a minimum of hours of practice-based learning. in response to the challenges faced by hei's to accommodate the hours of practice-based learning during covid- , the csp issued guidance that compliments that of the health and care professions council (hcpc), to focus the need for flexible contingency plans to ensure students meet the physiotherapy standards of proficiency on graduation. health education england (hee) and the hcpc have also implemented a model whereby students can opt into a paid placement as a support worker in order to support the nhs and continue their studies. however, these placements often take longer to set up as students need to be added to the organisational infrastructure for example, pay roll. further, they are also not accessible to those students with underlying health conditions who are at greater risk from covid- -related complications or international students that may have moved abroad to be with family during the pandemic. the csp and hcpc have both encouraged hei's and placement providers to be creative and innovative in their ability to provide workplace learning for students. this encouragement highlights the potential significant impact and future workforce risk associated with lack of placement opportunities. with the recent introduction of the -year general practice contract framework to assist delivery of the commitments within the nhs long term plan, this framework provided funding for new primary healthcare professionals such as physiotherapists and first contact practitioners through the additional roles reimbursement scheme. without a new graduate workforce to backfill these posts, there will be significant shortfall within both primary care and physiotherapy service provision. this pressure to train sufficient allied health professionals has been recognised by hee who have extended their clinical placement expansion programme to selected allied health professions, including physiotherapy. the social distancing regulations introduced as part of the covid- response prevents direct patient contact to reduce the risk of covid- transmission. the use of digital technology in response to these regulations in order to maintain service delivery has seen an increase in virtual consultations. virtual consultations delivered via telephone or video have demonstrated a number of advantages to service delivery including a reduced need for patients to travel to their appointments, ability to provide care to those who are shielding or self-isolating, and supports clinicians to conduct clinical work from home. connect transitioned to offering all appointments as virtual consultations in march and then considered the potential to innovate through virtual placements following the need to postpone the undergraduate students who were to commence in april . a search of the published literature returned no results for virtual placements in healthcare indicating that this is a previously unexplored area. with the national demand for student practice placements increasing, it soon became clear that a virtual student placement model could be expanded throughout connect to support hei's in placement provision. the aim of this project was, therefore, to develop a novel model for virtual undergraduate clinical placements for physiotherapy students that would allow fulfilment of the postponed placements and be scalable to be delivered nationally throughout connect and across multiple hei's. the primary evaluative outcome measure for the virtual student placement project was the number of student placements that commenced from april , which was when the original student placements were due to start pre-covid- social distancing regulations. this data will be compared with traditional face-to-face student placement numbers in - . given the recognition of a national challenge to placement provision across heis, and the potential that a virtual placement has to be scalable, a second outcome measure of the number of hei's we were able to provide placements to was selected. the - data were extracted from connect placement records while the data from virtual placements was readily available to the team. these data were gathered for all connect services which had provided placements for students since . when connect was running a traditional, face-to-face student placement model we had students from four hei's in april-august and students across five hei's in april-august . initially using a modification of experience-based codesign, it was clear from discussions between the placement team at connect and existing partner hei's, that there was a pressing demand for student placements and an appetite for innovation and collaborative working to meet this demand. the virtual student placement project was started in may following discussions and input from the heis as to what requirements a new placement model would need to fulfil. following the move to virtual consultations, we continued to complete clinical supervision for clinical staff using microsoft teams (microsoft corporation, washington, usa) within connect and so hypothesised that we could introduce students shadowing virtual clinics as it had proved viable to have qualified clinicians shadowing each other. this software has been made freely available to nhs services. as part of the covid- response connect has also launched live, online exercise classes using facebook (facebook, california, usa) as a medium, to replace the usual class and gym-based open access rehabilitation that were publicly available. this presented a novel opportunity for students to plan, lead and deliver an exercise class as part of a clinical placement. as a result of the shift to virtual clinical delivery due to covid- and a desire to fulfil our commitment to taking students on placement an initial model for virtual placements was developed as outlined in figure . this initial model combined exposure to patient care via shadowing virtual clinics, opportunity to deliver publicfacing exercise classes via facebook live and knowledge development via self-directed learning and preparation and delivery of virtual presentations. to ensure that the initial model designed would provide sufficient exposure to patients and learning opportunities to contribute toward the required placement hours required by the csp, two separate heis contributed to development of the model. to gauge initial capacity for placement provision, we gathered expressions of interest from our clinical staff in acting as a clinical mentor for a student on virtual placement, as we anticipated that the number of mentors would be the primary limiting factor to number of virtual placements that we could accommodate. from these responses we were able to provide placements across two partner hei's starting on may . we planned to continue gathering support of clinicians across connect with the aim of offering more placements throughout the summer months in order to be able to expand our offering to heis across england. with the initial model finalised, the virtual placements team allocated a lead clinician to coordinate the placements and with a remit to develop the initial model as required, to be able to implement a sustainable, scalable virtual placement offering, using quality improvement (qi) methodology. the virtual placements team agreed to meet weekly via microsoft teams to review progress and plan the next stage of the project as well as staying in regular email contact. various methodologies exist to support a qi process. the virtual placements project was a novel, untested idea and in keeping with the aims of the project, we utilised the model for improvement which is well suited to use when introducing new systems. the model for improvement incorporates plan-do-study-act (pdsa) cycles within a broader framework and allows experimentation, to test changes and observe the outcome prior to implementing the learning into the next cycle. we completed three pdsa cycles between may and june which can be divided into initiation, implementation and improvement. these cycles are fully detailed in table . the primary outcome measure was the number of students starting on placement within connect (figure ) in april-august . from april to august , virtual student placements were provided. the traditional face-to-face model over the same time period of april-august in was able to accommodate placements, and in , placements. the virtual placement provided a placement capacity increase of % ( ) and % ( ), respectively. the secondary outcome measure was the number of heis we were able to provide placements to. in the period between april-august , placements were provided to students from heis using the virtual model. the traditional face-to-face model over the same time period of april-august in was able to accommodate students from hei's, and in , heis. figure the initial virtual placement model is shown on the left, this model was implemented with the first cohort of students in may . the current connect health virtual student placement model is shown on the right and demonstrates the development following pdsa cycles. pdsa, plan-do-study-act. we were unable to fulfil planned student placements with two partner hei's in april due to covid- . we had made the transition to virtual working during march-april and felt there was potential to offer virtual placements starting in may . there was clear demand from our partner hei's for student placements and so we developed an initial placement model that combined shadowing virtual clinics with creation of online exercise classes using the facebook live platform and virtual projects and presentations (figure ). we agreed further intakes of students on and june, for a total of students, and were able to include students from a third partner hei. we planned to introduce a student peer mentoring system to minimise the administrative workload on the placement co-ordinators and to give the student an opportunity to develop mentorship skills. drop-in virtual meetings with hei link tutors and mentors were scheduled to support clinicians in mentoring virtual students. we wanted to offer placements to a larger range of hei's across the country as we knew there was demand and our virtual model had the potential to help meet that demand. we developed a feedback survey to evaluate the patient and clinician experiences of virtual placements. we took our first cohort of virtual students on may with a total of students from two partner hei's and rapidly created a virtual infrastructure to support them within microsoft office and facebook workplace. we initially struggled to get enough clinics available for students to shadow. however, the virtual shadowing clinics that did run were successful and early adopter clinicians started to get students involved in joint consultations such as leading the subjective assessment component of the consultation. we improved the process for timetabling clinics for students to shadow and created how to guides to support people with using new technology to build a sustainable virtual shadowing system. we encouraged clinicians to run joint clinics with students where time permitted. the placement team hosted a webinar on our virtual student placement model with engagement from a wide range of hei's and potential placement providers in order to broaden the reach of our placement model. students started to host live, online exercise classes via facebook live. hei link tutors held drop in q&a session to support mentors. these were recorded and shared for those unable to attend live. we developed a standard virtual student placement model from what we had learnt in cycles and (figure ). a student-led virtual conference was developed where projects and presentations were delivered virtually using microsoft teams. this provided an opportunity for students to present their projects and receive feedback from their mentors and connect clinicians. study the limiting factor to the no of students we could take on virtual placement was identified as the number of clinicians volunteering to act as mentors. there was some confusion from clinicians at how to offer up clinics to shadow and how the technology would work. students were engaged with the idea of online exercise classes via facebook and started to submit ideas. students were initially expected to deliver four different virtual projects, but this provided to be too many from both a timetabling and student workload perspective. a primary concern of the mentors was how they would assess students on virtual placement on june we had a total of students from three cohorts on virtual placement within connect, each with their own dedicated mentor, surpassing our expectations of the scalability of the virtual placement model in such a short time frame. virtual projects and classes were running well, and students were becoming adept at managing their time and learning autonomously. the student mentor model proved popular with positive feedback from the students. students within connect at any one point proved sustainable and we planned our future placement offering to ensure this would be the maximum no of students on placement at any one time with students starting in cohorts of . the student led conferences were very successful and allowed a high volume of interaction and feedback between the students and clinicians. recording these conferences meant that mentors who were unable to attend live could catch up later. initial feedback surveys using a likert scale where one is very dissatisfied and five very satisfied showed mean scores of / for mentors and . / for students with the initial virtual placement model. open access the initial project aim was to develop a model that allowed for the completion of the postponed student placements in a virtual manner. this then evolved into the development of a sustainable nationwide, virtual student placement model. throughout this process several key lessons emerged. a robust virtual infrastructure is vital to running effective placements. with no face-to-face contact between any stakeholders there is a challenge to effective communication between placement coordinators, clinicians, students and hei's. all students were given a dedicated connect user account to provide access to this virtual infrastructure. we used the microsoft (microsoft, washington, usa) platform to run the logistics of the placement with a shared placement calendar enabling students to see all the learning opportunities available. facebook workplace is used by connect for internal communications and a student community group was created within the wider connect community group to provide a space for student discussion and engagement as well as repository for resources. to support connect clinicians in mentoring virtual students we arranged microsoft teams meetings with the hei tutors to provide a forum for question and discussion. these were all recorded and circulated to all mentors afterwards. we attempted to increase the no of clinics being offered for student shadowing by providing a step-bystep guide and testimonials from early adopter clinicians. we reduced the no of projects that the students were expected to deliver to three to ensure a manageable workload. discussed with hei's about supporting mentors with assessing virtual placements, including running a session on 'assessing virtual placements' on an internal study day. we realised this model had the potential to help address the national shortage of student placements and planned to engage with other interested hei's and organisations via a webinar. the virtual placement model proved viable and scalable across multiple sectors and offered a part solution to the national shortage of physiotherapy placements. we started to formulate a plan for offering virtual placements through july & august that would be available to heis across england. we were able to offer a further students in rolling cohorts of in june, july and august across national heis. split the placements into north and south so that clinicians and students would be relatively local to each other but maintained the ability for students to shadow any clinic nationally. with the virtual placement model now familiar to connect clinicians, we were able to ensure we had sufficient mentors available to accommodate the planned volume of students. shared a guide to running virtual placements on the connect health website. hei, higher education institutes; pdsa, plan-do-study-act. figure the bar chart demonstrated the number of student placements provided between april-august for three successive years ( - ). the blue and red bars highlight placements provided using a face-to-face model, the green bar represents the virtual placement developed within this qi project. qi, quality improvement. when introducing a new model of practice, role modelling is vital. we had two of our consultant physiotherapists involved with the first cohort and this commitment from the senior clinical team signalled the importance of this project. we engaged heavily with the early adopters to support them in virtual mentoring of students and encouraged them to share their success stories and lessons learnt across the clinical workforce. this helped drive the momentum of the project and ensure clinicians were engaged with mentoring and offering clinics for students to shadow virtually. this leadership ensured we had the clinical capacity to support the students on virtual placement. the iterative nature of qi and the model for improvement allowed for experimentation in order to innovate and demonstrate continuous improvement. we made several changes to how the calendar was structured and organised in the first week in order to ensure the administrative workload on the virtual placement team was both manageable and sustainable. we cut one of the virtual projects in week of the first cohort to better support student workload and timetable pressures. we introduced the peer mentor model at the start of week when the second student cohort had started which was not something we had considered in our initial planning. considering these improvements within the pdsa cycles helped provide structure and consistency throughout the improvement process. some unique strengths of this virtual placement model became apparent during implementation. students were able to shadow a broad range of clinics including physiotherapy, advanced practice, rheumatology, consultant physiotherapist led, specialist pain and occupational health. students reported that they enjoyed the opportunity to engage with so many different clinical settings and learn from a wide range of clinicians within one placement, which is not usually readily available. the students from the preceding cohort would provide peermentorship, alongside the clinical mentor. this peer mentor model provides a novel opportunity for early development of leadership and mentoring skills as well as supporting the continuation of the peer learning associated with traditional placements. the virtual nature of the placement also enabled those students with pre-existing health conditions or living abroad to complete a clinical placement and thus continue with their studies. ensuring that students had control over their timetable enabled them to fit the placement to their needs with several students doing flexible hours to accommodate childcare arrangements. without a virtual placement they would have been unable to complete a practice-based placement and would have had to delay progress through their course thus adding to the future workforce pipeline problem. while we achieved our aim of creating a virtual student placement model it is not without limitations. the primary limitation, as with all virtual working, is the reliance on technology. for some students and clinicians there is a familiarity issue with virtual platforms. this was addressed in pdsa cycle through appropriate support and development of easy to follow guides to help students and clinicians navigate the new virtual landscape. the key solutions implemented to overcome this problem were: ► production of walk-through videos to assist clinicians and students in setting up and navigating the central clinic calendar in order to populate shadowing clinics. ► dedicated 'how-to' guide and walk-through videos for successful delivery of facebook live classes. ► ensuring all students had access to, and understood how to contact, the connect it team should they experience any technology issues. a more difficult challenge to overcome is the accessibility issues some people may experience with technology, for example a clinician with a hearing impairment. furthermore, while our virtual placement model offers a learning rich environment it is not possible for students to take the lead as much within consultations. due to information governance risks associated with students working remotely we were unable to give access to clinical records systems for them to input clinical notes. to mitigate this, students were encouraged to write their own notes during consultations and share these with their mentors for discussion afterward allowing them to develop this skill. the virtual clinic environment also means that there is no opportunity to for students to practice their 'hands-on' objective assessment skills, which is usually seen as a key component of clinical placements. we decided that, rather than trying to artificially include teaching on this, we would better serve students by focusing on the skills needed to run a successful virtual clinic as well as the opportunity to develop skills not previously included on clinical placements such as the delivery of virtual rehab classes. this is a challenge that many qualified clinicians faced during covid- as well as the students on clinical placement. to this end, the senior clinical leadership within connect produced a series of webinars to help clinicians' up-skill in virtual consultations and these were made available to all students as well. these skills are likely to form part of the future of healthcare delivery and this model provides a unique learning opportunity for exposure to such skills early in the student's careers. examples of these webinars can be found at these urls: 'remote rehabilitation' with matthew wyatt: https:// www. youtube. com/ watch? v= o__ ltqfilu& feature= youtu. be (online supplemental file ). 'video consultations' with andrew cuff: https://www. youtube. com/ watch? v= dni fkfrizg& feature= youtu. be (online supplemental file ). further, students were encouraged to write up case studies and plan hypothetical objective assessments based on the virtual assessments conducted. this helps to develop the clinical reasoning which underpins a good objective examination and is arguably the most important skill to start developing on placements with the mechanics of objective assessment developed later. it seems likely open access that aspects of virtual clinics will be carried forward into service models after the covid- pandemic and thus the opportunity to develop these skills now equips students to thrive in the post-covid- era of service delivery. due to the covid- pandemic clinical diaries are quieter than normal due to the interruption of routine care, and this has allowed most students the opportunity to lead on some patient consultations. however, as diaries start to get busier as part of covid- recovery, it is anticipated that this may become more difficult to manage and we may have to scale down our student numbers for the model to remain sustainable. the virtual placements qi project was successful and useful as we were able to design, implement and improve, to arrive at a model for virtual placements that allowed us to achieve our aims. to our knowledge, this is the first report on the implementation of virtual placements in response to the covid- pandemic. we believe this model, or a version of it, could be implemented in any setting running virtual clinics to facilitate the continuation of student placements during the covid- pandemic and thus supporting the progress of students into the workforce. the qi process was conducted rapidly, in response to an ever-changing environment, and should be considered with respect to its limitations. we continue to run an iterative qi approach to develop a blended student placement model combining the best of both traditional and virtual models as we transition back to face-to-face working. we are also looking to undertake a qualitative evaluation of the student and clinician experience of the virtual student placement model. twitter rory twogood @rorytwogood full guidance on staying at home and away from others (internet) infectionprevention-and-control/ transmission-characteristics-and-principlesof-infection-prevention-and-control who. coronavirus disease (covid- ) situation report - (internet) pm statement on coronavirus csp. find a physiotherapy degree. (internet) csp. covid- guidance for higher education institutions. (internet) advice for education providers hcpc. the standards of proficiency for physiotherapists. (internet) investment and evolution: a five-year framework for gp contract reform to implement the nhs long term plan clinical placement expansion programme safe-social-distancingguidance-for-young-people/ staying-alert-and-safe-social-distancingguidance-for-young-people rapid implementation of virtual clinics due to covid- : report and early evaluation of a quality improvement initiative point of care foundation. experience-based co-design toolkit. (internet) microsoft teams to be rolled out across nhs in response to coronavirus. (internet) guide to qi methods connect health's -point guide to setting up virtual student placements acknowledgements the authors would like to thank thomas flanagan for critical review and input as well as the clinical education teams at kings college london and brunel university for their review of the initial placement model and support of the programme.contributors mw and rt conceived and designed the initiative. all authors were involved in collection, analysis and interpretation of data. rt, eh and ac drafted the manuscript with critical review and final approval from all authors.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.competing interests connect health receive a standard placement tariff for each undergraduate physiotherapy student on placement within the organisation.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. provenance and peer review not commissioned; externally peer reviewed.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. rory twogood http:// orcid. org/ - - - andrew cuff http:// orcid. org/ - - - key: cord- -xvfybif authors: tabatabai, shima title: simulations and virtual learning supporting clinical education during the covid pandemic date: - - journal: adv med educ pract doi: . /amep.s sha: doc_id: cord_uid: xvfybif currently, the covid- pandemic has a critical impact on clinical education, and it has resulted in the widespread disruption of clinical assessment. clinical mentors and students in all the health professions are working within the most troublesome of circumstances in the hospital-based educational settings. medical educationists ought to concentrate on the health and the safety of the students and communities. the safety issues have prompted the ministry of health to suggest that schools develop action plans for the adoption of available technologies to keep medical education moving forward with high quality, active, and interactive learning for more demanding tomorrow. a key challenge for medical educators is to simulate the clinical encounters at this unprecedented time, and this emphasized the necessity of applying virtual simulation-based educational tools in clinical education. this commentary explores how covid- has challenged medical education. it also has discussed the future implications and potencial challenges of incorporating simulation-based virtual learning technologies into the medical curriculum, for the future of clinical education, and students' or residents' competency evaluation. since the perspective of medical education after the pandemic will transform, it is necessary to engage in futuristic plans to adapt to the impact of covid- . the goal of this manuscript is to briefly explain the challenges in clinical training due to covid and the use of simulation-based technology through virtual education to keep the clinical education on stream throughout the pandemic. futuristic plans should have a holistic approach to the ongoing crisis. in this regard, we should initially define the problem and then delineate future horizons. in this commentary, i will briefly outline the potential implications and challenges of integrating virtual simulation technologies into medical education and assessment and how we can overcome those challenges. covid- is an emerging situation, and it continues to spread worldwide, overwhelming the intensive care unit and health system ability. the covid- irruption has influenced each member of the community, not least within the health professions who serve in the front-line of patient care. when the world health organization declared the pandemic of covid- , every country used different strategies, such as epidemiological studies, isolation of diagnosed cases, and school closure, to prevent and to postpone the spread of the disease. currently, covid- pandemic has a critical impact on education system. meanwhile, it cannot be ignored that clinical mentors and students in all the health professions, working within the most troublesome of circumstances are potential vectors for covid- . in this regard, medical education is shifting to virtual universities. virtual learning in response to the covid- outbreak in iran iran's ministry of health and medical education (mohme) suggests that schools develop an action plan for reducing the spread of this extremely contagious disease. in addition, the safety issues have made administrators and educators seeking tools to help them in transferring to virtual learning. virtual learning refers to instruction in a learning environment where educators and students separated by time or space or both, and the instructors provide course content through course management applications, multimedia resources, the internet, videoconferencing, etc. students receive the content and communicate with the teacher via the same technologies. therefore; virtual learning could consider as a turning point in medical education in iran due to covid- . in iran, most medical schools have developed a virtual learning platform. also, iran's virtual university of medical sciences (vums) has provided authentic resources and educational content to help medical schools all around the country. the national vums in partnerships with leading iranian medical schools is providing what are known as massive open online courses-moocs -through arman systems, accessible at no cost, and without limits on participant numbers or prerequisites. also, to offer integrated learning experiences for iranian medical students under the current circumstances, the educational contents deliver through the national learning management system entitled navid. like similar learning management systems (lms), navid is helping instructors monitor the learners as well as meeting the individual needs of learners. some of its main facilities included course content repository, managing users, courses, instructors, facilities, and generate reports, course calendar, learning path, discussion lists. through this infrastructure, members could offer their contributions, provision of exercises, assigning deadlines to the educational projects and works, assessing the learner's theoretical knowledge, correcting the tests, and providing immediate feedback. there are several free tools enabling video communications, video and audio conferencing, chats, and webinars for medical educators such as skype, zoom, and google hangouts meet. besides, we can set up a real-time classroom experience that elevates using hd-quality mobile or fixed-camera live and ensures all distance learners can collaborate at an equivalent baseline. how to keep the clinical education on track throughout the covid- ? preparing for future transformation after the pandemic to maintain high-quality medical education, administrators and medical educationists forced to look for innovative technologies. moreover, they will need to use emerging technologies that impact on the future way that their institutions will provide medical education. the challenges for educational institutes are how they could follow the best practices offered by the mohme to protect students, including social distancing practices, and develop engaged and high-quality clinical education. in this unique time, the major challenge for medical educators is to simulate clinical encounters.there is an essential question to look at "do medical education administrators and educators have the tools required to keep the clinical education on track? current virtual learning management systems offer many benefits such as accessibility to educational content from anywhere at any time, asynchronous discussions, and flexibility; however, the challenge is to apply theoretical knowledge to managing the patients. the latest innovations in flexible educational technologies will change the future of medical education and can facilitate clinical training moving forward with interactive simulation learning. computerized simulation education products for healthcare training environments need massive infrastructures ranging from clinical simulation management software and hardware, design and planning tools, file backup, cloud-based elearning, as well as an expert team for providing support to counselor education, case developers, and virtual patient training. [ ] [ ] [ ] there are still major barriers to the use of virtual simulation in clinical education. fidelity and validity issues, cost, and the simulation-based tools for healthcare training would be desperately required by health and medical education programs to support continual clinical education and assessment. computerized simulation education products and virtual simulation-based solutions provide the necessary tools to provide benchmarking and best practice insights to medical sciences students, better preparing them for real-world medical practice. - some medical simulation products are also available and ready for immediate deployment on the medical education lms and cloud-based platform. moreover, in recent years, medical schools are using virtual patient simulations in the education of health care professionals. england's health education systems and oxford university hospitals are using virtual simulationbased tools in undergraduate and postgraduate medical education. clinical skills assessment is one of the main parts of clinical education to assess practical qualifications. iran's board exam for evaluation of medical students and residents' clinical qualifications is an objective structured clinical examination (osce). this high-stakes performance assessment method requires experienced human resources, accurate planning, facilities, and reliable evaluation tools. protecting the safety of all participants, minimizing risk and maintaining defensibility to key stakeholders whilst ensuring the validity, and reliability of high-stakes performance assessments are other challenges. the future of clinical education depends on the integration of virtual simulation-based technologies and virtual clinical experience into the medical curriculum. as virtual simulation will continue to expand - , some educational institutes are investigating virtual simulation application in objective structured clinical examinations (osces), as a method of increasing the objectivity of their assessment processes. simulation-based educational technologies keep the clinical education on stream in the following ways: • the simulation platform's optional course module allows learners to move to a virtual environment. • the simulation-based platform changes traditionally time-consuming manual processes to create an integrated approach that improves clinical outcomes, saves time, and delivers electronic-based content. schedule simulated meetings, facilitate distance learning with video conferencing, and review the clinical decision-making with learners. , • it allows the learners to access the clinical scenarios via the computer or mobile device. the dashboard improves educational task flows and customizes remote learning parameters specific to the program requirements regardless of the learners' location. , • by simulation-based platform, clinical educators could conduct high-impact cased-based simulated training scenarios online and run live, virtual osces from anywhere. , • simulation-based virtual osce offers the perfect cloud-based platform to lead standardized patient (sp) confronts in a completely virtual, video-enabled environment to address all clinical education needs. , • simulation-based virtual osce facilitates core learning for clinical decision making in distance learning platforms, as well as the emerging demand to transform clinical practice into telemedicine forms. considering the benefits of simulation-based healthcare environments, medical school administrators should invest in simulation-based educational management technologies and products to keep the clinical education and competency assessment on track throughout the covid- pandemic. there is no conflicts of interest in this work. advances in medical education and practice is an international, peerreviewed, open access journal that aims to present and publish research on medical education covering medical, dental, nursing and allied health care professional education. the journal covers undergraduate education, postgraduate training and continuing medical education including emerging trends and innovative models linking education, research, and health care services. the manuscript management system is completely online and includes a very quick and fair peer-review system. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. submit your manuscript here: http://www.dovepress.com/advances-in-medical-education-and-practice-journal necessity of designing a national model of foresight-based policy-making in medical education covid- and medical education covid- reviving need explore online teaching and learning opportunities the influence of virtual learning environments in students' performance effects of physician-patient electronic communications on the quality of care polluino: an efficient cloud-based management of iot devices for air quality monitoring applications and challenges of implementing artificial intelligence in medical education: integrative review challenges of biological realism and validation in simulation-based medical education ronsen kr. the history of medical simulation simulated patient methodology: theory, evidence, and practice ophthalmic education and ophthalmologists growth trends in iran ( - ) a critical review of simulation the crucial necessity of designing competency based curriculums for post graduate medical education in iran conducting a high-stakes osce in a covid- environment advances in medical education and practice : submit your manuscript | www.dovepress.com key: cord- -rrgpkwey authors: faes, livia; fu, dun jack; huemer, josef; kern, christoph; wagner, siegfried k.; fasolo, sandro; hamilton, robin; egan, catherine; balaskas, konstantinos; keane, pearse a.; bachmann, lucas m.; sim, dawn a. title: a virtual-clinic pathway for patients referred from a national diabetes eye screening programme reduces service demands whilst maintaining quality of care date: - - journal: eye (lond) doi: . /s - - -z sha: doc_id: cord_uid: rrgpkwey aim: to evaluate the potential of an integrated virtual medical retina clinic in secondary care for diabetic patients screened and referred by the uk national diabetic eye screening program (desp). methods: this retrospective cohort study included diabetic patients referred by the desp to either a virtual or a traditional doctor’s appointment (face-to-face, f f) at the moorfields eye hospital nhs foundation trust (london, uk) between january and december . the primary outcome was the proportion of patients that qualified for a virtual-clinic appointment according to hospital guidance. secondary outcomes included the rate of attendance, mean time from desp referral to initial hospital appointment, mean time-to-discharge and -to-treatment of either panretinal photocoagulation or intravitreal injection of anti-vascular endothelial growth factor. results: we included , patients in this study. while patients ( . %) would have qualified for a virtual appointment according to local triage guidance, only ( . %) were referred to a virtual consultation due to capacity constraints. for routine referrals, mean time to the first hospital appointment was . days with a standard deviation of ± . and . ± . days for a virtual and a f f consultation, respectively. the mean time from referral to discharge to community was . ± . and . ± . days for a virtual and a f f consultation, respectively. we did not observe a statistically significant difference in the mean time-to-treatment in the sub-cohort that required intravitreal therapy for maculopathy (virtual clinics: . ± . ; f f: . days ± . ; p value > . ). moreover, we observed a non-inferior attendance rate in virtual as compared to f f clinics. conclusion: a significant proportion of diabetic patients referred to a f f clinic could initially be managed in a virtual clinic. increasing the adoption of virtual clinics in the management of diabetic patients that do not need long-term management or monitoring in secondary services may help alleviate service demands without diminishing quality of clinical care. collectively, our analyses suggest that virtual consultations are a faster and clinically appropriate alternative for a substantial proportion of diabetic patients. diabetes mellitus is estimated to affect more than million people by worldwide [ ] . more than a third of those patients will develop diabetic eye disease, of which these authors contributed equally: livia faes, dun jack fu % will develop visual impairment. early identification of diabetic eye disease is crucial in the prevention of sight deterioration [ , ] . in , the united kingdom (uk) national health service (nhs) launched a nationwide diabetic eye screening program (desp) aimed at reducing the risk of sight loss through early detection and treatment. the desp offers an annual screening appointment to all people with diabetes aged years or older. here, colour fundus photography takes place in the primary care setting and identifies patients that may require secondary-carebased hospital eye services (hes) [ , ] . in secondary care, patients undergo assessment for whether: (i) intervention (panretinal photocoagulation (prp), intravitreal injections, surgery) or active monitoring (more frequent than annual) is indicated; or (ii) whether they can safely be discharged back to the desp [ ] . following the implementation of the screening programme, marked the first year within five decades in which diabetic retinopathy was no longer the leading cause of blindness in england and wales [ , ] . consequently, over two million diabetic patients were screened and over , (about % were referred to hes in alone [ ] . the introduction of the desp has increased referrals to hes by % between and . this has massively strained the capacity of hes to deliver high quality ophthalmic care [ , ]-a problem not exclusive to the uk [ ] . hence, there is a worldwide need for efficient review of the relentlessly growing numbers of patients referred to secondary care. ideally, such a review would allow rapid identification of patients that can be safely discharged to and monitored in primary care [ , ] . the royal college of ophthalmologists defines virtual clinics as patient-clinician consultations in which the faceto-face (f f) interaction is removed. broadly, these can be either synchronous (interaction between patient and clinician occurs in real time e.g., via teleconferencing) or asynchronous; wherein patient examination and clinician assessment are separated in both time and space. both are key innovations that can enhance the efficiency of referral review. in particular time-independent review of patients, which allows additional flexibility for both physician and the patient by overcoming the need for patient-clinician schedules to overlap. patients with diabetes are ideally suited for virtual consultations as retinal imaging including optical coherence tomography (oct) and colour fundus photography are the foundation of modern retinal examination, and can be digitally stored and reviewed remotely [ , ] . virtual clinics in other ophthalmologic subspecialities have demonstrably reduced patient journey time, allowing for reduced waiting times and more patients to be monitored [ ] . accordingly, virtual medical retinal consultations were integrated into the medical retina service of moorfields eye hospital (meh) nhs foundation trust in [ , ] . the meh is a tertiary eye care hospital providing secondary care in this instance. at present, desp referrals to meh are invited to an initial assessment at a traditional f f or virtual clinic. a proportion of referrals is directly triaged to f f, either those identified by the: (i) desp to likely to require intervention i.e., proliferative retinopathy, best-corrected visual acuity (va) below / snellen ( early treatment diabetic retinopathy [etdrs] letters); or (ii) triaging meh ophthalmologist as unsuitable for a virtual consultation (ungradable fundus image in secondary care, vulnerable adult, lens or media opacities, pregnancy, or requirement of interpreter services). patients are otherwise indiscriminately assigned to either f f or vc according to booking availability (fig. ) . in this study, we evaluated the potential of a combined f f-and virtual-clinics system at the meh by investigating the proportion of patients eligible for an initial assessment in the virtual setting. we also sought to collect preliminary evidence for the efficiency, safety, patient acceptance, and accessibility of the service through assessment of mean time from referral to first hes appointment, mean time-todischarge, mean time-to-treatment, the rate of attendance, and social and economic deprivation indices. all diabetic patients (n = , ) referred by the desp to secondary care at meh nhs foundation trust (london, uk) between january and december were eligible. the cutoff date of january was chosen as it marks the period, in which the medical retina service at meh integrated, a virtual-clinic option for the management of diabetic patients referred by the desp. patients that were re-referred after having been discharged from secondary care and patients without record of retinopathy, maculopathy, or best-corrected va in both eyes at the secondary care appointment were excluded. we obtained approval by the institutional review board of the hospital (road / ) for this study. an audit registration was completed (meh- ). we comply with the declaration of helsinki and strobe guidelines for the reporting of cohort studies [ ] . the desp invites all diabetics aged years or over to an annual assessment detailed elsewhere [ ] and summarised in fig. . patients that meet referral criteria to hospital were invited to a clinical appointment in either a traditional f f or virtual setting triaged according to hospital guidelines ( fig. ) . initial assessments in the f f or virtual settings were carried out as previously described [ , ] . briefly, va and noncontact intraocular pressure were taken by trained nurses and entered into an electronic health record system, either medisoft (medisoft ltd., leeds, uk) or openeyes (openeyes foundation, london, uk). patients then received dilated fundus photography. depending on the availability of retinal imaging at the site, either -field °fundus photography or wide-field fundus photography (optos) was obtained. all patients underwent macula oct volume scan (topcon d oct scan). in a virtual consultation, a structured history was taken by a trained nurse. history and investigations were remotely reviewed by an ophthalmologist within week with outcome determined as per hospital guidelines ( supplementary fig. ). in f f clinics, the consultation with the retinal specialist took place on the same day as the investigations. herein, history taking, dilated slit-lamp examination, imaging review, and a management plan were carried out. all clinical data were extracted from the initial meh appointment. va is reported in etdrs letters. for each patient, the eye with the greater va was considered the better-seeing eye. where va for both eyes was identical, this value was used for both better-and worse-seeing eye. diabetic grading was performed according to the national desp standards [ ] . for each patient, the most severe retinopathy and maculopathy grade was taken forward for analysis. socio-economic deprivation was extrapolated using postcodes of patient residence to identify corresponding decile index of multiple deprivation based on the english indices of deprivation [ ] . the primary study outcome was the proportion of patients who meet hospital guidelines for initial assessment in vc; fig. referral pathway from the nhs diabetic eye screening program (desp) to moorfields eye hospital. the desp invites all diabetic patients aged years or over to annual primary-care-based screening. here, two-field fundus photography (one image centred on the macula and a second image centred on the optic disc) is acquired and graded according to the english screening programme for diabetic retinopathy standards ( supplementary fig. ). if criteria were met (r , r , r , m , or ungradable photo), patients are referred to hospital eye services and suspended from screening while under secondary care. urgently referred patients (retinopathy grade r ) are to be seen within , routinely referred patients within weeks. at moorfields eye hospital, patients referred by the desp can initially be seen in a face-to-face (f f) or virtual-clinic (vc) appointment. this is determined by ophthalmologist-led eminence-based triage guidance. patients with proliferative retinopathy grade (r ), visual acuity below early treatment diabetic retinopathy (etdrs) letters, ungradable fundus imaging in primary care, vulnerable adult, lens or media opacities, pregnant women, or requirement of interpreter services are ineligible for initial appointments in vc. patients eligible for both f f and vc are indiscriminately assigned to either based on booking availability. outcome of initial assessment can be either follow-up in the hospital or discharge back to the desp. chosen as a surrogate variable for vc adoption and capacity. secondary outcomes included (i) mean time from the referral of the desp to the first appointment at the meh; (ii) mean time from referral of the desp to discharge; (iii) mean time from referral of the desp to treatment (either prp or intravitreal anti-vascular endothelial growth factor)-as surrogate variables for efficiency and safety; (iv) the rate of attendance at the first and if the first has not been attended, second scheduled appointment in f f compared to virtual clinic (as a surrogate variables for appointment adherence and acceptance); and (v) the distribution of social and economic deprivation indices (as a surrogate variable for accessibility). statistical analyses have been carried out in r: a language and environment for statistical computing, r foundation for statistical computing, vienna, austria (https://www.rproject.org/) [ ] . distribution of data was tested by the shapiro-wilk normality test. means of nonparametric groups were compared using wilcoxon signed-rank, wilcoxon rank-sum, or kruskal-wallis tests as appropriate. for more than two groups, multiple pairwise analyses have been carried out using the wilcoxon rank-sum test. calculated means in text and figures are expressed with sd error margin corresponding to the standard deviation, unless otherwise specified. a p value < . was considered statistically significant. from january to december , there were , desp referrals that attended an appointment at meh. , patients met the study's selection criteria and were therefore taken forward for analysis (fig. ) . we compared demographics between patients that were initially seen in a f f clinic versus a virtual clinic. a statistically significant difference was not detected in the distribution of gender or mean decile of social and economic deprivation indices. however, statistically significant differences were noted in mean age-those attending a virtualclinic appointment being younger ( . years sd . versus . years sd . , p value . e − )-and in the distribution of ethnicity. differences in ethnicity are potentially accounted for by the large proportion of missing data ( . and . %) seen in both f f and virtual clinics (table ) . routinely referred patients initially seen in a virtual clinic exhibited a greater mean va in both the better-seeing ( . letters sd . versus . letters sd . ; p value < . ), and the worse-seeing eye ( . letters sd . versus . letters sd . ; p value < . ) than those seen in a f f consultation (table ). this was expected as current guidance direct patients with va of < / snellen or etdrs letters to f f clinics. similarly, the retinopathy grade r is excluded from virtual clinic and therefore features a higher proportion of r , r , and r ( patients, %) than the f f clinic ( patients, %, p value < . ). in terms of maculopathy grade, we found a statistically significant difference in the distribution of maculopathy grades between f f and virtual clinics ( fig. ). data from the total cohort presented collectively and sub-stratified by first clinic type: face-to-face or virtual. the mean and standard deviation (sd) of patient age at the initial appointment (baseline), index of multiple deprivation (imd) decile, and index of deprivation affecting older people (idaop) decile were compared. wilcoxon signed-rank test was used for comparison of face-to-face and virtual-clinics sub-cohorts. the chisquare test was used for categorical comparison i.e., gender and ethnicity. mean duration between receiving a patient referral and first attended appointment was calculated and substratified by clinic type (face-to-face and virtual clinic) as well as referral urgency (routine and urgent). for patients whose initial appointment resulted in the clinician's decision to discharge, duration between initial referral and date of discharge decision were similarly extrapolated. sd signifies standard deviation. current meh guidance directs a subset of desp referrals (retinopathy grade r or va below or equal / snellen or letters) for initial assessment in f f clinics; patients can otherwise indiscriminately be seen in either a f f or a virtual clinic. of all patients included in this study, ( . %) met the criteria for a virtual consultation. similarly, ( . %) of routine referrals initially seen in the f f setting met the criteria for virtual consultation (fig. a) . a considerable proportion of routine referrals that were discharged on the initial f f appointment also met triage criteria for virtual clinics ( patients, . %). notably, the proportion of initial appointments taking place in a virtual setting has progressively increased over the past years; from % in to % in . still, the majority of patients in are initially assessed f f (fig. ). we queried whether the smaller proportion of referred patients initially assessed in virtual clinic reflected a greater reluctance from patients to attend a virtual than a f f consultation. of all initial invitations to a meh appointment, % ( of , ) and % ( of ) did not attend their booked f f or virtual consultation, respectively. for the sub-cohort that did not attend their initial appointment, a similar trend was apparent for the second appointment as % ( of ) and % ( of ) did not attend following an invitation to a f f or a virtual consultation, respectively. patients referred by the desp seen in hes can be substratified into those: (i) where management by secondary services is not indicated and therefore they are immediately discharged for desp surveillance; (ii) that require treatment or active monitoring by secondary care. of all routine desp referrals, a greater proportion was discharged following initial assessment in a f f ( patients, . %) than in a virtual consultation ( patients, . %). triage guidelines divert patients with proliferative retinopathy and active maculopathy to f f clinics. as such, a greater proportion of patients initially seen in f f clinics was indicated for prp ( time from referral acceptance to appointment, discharge, and treatment when compared with f f, we observed a mean time from routine referral to initial assessment to be shorter for virtual clinics ( . days sd . versus . days sd . , p value < . ). consequently, the decision to discharge a patient back to the primary care at the first appointment (when indicated) was also made sooner in virtual clinics ( . days sd . versus . days sd . ; p value < . ). consistent with meh guidelines, urgent desp referrals ( . % of all referrals) were largely seen in a f f clinic ( / ; . %). all urgent referrals to a virtual clinic were due to clerical error i.e., patients were clinically appropriate for routine referral, but accidently marked as urgent. nevertheless, there was no statistically significant difference in the mean time from referral to appointment attendance between f f ( . days sd . ) and virtual clinic ( . days sd . ; p value . ). of routine referrals that underwent intravitreal injections, the clinic type of the first appointment did not affect the mean time from referral to receiving treatment (vc . days sd . versus f f clinics . days sd . , fig. current face-to-face first appointments that meet the virtual clinic criteria anad a comparison of outcomes from both clinics. a proportion of routine face-to-face appointments that meet current triage criteria for assessment in virtual clinic. b a comparison of initial clinic type (face-to-face [blue] and virtual retina clinic [red]) in terms of mean duration from receiving patient referral to: initial appointment, discharge decision, receiving initial intravitreal injection. this was further stratified by urgency of referral, routine (left panel), and urgent (right panel). error bars signify standard deviation. p value . ) ( fig. b and supplementary table ). of all desp referrals initially seen f f, patients ( %) underwent prp (fig. b and supplementary table ). here, the mean duration from referral to treatment was . days (sd . ) for routine and . days (sd . ) for urgent referrals. of patients referred to virtual clinics, only five presented with a retinopathy grade that potentially warranted prp (r or r a). two received prp within days of the referral acceptance as the others had previous treatment. this study sought to evaluate the potential of a combined f f-and virtual-clinic system at meh over a -year observation period. notably, only a fifth of all referred patients was initially assessed in a virtual consultation. however, nearly three quarters of all patients initially seen in a f f clinic were suitable for a virtual consultation in terms of retinopathy grade and visual function. in terms of efficiency, desp referrals triaged to virtual clinics were able to attend their first hes appointment weeks sooner (on average) than if triaged to a f f clinic. consequently, the time to clinical decision was also faster for patients discharged back to the desp at the first appointment. hence, patients that did not require secondary care spent less time in the hes when managed in a virtual clinic. this gain in efficiency did not adversely affect patient safety. we did not observe a statistically significant difference in the mean time from referral acceptance to urgent appointments or intravitreal injections between the two clinic types. in addition, our findings suggest that patient acceptability and accessibility of virtual clinics were uncompromised. that is, a statistically significant difference in attendance rates or indices of socio-economic deprivation between patients assessed in virtual versus f f clinics was not detected. eminence-based hospital guidance directs patients referred by the desp with suspicion of severe retinal disease to a f f clinic. the intention here is to minimise and prevent unnecessary delays between referral and potential visionpreserving treatment [ , ] . yet, we did not observe a statistically significant difference in the mean duration from urgent referral to appointment in f f and virtual clinics; despite all urgent referrals to virtual clinic being clerical errors. a statistically significant difference was also not detected in the mean duration between routine referrals and intravitreal injection when comparing f f and virtual consultation. this is likely because patients requiring treatment are booked into a specialised interventional clinic (prp for proliferative retinopathy and intravitreal anti-vegf injections for maculopathy) regardless of whether they are assessed virtually or f f. however, we were unable to compare the mean time to prp as this was only indicated in two referrals assessed in the virtual setting. larger numbers will be required for adequate statistical comparison. if these preliminary analyses are confirmed by adequately powered prospective studies, a revision of current triage guidelines toward inclusion of patients with a higher risk profile for sight-threatening disease into virtual clinics may be warranted. our preliminary results suggest that the modest adoption of virtual clinics reflect a capacity patients are initially assessed in either a face-to-face or virtual consultation. proportion of initial assessments that are virtual versus face-to-face is indicated in red (right axis). constraint of the current infrastructure in the hospital service, rather than patients' reluctance in regards to virtual consultations. at present, the medical retina virtual-clinic capacity ( per annum) is unable to match the referral rate from desp to meh (circa per annum). however, upscaling of virtual-clinic capacity has been accomplished for other ophthalmic services, including the meh glaucoma service wherein all new patients referred by primary care (circa per annum) are first assessed in an analogous virtual consultation [ , , ] . certainly, the demand for telemedicine solutions has taken centre stage with pressures from the current covid- climate to deliver clinical care with minimal time spent in close proximity. key factors required for the expansion of the service capacity include training of qualified graders, automating administrative and failsafe processes, and utilising community imaging devices, such as oct, where available. moreover, cloud-based platforms that are robust, configurable, and interoperable will be imperative to the success of scaling these teleophthalmology solutions. in light of current national efforts to rapidly scale up telemedicine services (e.g., nhs england extending attend anywhere and heath at home to over providers), the stage has been set for post hoc analyses that will further our understanding of efficacy, safety, upscaling, and maintenance of these innovations. to the best of our knowledge, this is the first retrospective cohort study to report on the efficiency, safety, and acceptability of a combined f f-and virtual-clinic system for patients referred from a national diabetic eye screening service. our study has several limitations. while we found that about three-fourths of patients seen in f f clinic would have been suitable for a virtual consultation in terms of severity grading and visual function, we could not exclude that they were triaged to a f f clinic because of the need for interpreter service, vulnerability, or pregnancy. moreover, we performed our analyses by taking the most severe retinopathy and maculopathy grade for each patient, which means that the combinations of retinopathy and maculopathy gradings does not reflect true constellations that occurred in a study eye. this study presents preliminary evidence that suggests that virtual consultations are a safe and efficacious alternative to traditional appointments for patients referred by the national diabetic eye screening service. particularly for those carrying low risk for sight-threatening disease and good visual prognosis. however, its potential is limited by the current lack of resources required for expansion. we envisage further research in this arena to focus on automation of image analysis and clinical decision making, as well as, the crucial administrative processes that enable the delivery of a robust teleophthalmology service. what was known before • the uk diabetic eye screening service has strained capacity of hes. • virtual consultation is an appropriate alternative to traditional f f consultations for a substantial proportion of referrals from the uk diabetic eye screening service. • its implementation can alleviate service demands without diminishing quality of clinical care. conflict of interest the authors declare that they have no conflict of interest. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. idf diabetes atlas: global estimates of diabetes prevalence for and projections for progression of diabetes retinal status within community screening programs and potential implications for screening intervals a comparison of the causes of blindness certifications in england and wales in working age adults ( - years) the english national screening programme for diabetic retinopathy - nhs screening programmes-diabetic eye screening rates of referable eye disease in the scottish national diabetic retinopathy screening programme increasing demand on hospital eye services risks patients losing vision. the royal college of ophthalmologists telemedicine and diabetic retinopathy: moving beyond retinal screening the role of telemedicine in improving the referral service for consideration of treatment for age-related macular degeneration in a tertiary referral centre delay in diabetic retinopathy screening increases the rate of detection of referable diabetic retinopathy spectral-domain optical coherence tomography: a comparison of modern high-resolution retinal imaging systems nonmydriatic ultrawide field retinal imaging compared with dilated standard -field -mm photography and retinal specialist examination for evaluation of diabetic retinopathy experiences with developing and implementing a virtual clinic for glaucoma care in an nhs setting implementation of medical retina virtual clinics in a tertiary eye care referral centre clinical outcomes of a hospital-based teleophthalmology service: what happens to patients in a virtual clinic? strengthening the reporting of observational studies in epidemiology (strobe): explanation and elaboration grading and disease management in national screening for diabetic retinopathy in england and wales english indices of deprivation r: a language and environment for statistical computing. r foundation for statistical computing indications for photocoagulation treatment of diabetic retinopathy: diabetic retinopathy study report no. . the diabetic retinopathy study research group diabetic retinopathy preferred practice pattern ® . ophthalmology effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ed performance a new 'virtual' patient pathway for the management of radial head and neck fractures key: cord- - bfchw u authors: rollinger, judith m.; stuppner, hermann; langer, thierry title: virtual screening for the discovery of bioactive natural products date: journal: natural compounds as drugs volume i doi: . / - - - - _ sha: doc_id: cord_uid: bfchw u in this survey the impact of the virtual screening concept is discussed in the field of drug discovery from nature. confronted by a steadily increasing number of secondary metabolites and a growing number of molecular targets relevant in the therapy of human disorders, the huge amount of information needs to be handled. virtual screening filtering experiments already showed great promise for dealing with large libraries of potential bioactive molecules. it can be utilized for browsing databases for molecules fitting either an established pharmacophore model or a three dimensional ( d) structure of a macromolecular target. however, for the discovery of natural lead candidates the application of this in silico tool has so far almost been neglected. there are several reasons for that. one concerns the scarce availability of natural product (np) d databases in contrast to synthetic libraries; another reason is the problematic compatibility of nps with modern robotized high throughput screening (hts) technologies. further arguments deal with the incalculable availability of pure natural compounds and their often too complex chemistry. thus research in this field is time-consuming, highly complex, expensive and ineffective. nevertheless, naturally derived compounds are among the most favorable source of drug candidates. a more rational and economic search for new lead structures from nature must therefore be a priority in order to overcome these problems. here we demonstrate some basic principles, requirements and limitations of virtual screening strategies and support their applicability in np research with already performed studies. a sensible exploitation of the molecular diversity of secondary metabolites however asks for virtual screening concepts that are interfaced with well-established strategies from classical pharmacognosy that are used in an effort to maximize their efficacy in drug discovery. such integrated virtual screening workflows are outlined here and shall help to motivate np researchers to dare a step towards this powerful in silico tool. in the field of drug discovery we are confronted by a paradox situation: highly efficient tools and advanced technological and molecular knowhow, e.g., in the area of genomics, combinatorial chemistry, high throughput screening (hts), robotized and miniaturized process cycles, could find entrance in big pharmaceutical industries. these costly procedures were expected to raise the number of launched drug substances; however the results were disappointing [ , ] . in , adam smith, the chief-editor of nature presented the sobering data of research and development expenses of the leading pharma companies versus new drugs on the market. they have steadily fallen in recent years despite the increasing financial efforts [ ] . on the other side we are faced by a high traditional impact of naturally derived medicines and incredible success stories of natural products (nps) as potent remedies from the beginnings of human therapeutic activity to modern research and drug development. nevertheless, most large pharmaceutical companies scaled down or terminated their work in nps operations. the reasons behind this are that the drug discovery process starting from natural sources is hardly compatible with the today's highly automated drug discovery technologies. thus, the pre-eminence of combinatorial chemistry as the preferred method for generating new drug leads has led to the comparative neglect of this valuable resource. william strohl from merck research laboratories summarized the difficulties of np programs versus synthetic chemicals in his editorial remarks in drug discovery today [ ] . these include (i) the existence of already found potent antimicrobic and antitumor nps and the lack of sufficient dereplication programs which prevent their repeated discovery; (ii) the fact that -in contrast to the highly sophisticated molecular targets -np extracts are generally regarded as too 'dirty', too difficult to assay and too time-consuming; (iii) obtaining an assay hit resulting from a bio-guided fractionation, the nps' structure still has to be elucidated compared with synthetic chemicals; (iv) nps are often deemed as too structurally complex, possessing multiple hydroxyl moieties, ketones and chiral centers. strohl nevertheless concluded by listing a number of advantages applying an active np program, which he finally described as an 'expensive endeavor' which, however, is 'well worth the cost'. the use of nps has been the single-most successful strategy for the discovery of new drug leads, which is clearly shown by different statistics [ , ] . with increased calls in recent years for further research on nps [ , ] there are again signs that they may play a more active role in the future drug discovery process, since their reintroducing may help to re-discover the sweet spot in drug discovery [ ] . to date some , natural compounds [ - ] have been published. the terrestrial flora has been intensively investigated over the last decades; the potential in finding new nps slumbering in untapped biota is however nearly inconceivable. it is estimated that only - % of the approximately , described high plant species have ever been in the focus of phytochemical and pharmacological investigations [ ] . more sobering is the percentage in the field of bacterial (less than %) and fungal species (less than %) [ ] . the main part of known nps belongs to secondary metabolites. these compounds provide living systems with their characteristic features mandatory for surviving. they contain an inherently large-scale of structural diversity. about % of the chemical scaffolds of published nps are unique and have not been made by any chemist [ ] . in the past years researchers have discovered many potential therapeutic targets. since the completion of the human genome, , to , genes and at least the same number of proteins are assumed [ ] . thus, we are up against an increasing number of macromolecular targets, like proteins, receptors, enzymes, and ion channels -that might be of pathological concern for humankind. among them, proteins continue to attract significant attention from pharmaceutical technology as a valuable source of drugable targets [ ] . proteins provide the critical link between genes and disease, and thus are the key to understanding the basic biological processes. up to now drug discovery has been performed against only approximately targets [ ] , though the number of potential targets are estimated to be in the range of , to , [ , ] . taken together, it can be assumed that a large number of drug leads and hits are conserved in the inexhaustible pool of nps pre-screened by evolution. but how to dig out and to recognize the respective drug leads is a challenging task for both industry and academia, for medicinal chemists, pharmacognosists and pharmacologists. np research is affected with a wealth of time-consuming and cost intensive investigations. collection of the natural material, phytochemical analysis, isolation and identification of the constituents is just the basic procedure. a biological screening of extracts or even the arbitrary testing of isolated metabolites is feasible and often performed, though is not at all a focused procedure, thus unpractical and too expensive. the nps' diversity has to be accessed in a more rational way. holistic versus molecular approaches in drug discovery from nature during the last century and even today the discovery of bioactive nps and their development into potential drug candidates are mainly covered by a holistic approach. a characteristic workflow of this procedure is given in figure . starting from the knowledge or assumption about a biological effect the natural material is selected and adequately extracted. if a positive effect in the obtained multi-component extract is recorded, it is attempted to trace it back to the active principle/s by intense phytochemical and analytical investigations (fig. ). this can for instance be achieved by a bioactivity-guided fractionation. a more targeted approach focuses on innovative technological tools combining analytical and biological information. an overview of recent developments in this area and successful examples thereof are presented by potterat and hamburger [ , ] . as soon as the constituent regarded to be responsible for the overall effect is isolated, further research focuses on a molecular level including structure elucidation and pharmacological profiling. synthesis and testing of series of derivatives enable an insight into a structure-activity-relationship and pharmacokinetic aspects. finally, potential drug leads become drug candidates after some intense toxicological studies and after the verified effectiveness in vivo (fig. ) . recent advances in lead identification from nature work on a molecular base more than on a holistic one. a first prerequisite for that is on bioin- traditional early drug development of a nature based drug candidate formatics comprising d structures from genes and proteins (bioinformatics), substantial knowledge on molecular target functions with accurate structural information and protein-ligand interactions. secondly, it is essential to refer to unambiguously characterized structures of secondary metabolites preferably with some information to their biological effect. based on available structural as well as biological knowledge from both sides, information can be deduced from chemoinformatics to bridge the gap between known ligands and the discovery of new lead structures (fig. ). the increasing understanding of fundamental principles of protein-ligand interactions and the steadily growing number of d-structures of potential and experimentally proved ligands provide undreamed of possibilities towards more rationalized concepts in drug discovery. however, too much is expected of the human brain to profit from the already published information. thus, efficient and effective approaches benefit from today's knowledge about nps. in the area of medicinal chemistry, computational methods, like virtual screening experiments, have already proved to satisfy these requirements. they are needed to exploit the available structural information, to understand specific molecular recognition events, and to clarify the function of the target macromolecule. though rationalized procedures in the search for bioactive natural products are in great demand to find the 'needles in a haystack', computational assistance could hardly break into natural product research. the common idea of all computational approaches within the early drug discovery process is to mine more or less large compound databases in silico and to select a limited number of candidates proposed to have the desired biological activity. for this process the term 'data mining' was coined in [ ] , which was concisely defined by gasteiger and coauthors: 'to extract knowledge from a large set of data in order to make predictions of new events' [ ] . within the lead discovery process, virtual screening technologies have largely enhanced the impact of computational chemistry and nowadays chemoinformatics plays a predominant role in early phase drug research [ , ] . the key goal of the use of such methods is to reduce the overall cost associated to the discovery and development of a new drug, by identifying the most promising candidates to focus the experimental efforts on. recently published books and reviews on the impact of computational chemistry for lead structure determination highlight these efforts [ ] [ ] [ ] [ ] . if the d structure of the biological target is known, high throughput docking turned out to be a valuable structure-based virtual screening method to be used [ ] [ ] [ ] [ ] . within this context, the scoring of hits retrieved still remains a question that is often discussed. in fact, currently the major weakness of docking programs lies not in the docking algorithms themselves but still in the inaccuracy of the functions that are used to estimate the affinity between ligand and target, the so-called scoring functions. previously, stahl and rarey analyzed scoring functions for virtual screening [ ] , giving valuable insight into strengths and weaknesses of currently used models for affinity estimation. the combination of several different scoring functions termed as consensus scoring turns out to be one of the possible answers to the question raised previously. in fact, several authors recently described their efforts in this area; an example is given in reference [ ] . in a theoretical study, other authors demonstrate that consensus scoring outperforms any single scoring for simple statistical reasons and that a moderate number of scoring functions (i.e., three or four) are sufficient for the purpose of consensus scoring [ ] . however, it has been shown that consensus scoring alone is not suitable for all cases of docking, and, as highlighted in a recent review by krovat and co-authors, considerable efforts are still devoted to the optimization of scoring functions [ ] . because of the restricted free access to np d libraries (see below), the number of virtual screening studies published for the rational access to bioactive nps is limited. some examples using high throughput docking as a structure-based virtual screening tool will be given here: liu and zhou applied a theoretical approach to find natural ligands as potential inhibitors of the sars-cov protease, a virus target of the severe acute respiratory syndrome [ ] . they used a docking-based virtual screening cycle and applied drug-like filters to finally propose drug candidates out of two d databases comprising metabolites from marine organism and compounds from traditional chinese medicine. the same virus organism was the main interest in the study performed by toney et al., who focused on its main proteinase, clpro. the crystal structure of this attractive target was used as the starting point for the virtual docking screening of the nci database. searching for non-peptidyl inhibitors, the authors identified the naturally occurring terpenoid alkaloid sabadinine (i.e., cevine; ) as potential anti-sars agent [ ] . the author group around stefano moro could identify ellagic acid ( ) as inhibitor of the protein kinase ck screening an in-house generated database with almost , structures of natural compounds [ ] . a combination of four docking protocols and five scoring functions has been utilized to dock and rank the molecules in the database. the consensus docking suggested ellagic acid to be one of the most promising candidates. this assumption could be verified by experimental studies revealing this np as highly potent ck inhibitor (k i = nm). estrogen receptor-plays a key role in regulating brain development and estrogen-induced promotion of neurogenesis and memory. using the d coordinates of the co-crystal structure of human estrogen receptorbound with genistein as starting point, zhao and brinton pursued a receptor-based molecular docking approach [ ] . they focused on the search for natural estrogen receptor--selective ligands. twelve candidate molecules, which had been suggested by the database screening, were selected. the authors determined their binding affinity and selectivity; three of the com-pounds belonging to the flavanoid family ( ) ( ) ( ) displayed over -fold binding selectivity to the estrogen receptor-over . a similar approach was employed by liu and co-authors. applying a docking virtual screening filtering experiment, the authors discovered potent inhibitors of the potassium ion channel from a chinese np database [ ] . the pharmacophore concept has proven to be extremely successful, not only in rationalizing structure-activity relationships, but also by its large impact in developing the appropriate d-tools for efficient virtual screening [ ] . profiling of combinatorial libraries and compound classification are other often-used applications of this concept. although well established in combinatorial chemistry, it has to be pointed out that the tools described in this section have likewise a considerable impact on the rational finding of new potential lead compounds originating from the immense source of secondary metabolites. the prior use of pharmacophore models in biological screening of nps is an efficient procedure since it quickly eliminates molecules that do not possess the required features thus leading to a dramatic increase of enrichment, when compared to a purely random screening experiment. in a previous study conducted by doman and co-authors [ ] , only molecules or . % revealed as protein tyrosine phosphatase- b inhibitors (ic < µm) by a hts of approximately , compounds. on the other hand, of molecules suggested by molecular docking, or . % were found to be active. thus, dockingbased virtual screening enriched the hit rate by almost , -fold over random screening. one should not forget, however, that additional molecular characteristics not reflected by pharmacophore models (physicochemical properties relevant for adme and toxicological properties) must be taken into account when deciding upon which compounds should be further developed [ ] . a rapid identification and elimination of compounds with unsuitable physicochemical and pharmacokinetic properties is a pivotal step in the early drug discovery process [ , ] . they can be evaluated traditionally or by high throughput screening, which are discussed in detail by avdeef and testa [ ] . this must be considered for synthetics as well as nps, though studies revealed secondary metabolites not only high scaffold diversity; biosynthesized molecules also show structural and spatial characteristics that are closer to drug leads than those of synthetic molecules [ , ] . typically, nps include more chiral centers and their stereochemical architecture is much more complex than that of synthetic molecules. furthermore, they usually contain more carbons, hydrogen and oxygen, however, less nitrogen and other atoms compared to synthetics. surprisingly, nps often show a molecular weight higher than da combined with a high polarity [ ] , which is in clear contrast to lipinski's rule of five [ ] . nevertheless only about % of nps contain two or more violations of lipinski's rules [ ] . in summary, natural chemistry can be seen as highly diverse scaffolds endowed with potential drugable pharmacophores. structure-based pharmacophore model an inevitable prerequisite for generating a structure-based model is the knowledge about the ligand-target interaction [ ] including the availability of the d structure of the target either by x-ray crystallography or nmr or constructed on the basis of the structure of homologous proteins. a unique platform containing d coordinates of experimentally solved protein structures is the brookhaven protein data bank (pdb [ ] ). a crystalline complex with a ligand bound to a protein's active site is the best requirement to start the construction of a structure-based d model. in this case, one may profit from the exact information of the ligand's bioactive conformation which is preserved in the binding site of the crystalline complex. the building of a structure-based pharmacophore is depicted in a step by step way in figure . a new software tool has recently been described for the successful generation of such chemical features-based models: the software ligand-scout [ ] is a program for ligand interpretation and data mining in the pdb. the performance of this program allows the detection of relevant interaction points between ligand and protein. the binding mode of the ligand in the active site of a protein can be visualized in a sophisticated way. ligandscout's algorithms perform a stepwise interpretation of the ligand molecules: planar ring detection, assignment of functional group patterns, determination of the hybridization state and finally the assignment of kekulé pattern. the interpretation of the ligand molecules is the basis for the next step, an automated generation of pharmacophore models, derived from the data provided by a crystalline complex of the pdb. an automatic detection and classification of protein-ligand interactions into hydrogen bonds, charge transfer, and lipophilic regions leads to a collection of chemical features in a pharmacophore model. the graphical user-interface can provide an integrated view of protein, ligand, pharmacophore model, and interaction lines. in a previously published study, ligandscout was used for the detection and interpretation of crucial interaction patterns between ligands and the factor xa protein structure [ ] . in a second step, the program catalyst, a state of the art virtual screening platform, was used for rapid virtual screening of multiconformational d structure databases. the information for the pharmacophore pattern (i.e., d coordinates of interaction points) was obtained by the interpretation of ligandscout pharmacophore definitions and resulted in specific interaction models that were able to map the ligand in their bioactive conformation and to retrieve selectively a % fraction of the known factor xa inhibitors within a small subset of the large derwent world drug index library. a further application of the ligandscout pharmacophore definitions covers the rationalized search for angiotensin converting enzyme (ace)- inhibitors by virtual screening of approximately . million compounds from various commercial databases [ ] . hit reduction and selection was achieved using a five feature hypothesis based on a recently resolved inhibitor-bound ace crystal structure. seventeen virtual hits were selected for their experimental validation in a bioassay; the concept was confirmed since all of them were revealed as ace- inhibitors. barreca and co-authors developed a d structure-based pharmacophore model with ligandscout for the discovery of new scaffolds acting as hiv- non-nucleoside reverse transcriptase inhibitors by virtual screening of large chemical databases. six virtual hits were finally selected for determination of their inhibitory effects. those belonging to the new scaffold class of the quinolin- ( h)-one family exhibited reverse transcriptase inhibitory activity at sub-micromolar concentrations [ ] . in a recently published work, schuster et al. presented a so-called cytochrome p profiler [ ] . several structure-based (generated with ligandscout) and ligand-based pharmacophore models (using cata-lyst) for substrates and inhibitors of five cytochrome p isoenzymes ( a , p c , p c , p d , and p a ) were created and validated by the authors' group. their results showed that the models were suitable for fast pharmacokinetic profiling of large drug-like databases. in this context the parallel screening is of particular interest. whereas in usual virtual screening cycles interactions of thousands or even millions of d database entries are browsed against one pharmacophore model, it is contrary in the case of parallel screening; low-energetic conformers of one structure are screened for their potential interactions against numerous models. the basics of parallel screening have just recently been presented by steindl and co-authors [ , ] . furthermore, the authors exemplified this strategy for the activity profiling using a set of hiv protease pharmacophore models [ ] . this in silico concept is of particular interest to virtually scrutinize drug candidates for their preliminary activity profiling relevant to putative side effects and toxicity [ ] . according to the obtained interactions to virtually screened antitargets (e.g., herg, sigma- , sigma- , alpha- a, alpha- b, alpha- d, alpha- a, alpha- b, alpha- c, d l, d , d . , -ht a , -ht a , -ht , h , i , a a, a b, cytochrome p ) a first insight to potentially risky affinities is provided before time and cost intensive toxicological studies are performed. the virtual screening approach using a structure-based pharmacophore model has revealed some first application examples in np research: niko-lovska-coleska and co-authors successfully pursued this in silico strategy in the area of x-linked inhibitors of apoptosis (xiap) [ ] . a high resolution d structure of the xiap bir domain complexed with the n-terminal end of the smac/diablo protein [ ] , which is an endogenous ligand of the respective xiap binding pocket, was used as the starting point to virtually screen an in-house d-np database. embelin ( ) from the japanese ardisia herb emerged as virtual small molecule weight hit, which was found to be a fairly potent inhibitor of xiap using a fluorescence polarization binding assay. in our group, we previously focused on acetylcholinesterase (ache) [ ] ; according to the cholinergic hypothesis of the pathogenesis of alzheimer's disease, inhibitors of the ache are successfully used as therapeutic strategy. based on the co-crystal structure of ache with its ligand galanthamine, a structure-based pharmacophore model was generated and used for an in silico screening of a multi-conformational database consisting of more than , nps. from the obtained hit list, promising, virtually active candidates were selected, namely scopoletin ( ) and its glucoside scopolin ( ) . their ache inhibitory effect was first verified from the crude extract of scopolia carniolica roots using a bioautographic tlc assay. the isolated coumarins showed a significant and dose-dependent inhibition of the ache in the microplate enzyme assay as well as in the in vivo test. the i.c.v. application of both coumarins on rats resulted in a long-lasting, pronounced and -in case of the glucoside -even in a two-fold higher increase of the neurotransmitter's concentration than the one caused by the positive control galanthamine. ligand-based pharmacophore model very often, however, lead discovery projects have reached a well-advanced stage before detailed structural data on the protein target has become available, even though it is well recognized that modern methods of molecular biology together with biophysics and computational approaches enhance the likelihood of successfully obtaining detailed atomic structure information. a possible consequence is that often scientists identify and develop novel compounds for a target using preliminary structure-activity information, together with theoretical models of interaction. only responses that are consistent with the working hypotheses contribute to an evolution of the used models. within this framework, the chemical feature-based pharmacophore approach has proven to be successful [ ] allowing the perception and understanding of key interactions between a receptor and a ligand on a generalized level. a function-based pharmacophore represents the common ensemble of steric and electrostatic features of different compounds which are necessary for their interaction with a specific biological target structure (fig. ) . such pharmacophore models together with large d structure databases originating either from in-house compound collections, from commercial vendors, or from natural products databases have proven to be extremely useful in silico screening experiments. when using ligand-based pharmacophore models as screening filters instead of protein d structures, affinity estimation is only based on geometric fit of compound atoms or groups to features of the model. in these cases, the values calculated are often far away from reality, however, still are useful for filtering possible hits from non-binding molecules. additionally, in pharmacophore fitting procedures, calculation demands are considerably lower than in docking algorithms allowing the number of compounds to be processed in the same time to be by far higher than even in high throughput docking. since in most of the studies no experimental information on either the biological conformation of the ligand or the target protein are currently available, the ligand-based chemical feature pharmacophore approach can provide essential information for medicinal chemists. several successful applications within this subject have been performed using the cata-lyst program, one of the leading software packages in chemical featurebased pharmacophore modeling. schuster and co-workers succeeded in the identification of -hydroxysteroid dehydrogenase type inhibitors applying a common feature-based pharmacophore model for their virtual screening filtering experiments [ ] . similarly, the authors preceded by suggesting compounds with a proposed inhibition to the cytochrome p isoenzyme [ ] . several reviews covering successful applications of such feature-based methods have been published by kurogi et al. [ ] , by krovat et al. [ ] and by güner et al. [ ] . they outline the theoretical background and describe several significant studies including d database search strategies. in the field of nps only a very limited number of studies report from the rationalized access to bioactive compounds via ligand-based virtual screening. for example, this method was pursued for the discovery of inhibitors of the cop signalosome (cns) associated kinases ck and pkd [ ] . using nps curcumin and emodin as lead structures, a virtual screening of an in-house database was carried out. among the virtual hits seven nps, e.g., anthraquinone ( ) and piceatannol ( ), were found to significantly induce apoptosis by inhibition of the csn-associated kinases using in vitro and cell culture experiments. a further study has demonstrated the power of the ligand-based approach applied to pharmacophore modeling of sigma- ligands [ ] . therein, some reliable pharmacophore models could be extracted solely from ligand structure information. compounds with potent affinities to the sigma- receptor known from literature were structurally aligned to derive distinct common features. their d arrangement in combination with a spatial restriction was then used for the generation of a pharmacophore model, which was able to retrieve compounds with high affinity values, among them also nps, like solanidine ( ). further ligand-based approaches use various forms of discriminant analysis, e.g., artificial neural network simulations. they are based on collections of mathematical models that are interconnected and organized in different layers. they are analogous to an adaptive human learning process and usually trained with learning sets applying one or more molecular descriptors in order to form clusters that enable to distinguish between different objects and their properties. the resulting models are then applied to make predictions on test sets, until the validated models may be used to derive a qsar of chemically related structures or to mine larger datasets. one may distinguish between supervised and unsupervised (e.g., kohonen network) learning methods as discussed in detail by zupan and gasteiger [ ] . a successful application example within the field of nps was published by wagner et al. [ ] . the authors used a dataset of structurally diverse sesquiterpene lactones with known nf-b inhibitory activity to derive a qsar. by the application of multiple d structure representations as descriptors, a single model was achieved which provided detailed information on the structural influence of the investigated biological activity. sangma and co-authors pursued a combination of two approaches to predict new inhibitors of the hiv- rt and hiv- pr from a np database comprising metabolites from thai medicinal plants. after a high throughput docking of the molecules into the target enzymes, self-organizing maps were generated to reduce the number of promising candidates to be tested [ ] . a set of different in silico methodologies was previously applied by cherkasov and co-authors to aid in the discovery of natural non-steroidal ligands for human sex hormone binding globulin [ ] . therein, a rigorously cross-validated neural network based qsar model identified prospective compounds from a structure collection of , commercial natural substances. this stringent qsar ranking was combined with docking studies and pharmacophore-aided database search. the integrated computational methods resulted in a convincing predictive tool which identified a set of structurally diverse nps, of which every fourth compound was able to inhibit the target protein in a micromolar range. compounds of arbitrary structural diversity and with known activity against a target are particularly suitable not only for generating a ligand-based pharmacophore model (as described before), but also for structure similarity studies using a decision tree. the object is to find as good a distinction as possible on the basis of a set of molecular descriptors, which identify molecular features shared by different subsets of active compounds and accordingly filter out compounds within the dataset in which these combinations are lacking. using not only a simple logical description of one model, but an ensemble of decision trees tend to be the preferred option, since the consensus voting among trees give the approach higher predictive accuracy. one form of multiple decision trees well performed to virtually screen large d databases is random forest [ ] . this chemoinformatic method was recently applied in a theoretical work performed by ehrman and co-workers to predict ligands of multiple targets, like cyclooxygenase (cox), lipoxygenase (lox), aldose reductase, hiv- enzymes etc., from a large dataset of chinese herbs [ ] . the advent of structure databases has provided a basis for the development and feasibility of automatic methods for the search of new lead structures. conceptually, all the virtual screening concepts presented above have their origins in synthetic chemistry. their application, however, is just as well adaptable to nps' chemistry. prior to the in silico filtering experiment, a d structure database requires an efficient generation of reasonable, energetically minimized conformations assumed to meet approximately those conformations that might be of biological relevance [ ] . the underlying algorithms for d structure generation and conformation analysis are implemented in commercial software tools, e.g., in corina [ ] or the catalyst program (catalyst, available from accelrys inc., san diego, ca, usa; www.accelrys.com). in the field of nps the virtual screening application is mainly restricted due to the lack of searchable resources for structurally well defined natural compounds. in general, molecular databases with free access on the internet may comprise a high number of molecules, e.g., chembank (> , , , http://chembank.broad.harvard.edu) or pubchem (> , , ; http:// pubchem.ncbi.nlm.nih.gov); however, information about the number of contained natural molecules is rarely available. the library of the national cancer institute (nci) stores structural information of more than half a million compounds from both synthetic and natural origin that have been collected and tested by the nci since . about half of the synthetic compounds, which represent the large majority of the samples, may be used for free and are thus in the public domain. it is called the 'open nci database' (development therapeutics program nci/nih; http://dtp.nci. nih.gov/webdata.html). an interesting property prediction approach to the more than , compounds contained in this open database was provided by poroikov and co-authors [ ] . by use of the program pass (prediction of activity spectra for substances) an in silico tool for complex searches of different types of activities is provided; e.g., in the case of antineoplastic effects, the authors could demonstrate a substantial dataset enrichment over random selection by the use of pass-predicted probabilities. libraries covering a major part of entities from nature (at least some thousands) or consisting of structural information exclusively from natural origin are not free of charge, e.g., the traditional chinese medicinal database (tcmd; http://tcm d.com/services.htm [ ] ) or the dictionary of natural product database launched by chapman & hall (dnp; http:// www.chemnetbase.com) providing chemical and physical data on some , natural compounds gathered from the world's chemical literature. an excellent survey of public and commercial databases focusing on nps has recently been published by füllbeck and co-authors [ ] . the authors provide information as to storing characteristics of the databases, web-addresses, total number of compounds and -if given -number of natural ones. in addition, a selection of suppliers and manufacturers of natural compounds and extracts are given. a new database is introduced by the authors (super natural database [ ] ) storing information on available nps, thus allowing the selection of compounds that can be purchased. moreover a number of non-commercial in-house created databases have been used from different groups for their virtual screening studies on nps, e.g., a marine natural product database (mndp [ ] ), a natural product database (npd [ , ] ), a database based on the antique source 'de materia medica' by pedanius dioscurides (dios [ ] ), or a database fed with metabolites of ethnopharmacologically known plants [ ] . recently, ehrman and co-authors generated a d multiconformational database of chinese herbal constituents containing a total of more than , compounds from chinese herbs [ ] . integrated strategies for the discovery of bioactive nps the more or less accurate prediction of potentially active compounds by virtual screening has doubtlessly rationalized the early drug discovery process. these filtering experiments definitely assist in saving costly and time-intensive pharmacological assays, since the pool of predicted ligands (i.e., virtual hits) is usually drastically reduced compared to the initial amount of compounds (i.e., d-database). demands to be made on a good model are selectivity and target-specificity on the one hand, but it is also seminal not to lose too many valuable ligands during the filtering process. how far all of these demands can be fulfilled strongly depends on the quality of information used as the basis for generating the model and the algorithm underlying the virtual screening process. in medicinal chemistry, an activity prediction of - % is usually regarded as satisfying enrichment. in np research, however, this percentage may be too scarce. it is rarely found that a large set of natural compounds can be acquired so easily. only a minority of secondary metabolites are commercially available -usually at incredibly high prices. thus, extraordinary charges and efforts are typically necessary before a virtual hit from nature is available for pharmacological testing. this process embraces the acquisition of the natural material described to contain the desired metabolite to the point of phytochemical analysis and isolation. though advanced separation techniques, analytical instrumentation, and innovative tools for structure identification are at the phytochemists' disposal, it remains a complex and sometimes uncertain endeavor. this is why the results obtained from in silico predictions may nevertheless be too vague for a np researcher. methods are asked to further increase the probability of following the straight tip. there is the possibility to hyphenate sundry computational approaches, e.g., pharmacophore-based virtual screening combined with docking of the resulting virtual hits, or to consider only the consensus hits applying two or more screening concepts. nevertheless all these strate-gies remain virtual and speculative. the combination of two approaches, which are completely divergent in nature, like a computational and an empirical one may however offer a more deepened access to bioactive nps and may sometimes help to avoid a distorted view. thus, the computer-aided molecular selection is best combined with further discovery methods, labeled as integrated approaches, to increase the probability in finding a real hit. in traditional pharmacognosy there are some well established methods in targeting this aim starting from a holistic level. these include (i) hints from ethnopharmacology, (ii) phenomenological effects registered after application of naturally derived preparations, (iii) guidance of chemotaxonomy, (iv) phylogenetic selection criteria, or (v) simply information gathered from a high/medium throughput screening of extracts. in a recently published review from our group, different strategies in the field of nps have been presented with special emphasis on anti-inflammatory nps interacting within the arachidonic cascade [ ] . integrated computational strategies for the discovery of natural bioactive compounds have been introduced elsewhere concentrating on their scope, strengths and limits [ ] . some strategies and examples from literature combining virtual screening approaches and classical methods for activity exploitation are outlined below. as soon as a sensitive data-mining tool has been developed and has proved itself by more or less selectively finding the active compounds within a test set, it can be applied for screening a d multi-conformational database. the subsequent procedure consists of the evaluation of the virtual hits considering physicochemical properties, toxicity and pharmacokinetics. in this stage additional virtual filtering tools for the profiling of adme parameters [ ] might have an invaluable impact to aid a refined selection of compounds. then, a sensible choice of natural materials known to contain the focused metabolites and worth investigating in detail is a crucial step. it requires a comprehensive study in literature considering the hit content in the natural source, its availability and maybe hints from ethnopharmacology. once some natural materials are selected, it is advisable to perform a preliminary assay with those crude extracts and fractions assumed to contain the promising metabolite/s. though being aware that in case of small hit amounts present in the natural material the activity may be overseen. therefore, it is advisable to first identify the promising constituent and to possibly enrich it in the extract to be tested. those samples that scored well are then subjected to phytochemical investigations. in this way, the tricky selection of the natural material turns from a bold venture to a more rationalized endeavor. as soon as a promising (i.e., active) starting material is found, there are in principle two possible strategies to embark on: the first one relies more on the in silico approach and focuses directly on . strategy a for the discovery of bioactive nps using an integrated virtual screening approach the identification of the initially obtained virtual hits within the natural matrix applying analytical tools, like lc-ms or lc-nmr, gc-ms etc. in a straightforward manner the hits are isolated using different chromatographic separation steps. after structural confirmation the compounds are then tested to hopefully verify the predicted activities. this strategy is very goal-oriented, since only pharmacological assays for the finally isolated virtual hits are necessary. on the other side, one may run the risk of ignoring further active nps not necessarily fitting into the pharmacophore model. the second strategy focuses on a bioactivity-guided fractionation irrespective of the virtual hits used for the selection of the starting material. following the concept, the finally isolated active ingredients should correspond to the predicted virtual hits. this approach is usually associated with higher phytochemical efforts and costs, because it requires an iterative testing of all arising fractions and sub-fractions. for the evaluation of all the bioactive constituents in detail and for the discovery of possibly unknown metabolites this procedure is however indispensable. the decision, which of the presented ways is the more appropriate for the investigation at hand, strongly depends on the reliability and selectivity of the used pharmacophore model, and the costliness of the used assay. the strategy schematized in figure was recently applied to a medicinal plant with anti-inflammatory potential known from ethnopharmacological sources [ ] . from the pharmacophore based virtual screening filtering experiment a number of secondary metabolites known from the mulberry tree complied with all the models' requirements, thus revealed as virtual hits. indeed, in vitro tests attested extracts of morus root bark a distinct cox inhibitory potential. the objective was to find the active principles from this plant material applying both different methods for their discovery. first, the computer-aided approach was used to identify the virtually active compounds able to interact with the pharmacophore models for cox- and - . second, the bioactivity-guided fractionation was conducted for the isolation of the cox-inhibiting constituents. this resulted in the isolation of nine compounds belonging to the chemical classes of sanggenons and moracins. in the enzyme assay, all the isolates showed moderate to potent inhibitory effects on cox- and - . when comparing the hits of the virtual screening with the experimental data, a good correlation between predictions provided by the computer assisted method and in vitro data could be obtained in the case of the isolated sanggenons (e.g., sanggenon c; ). however, this agreement could not be achieved with the moracins (e.g., moracin m; ). in any case the virtual screening was particularly helpful for the decision regarding which plant material is worth extensive study. furthermore, the disclosed interactions of the sanggenons with the pharmacophore model -miming the binding site of the target -provided us with some essential information about the molecular requirements of cox-ligands. a different integrated procedure is schematized in figure . applying this approach, the pre-selection of the natural material is not guided by virtual prediction; but a number of extracts is roughly screened with a bioassay to identify the active ones. a similar strategy is to collect information about the traditional application of natural preparations in the field of the focused pharmacological target. a d database is then generated consisting of all the metabolites known from literature to be included in that extract/s that came off well. likewise, ethnopharmacological knowledge about useful preparations from nature may guide the selection of nps. the resulting biased database is virtually screened with an established pharmacophore model of the aiming target. the impact of ethnopharmacology has been analyzed in a previous study from our group; there we investigated the statistical evidence considering hints from folk medicine for the discovery of anti-inflammatory nps utilizing pharmacophore-based virtual screening techniques [ ] . cox- and - were used as preferential targets, since they are key enzymes in the inflammation process. dioscorides' de materia medica, which was written in the st century ad, was used as the ethno-pharmacological source. secondary metabolites of those medicinal plants, which dioscorides described as active against fever, rheumatism, pain and pus were stored in a multiconformational d database. this was virtually screened against the validated pharmacophore models. the resulted hit list was analyzed and compared with those obtained by screening unbiased databases of natural as well as of synthetic origin. the effectiveness of an ethnopharmacological approach could be statistically demonstrated by obtaining a significantly higher hit rate compared to the hit rates of the unbiased natural as well as synthetic databases. following this strategy the putative hits may then be identified by modern analytical tools like lc-ms or lc-nmr to isolate them from the natural matrix in a target-oriented way for pharmacological testing. this approach is especially helpful for intricate pharmacological assays, which would turn a bioguided fractionation into an unrealistic endeavor. a combination of an ethnopharmacologically based pre-selection of plant material and a computational approach was reported by bernard and co-workers, who used this strategy to rationalize a phytochemical lead discovery [ ] . starting with an in vitro screening on phospholipase a performed with traditionally used anti-inflammatory plant extracts, a focused structural database was generated and virtually screened on an established ligand-based pharmacophore model for human non-pancreatic phospholipase a . the combination of experimental data with database exploitation and molecular modeling resulted in the efficient identification of betulin ( ) and betulinic acid ( ) as extract ingredients with distinct anti-inflammatory in vitro effects. the combination of the two different, but complementary strategies consisting of in vitro screens and in silico assessment has recently been described by van de waterbeemd [ ] . he labeled this method as 'in combo' approach and used it for the straight forward access of various adme properties. the application of the 'in combo' approach for the discovery of nps has recently been tested in our group by the search of natural acetylcholinesterase inhibitors [ ] . in a medium-sized throughput screening about plant extracts were investigated using an acetylcholinesterase enzyme test. from the sample showing the best inhibitory activity, all the known secondary metabolites were fed into a small d multiconformational database and subsequently subjected to a virtual screening on a generated pharmacophore model. the efficacy of this procedure could be confirmed by the isolation of the obtained virtual hits, i.e., -deoxylactucin ( ) and lactucopicrine ( ) . they showed a significant and dose-dependent inhibitory effect in the enzyme assay. methods and expectations of this integrated virtual screening concept have previously been discussed in detail by j. bajorath [ , ] with the author's final statement that 'a meaningful integration of virtual and experimental screening programs, together with lessons to be learned from structural genomics, holds great promise for more rapid and consistent identification of high quality hits or leads across divers classes of therapeutic targets'. though this conclusion was not particularly coined to nps, it comes especially true in the rich world of secondary metabolites. further hybridized computational strategies are quite sensible to get an improved understanding of ligand-target interactions. in the following two examples docking protocols helped enlighten the molecular mechanism of bioactive natural compounds. chimenti and co-authors isolated quercetin ( ) among other secondary metabolites from the mediterra-nean shrub hypericum hircinum and identified this flavonol as selective inhibitor of the mao-a with an activity in the nanomolar range (ic = nm) [ ] . for a more comprehensive understanding of the underlying molecular selectivity, conformation analysis and docking simulations were performed using the most recent crystallographic structures of both human isoforms mao-a and mao-b. this enabled the authors to identify the most important interactions between the residues and the cofactor within the enzymatic cleft. the estimated free energies of complexation were in agreement with experimental data and confirmed the distinct preference for the mao-a cleft with more intermolecular hydrogen bonds and -interactions. the goal of a recent in-house study was to rationalize the binding interaction of the protoalkaloid taspine ( ) within acetylcholinesterase. taspine was isolated in a bioactivity-guided manner from magnolia x soulangiana and revealed as selective inhibitor of acetylcholinesterase with a significantly higher effect than the positive control galanthamine ( ; ic = . ± . µm). extensive molecular docking studies were performed with human and torpedo californica-acetylcholinesterase employing gold software (vers. . ; www.ccdc.cam.ac.uk/products/life_sciences/gold/). the results suggested taspine to bind in an alternative binding orientation than galanthamine [ ] . while this is located in close vicinity to the catalytic amino acid triad, taspine was found to be mainly stabilized by sandwichlike -stacking interactions in the aromatic gorge of the enzyme. in both case studies the active natural compound was already identified. thus, the in silico tool was not employed for data mining, but to elicit the putative binding mode in the macromolecular target. docking simulations turned out to be excellent tools to get an idea about the assumed molecular ligand target interaction. another approach capitalizes exactly on the just-mentioned observation that computational predictions may reveal an idea about the interaction to a specific target's binding site. thus, it is possible to start with one compound of unknown activity and to mine it against a number of structurally disclosed targets in terms of elaborated pharmacophore models (fig. ) , i.e., parallel in silico screening (see previous). as soon as the orphaned molecule is able to comply with all the requirements and restrictions imposed by any model, it can be assessed as rational hint. consequently, the focused compound will be subjected to a pharmacological testing on the predicted target/s. in this way, the parallel screening is not only helpful to estimate the interactions of a drug candidate with diverse antitargets; or to canvass its interactions to related targets as is performed for an activity profiling. in this approach, the parallel screening is a computational tool for target fishing to get a rational idea about any potential target interaction and to prioritize a few targets for experimental evaluation by applying simple ligand-based or target-based queries. the potential of virtual screening of target libraries was recently discussed by didier rognan [ ] . in his group a structure-based method for target screening was pursued applying inverse docking [ ] . the authors used , structurally well-defined pdb entries to build a d protein library. the virtual screening of this protein library with four unrelated ligands was suitable for recovering the true targets of specific ligands and may as well be used for virtual selectivity profiling of any ligand of interest. nettles and co-authors performed the target fishing approach using a ligand-based procedure [ ] . the potential of both d and d chemical descriptors were compared as tools for predicting the biological targets of ligand probes on the basis of their similarity to reference molecules in a chemical database comprising , biologically annotated compounds. the ligand-based d tool fepops (feature point pharmacophores), which provides pharmacophoric alignment of the small molecules' chemical features consistent with those seen in experimental ligand/receptor complexes, was used for scaffold jumping within the screened database. using atp the authors were able to identify the natural compound balanol ( ) as ligand of cdk . the highest effort applying this strategy is the availability of a representative amount of reliable pharmacophore models covering a wide range of relevant targets (fig. ) . thus, it may be of particular interest to focus on one pathological syndrome, e.g., obesity, inflammation, apoptosis etc., where a phenomenological activity of a np is already evident. applying this approach the disposition of pharmacophore models for targets involved in the respective pathological complex is easier to manage. in this way, a goal-oriented strategy may help to bridge the gap between a phenomenological effect and the underlying molecular mode of action. pertaining to the drug discovery from nature we are facing two facts: (i) statistics show that the myriad of structurally diverse natural compounds are the most favored source of new drugs for clinical use [ ] ; (ii) the drug discovery process has moved towards more rational concepts based on the increasing understanding of the molecular principles of protein-ligand interactions. spurred on by economic interest fundamental advances have been made in research applying data mining strategies, like virtual screening. though being aware of both potentials, their combined benefit could only rudimentary be savored. only limited attempts applying innovative in silico tools in np research are pursued so far, because the search for bioactive compounds is a complex and multidisciplinary challenge. thus, a sensible adaptation of computational strategies is in demand to profit in an economic way from the unique chemical and biological diversity associated with nps. virtual screening techniques, however, must not be used exclusively as activity-predicting tools, since the results provide merely an indication for a putative activity: it is only by the creation of interfaces between computational tools and well-established methods from pharmacognosy that a reasonable standard of success can be achieved. the search for the most effective strategy is best performed by a drug discovery process that involves the exploitation of all the information which can be gathered from bioactivity-guided fractionation, on-line analytical activity profiling, ethnopharmacological screening, chemoinformatics, virtual and in vitro screening studies. in the first instance it behoves modern pharmacognosy to skillfully exploit knowledge from all these fields because it is of paramount importance to sift through the enormous wealth of nps. examples underlining the impact of virtual screening on the identification of active nps have been presented in this survey. though the full potential in this field is by far untapped, these early results indicate that the integrated virtual screening approaches are target-oriented and trendsetting strategies. however, as any computer-based technique, the successful use of virtual screening will entirely depend on the way it is utilized and the quality of its underlying experimental data. the advantages implemented to a virtual screening cycle compared to a conventional in vitro screening are obvious: (i) higher capacity, (ii) no need for isolated compounds, (iii) less experimental efforts for testing; (iv) theoretically, interactions of all known nps to all structurally defined targets can be calculated and predicted, (v) the quality of hit compounds can be increased by additional drug-like filters and virtually restricted adme properties; thus diminishing failures in the early drug development. nevertheless experimental investigations are seminal, but can be focused in a more effective fashion. a cautious handling of virtual hits together with lessons learned from traditional pharmacognosy seems to be crucial for a successful exploitation of treasures from nature. in this area, virtual screening will most likely play an essential role in accelerating the early stage of drug discovery by efficiently digging out lead compounds from nature. rediscovering the sweet spot in drug discovery strategic trends in the drug industry screening for drug discovery: the leading question the role of natural products in a modern drug discovery program natural products as sources of new drugs over the last years strategies for discovering drugs from previously unexplored natural products lessons from natural molecules the role of pharmacognosy in modern medicine and pharmacy rediscovery of known natural compounds: nuisance or goldmine strasburger -lehrbuch der botanik, . auflage, spektrum akademischer verlag plant-derived natural products in drug discovery and development: an overview natural products in drug discovery and development statistical investigation into the structural complementarity of natural products and synthetic compounds initial sequencing and analysis of the human genome recent developments in computational proteomics natural products in drug discovery -concepts and approaches for tracking bioactivity targeted approaches in natural product lead discovery mining information from databases for drug discovery neural networks as data mining tools in drug design chemoinformatics and drug discovery virtual screening in drug discovery the impact of informatics and computational chemistry on synthesis and screening virtual screening: an effective tool for lead structure discovery? virtual screening for bioactive molecules recent advances in docking and scoring high-throughput docking for lead generation virtual screening and fast automated docking methods lead discovery using molecular docking detailed analysis of scoring functions for virtual screening consensus scoring: a method for obtaining improved hit rates from docking databases of three-dimensional structures into proteins how does consensus scoring work for virtual library screening? an idealized computer experiment sars-cov protease inhibitors design using virtual screening method from natural products libraries sabadinine: a potential nonpeptide anti-severe acute-respiratory-syndrome agent identified using structure-aided design identification of ellagic acid as potent inhibitor of protein kinase ck : a successful example of a virtual screening application structure-based virtual screening for plant-based er -selective ligands as potential preventative therapy against age-related neuro-degenerative diseases structure-based discovery of potassium channel blockers from natural products virtual screening and electrophysiological assay testing pharmacophore modelling: applications in drug discovery molecular docking and high-throughput screening for novel inhibitors of protein tyrosine phosphatase- b rational selection of structurally diverse natural product scaffolds with favorable adme properties for drug discovery drugs? drug research? advances in drug research? musings of a medicinal chemist pharmacokinetics and metabolism in drug design physicochemical profiling in drug research: a brief survey of the state-of-the-art of experimental techniques property distributions: differences between drugs, natural products, and molecules from combinatorial chemistry distinguishing between natural products and synthetic molecules by descriptor shannon entropy analysis and binary qsar calculations experimental and computational approaches to estimate solubility and permeability in drug discovery and development settings structural biology and drug discovery the protein data bank ligandscout: d pharmacophores derived from proteinbound ligands and their use as virtual screening filters pharmacophore identification, in silico screening, and virtual library design for inhibitors of the human factor xa structure-based pharmacophore design and virtual screening for novel angiotensin converting enzyme inhibitors structure-based pharmacophore identification of new chemical scaffolds as non-nucleoside reverse transcriptase inhibitors development and validation of an in silico p profiler based on pharmacophore models parallel screening: a novel concept in pharmacophore modelling and virtual screening high throughput structure-based pharmacophore modeling as a basis for successful parallel virtual screening parallel screening and activity profiling with hiv protease inhibitor pharmacophore models discovery of embelin as a cell-permeable, small-molecular weight inhibitor of xiap through structure-based computational screening of a traditional herbal medicine three-dimensional structure database structural basis of iap recognition by smac/diablo acetylcholinesterase inhibitory activity of scopolin and scopoletin discovered by virtual screening of natural products chemical feature-based pharmacophores and virtual library screening for discovery of new leads the discovery of new -hydroxysteroid dehydrogenase type inhibitors by common feature pharmacophore modeling and virtual screening pharmacophore modeling and in silico screening for new p (aromatase) inhibitors pharmacophore modeling and three-dimensional database searching for drug design using catalyst pharmacophore modeling and three dimensional database searching for drug design using catalyst: recent advances novel curcumin-and emodin-related compounds identified by in silico d/ d conformer screening induce apoptosis in tumor cells feature based pharmacophore models for sigma receptor, erg and ebp neural networks in chemistry and drug design development of a structural model for nf-b inhibition of sesquiterpene lactones using self-organizing neural networks virtual screening for anti-hiv- rt and anti-hiv- pr inhibitors from the thai medicinal plants database: a combined docking with neural networks approach successful in silico discovery of novel nonsteroidal ligands for human sex hormone binding globulin random forest: a classification and regression tool for compound classification and qsar modeling virtual screening of chinese herbs with random forest comparative analysis of proteinbound ligand conformations with respect to catalyst's conformational space subsampling algorithms pass biological activity predictions in the enhanced open nci database browser a traditional chinese medicine plant-compound database aid its application for searching natural products: sources and databases supernatural: a searchable database of available natural compounds a marine natural product database combining ethnopharmacology and virtual screening for lead structure discovery: cox-inhibitors as application example computer-aided molecular selection and design of natural bioactive molecules phytochemical databases of chinese herbal constituents and bioactive plant compounds with known target specifities strategies for efficient lead structure discovery from natural products integrated in silico tools to exploit the natural products' bioactivity admet in silico modelling: towards prediction paradise? discovering cox-inhibiting constituents of morus root bark: activity-guided versus computer-aided methods ethnopharmacology and bioinformatic combination for leads discovery: application to phospholipase a inhibitors which in vitro screens guide the prediction of oral absorption and volume of distribution? application of the in combo screening approach for the discovery of non-alkaloid acetylcholinesterase inhibitors from cichorium intybus virtual screening in drug discovery: methods, expectations and reality integration of virtual and high-throughput screening quercetin as the active principle of hypericum hircinum exerts a selective inhibitory activity against mao-a: extraction, biological analysis, and computational study taspine: bioactivity-guided isolation and molecular ligand-target insight of a potent acetylcholinesterase inhibitor from magnolia x soulangiana in silico screening of the protein structure repertoire and of protein families recovering the true targets of specific ligands by virtual screening of the protein data bank bridging chemical and biological space: "target fishing" using d and d molecular descriptors key: cord- -n jq g authors: riva, giuseppe title: virtual reality in clinical psychology date: - - journal: reference module in neuroscience and biobehavioral psychology doi: . /b - - - - . - sha: doc_id: cord_uid: n jq g from a technological viewpoint, virtual reality (vr) is a set of fancy technologies: a helmet, trackers, and a d visualizing system. however, from a psychological viewpoint, vr is simultaneously a simulative, a cognitive, and an embodied technology. these features make vr the perfect tool for experiential assessment and learning with great clinical potential. this potential is already supported by clinical outcomes. two recent meta-reviews assessing more than systematic reviews and meta-analyses support its use in anxiety disorders, pain management, and eating and weight disorders, with long-term effects that generalize to the real world. recent studies have also provided preliminary support for the use of vr in the assessment and treatment of psychosis, addictions, and autism. this chapter examines the clinical potential of virtual reality (vr) in the assessment and treatment of mental health diseases. first, it explores the technologies behind the vr experience. in particular, the second paragraph describes the different hardware and software componentsdinput devices, output devices, and the simulated scenario (i.e., the virtual environment)drequired for a vr experience, as well as the difference between immersive and non-immersive vr and the evolution of vr technologies. the third paragraph presents vr as an advanced form of reality simulation that has many similarities with the functioning of the brain. as suggested by the "predictive coding" paradigm, the brain actively creates an internal model (simulation) of the body and the space around it, which it uses to make predictions about the expected sensory input and to minimize the number of prediction errors (or "surprise"). in this view, the vr experience tries to mimic the brain model as much as possibledthe more similar the vr model is to the brain model, the more the individual feels present in the vr worlddmaking it the perfect tool for experiential learning. the fourth paragraph suggests that vr is able to fool the predictive coding mechanisms that regulate the experience of the body, allowing it to make people feel "real" within a virtual environment. in other words, vr can offer new ways to structure, augment, and/or replace the experience of the body for clinical goals. it may also offer new embodied ways to assess the functioning of the brain by directly targeting the processes behind real-world behaviors. the final paragraph presents and discusses different clinical applications of vr in the mental health domain. in line with the results of two recent meta-reviews assessing more than systematic reviews and meta-analyses exploring the current use of vr in clinical psychology (riva et al., , b , existing research supports the clinical use of vr in the assessment and treatment of anxiety disorders, pain management, and eating and weight disorders, with long-term effects that generalize to the real world. recent studies have also provided preliminary support for the use of vr in the assessment and treatment of psychosis, addictions, and autism. for many clinicians, virtual reality (vr) is primarily a set of fancy technologies: a computer or mobile device with a graphics card capable of interactive d visualization, controllers, and a head-mounted display embedding one or more position trackers. the trackers sense the position and orientation of the user and communicate this information to the computer, which updates the images for display in real time. this description allows us to clearly identify the key technological components of a vr system : input devices, output devices, and the simulated scenario (i.e., the virtual environment). input devices include all the sensors and trackers that capture the user's actions (e.g., head and hand movements) to allow the user to interact with the virtual environment. in fact, there are many different input devices that can be used in a vr system: -tracking devices: data gloves, head-positioning sensors, embedded cameras, eye trackers, etc. -pointing devices: six-degrees-of-freedom mouse, trackball, joystick, etc. output devices include all the technologies that provide continuous computer-generated information to the user. even though the most important sensory modality for most vr clinical applications is the visual channel, more advanced vr systems also offer auditory, olfactory, and haptic (tactile) feedback. finally, the simulated scenario is the computer-generated d virtual environment (ve) . ves are designed to be explored, so users can interact (e.g., moving, pushing, picking, rotating, etc.) with their contents. multi-user virtual environments (muves) allow two or more users to share the same simulated scenario. to allow communication and interaction between users, muves use avatars, which are personalized graphical representations of the individuals that are directly controlled by them in real time. embodied virtual agents, on the other hand, are graphical representations of the individuals controlled by the computer itself using an artificial intelligence program. vr technology is usually classified as immersive or non-immersive (gaggioli et al., ) . in general, a vr technology is immersive when it is able to sensorially separate the user from the physical world and to replace his/her sensory stream with the simulated scenario generated by the computer. head-mounted displays (hmds) are the most common immersive vr technology ( fig. ) . they occlude any visual contact with the external world, and the internal display replaces it with computer-generated images. thanks to the sensors embedded in the hmd, the computer-generated image is dynamically adapted to different viewing positions. a more advanced and expensive immersive vr technology is the cave automatic virtual environment (cave) (cruzneira et al., ) , a cube-like space that surrounds a user in which images on the walls (including the floor and ceiling) are displayed by a series of projectors in stereoscopic modality (fig. ) . to see the d graphics projected in the cave, users wear d glasses. a motion capture system records the real-time position of the user, who can move inside the space, and adapts the images to continually retain the viewer's perspective. non-immersive vr systems use standard high-resolution monitors (desktop or laptop screens) as output devices, but these are unable to fully occlude the visual channel of the user. in addition, they have limited interactive capabilities (e.g., no motion tracking). non-immersive virtual environments include d video games and desktop-based d modeling applications. the use of vr in clinical practice has long been limited by two main factors: the lack of usability and the cost of virtual tools (lindner et al., ; zanier et al., ) . the early generation of vr devices, available between and , was characterized by low display resolution, limited field of view, and uncomfortable designs. these problems were linked to different side effects such as motion sickness (due to low display quality) and neck pains (due to the weight of the hmd), limiting its use with patients. further, the typical immersive vr system required expensive hmds, often costing more than , usd, paired with equally expensive high-end computers equipped with professional graphics cards. finally, the development and use of a vr system required a high degree of technological expertize (to design the environment and operate it) that was typically unavailable in clinical settings. march saw the release of the first generation of virtual reality headsets targeted at consumers. the oculus riftdan hmd developed and manufactured by oculus vr, a division of facebook inc., and sold for usddmarked a new generation of vr devices (see table ) that is revolutionizing how vr is used in general. in a few years, the cost of a complete vr devicedincluding input, output, and d graphic computationddropped by tens of thousands of dollars to just a few hundred, the price of the cheapest standalone vr systems. the simplest and cheapest form of vr comprises nothing but a pair of magnifying lenses and a sheet of cardboard. it sells for - usd and uses a standard smartphone as a tracker and a display and to generate the d environment. mobile-based vr made vr available even to casual users who own a smartphone, widening its availability to the general population. mobile-based vr is particularly suited to a specific vr content that can be very useful for vr-based exposure: -degree videos (li et al., ) . these videos, also known as immersive videos or spherical videos, are special video recordings created using a camera with multiple camera lenses or a rig of multiple cameras. the use of different lenses allows the recording of every direction at the same time, effectively giving a full view of what is around the camera. one advantage of projecting a -degree video in a vr hmd is that when users turn their head, their view of the live-action video footage turns with them in real time, allowing the user to look around anywhere in the filmed footage. in other words, -degree videos have the power to virtually transport users in the video recording, allowing them to actively explore its content and see the video from any angle. as recently demonstrated by li et al. ( ) , these videos have the ability to induce specific emotions characterized by different levels of valence and arousal. more, they can be used as a sensitive, and ecological tool that captures real-world executive dysfunctions in patients (realdon et al., ) . different from traditional vr content that requires a specific platform and programming skills, -degree videos can be easily recorded by a clinical team using specific cameras (e.g., gopro max, insta one, or ricoh theta sc) that cost less than usd. finally, immersive videos are directly supported by youtube and facebook, allowing for easy sharing of the developed content (nason et al., ) table in a different file) in the previous paragraph, vr was described as a set of fancy technologies (riva et al., ) : an interactive d visualization system (a computer, game console, or smartphone) supported by one or more position trackers and a head-mounted display. however, vr is more than a set of technologies. the word "virtual reality" comprises two words: "virtual" (almost or nearly as described) and "reality" (the actual state of things). consequently, we can state that the term "virtual reality" basically means "almost reality" or "near reality," suggesting that vr is a form of reality simulation. in this view, vr can be defined as (schultheis and rizzo, ) "an advanced form of human-computer interface that allows the user to interact with and become immersed in a computer-generated environment in a naturalistic fashion" (p. ). from a cognitive viewpoint, vr is mainly a subjective experience that makes the user believe that he/she is there and that the experience is real . specifically, what distinguishes vr from other media is the sense of presence: the feeling of "being there" inside the virtual experience produced by the technology. vr research includes various descriptions of users believing, at least for a short time, that they were "inside" and "present" in the virtual experience. but what is presence? this term was first used in in the title of a new journal dedicated to the study of vr: presence: teleoperators and virtual environments. in the first issue, sheridan describes "presence" as an experience elicited by technology use (sheridan, ) : "the effect felt when controlling real world objects remotely as well as the effect people feel when they interact with and immerse themselves in virtual environments" (p. ). following this approach, the international society for presence research today defines "presence" (a shortened form of the term "telepresence") as (ispr, ) "a psychological state in which even though part or all of an individual's current experience is generated by and/or filtered through human-made technology, part or all of the individual's perception fails to accurately acknowledge the role of the technology in the experience." this definition describes the feeling of presence experienced in vr as "media presence," a function of our experience of a given medium (schloerb, ; sadowski and stanney, ; lombard and ditton, ; sheridan, ) . the main outcome of this approach is the perceptual illusion of non-mediation (lombard and ditton, ) definition of presence: "the term 'perceptual' indicates that this phenomenon involves continuous (real time) responses of the human sensory, cognitive, and affective processing systems to objects and entities in a person's environment. an 'illusion of non-mediation' occurs when a person fails to perceive or acknowledge the existence of a medium in his/her communication environment and responds as he/she would if the medium were not there." according to this definition, presence is produced by means of the disappearance of the medium from the conscious attention of the subject. as clarified by lombard and ditton ( ) : "presence in this view cannot occur unless a person is using a medium. it does not occur in degrees but either does or does not occur at any instant during media use." the main advantage of this approach is its predictive value: to increase the level of presence, vr has to reduce the experience of mediation offered to the user. at the same time, however, it does not provide any answers to different critical questions: are we present only in vr? what is presence for? as underlined by biocca ( ) , "while the design of virtual reality technology has brought the theoretical issue of presence to the fore, few theorists argue that the experience of presence suddenly emerged with the arrival of virtual reality" (p. ). however, the findings of recent neuroscience studies consider presence as inner presence (waterworth et al., ; revonsuo, ; riva et al., riva et al., , b , which is the outcome of a broad simulative phenomenon, not necessarily linked to the experience of a medium, used by our brains to minimize the number of prediction errors (or "surprise"). in his book inner presence, revuonso ( ) clearly states: "to be conscious is to have the sense of presence in a world. to have contents of consciousness is to have patterns of phenomenological experience present. in the philosophy of presence, consciousness is an organized whole of transparent surrogates of virtual objects that are immediately present for us in the here-and-now of subjective experience" (pp. - ). thus, media presence is the result of the ability of vr to reproduce the same simulative mechanisms used by inner presence. in other words, the more similar the vr model is to the brain model, the more the individual feels present in the vr world. we will further explore this claim in the next paragraph. "predictive coding" (friston, (friston, , clark, ) is an increasingly popular hypothesis in neuroscience suggesting that our brains actively create an internal model (simulation) of the body and the space around it. this model is used to provide predictions about the expected sensory input and to minimize the number of prediction errors (or "surprise"). specifically, to effectively interact with the world, our brains create an embodied simulation of the body that reflects its expected future states (intentions and emotions). there are two main characteristics of this simulation (riva et al., b) . first, it is a simulation of sensory-motor experiencesdtypes of these experiences include visceral/autonomic (interoceptive), motor (proprioceptive), and sensory (e.g., visual, auditory) information. second, embodied simulations are based on the expectations of the subject and reactivate multimodal neural networks that have previously produced the simulated/expected effect. a critical goal of this process is to minimize the average of surprise (i.e., the disparity between intentions and the effects of enacting them) across the different representations and to learn how best to model and predict incoming contents. in other words, the embodied simulation is adjusted on the basis of the (dis)agreement (talsma, ) between the perceived sensory activity (perception) and the contents of the simulations used to predict the effects of the being in the world of the individual. virtual reality works in a similar way (riva et al., b) : it uses technology to create a virtual experience that individuals can manipulate and explore as if they were in it. in other words, vr technology attempts to predict the sensory consequences of users' actions by showing them the same outcome expected by our brains in the real world. as underlined by riva et al. ( b) : "to achieve it, like the brain, the vr system maintains a model (simulation) of the body and the space around it. this prediction is then used to provide the expected sensory input using the vr hardware. obviously, to be realistic, the vr model tries to mimic the brain model as much as possible: the more the vr model is similar to the brain model, the more the individual feels present in the vr world" (p. ). experiential learning has a long history as a therapeutic technique, and the simulative power of vr makes it the perfect tool for experiential learning. vr allows patients to learn through reflection on doing. as noted by glantz et al. ( ) , "one reason it is so difficult to get people to update their assumptions is that change often requires a prior steprecognizing the distinction between an assumption and a perception. until revealed to be fallacious, assumptions constitute the world; they seem like perceptions, and as long as they do, they are resistant to change" (p. ). through the vr experience, it is easier for the therapist to demonstrate to the patient that what looks like a fact is actually a result of his/her mind. once this concept is understood, individual maladaptive assumptions can be challenged more easily. vr can also be described as an advanced imaginal system: an experiential form of imagery that is as effective as reality at inducing emotional responses (north et al., ; vincelli, ; vincelli et al., ) . this outcome has been demonstrated by multiple studies. for example, slater et al. ( ) reproduced stanley milgram's s experiment using vr: the selected sample was asked to administer a memory test to a female virtual human (avatar) and to provide an "electric shock" to her in the event of an incorrect answer, increasing the voltage each time. during the vr experiment, like in the original one, the avatar responded to the electric shocks with increasing discomfort, eventually demanding termination of the experiment. their results confirm the simulative efficacy of vr: even though all participants knew for sure that neither the avatar nor the shocks were real, they responded to the situation at the subjective, behavioral, and physiological levels as if it were real. more, as demonstrated by balzarotti and colleagues , vr avatars are recognized as intentional agents and users adjust their emotion nonverbal behavior according to the behavior of the avatar. vr is also able to induce emotional responses in clinical patients. as will be described later, numerous studies have shown that vr is capable of increasing subjectively reported anxiety in phobic participants confronted with a threatening virtual situation, similar to the effects experienced in in vivo conditions (powers and emmelkamp, ; opris et al., ) . consequently, as demonstrated by a recent meta-analysis, vr is an effective and equal medium for exposure therapy. however, vr does have advantages over in vivo exposure (riva et al., ) : -cost: in vivo exposure is costly because it requires the therapist to go to the feared place with the patient. exposure interventions "without a therapist" are still not very frequent, and patients are often reluctant to participate in this type of treatment. -availability: the feared situations are not always easily accessible, and imaginal exposure (that is, exposure to imagined situations) in these cases is less effective. -engagement: the immersion and interaction offered by vr improves the engagement of the intervention, which in turn would permit to enhance the adherence of participants to the interventions. -control: vr exposure allows almost total control of everything occurring in the situation experienced by the person in the virtual world, including different elements that can make the situation more or less threatening (e.g., the number or the size of feared persons, animals, or objects; the height of the spaces; the presence of protecting elements, etc.). furthermore, the therapist is always able to know what is happening in the situation, what elements are being faced by the patient, and what is disturbing him/ her. more, in vr it is also possible to control the framing of the experience. as underlined by balzarotti and ciceri positively framed experiences generate less fear than negatively framed ones -realism and presence: different from imaginal exposure, users in vr feel present and judge their situation as real. this aspect is fundamental since exposure therapy is intended to facilitate emotional processing of fear memories. -going beyond reality: virtual worlds allow for the creation of situations or elements so "difficult or threatening" that they would not be expected to happen in the real world. -personal efficacy: vr is an important source of personal efficacy. it allows for the construction of "virtual adventures" in which the person experiences him/herself as competent and efficacious. the goal is for the person to discover that the obstacles and feared situations can be overcome through confrontation and effort. -safety: in vivo exposure can be very aversive for patients and can make them feel very insecure, as there is no assurance that something will not go wrong (e.g., an elevator stopping, technical problems on a plane, etc.). safety is an important advantage of vr. patients can control the context and the computer-generated setting with the therapist as they wish and with no risk involved. -privacy and confidentiality: the possibility offered by vr of confronting many fears inside the therapist's office, without the need for in vivo exposure, offers significant advantages of increased privacy and confidentiality. as we will see in the following pages, the most common clinical application of vr is exposure therapy (virtual reality exposure therapy, or vre), which is used to simulate an external reality. in other words, vr is used clinically to make people feel that what is actually not there is "real." in the previous paragraphs, we have seen the ability of vr to fool the predictive coding mechanisms that regulate the experience of the body, allowing it to make people feel "real" in situations that are not. in other words, vr offers new ways to structure, augment, and/or replace the experience of the body for clinical goals (riva, riva et al., ) . further, it may offer new embodied ways to assess the functioning of our brain (parsons, ; parsons et al., ; riva, by directly targeting the processes behind real-world behaviors cipresso, ; cipresso et al., ) . but what is the real clinical potential of vr as an embodied technology? according to neuroscience, the body matrix is a complex brain network (moseley et al., ; gallace and spence, ; finotti et al., ; finotti and costantini, ) that serves to maintain the integrity of the body at both the homeostatic and psychological levels by supervising the cognitive and physiological resources necessary to protect the body and the space around it. specifically, the body matrix plays a critical role in high-end cognitive processes such as motivation, emotion, social cognition, and self-awareness maister et al., maister et al., , while exerting a top-down modulation over basic physiological mechanisms such as thermoregulatory control (macauda et al., ; and the immune system (finotti and costantini, ) . in addition, contents within the body matrix are shaped by predictive multisensory integration (apps and tsakiris, ; calvert et al., ; sutter et al., ) : higher-order networks generate predictions about expected sensory inputs with the ultimate goal of using these predictions to coordinate all bodily inputs in a coherent and functional mental representation (bayesian principle). in this view, multisensory integration conflicts (ehrsson, ) represent a failure in this functional adaptation process, leading to several pathological conditions. as underlined by ho et al. ( ) : "impaired feedback affecting any level of the multisensory hierarchy could disturb the coherent integration of lower-level signals with the bodily self and disrupt the individual's optimal interaction with the external and social world" (p. ). specifically, altered functioning of the body matrix and/or multisensory integration processes might produce disorders of the bodily self that underlie different neurological and psychiatric conditions (riva, ; riva et al., ; brugger and lenggenhager, ; tsakiris and critchley, ; ho et al., ) . if this theory is true, vr could be the core of a new trans-disciplinary research fielddembodied medicine riva et al., ) dthe main goal of which is the use of virtual reality to alter the body matrix with the goal of improving people's health and well-being. specifically, using vr could alter the body matrix in three different ways: • by replacing multisensory bodily contents with synthetic ones (synthetic embodiment): as we have seen before, vr allows for different types of synthetic bodily experiences. the most advanced of these is full body swapping, in which the individual's body is substituted by a virtual body (petkova and ehrsson, di lernia et al., ) introduced the concept of "sonoception," a novel non-invasive technological paradigm based on wearable acoustic and vibrotactile transducers, as a possible approach to replacing the contents of the inner body (e.g., interoception). the first outcome of this approach is the development of an interoceptive stimulator that is able to enhance heart rate variability (the short-term vagally mediated component rmssd) by delivering precise interoceptive parasympathetic stimuli to c-tactile afferents connected to the lamina i spinothalamocortical system . • by structuring multisensory bodily contents through awareness and reorganization (mindful embodiment): individuals have different levels of body awareness, which is the extent of sensitivity and attentiveness to bodily signals and sensations (ginzburg et al., ) . vr can be applied to improve body awareness when it is integrated with other technologies like biosensors. for example, in integration with biofeedback training, it can be used to assess and control specific body signalsdlike heart rate, galvanic skin response, electromyography, or electroencephalography (gaggioli et al., ; repetto et al., a) dthat are normally not consciously perceivable and to report these signals back to the patient. the patient can then learn to shift these measured signals in the desired direction by means of the feedback provided by vr (e.g., a waterfall changes its flow according to the heart rate of the individual). • by augmenting multisensory bodily contents by altering/extending their boundaries (augmented embodiment): by integrating vr with biosensors, stimulation, and haptic devices, it is possible to map the contents of a sensory channel to a different one (e.g., vision to touch or to hearing) in order to increase sensitivity and replace the impaired channels (waterworth and waterworth, ) . for example, ward and meijer ( ) developed a virtual sound experience to convert information normally delivered to the visual field into an auditory representation. in a different study, suzuki and colleagues (suzuki et al., ) combined feedback of interoceptive information (heart rate) with computer-generated augmented reality to produce a "cardiac rubber hand illusion." their results suggest that the feeling of ownership of the virtual hand is enhanced by cardio-visual feedback in time with the actual heartbeat, supporting the use of this technique to improve emotion regulation. with these approaches, it is possible to use vr to reach the following two clinical goals (riva, ) . first, vr can be used to facilitate the integration of external and internal body signals (suzuki et al., ; azevedo et al., ) and to improve the multisensory integration processes. second, vr and sonoception can be used to induce a controlled mismatch between the predicted/dysfunctional content and the actual sensory input (serino et al., a) that is able to correct the prediction of the brain. the clinical potential of vr is clearly supported by clinical outcomes. two recent meta-reviews (riva et al., , b ) assessing more than systematic reviews and meta-analyses exploring the current use of vr in clinical psychology support its use in anxiety disorders, eating and weight disorders, and pain management, with long-term effects that generalize to the real world. vr also has significant applicative potential in other areas like psychosis and addictions. in the following paragraphs, we will discuss how vr has been applied in these different areas and the achieved clinical results. according to the american psychological association's guidelines for empirically supported treatments (practice, ) , exposurebased therapies can be considered as a reference treatment for the treatment of obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder (pd), specific phobias, and social anxiety disorder. however, only a small group of individuals with anxiety disorders receive this treatment (olatunji et al., ) ; vr technology can increase the number of patients treated with this approach (fernández-Álvarez et al., ) . as discussed previously, vr can be described as an advanced imaginal system, an experiential form of imagery that is as effective as reality at inducing emotional responses (north et al., ; vincelli, ; vincelli et al., ) . this feature makes vr exposure therapy (vret) the perfect tool for disseminating exposure therapy. in addition, vret offers multiple advantages over in vivo exposure (riva et al., ) dcost, availability, safety, etc.dthat we discussed before. a recent meta-analysis confirms strong treatment effects for vr exposure-based therapy for anxiety disorders (carl et al., ) : vret showed a large effect size (hedge's g ¼ . ) compared to waitlist conditions and a medium to large effect size compared to psychological controls. further, vret was not significantly more or less effective than in vivo exposure. a recent study (fernandez-alvarez et al., ) examining the deterioration rates of vr-based treatments for anxiety disorders showed that the number of deteriorated patients coincided with other therapeutic approaches and that deterioration is less likely to occur compared to waitlist conditions. a common opinion between clinicians is that vr may induce more dropouts than non-vr approaches. however, a recent metaanalysis on attrition rates in vret showed that among the participants involved in different studies only % dropped out. these results are similar to in vivo exposure. more, the meta-analysis indicates that the inclusion of homework assignments is the most significant predictor of non-attrition, suggesting its implementation in any vret protocol . specific phobias were the first anxiety disorders to be treated using vret, and its efficacy is now supported by multiple metaanalyses (powers and emmelkamp, ; opris et al., ) . a growing body of literature is now supporting vret for additional disorders. the meta-analysis (carl et al., ) expands support for the use of vr for social anxiety disorder and performance anxiety (hedge's g ¼ . ), post-traumatic stress disorder (hedge's g ¼ . ), and panic disorders (hedge's g ¼ . ). vret has also been used in several additional areas of anxiety from stress management (pallavicini et al., ; shah et al., ) to generalized anxiety disorders (repetto et al., ) . recently, some researchers have also explored the possible use of consumer-ready, gamified self-help vret applications using low-cost, commercially available vr hardware (lindner et al., ) . for example, covid feel good (www.covidfeelgood.com) is a free self-help solution for providing stress management and social support during the covid- pandemic using a smartphone and a low-cost (> us$) headset (riva & wiederhold, ) . a randomized controlled study by freeman et al. ( ) compared an automated vret protocol for fear of heights versus usual care (control group). the automated psychological intervention delivered by immersive vr was highly effective at reducing fear of heights. in a second randomized controlled trial, lindner et al. ( ) compared the efficacy of therapist-led vret for public speaking anxiety with self-led, at-home vret. both vret formats led to significant improvements in the level of anxiety. moreover, the improvements achieved by the self-led arm were maintained at the six-month follow-up, and patients undergoing the therapist-led arm also continued to improve at the twelve-month followup. these results support the use of self-led vret and suggest that currently available internet-based treatments may benefit from the inclusion of vr exposure tools. another emerging approach in the treatment of anxiety disorders is the use of vr biofeedback systems (fernández-Álvarez et al., ; schoeller et al., ) . biofeedback is an effective way for supporting emotion regulation through the conscious registration of normally unconscious body procedures (e.g., electrocardiogram, electromyography, brain activity, or skin conductance) that are represented by a visual, haptic, or audio signal (schoenberg and david, ) . through the monitoring and visualization of human physiological reactions, individuals can see their body functions and understand their reaction to different anxious or stressful stimuli. in practice, biofeedback helps individuals to understand these habitual patterns and to take steps to change them to reduce symptoms associated with different diseases and disorders. vr offers a significant advantage to these processes (fernández-Álvarez et al., ) : it allows to represent the physiological process through virtual stimuli that are connected to biosensors, strengthening the engagement of users and potentially augmenting also the effectiveness of the interventions. a first support to this approach it is offered by different studies with healthy and clinical population (repetto et al., b (repetto et al., , . finally, a possible new approach, is the combination of vr with transcranial magnetic stimulation (tms), transcranial direct current stimulation (tdcs) or intermittent theta burst stimulation (itbs). as demonstrated by different studies neurostimulation of the dorsolateral prefrontal cortex (dlpfc) has an effect on the processing and memory of emotional visual stimuli (balzarotti and colombo, ) . in this view, combining vret with neurostimulation may improve the clinical efficacy of this approach, even if strong clinical evidence is still missing (riva et al., b; notzon et al., ; van 't wout-frank et al., ) . vr interventions have been used in acute pain management related to healthcare interventions for over two decades (chan et al., ) . pharmacological approaches remain the mainstay for most interventions, but their significant drawbacksdincluding narrow therapeutic windows, adverse side effects, and drug misuse and dependencedare making vr-based interventions a valuable option . the most common approach used in vr acute pain management is distraction. this approach uses vr to draw the patient's attention to the computer-generated world, diverting it from incoming pain signals (ahmadpour et al., ) . as underlined by a systematic review (triberti et al., ) , while the feeling of presence in the vr experience influences its effectiveness as a distraction tool, anxiety as well as positive emotions directly affect the experience of pain. in fact, it is well known that negative affect worsens reported pain by activating the insula cortex. in this view, distraction can also be enhanced by the use of vr to induce positive emotions (sharar et al., ) . a more advanced form of distraction is focus shifting (ahmadpour et al., ) , which uses agency to improve engagement and shift of attention. in vr focus shifting experiences, the user is required to interact with the virtual environment and achieve specific goals. a final mechanism used to induce vr analgesia is skill building (ahmadpour et al., ) . this approach uses vr to build the skills and competences needed to help individuals regulate their response to painful stimuli. as in focus shifting, the user plays an active role. however, the goal of the vr experience in this case is to help patients self-regulate pain, for example, by controlling respiration during the pain experience to improve the patient's sense of control. a recent meta-analysis confirmed the efficacy of these approaches (chan et al., ) : across trials, it found a À . standardized mean difference reduction in pain score with vr. more recently, vr-based interventions have also been used for chronic pain management (jones et al., ) . although chronic pain is substantially different from acute pain because of the many psychological factors and central nervous system processes involved, most vr chronic pain interventions are based on the same three approaches previously discussed. and the results are similar: vr is effective during the sessions, but its analgesic effects beyond the vr session are limited (ahmadpour et al., ) . to improve long-term results, some researchers are starting to use synthetic embodimentdthe use of vr to replace multisensory bodily contents with synthetic onesdfor chronic pain management. the rationale of this approach is to use the embodiment potential of vr to correct a dysfunctional representation of the affected part of the body. for example, synthetic embodiment is currently used for the treatment of phantom limb pain, an experience caused by dysfunctional alterations in amputees' representations of their body. as discussed by dunn and colleagues in their review (dunn et al., ) , vr has been used to allow patients to gain agency of a virtual limb to perform assigned tasks. randomized controlled trials are not yet available, but the case studies reveal the great potential of vr intervention as patients achieved reduced pain intensity. another form of synthetic embodiment used in vr analgesia is vr body swapping, the illusion of owning a virtual body (hansel et al., ; martini et al., ) . a narrative review by matamala-gomez et al. ( b) suggests that this approach can modulate body representation and change pain perception in healthy and clinical populations. again, even though research in this field is quite new (matamala-gomez et al., a) , the approach is very promising. over the last years, vr has offered innovative solutions for reducing food cravings, improving body image, and enhancing emotion regulation skills in eating and weight disorders (riva et al., , a . in particular, four different randomized controlled trials (marco et al., ; manzoni et al., ; cesa et al., ; ferrer-garcia et al., ) have shown at long-term follow-ups that vr had a higher efficacy in treating eating disorders and obesity than the gold standard in the field, i.e., cognitive behavioral therapy (cbt). the first application of vr in this field was in body image research to explore the concept of body image and to aid the evaluation of body image disturbances. the possibility of developing vr-based applications exploring body representations has advanced due to substantial progress in technology that now supports the use of increasingly realistic and interactive "avatars." the term "avatar" refers to virtual self-representations in digital worlds, including online collaborative virtual worlds (e.g., second life) as well as video games and virtual environments for clinical purposes (gaggioli et al., ) . typically, these applications consist of a d human figure whose body parts can be modified using sliders. the main advantage of this approach is that the software allows clinicians to assess several dimensions or indexes of body image (e.g., the perceived body, the desired body, the healthy body, etc.) and body weight (actual weight, subjective weight, healthy weight, and desired weight), all in different contexts. researchers have also used the ability of vr to reproduce everyday life environments to study whether body image disturbance in patients with eating disorders changes depending on the situation (ferrer-garcia and gutierrez-maldonado, ) . results show that body image distortion and dissatisfaction can be influenced by situational factors. in this view, the use of different virtual scenarios representing a range of stressful real-life situations can provide clear, therapist-independent information about the subjective view that patients have of their bodies (riva et al., a) . a recent neuroscientific model suggests that eating disorders may reflect a deficit in the processing and integration of multisensory bodily representations and signals (riva and dakanalis, ; riva and gaudio, ) . specifically, the multisensory body integration deficit may impair an individual's abilities: (a) to identify the relevant interoceptive signals that predict potential pleasant (or aversive) consequences and (b) to modify/correct the autobiographical allocentric (observer view) memories of body-related events (self-objectified memories). vr allows the targeting of impaired multisensory body integration through two different strategiesdreference frame shifting (akhtar et al., ; riva, ) and body swapping (normand et al., ; gutiérrez-maldonado et al., ) dthat can be integrated within classical cognitive behavioral therapy (cbt). the first method, reference frame shifting (akhtar et al., ; riva, ) , attempts to modify the individual's bodily selfconsciousness through the focus and reorganization of body-related memories (osimo et al., ; riva, ) . to achieve this goal, the subject re-experiences in vr a negative situation related to the body (e.g., teasing) both from first-person and thirdperson perspectives (e.g., seeing and supporting his/her avatar in the vr world). in general, the therapist asks the patient to give detailed descriptions of the virtual experience and the feelings associated with it. furthermore, the patient is taught how to cope with these feelings using different cognitive techniques. this approach has been successfully used in different randomized trials with obese patients (cesa et al., ; manzoni et al., ) , allowing them to both update the contents of their body memory and to improve the clinical outcomes over traditional cbt. in the second methoddbody swapping (normand et al., ; gutiérrez-maldonado et al., ; serino and dakanalis, ) dvr is used to induce the illusory feeling of ownership of a virtual body with a different shape and/or size. as for chronic pain management, the clinical goal of body swapping is to correct the dysfunctional representation of the body. although bodily illusions have yet to be tested in an rct against an active treatment, preliminary results support the rationale of this approach (serino et al., a (serino et al., ,b, ehrsson, , ; keizer et al., ) . vr can also reduce eating-related anxiety during and after exposure to virtual food, helping to disrupt the reconsolidation of adverse food-related memories and to modulate food craving, which is the intense desire to consume a specific food (riva, ) . as demonstrated by an experimental study (gorini et al., ) , real food and vr food produce comparable emotional reactions in patients with eating disorders, and this reaction is stronger than the one produced by photographs of food. in this view, cue exposure therapy (cet) using vr food has been used to extinguish/habituate craving and anxiety responses and thus reduce the associated risk of overeating. a recent randomized controlled trial with a six-month follow-up confirmed the validity of this approach in a sample of patients with bulimia and binge eating disorder: vr cet produced better results than cbt, the gold standard for these pathologies. finally, vr-based exergames have been used in the treatment of obesity. the term "exergames"da portmanteau of the words "exercise" and "gaming"dindicates video games that provide a form of exercise (rizzo et al., ) . via engaging digital gaming interacted with via body movements, exergames increase motivation to participate in calorie-burning cardiovascular exercise activities. in particular, the three factors influencing motivation and compliance (lyons, ) dfeedback, challenge, and rewardsdare all supported by virtual reality experiences. over the last years, studies have attempted to establish the safety of using vr with individuals experiencing psychosis and to understand the psychological mechanisms behind the onset and maintenance of psychotic symptoms (valmaggia, ) . as underlined by two recent systematic reviews (valmaggia et al., ; rus-calafell et al., ) , vr was first applied in this field to explore the psychological processes and mechanisms associated with the onset and maintenance of psychosis. specifically, vr has been used as a controlled setting in which to study the effect of adverse life events on real-time response to social situations. through the manipulation of population density, the ethnic density of avatars, or even the height of the user, it is possible for researchers to control the levels of paranoid ideation and auditory hallucinations (veling et al., ; freeman et al., ) . in addition, by using virtual agents and virtual scenarios, researchers can assess functional capacity, social cognition, and social competence (freeman et al., ) . all these studies suggest that vr is a safe setting for assessing psychotic symptoms. in particular, patients did not show any aggravation of psychotic symptoms after vr exposure, and they did not report any distress related to the vr experience (valmaggia et al., ; rus-calafell et al., ) . more recently, vr has also been used to improve cognitive remediation therapy for psychotic disorders, a clinical approach that aims at improving cognitive processes with the goal of durability and generalization to functioning in daily life (wykes and spaulding, ) . vr allows for the creation of specific scenarios in which to train and develop problem solving, social, and interpersonal skills (fernández-sotos et al., ) . patients are much more likely to test out their competences in vr because they know it is a simulation, but what they learn in vr then transfers to the real world. vr treatment can also include engaging tasks that make treatment much more enjoyable. finally, vr scenarios can offer graded experiences that allow the individual to repeatedly test situations they find difficult and learn new skills (freeman et al., ) . despite the low number of published trials, all studies obtained promising results with short-term improvements in social skills and/or social cognition (fernández-sotos et al., ) . a future step, as for anxiety disorders, is the use of automated vr applications using low-cost, commercially available vr hardware. a running trial (freeman et al., ) is currently testing this approach with psychotic patients who have difficulties being in everyday social situations due to anxiety. vr interventions have been used in the assessment and treatment of addictive disorders for over years (segawa et al., ) . the first application of vr in this field was to study cue reactivity (bordnick et al., (bordnick et al., , . specifically, using vr cue environments, researchers assessed craving and reactivity to drug cues. in these studies, participants were exposed to cues in a vr environment, and subjective (e.g., craving or desire to use) and objective (e.g., physiology) measurements were recorded. the vr experience can also be modulated to evaluate behavioral responses to a distressing situation. as underlined by a recent systematic review (segawa et al., ) , vr has been effectively used to elicit craving and cue exposure in people addicted to alcohol, cocaine, gambling, marijuana, methamphetamines, and nicotine. in particular, vr exposition is able to drive cue attentional bias and cognitive distortions and to activate interoceptive reactions such as heart rate variation. recently, vr cue exposure has also been used in treatment. however, treatments based exclusively on virtual exposure to drugrelated cues have provided heterogenous results . as indicated by a recent randomized controlled trial, the integration of vr exposure in a cbt protocol for smoking addiction achieved similar outcomes to cbt alone in both retention and smoking cessation rates (pericot-valverde et al., ) . vr, which has been used in the assessment and treatment of autistic children since (strickland et al., ) , has been used to improve social skills, nonverbal communication, and emotional skills (lorenzo et al., ) . one of the first approaches was the use of vr for social and communicative skills training (miller et al., ) . specifically, vr social simulations that replicate real-life events (e.g., a virtual café, a bus, or a crossing road) have been used to train autistic children to manage different graded scenarios (moon and ke, ) . during the vr experience, they have to initiate social actions and verbal discourses with simulated social actors to reach training goals and build their self and social identities. another important area is the use of vr to improve emotional skills. for example, ghanouni et al. ( ) developed a validated library of vr social stories focused on perspective-taking that offer gradual levels of emotion intensity and difficulty. this approach needs to better tailor the vr experiences to the specific coping skills of each child. in a recent randomized controlled trial (maskey et al., ) , clinicians used vr to treat autistic children experiencing specific phobias with positive results. in general, available results suggest that vr is a promising tool for improving social skills, cognition, and functioning in autism. however, existing studies do not clarify if autistic children generalize the learned skills to real life (lorenzo et al., ) . in addition, there remain obstacles to developing robust and easy-to-use vr experiences that can really make a difference in real-world classrooms (parsons and cobb, ) . the vr protocols and tools discussed above are not exhaustive of all the different applications of vr in mental health. however, evidence of vr's effects in other mental health diseases is sparse, and methodological flaws and/or gaps in reporting are common. another area in which vr has been used is the assessment and treatment of sexual disorders. in this field, the integration of vr in the psychodynamic therapy for erectile dysfunction and premature ejaculation achieved interesting preliminary results, even in a small case series with no control conditions (optale et al., ; optale, ) . moreover, renaud and colleagues (renaud et al., (renaud et al., , successfully used vr exposure to virtual characters depicting sexual stimuli to assess deviant sexual preferences (e.g., pedophilia). another notable area is depression (zeng et al., ) . falconer and colleagues explored body swappingdthe illusory feeling of ownership of a virtual body with a different shape and/or sizedto increase the level of compassion in depressed patients. other researchers used vr-based exergames (e.g., vr-based treadmill or stationary bike exercises) to reduce depressive symptoms. in both cases, results were encouraging, even though the study designs and methodology do not allow for a conclusive statement regarding the effectiveness of these approaches. from a technological viewpoint, virtual reality (vr) is a set of fancy technologies: a helmet, trackers, and a d visualizing system. however, from a psychological viewpoint, vr is simultaneously a simulative technology, a cognitive technology, and an embodied technology. first, vr is a form of reality simulation. specifically, what distinguishes vr from other media is the sense of presence: the feeling of "being there" inside the virtual experience produced by the technology. the simulative power of vr makes it the perfect tool for experiential learning. on the one hand, vr allows patients to learn through reflection on doing. on the other hand, vr can be described as an advanced imaginal system, or an experiential form of imagery that is as effective as reality at inducing emotional responses. moreover, vr is also a cognitive technology with the ability to reproduce the mechanisms behind the functioning of the brain. as recently suggested by neuroscience research, our brains are simulation machines that develop an internal model (simulation) of the body and the space around it to provide predictions about the expected sensory input and to minimize the number of prediction errors (or "surprise"). vr works in a similar way: it uses technology to create a virtual experience that individuals can manipulate and explore as if they were in it. in other words, vr technology attempts to predict the sensory consequences of users' actions by showing them the same outcome expected by our brain in the real world. in this view, the more similar the vr model is to the brain model, the more the individual feels present in the vr world. finally, vr can also be considered an embodied technology for its ability to fool the brain mechanisms that regulate the experience of the body. this ability offers new waysdat present only partially exploreddto structure, augment, and/or replace the experience of the body for clinical goals. in addition, it provides new embodied ways to assess the functioning of our brain by directly targeting the processes behind real-world behaviors. all of these characteristics make vr an effective clinical tool. as discussed in this chapter, and in agreement with the results of two recent meta-reviews (riva et al., , b , existing research supports the clinical use of vr in the assessment and treatment of anxiety disorders, pain management, and eating and weight disorders, with long-term effects that generalize to the real world. recent studies have also provided preliminary support for the use of vr in the assessment and treatment of psychosis, addictions, and autism. a further boost to the research and clinical applications of vr comes from the recent availability of low-cost, commercially available vr hardware. smartphones and -degree videos will also make possible the development of a new generation of self-help vr applications that will make mental health treatment more accessible to individuals who do not have enough time or money to see a clinician in person. however, vr like any other technology, is only a tool, which can be used for better or for worse. in that sense, the core interest for clinical psychology, is to understand the clinical phenomena and not be led by the idea that cutting-edge technologies will necessarily entail solutions for the problems we have to face with. in other words, we will need to elucidate which people can benefit from vr, in which way and at which moments of the psychopathological evolution. virtual reality interventions for acute and chronic pain management switching memory perspective the free-energy self: a predictive coding account of self-recognition the calming effect of a new wearable device during the anticipation of public speech news reports of catastrophes and viewers' fear: threat appraisal of positively versus negatively framed events effects of unilateral transcranial direct current stimulation of left prefrontal cortex on processing and memory of emotional visual stimuli i know that you know how i feel": behavioral and physiological signals demonstrate emotional attunement while interacting with a computer simulating emotional intelligence a meta-analytic examination of attrition in virtual reality exposure therapy for anxiety disorders humane interfaces: questions of method and practice in cognitive technology virtual reality cue reactivity assessment in cigarette smokers assessing reactivity to virtual reality alcohol based cues the bodily self and its disorders: neurological, psychological and social aspects the handbook of multisensory processes virtual reality exposure therapy for anxiety and related disorders: a meta-analysis of randomized controlled trials virtual reality for enhancing the cognitive behavioral treatment of obesity with binge eating disorder: randomized controlled study with one-year follow-up clinical efficacy of virtual reality for acute procedural pain management: a systematic review and meta-analysis psychometric assessment and behavioral experiments using a free virtual reality platform and computational science modeling behavior dynamics using computational psychometrics within virtual worlds whatever next? predictive brains, situated agents, and the future of cognitive science the cave -audio-visual experience automatic virtual environment toward an embodied medicine: a portable device with programmable interoceptive stimulation for heart rate variability enhancement virtual and augmented reality in the treatment of phantom limb pain: a literature review the concept of body ownership and its relation to multisensory integration deep reality: an underwater vr experience to promote relaxation by unconscious hr, eda, and brain activity biofeedback deterioration rates in virtual reality therapy: an individual patient data level meta-analysis virtual reality for anxiety disorders: rethinking a field in expansion virtual reality for psychosocial remediation in schizophrenia: a systematic review effect of the mood produced by virtual reality exposure on body image disturbances a randomized trial of virtual reality-based cue exposure second-level therapy and cognitive behavior second-level therapy for bulimia nervosa and binge-eating disorder: outcome at six-month followup multisensory body representation in autoimmune diseases height, social comparison, and paranoia: an immersive virtual reality experimental study virtual reality in the assessment, understanding, and treatment of mental health disorders automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial automated virtual reality (vr) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gamechange) embodied inference and spatial cognition being there: concepts, effects and measurement of user presence in synthetic environment advanced technology in rehabilitation: empowering cognitive, physical, social and communicative skills through virtual reality, robots, wearable systems and brain-computer interfaces experiential virtual scenarios with real-time monitoring (interreality) for the management of psychological stress: a block randomized controlled trial touch with the future: the sense of touch from cognitive neuroscience to virtual reality temporary interference over the posterior parietal cortices disrupts thermoregulatory control in humans social stories for children with autism spectrum disorder: validating the content of a virtual reality program body awareness: differentiating between sensitivity to and monitoring of bodily signals virtual reality (vr) and psychotherapy: opportunities and challenges assessment of the emotional responses produced by exposure to real food, virtual food and photographs of food in patients affected by eating disorders future directions: how virtual reality can further improve the assessment and treatment of eating disorders and obesity seeing and identifying with a virtual body decreases pain perception neuropharmacological modulation of the aberrant bodily self through psychedelics the concept of presence: explication statement the impact of virtual reality on chronic pain a public database of immersive vr videos with corresponding ratings of arousal, valence, and correlations between head movements and self report measures creating state of the art, next-generation virtual reality exposure therapies for anxiety disorders using consumer hardware platforms: design considerations and future directions therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: a randomized controlled trial at the heart of it all: the concept of presence the application of immersive virtual reality for students with asd: a review between - cultivating engagement and enjoyment in exergames using feedback, challenge, and rewards binding body and self in visuo-vestibular conflicts experiencing ownership over a dark-skinned body reduces implicit racial bias changing bodies changes minds: owning another body affects social cognition virtual reality-enhanced cognitive-behavioral therapy for morbid obesity: a randomized controlled study with year follow-up effectiveness of cognitive behavioral therapy supported by virtual reality in the treatment of body image in eating disorders: one year follow-up modulation of pain threshold by virtual body ownership a randomised controlled feasibility trial of immersive virtual reality treatment with cognitive behaviour therapy for specific phobias in young people with autism spectrum disorder decreasing pain ratings in chronic arm pain through changing a virtual body: different strategies for different pain types immersive virtual reality and virtual embodiment for pain relief assessment and treatment of autism spectrum disorders with virtual reality: a comprehensive research chart exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism bodily illusions in health and disease: physiological and clinical perspectives and the concept of a cortical 'body matrix virtual treatment for veteran social anxiety disorder: a comparison of video and d virtual reality multisensory stimulation can induce an illusion of larger belly size in immersive virtual reality psychophysiological effects of an itbs modulated virtual reality challenge including participants with spider phobia efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis male sexual dysfunctions: immersive virtual reality and multimedia therapy male sexual dysfunctions and multimedia immersion therapy conversations between self and self as sigmund freud-a virtual body ownership paradigm for self counselling virtual reality applications for stress management training in the military state-of-the-art of virtual reality technologies for children on the autism spectrum virtual reality for enhanced ecological validity and experimental control in the clinical, affective and social neurosciences virtual reality exposure therapy for anxiety disorders: a meta-analysis evidence-based practice in psychology illusory changes in body size modulate body satisfaction in a way that is related to non-clinical eating disorder psychopathology illusory obesity triggers body dissatisfaction responses in the insula and anterior cingulate cortex an ecological measure to screen executive functioning in ms: the picture interpretation test (pit) using immersive virtual reality and ecological psychology to probe into child molesters' phenomenology using immersive virtual reality and anatomically correct computer-generated characters in the forensic assessment of deviant sexual preferences. virtual real the use of biofeedback in clinical virtual reality: the intrepid project virtual reality and mobile phones in the treatment of generalized anxiety disorders: a phase- clinical trial inner presence, consciousness as a biological phenomenon altered processing and integration of multisensory bodily representations and signals in eating disorders: a possible path toward the understanding of their underlying causes locked to a wrong body: eating disorders as the outcome of a primary disturbance in multisensory body integration from intention to action: the role of presence how cyberpsychology and virtual reality can help us to overcome the psychological burden of coronavirus presence-inducing media for mental health applications transforming experience: the potential of augmented reality and virtual reality for enhancing personal and clinical change virtual worlds versus real body: virtual reality meets eating and weight disorders embodied medicine: mens sana in corpore virtuale sano virtual reality in the assessment and treatment of weight-related disorders neuroscience of virtual reality: from virtual exposure to embodied medicine from virtual to real body: virtual reality as embodied technology the key to unlocking the virtual body: virtual reality in the treatment of obesity and eating disorders embodied medicine: what human-computer confluence can offer to health care letter to the editor: virtual reality in the treatment of eating and weight disorders the neuroscience of body memory: from the self through the space to the others virtual reality and interactive digital game technology: new tools to address obesity and diabetes virtual reality in the assessment and treatment of psychosis: a systematic review of its utility, acceptability and effectiveness measuring and managing presence in virtual environments combining virtual reality and biofeedback to foster empathic abilities in humans the application of virtual reality technology in rehabilitation virtual reality (vr) in assessment and treatment of addictive disorders: a systematic review bodily illusions and weight-related disorders: clinical insights from experimental research virtual reality body swapping: a tool for modifying the allocentric memory of the body a novel technique for improving bodily experience in a non-operable super-super obesity case picture interpretation test (pit) degrees: an innovative measure of executive functions from avatars to body swapping: the use of virtual reality for assessing and treating body-size distortion in individuals with anorexia efficacy of the virtual reality-based stress management program on stress-related variables in people with mood disorders: the feasibility study circumplex model of affect: a measure of pleasure and arousal during virtual reality distraction analgesia musing on telepresence and virtual presence a virtual reprise of the stanley milgram obedience experiments two case studies using virtual reality as a learning tool for autistic children multisensory integration in action control multisensory integration across exteroceptive and interoceptive domains modulates self-experience in the rubber-hand illusion predictive coding and multisensory integration: an attentional account of the multisensory mind virtual reality exposure therapy on alcohol and nicotine: a systematic review psychological factors influencing the effectiveness of virtual reality-based analgesia: a systematic review interoception beyond homeostasis: affect, cognition and mental health using virtual reality to investigate psychological processes and mechanisms associated with the onset and maintenance of psychosis: a systematic review the use of virtual reality in psychosis research and treatment combined transcranial direct current stimulation with virtual reality exposure for posttraumatic stress disorder: feasibility and pilot results virtual reality experiments linking social environment and psychosis: a pilot study virtual reality as clinical tool: immersion and three-dimensionality in the relationship between patient and therapist. stud from imagination to virtual reality: the future of clinical psychology visual experiences in the blind induced by an auditory sensory substitution device interacting with presence: hci and the sense of presence in computer-mediated environments on feeling (the) present: an evolutionary account of the sense of presence in physical and electronically-mediated environments future directions: advances and implications of virtual environments designed for pain management thinking about the future cognitive remediation therapy-what works and could we do better? virtual reality exercise for anxiety and depression: a preliminary review of current research in an emerging field key: cord- -wxlcf w authors: qasem, zainah title: the effect of positive tri traits on centennials adoption of try-on technology in the context of e-fashion retailing date: - - journal: int j inf manage doi: . /j.ijinfomgt. . sha: doc_id: cord_uid: wxlcf w to provide a more realistic experience, e-retailers have implemented virtual try-on systems. it is, therefore, important to examine the variable that influences customers’ intention to use try-on technologies when online shopping for apparel. the main aim of the current study is to identify and examine the design and individual characteristics that influence centennials to adopt virtual try-on systems. factors extracted from the utaut model and technology readiness were proposed in the current study model, which was empirically validated based on data collected from participants. the main results of structural equation modeling largely supported the significant role of “optimism” and “innovativeness” in performance expectancy and price value. behavioral intention was also predicted by all the factors of utaut apart from effort expectancy. these results provide a guideline for online retailers on how to communicate with their centennial customers to influence them to adopt try-on technology. apparel and fashion e-retailing is an increasingly booming sector. it is expected that the worldwide revenue of this sector will achieve a stable yearly growth rate from $ . billion in to $ . billion by (orendorff, ) . low barriers have enabled more retailers to start selling their fashion products globally. in recent years, exclusively online apparel and fashion vendors, such as asos, have emerged (wood, coe, watson, & teller, ) . customers are progressively perceiving the internet as an additional channel for purchasing different types of products, including apparel and fashion products (petit, velasco, & spence, ; sebald & jacob, ) . however, the online apparel and fashion retail sector is not growing as fast as other sectors, such as retailers of sporting equipment, technology, and diy products (customers, ) . this is attributed to apparel being a high-involvement product (blázquez, ) . the inability to directly experience the productby touching it and feeling it, and by trying it onprevents customers from answering the critical questions about whether the item suits and fits (moroz, ; pachoulakis & kapetanakis, ) ; this, in turn, negatively affects the purchase decision (pantano, rese, & baier, ) . hence, it is a priority for apparel and fashion e-retailers to help customers answer these questions and to create a positive and enriched customer experience. advances in internet-related technology have provided retailers with various solutions that can reshape their practices and allow consumers to experience shopping differently (souiden, ladhari, & chiadmi, ) . retailers have utilized different technologies, among which are virtual try-on technology and virtual online fitting rooms, to overcome the online environment's limitations and enrich the shopping experience (zhang, wang, cao, & wang, ) . one example of this technology is three-dimensional virtual try-on systems (moroz, ) , which can be incorporated in platforms, such as retailers' website pages and mobile apps, to enable consumers to experiment with clothing in a virtual way (sánchez-ferrer, pérez-mendoza, & shiguihara-juárez, ) . using this technology, shoppers can adjust the angle from which to view the item, change the focus to zoom in on item features, and view the item in diverse colors (yim, chu, & sauer, ) , all on a d avatar that resembles the customer's body. try-on technology has the potential to influence the shopping experience significantly by improving consumers' sensory perceptions (yaoyuneyong, foster, johnson, & johnson, ) . it allows consumers to more realistically experience and gather sufficient information about retailers' products, to try on clothes virtually, to enjoy the shopping experience, and ultimately to have a very similar experience to that of trying the product in the physical store (cho & schwarz, ) . some retailers such as macy's and gap have already invested in d virtual try-on technology and enabled their customers to investigate how the item looks on them by dressing an avatar representing the customer. however, this technology is new to customers (klarna, ; moroz, ) and retailers. in europe, retailers have described the process of adopting d virtual reality (vr) technology as a slow process; however, they have also shown great enthusiasm for investing in such as technologies (sabanoglu, ) . in the us, on the other hand, about % of consumers have stated a lack of interest in using vr while shopping (o'connell, ) . thus, there is a need to understand the factors that influence customers' decisions to adopt try-on technology. papahristou and bilalis ( ) stated that try-on technology is not the future since it is already here. hence, it is vital that researchers and practitioners understand virtual try-on technology and investigate how, through using the technology, utilitarian and hedonic value can be delivered to consumers, leading to the creation of rich shopping experiences (lee & kim, ) . furthermore, due to the crucial role that virtual try-on technology is anticipated to play in e-retailing, this study also investigates the variables that might affect customers' intention to adopt and use d virtual try-on technology when making online purchases of apparel and fashion in emerging markets such as jordan and gulf countries. to explain the adoption of try-on technology, previous studies have commonly built on theories, such as the technology acceptance model (tam) and the unified theory of acceptance and use of technology (utaut), and have focused on factors that represent computer system design (e.g., kim & forsythe, ) , while ignoring individual differences and their role in technology adoption. among these individual characteristics are personality traits like technology readiness, which could play a considerable role in shaping customer perception, intention, and behavior toward new technologies. utaut was developed primarily to explain technology adoption in the consumer context (venkatesh, thong, & xu, ) . therefore, the present study builds a model based on an extensive analysis of prior literature on information systems and digital marketing to investigate technology readiness, alongside other factors derived from utaut , in relation to "generation z" consumers. generation z is described as a generation that values individual identity (fontein, ) , so studying individual differences, such as technology readiness role in adopting technology, is important when investigating try-on technology. this research occurs during the covid- pandemic, which has resulted in a significant (and often forced) shift towards e-retailing. therefore, this research is expected to provide both the literature and the industry with insights into how to communicate with their future consumers, specifically the centennials who constitute the present and the future of e-retailing. the rest of this paper is organized as follows. in section , we discuss the literature relating to the main research question of this paper. the literature review will consider e-fashion shopping and e-fashion retailing, virtual reality and its relationship to fashion e-shopping, and the relevant theories of technology adoption. in section , we introduce the developed research framework and the hypotheses. the research methodology and the analytical results are described in sections and . the findings are discussed from a theoretical standpoint in section , while section presents limitations and suggestions for future research. vr technology is a form of interactive image technology that produces an experience similar to that of reality and stimulates innovative thinking and imagination (yang & xiong, ) . vr technology allows consumers to view products in different colors and from different angles, and to change the zoom view (zhang, lv, chen, & jiang, ) . generally, there are two forms of vr. the first is the two-dimensional form that represents a d photograph of the outfit. the second is the three-dimensional form, which is also known as the d mannequin (moroz, ) . virtual-try-on technology is defined as those platforms, such as retailers' website pages and mobile apps, that allow the consumer to experiment with clothing in a virtual representation of the consumer (sánchez-ferrer et al., ) . virtual try-on technology is, therefore, considered a d form of vr. van kerrebroeck, brengman, and willems ( ) stated that using vr increases the engagement of the human senses. hence, interacting with objects in an immersive virtual environment provides customers with a similar experience to interacting with objects in the physical environment. in the early twenty-first century, e-commerce has utilized vr to create an efficient and more realistic shopping experience by providing websites with vr interfaces (brusilovski et al., ; pizzi, scarpi, pichierri, & vannucci, ) . in this study, we focus on d try-on technology as an application of vr in apparel e-retailing. online apparel shopping provides customers with an efficient shopping experience in comparison to traditional shopping; however, it also deprives them of physical apprehension of products. to overcome this problem, e-retailers have resorted to virtual try-on technology (ayush, jandial, chopra, hemani, & krishnamurthy, ) . such technology is used by many retailers to enhance the customer experience, advance product visualization, and offer sensory input to fashion e-shopping (kim & forsythe, ) . it enables customers to use images of themselves and to dress virtual models with apparel and accessories (baier, rese, & schreiber, ; daponte, de vito, picariello, & riccio, ; rese, baier, geyer-schulz, & schreiber, ) . hence, the experience will become more meaningful and the customer will have sufficient information to enhance product evaluation and minimize associated risk. three-dimensional virtual modelling of clothing is the traditional method for providing precise control, geometric transformations, and physical constraints of clothing material (ayush et al., ) . however, according to another study, virtual fitting is not that easy, and d virtual prototyping in the apparel industry has been slow and complex. recent image-based virtual try-on systems provide a more economical solution without resorting to d information, and they have shown promising results by reformulating the problem as one of conditional image generation (papahristou & bilalis, ) . also, factors such as privacy and security expectancies, previous experience with technology, and consumer innovativeness have affected customer intention to accept and use new technology (margulis, boeck, & laroche, ) . the slow movement and complexity of d virtual try-on technology in apparel context indicates a need to further investigate variables that affects adoption of this technology. yim et al. ( ) used two fashion productssunglasses and watches to assess how effective virtual try-on is as an e-commerce tool. their results showed that virtual try-on positively influenced purchase intention by producing higher novelty, immersion, enjoyment, and usefulness, and that it enhanced the attitude toward online shopping for fashion products. beck and crié ( ) studied the effect on the intention to purchase resulting from try-on fitting rooms embedded on retailers' websites. they found that virtual try-on fitting rooms increased customers' intention to purchase products both online and offline. as the virtual try-on technology becomes more popular, more research is needed to understand what factors influence customers' intention to adopt this technology. rese et al. ( ) measured consumer acceptance of virtual try-on in marketing and retailing by using a basic tam. the results reinforced the validity of the basic tam. it also emphasized that both perceived ease-of-use and perceived usefulness influence online shoppers' intention to use virtual-try on technology. kim and forsythe ( ) investigated customers' use of virtual try-on to decrease the risk of purchasing apparel and increase enjoyment when online shopping for apparel. the researchers applied a modified tam to understand the virtual try-on technology adoption process. the results of the proposed model showed that perceived ease-of-use and perceived usefulness have a positive effect on attitudes toward using virtual try-on technology, which in turn positively influenced attitudes toward using virtual try-on technology in the fashion context. moreover, the positive attitude was reported to influence their intention to use virtual try-on favorably. kim and forsythe ( ) also emphasized the importance of consumer traits, such as technology innovativeness, which may directly affect intention to use virtual try-on irrespective of the shopper's attitude toward using it. more recently, zhang et al. ( ) demonstrated a relationship between customers' attitudes toward virtual try-on technology and their intention to purchase apparel online. the results of the proposed model, which incorporated tam and perceived privacy risk, also supported a positive relationship between perceived usefulness, perceived enjoyment, and perceived privacy risk of using virtual try-on technology. huang and qin ( ) examined user acceptance and adoption of virtual try-on technology by using an extensive model that combines the utaut model and perceived risk. their results confirmed a significant effect of performance expectancy, effort expectancy, social influence, and perceived risk on online customers' intention to use virtual try-on technology. like previous research on technology acceptance, huang and qin ( ) did not consider individual traits, focusing only on technology-related aspects. several models and frameworks have been developed to explain user acceptance by introducing factors that can affect user acceptance and adoption of new technologies (taherdoost, ) . examples include the diffusion of innovation theory (rogers, ) and the model of pc utilization (thompson, higgins, & howell, ) . however, a significant share of technology acceptance research has been built on tam, tam extensions (tam ), and utaut (maillet, mathieu, & sicotte, ; qasem, ; taherdoost, ) . while tam has a very high prediction of technology acceptance and adoption in mandatory settings, it does not have the same significance in voluntary settings. therefore, tam was introduced with the inclusion of different constructs. for example, social constructs (e.g., subject norms), cognitive constructs (e.g., result demonstrability), and emotional constructs (e.g., enjoyment) were incorporated as antecedents to perceived ease-of-use and perceived usefulness to advance the predictive power of the model in voluntary settings (taherdoost, ) . however, the incorporated variables did not consider individual differences and their role in technology acceptance. the success of tam and tam , as well as that of other models and theories, in explaining technology acceptance and adoption behavior encouraged venkatesh, morris, davis, and davis ( ) to unify the it acceptance literature and develop utaut as a holistic model that integrates the primary influencers of eight different models and theories to comprehend the factors influencing the adoption and use of technology (dwivedi, shareef, simintiras, lal, & weerakkody, ) . utaut consists of four fundamental variablesperformance expectancy, effort expectancy, social influence, and facilitating conditionsthat mirror tam's main constructs of perceived usefulness and perceived ease-of-use (holden & karsh, ) , as well as four moderating variables of gender, age, experience, and voluntariness of use. like tam, utaut contains constructs that focus on individual perception of a system's usefulness and its ability to increase productivity, as well as the ease by which an individual can learn to use the system in the work environment (maillet et al., ) . however, utaut failed to explain variables considered to be of high importance for the assessment of technology success, such as user satisfaction (merhi, hone, & tarhini, ) . to overcome these limitations, and to understand the voluntary use of new technology in the consumer context, venkatesh et al. ( ) developed utaut as an extension to the original utaut. the new model incorporates price value, hedonic motivation, and habit as additional constructs to the main model. utaut was designed to deliver a rigorous framework for explaining technology acceptance and use, primarily in the consumer context (venkatesh et al., ) . utaut inspects the effect of external factors on an individual's cognitive response, affective response, and intention to accept and adopt new technology (maillet et al., ) . compared to utaut, utaut improved the predictivity of behavioral intention and actual use of new technology (rasmi et al., ) , indicating that the theory is solid and well validated. due to utaut being a robust and well-established theory that can predict individuals' acceptance and use of technology in a consumer voluntary setting, this paper will adopt utaut as the main theory to explain consumer acceptance and adoption of virtual try-on technology. compared to tam and utaut, utaut does not consider the role that individual differences have on technology acceptance and adoption. the literature provides evidence supporting the active effect of individual traits and psychological factors. for example, pramatari and theotokis ( ) posited that individual traits, such as technology anxiety, affect an individual's attitude toward new technology. kim and shin ( ) also reported the importance of affective qualities (e.g., mood, emotions, feelings) as determinants of individual perceptions, cognitions, and behaviors. hence, ignoring the personality traits and their effect on technology adoption may lead to a poor understanding of how people adopt the technology. technology readiness (tr) is a personality trait that measures an individual's orientation to technologies (wang, so, & sparks, ) . parasuraman ( ) introduced the technology readiness index (tri) as a multiple-item scale that can be used to evaluate and assess an individual's readiness to embrace and use new technologies for accomplishing goals in different contexts (e.g., home life, work life). to measure technology readiness, the tri uses four personality traits that act as motivators and inhibitors: optimism, innovativeness, discomfort, and insecurity. optimism refers to "a positive view of technology and a belief that it offers people increased control, flexibility, and efficiency in their lives"; innovativeness relates to "a tendency to be a technology pioneer and thought leader"; discomfort refers to "a perceived lack of control over technology and a feeling of being overwhelmed by it"; and insecurity relates to "distrust of technology and skepticism about its ability to work properly" (parasuraman, , p. ) . tri motivators (optimism and innovativeness) represent variables that contribute to an individual's technology readiness; on the other hand, inhibitors (discomfort and insecurity) represent variables that weaken an individual's technology readiness (parasuraman & colby, ) . thus, individuals' openness to technology is determined by the relative strength of motivators and inhibitors. the stronger the individual score on motivators, the more he/she shows comfort using the technology, whereas the stronger the individual score on inhibitors, the less he/she shows comfort using the technology (walczuch, lemmink, & streukens, ) . however, each dimension is distinct, and individuals have varying combinations of these traits (mishra, maheswarappa, & colby, ) . the association between tri constructs and other acceptance models has been investigated in the context of work. for example, walczuch et al. ( ) explored the relationship between tri constructs and tam constructs in the context of services, reporting a positive relationship between service employees' optimism, perceived ease-of-use, and perceived usefulness. walczuch et al. ( ) also found a negative relationship between innovativeness and perceived usefulness. in more recent work, alsyouf and ishak ( ) emphasized the need to investigate the effect of tri constructs on technology adoption in the medical context. in their conceptual paper, they proposed tri variables as antecedents to effort expectancy and performance expectancy in utaut. following the literature, we propose incorporating tri and utaut to improve the understanding of variables that affect vr acceptance and adoption. however, our research will not look at the negative aspect of the tri index (discomfort and insecurity). this is because centennials are aware of technology and very comfortable around it (singh & dangmei, ) , so we assume that they have no discomfort or insecurity traits related to technology. centennials, also known as "generation z" (llopis-amorós, gil-saura, ruiz-molina, & fuentes-blasco, ), have distinctive characteristics that differentiate them from other generational cohorts. it is a digitally native generation that feels natural and at ease around technology (singh & dangmei, ) . as a result, centennials extensively use communication technology and are constantly connected to the world (priporas, stylos, & fotiadis, ) using different devices and technologies. with easy access to information, and having grown up around technology and technological innovations, centennials are characterized as impulsive and new challenge seekers. hence, centennials are described as innovative (wood et al., ) and as experience seekers who have a need to feel safe and to escape reality temporarily (priporas et al., ) . centennials are fashion-oriented and keen on customized fashion. however, they are also described as price-sensitive (muralidhar, ) . they are considered to be difficult customers who expect retailers to provide products at their comfort, but without showing any tendencies to be loyal customers (priporas et al., ) . therefore, there is an added pressure on retailers to find a suitable way to cater to this cohort's needs. centennials represent potentially important present and future customers of e-retailers. in particular, centennials' concerns about adopting shopping technology makes it very important for e-retailers and researchers to understand the personal and external variables that influence this generation's decision to adopt virtual try-on technology. given the increasing call to investigate the effect of merging models with a focus on both computer system design and individual characteristics in the consumer context, this study provides a holistic model that combines personality-based and cognitive antecedents (alsyouf & ishak, ) to explain centennials' adoption of try-on technology. to achieve our goal, we integrate both utaut and tri to investigate consumer adoption of try-on technology in the apparel retailing context. the legitimacy of this integration has two foundations. first, utaut was developed from utaut to explicate customers' acceptance of new technology in the consumer context (venkatesh et al., ) ; similarly, tri was intended to explicate people's perception of technology in several fields (alsyouf & ishak, ; parasuraman, ) . second, pocius ( ) stated that both computer system design and users' characteristics mediate the human-computer interaction. utaut is notable for using system-related variables to explain customer adoption of new technology, whereas tri focuses on personality characters to assess an individual's orientation to technologies. hence, combining the models is expected to give a more holistic view of new technology adoption. additionally, the association between tri constructs and other tams has been investigated in the working context (e.g., walczuch et al., ) . therefore, it is theoretically suitable to merge utaut with tri to create a single model of empirical investigation to examine consumers' acceptance and adoption of try-on technology in the online apparel shopping context. utaut proposes seven independent core variables: performance expectancy (pe), effort expectancy (ee), social influence (si), price value (pv), hedonic motivation (h), habit (hb), and facilitating conditions (fc) (venkatesh et al., ) . however, in this study we focus on only four of these variables: pe, ee, pv, and hm. three utaut variables have been excluded: fc, si, and hb. in both utaut andutaut , fc is proposed in a model that considers the actual users and adopters of new technology, and the relationship and impact of fc directly relates to actual adoption. the current study was conducted on potential users and examined the relationship of different variables on intention to adopt try-on as a new technology. also, the main participants in this study were potential adopters who had not formulated an experience with the facilities, the technical support, or the tools pertaining to try-on technology. hence, we decided to excluded fc from the proposed model. the relationship between si and behavioral intention has repeatedly been reported as insignificant in studies on technology acceptance in jordan (e.g., alalwan, dwivedi, & rana, ; alalwan, dwivedi, rana, & algharabat, ) . one reason for this result is the vast experience of using technology among jordanians. as jordanians have become more experienced and familiar with technology, they are showing less interest in other people's opinions regarding adopting a new technology (tarhini, alalwan, al-qirim, & algharabat, ). as this study's sample is centennials who are native to technology, it is expected that si has no impact on intention to adopt try-on technology. in addition, try-on technology is a self-service technology, so it is expected that people who would like to use it will largely depend on their own experience rather than on other people's experiences. in light of this, si was excluded from the proposed model. "habitual" indicates that individual has already formed a habitual behavior in using the system. the present study's sample consisted of potential adopters who had not been validated as having formed such behavior. venkatesh et al. ( ) reported a relationship between habitual behavior and actual behavior. given this, the current study was conducted on potential users and examined the relationship of different variables on intention to adopt try-on as a new technology. hence, hb was excluded from the proposed model. impact of utaut main constructs on the intention to use try-on technology in online fashion shopping performance expectancy is defined in utaut as an individual's belief that the new technology will aid him or her to achieve job performance (venkatesh et al., ) . it is expected that individuals who perceive new technology as beneficial will intend to adopt the new technology. venkatesh et al. ( ) conceptualized performance expectancy as depending on related factors such as perceived usefulness (davis, bagozzi, & warshaw, ) and relative advantage (rogers, ) . this construct has steadily been shown as a valid and strong predictor of behavioral intention (bi) in different fields (alalwan et al., ; lee & wan, ; qasem, ; venkatesh et al., venkatesh et al., , . try-on technology allows customers to try the outfit on an avatar that represents their own body, which will help customers to judge if they like the outfit and aid them in making the decision and eliminating any mistakes they might make when buying apparel and fashion products online (van kerrebroeck et al., ) . this, in turn, makes users of such systems feel more productive and efficient in their shopping process, and it improves the retailer's sales efficiency. therefore, we assume a positive relationship between performance expectancy and the adoption of virtual try-on technology: h . performance expectancy is positively related to the intention to adopt try-on technology in the fashion context. utaut also postulates that effort expectancywhich is defined as the level at which individuals perceive the system as easy to use (venkatesh et al., ) has a positive relationship with intention to adopt and use new technology. the definition of effort expectancy suggests that the easier it is to learn how to use a specific technology, the higher the intention to adopt the new technology. effort expectancy has similarities with tam's ease of use construct (venkatesh et al., ) ; hence, it also represents individuals' perceptions of how easy it is to invest effort in using the technology (li & xu, ) . generation z is native to technology, so it is expected that they have dealt with similar technology in a different context (e.g., games and e-learning: persada, miraja, & nadlifatin, ). as a result, it is expected that they only need to put minimal effort into learning how to use the try-on technology. hence, we assume a positive relationship between effort expectancy and intention to adopt try-on technology: h . effort expectancy positively influences intention to adopt try-on technology in the fashion context. in utaut , hedonic motivation is conceptualized as the fun or pleasure that individuals experience from interacting with a technology (venkatesh et al., ) . venkatesh et al. ( ) introduced hedonic motivation as a variable that, specifically in the customer context, impacts an individual's intention to perform a behavior. apparel and fashion customers are expected to enjoy the process of using try-on technology (erra, scanniello, & colonnese, ) . for example, customers are expected to enjoy virtually trying on and comparing multiple outfits. try-on technology in jordan is considered a unique and novel application that can create an outstanding shopping experience and heighten the customer's experience of pleasure in using such an application. therefore, it could be expected that customers who use try-on technology are more likely to have such a hedonic sense, and hence that they will be more motivated to use it. hedonic motivation has been reported to significantly affect behavioral intention in studies conducted in diverse contexts, such as mshopping (e.g., alalwan, ) , mobile banking (e.g., alalwan et al., ) , and online shopping (e.g., brown & venkatesh, ; van der heijden, ) . hence, we hypothesize that there is a positive relationship between hedonic motivation and behavioral intention: h . hedonic motivation positively influences intention to adopt try-on technology in the fashion context. price value is defined as individuals' rational trade-off between the expected benefit of using the system and the financial cost of using it (venkatesh et al., ) . in the consumer context, the financial cost has an important role in influencing the willingness of customers to adopt and accept new technology (mallat & tuunainen, ; venkatesh et al., ) . a recent study conducted by alalwan ( ) found the significant impact of price value in the customer experience satisfaction with mobile food ordering applications. try-on technology is expected to lower online purchase risk, particularly when a customer explores how the item will look on him/ herself before purchase. therefore, we hypothesize that there is a positive relationship between perceived price and behavioral intention: h . price value positively influences intention to adopt try-on technology in the fashion context. a person who possesses an optimistic belief toward technology thinks that new technologies are more controllable, flexible, and efficient (parasuraman, ) . the literature has established a relationship between optimism and functional factors such as perceived ease of use and usefulness of technology (e.g., wang et al., ) . lu, wang, and hayes ( ) have stated that optimism positively affects technology functionality in consumer to consumer platforms. performance expectancy is defined as the individual's belief that the new technology will aid him or her to achieve job performance (venkatesh et al., ) . as a new advanced system, try-on technology is more likely to be perceived as a novel technology that enjoys a high degree of convenience and customization. optimism also pertains to the customer's feelings that new technology could give him/her more flexibility in carrying out the shopping process at time and place of convenience (pham, nguyen, & luse, ) . in the e-payment context, acheampong et al. ( ) reported a positive relationship between optimism and perceived usefulness. similarly, a positive relationship has been reported between optimism and perceived usefulness in passengers' adoption of airport self-service systems (kim & park, ) . accordingly, it could be argued that customers with an adequate degree of optimism are more likely to perceive try-on technology as more efficient. hence, we hypothesize a positive relationship between optimism and performance expectancy: h . . optimism has a positive influence on performance expectancy of try-on technology in the fashion context. effort expectancy represents the degree of ease the user associates with using a system (venkatesh et al., ) . consumer behavior and reaction toward new systems are largely shaped by the extent to which the customer believes that the systems can provide more controllability of the shopping experience (meuter, ostrom, roundtree, & bitner, ; parasuraman, ) . pham et al. ( ) stated that optimism affects how people perceive technology in terms of its ease-of-use. jeong and ha ( ) reported a positive relationship between optimism and ease of use in the individual's intention to use retail service robots. as a new advanced system, try-on technology is more likely to be perceived as more controllable and novel by optimistic individuals who tend to think that they can easily learn how to use it. accordingly, it could be argued that customers with an adequate degree of optimism are more likely to perceive try-on technology as easy to use and expect to put less effort in using try-on technology. hence, we hypothesize a positive relationship between optimism and effort expectancy: optimism has a positive influence on effort expectancy of try-on technology in the fashion context. similar to many activities conducted in the online environment, online shopping is identified as a risky situation (yıldırım, arslan, & barutçu, ) . individuals are expected to develop a level of stress while shopping online. this stress might be attributed to the risk of choosing an item that does not fit their figure or spending too much time on a failure purchase. however, optimistic individuals are expected to cope with stress and decrease pessimism in general situations pathak & lata, ) . several studies have reported a significant and positive relationship between optimism and positive feelings in various situations. nguyen et al. ( ) and pathak and lata ( ) found that optimism allows individuals to cope with stress and to decrease pessimism in general situations. similar results were reported by mittal ( ) who found that optimistic individuals show fewer signs of stress while shopping online. optimism has also been linked to experiencing a higher amount of positive emotions, such as happiness (pacheco & kamble, ) . therefore, we hypothesize a positive relationship between optimism and hedonism: h . . optimism has a positive influence on perceived hedonism while using try-on technology in the fashion context. the financial cost of adopting a new technology is a significant concern for individuals when considering whether to adopt a new technology. venkatesh et al. ( ) introduced price value as the consumer's reasoning about the perceived benefit of adopting a new technology and the financial cost of using it. try-on technology is expected to lower the financial cost of online shopping. when using try-on technology, individuals are expected to save the money that would otherwise be spent on traveling to physical retail shops, to lower the risks of buying an apparel that does not fit and of losing time, effort, and money. optimism plays a dominant role in how people identify situations as risky (schaupp & carter, ) . it is expected that an optimistic individual does not think that he/she is at risk, which indicates that cost is minimized and value is maximized; thus, it is expected that an optimistic individual will perceive price positively. optimistic individuals are expected to perceive try-on technology as a means to lower the financial risks associated with choosing the wrong item (such as fees to return the item) as well as the costs of traveling. therefore, we hypothesize a positive relationship between perceived price and optimism: h . . optimism has a positive influence on perceived price while z. qasem using try-on technology in the fashion context. innovativeness represents an individual's willingness to be a technology pioneer and to try new technologies (parasuraman, ) . it is expected that individuals who enjoy a high level of innovativeness are more likely to positively value the technology systems in terms of usefulness. performance expectancy concerns the individual's perceived benefit of using a technology (venkatesh et al., ) . innovative individuals tend to link not being able to use a new technology with losing potential benefit; hence, they value the usefulness of new technology (walczuch et al., ) . try-on technology offers a number of utilitarian benefits, such as saving traveling time and effort. it also provides the flexibility of shopping at a convenient time. hence, it is expected to be perceived as useful. several studies have reported a positive relationship between innovativeness and perceived usefulness. lin, shih, and sher ( ) found that innovativeness resulted in a higher perceived usefulness of e-services. acheampong et al. ( ) reported a positive and significant relationship between innovativeness and usefulness in the e-payment sector. since performance expectancy represents the functional part of utaut and resembles perceived usefulness of technology, we hypothesize a positive relationship between innovativeness and performance expectancy: h . . innovativeness has a positive influence on performance expectancy of try-on technology in the fashion context. people with the trait of innovativeness have more flexible beliefs about new technology (karahanna, straub, & chervany, ) . effort expectancy represents the extent to which customers perceive a new technology as simple and effortless (venkatesh et al., ) . hence, it is expected that innovative individuals are more likely to perceive new technology as simple and to expect to invest less effort in learning how to operate the new technology. although try-on technology is considered new to jordanian centennials, they are experienced and knowledgeable in using technology in general. hence, it is expected that innovative individuals will perceive try-on technology as easy to use. a number of studies have reported a positive relationship between innovativeness and ease of use. for example, chen and lin ( ) reported a positive relationship between innovativeness and perceived ease-of-use of healthy eating apps. acheampong et al. ( ) found a positive and significant relationship between innovativeness and perceived ease-of-use in the e-payment sector. since effort expectancy represents the functional part of utaut and resembles perceived ease-of-use, we hypothesize a positive relationship between innovativeness and effort expectancy: hedonic value is defined as the pleasure and enjoyment resulting from using a technology (brown & venkatesh, ; venkatesh et al., ) , and it has been proven to impact intention to adopt new technology, especially in the case of hedonic systems that are described as creative and unique, such as mobile banking (alalwan et al., ) and virtual try-on technologies. innovativeness has been found to be an antecedent of hedonic value (hong, lin, & hsieh, ) . customers described as innovative are expected to possess fewer complicated beliefs about new technology (karahanna et al., ) . people with high technology innovativeness are more likely to accept and enjoy using new technology (yi, tung, & wu, ) , especially try-on technology which is expected to have a hedonic side to it. hence, we hypothesize a positive relationship between perceived hedonism and innovativeness: h . . innovativeness has a positive influence on perceived hedonism while using try-on technology in the fashion context (fig. ) . innovativeness is considered a stable trait that is manifested in inquisitive behavior and in the individual's belief that he/she can use technology and overcome the uncertainty associated with the usage of new technologies (agarwal & prasad, ; walczuch et al., ) . with the minimization of uncertainty, the associated risk is also minimized, which indicates that cost is minimized and value is maximized. try-on technology is a new type of technology, particularly for jordanians who are not yet familiar with it. however, this study's sample is centennials who are native to technology and considered to be an innovative generation. by possessing these traits, this group are expected to be able to overcome the uncertainty associated with try-on technology and, consequently, to perceive this technology as less risky and less costly. thus, it is expected that an innovative individual will perceive price positively: h . . innovativeness has a positive influence on perceived price while jordan was selected for data collection for this study because it is one of the seven middle eastern frontier markets (msci frontier markets index, ). hence, we can generalize the results of this study to other markets. the data was collected using a convenience sampling approach. to validate the proposed conceptual model, empirical data was collected by distributing self-administered questionnaires among jordanian centennials, of which were eligible for further analysis. the questionnaires were distributed in places where the potential targets were available, such as universities and cafes. the questionnaire aimed at generating answers regarding jordanian centennials' technology readiness, and their insights into the variables relating to intention to use tryon technology. notably, the primary variables of utaut (pe, ee, h, pv, and bi) were measured using scales adapted from venkatesh et al. ( ) . technology readiness was measured by items taken from parasuraman ( ) . to measure the participants' responses on the primary variables of utaut , a five-point likert scale ranging from strongly agree to strongly disagree was adopted. as for technology readiness, this study used the item from tri to measure optimism and innovativeness; participants specified the degree to which they agreed or disagreed with each of the items on a five-point likert scale. the questionnaire concluded with six closed-ended questions aiming to collect demographic data (age, gender, income, educational level, tryon technology experience, and marital status). the questionnaire was first developed in english. however, to minimize the impact of language differences, the questionnaire was translated into arabic. professional back-translation was performed to validate translation (brislin, ) . males accounted for % of participants and females for % of participants. most respondents ( %) were aged between and years, and the age group of - accounted for . % of participants. of the participants, % had achieved at least a bachelor's degree, and . % reported that they had used computers and the internet for more than three years. however, % of respondents reported having no experience with using try-on technology (table ) . to validate the proposed model and test the hypotheses, a two-step approach was followed (anderson & gerbing, ) . first, confirmatory factor analysis was run to ensure a suitable level of model fitness, as well as the validity and reliability of the constructs; secondly, the hypotheses were tested (structural model). to preserve satisfactory sample size-to-parameter ratios, the measures were separated into two subgroups of variables based on their theoretical relationship (morgan, kaleka, & katsikeas, ). the first group included utaut variables; the second subset included tri dimensions. to ensure the reliable production of an unbiased estimate, we performed the elliptical reweighted least-squares estimation procedure (yuan, bentler, & chan, ) . the preliminary measurement fit indices of the first subgroup were as follows: cmin/df = . ; incremental fit index (ifi) = . ; root mean square error of approximation (rmsea) = . ; goodness-of-fit index (gfi) = . ; normed-of-fit index (nfi) = . ; comparative fit index (cfi) = . . the preliminary measurement fit indices of the second subset were as follows: cmin/df = . ; ifi = . ; rmsea = . ; gfi = . ; nfi = . ; cfi = . . to confirm the reliability and validity of the constructs, composite reliability (cr) and average variance extracted (ave) were used in this study (anderson & gerbing, ) . the cr values for all constructs were above . (fornell & larcker, ) . the cr results recorded the highest value for optimism and the lowest value for social influence. all constructs had an acceptable ave value higher than . (fornell & larcker, ; hair, tatham, anderson, & black, ) . the highest ave value was for perceived hedonism, while the lowest value was for insecurity (see tables and ) . the second step of the two-step approach investigated the adequacy of the conceptual model and tested the hypotheses relating to it. results of running the structural model were within the acceptable levels: gfi = (hair et al., ; tabachnick, fidell, & ullman, ) . the proposed model was found to predict a satisfactory portion of the variance in the actual use of behavior, with an r value of . . the predictive validity of the current study model is, therefore, supported (table ). online fashion and apparel retail businesses are booming, yet they still lag behind other online retailing businesses such as sporting equipment, technology, and diy products (customers, ) . this lag has been attributed to the nature of apparel, which requires the customer to feel and try the product before making the purchase decision (blázquez, ) . to provide a more realistic experience, e-retailers have resorted to virtual try-on systems. hence, it is vital to explore the factors affecting customers' intention to use try-on technologies when online shopping for apparel. centennials were chosen as the focus of this study because they are innovative, optimistic about technology, and represent major customers for online retailers. centennials are also native to technology, so, to answer the main research question, we proposed and tested a model that incorporated factors from utaut and tri so that the study focused on both computer system design and individual characteristics. the factors that influence the intention to adopt try-on technology were based on the utaut model. out of four factors considered in this research, three of them positively influenced the behavioral intention that leads to the adoption of virtual try-on technology. the results indicated a positive relationship between performance expectancy, perceived hedonism, and price value on behavioral intention to use virtual try-on technology. performance expectancy was found to have a positive relationship with centennials' intention to accept try-on technology in the context of purchasing fashion online. this result matches previous research results that reported a strong relationship between performance expectancy and intention to adopt technology in different contexts, including that of online shopping (e.g., dwivedi et al., ; lian & yen, ; venkatesh et al., ) . centennials, who spend significant time shopping online, are looking for an efficient shopping experience (bruno, ) ; hence, it is expected that they will use try-on technology to shop online. the results show a significant relationship between hedonic motivation and centennials' intention to adopt try-on technology in the fashion context. this result matches previous research that found a significant relationship between hedonic motivation and behavioral intention to adopt new technology in different contexts, including online shopping (brown & venkatesh, ; van der heijden, ) and mobile and internet banking (e.g., alalwan et al., alalwan et al., , . centennials are described as an experience-seeking cohort who want to temporarily escape reality (priporas et al., ) . therefore, they are expected to show an intention to adopt technology that enhances their sensory experience and provides them with a similar experience to shopping in the physical environment. effort expectancy was found to have no influence on the intention to adopt virtual try-on technology. although this result was unexpected, the definition of effort expectancy resembles that of perceived ease-ofuse, and similar results have been found between perceived ease-ofuse and behavioral intention (venkatesh et al., ) . the insignificant relationship could be due to centennials' high level of experience in using technology. being well acquainted with technology, centennials find using new technology effortless and easy to learn, so effort expectancy does not affect their intention to use it. optimism was revealed to have the strongest impact on performance expectancy. this result is consistent with previous results reported in different contexts (e.g., koloseni & mandari, ) . possession of the optimism trait indicates that individuals have a positive perception of technology (napitupulu, pamungkas, sudarsono, lestari, & bani, ) . hence, it is expected that individuals will perceive technology as an aid in the process of shopping online. optimism also has a positive impact on hedonism, because optimistic individuals can cope with stress and expect a positive outcome (scheier & carver, ) . optimism has also been linked to experiencing a higher amount of positive emotions, such as happiness (pacheco & kamble, ) . the results show that optimism has a positive impact on the perceived price. optimism refers to an individual having a positive belief about technology, its functionality, and its efficiency (pham et al., ) . therefore, it is expected that optimistic individuals will perceive associated risks as very low (schaupp & carter, ) , and that, by comparing the perceived value to risk, they will start perceiving the associated price as adequate. innovativeness was found to positively impact performance expectancy. this can be attributed to the tendency of innovative individuals to be technology pioneers and thought leaders (napitupulu et al., ) . hence, they possibly carry out substantial performance while using any new technologies (turan, tunç, & zehir, ) . the results showed that innovativeness has no impact on perceived hedonism. this finding was not expected. however, innovativeness is divided into hedonist innovativeness (linked to the need for stimulation) and social innovativeness (linked to the need for uniqueness) (roehrich, ) . one possible explanation is that innovative centennials value uniqueness more than stimulation, especially when they are more familiar with the technology of augmented reality. innovativeness was found to positively impact perceived price. this can be attributed to the trait of innovativeness undermining the risk effect (walczuch et al., ) . as a result, an innovative individual perceives the price of technology as adequate. neither optimism nor innovativeness had any impact on effort expectancy, which was an unexpected result. however, this may have been because centennials are highly acquainted with new technologies and aware of the newest developments and possibilities to the extent that using any new technology is not perceived as a challenge. this study contributes to the existing literature on technology adoption in several ways. first, to the best of our knowledge, it is among the first studies to suggest a model that focuses on both computer system design and individual characteristics in the consumer context. as such, this study proposes a model that combines variables from both utaut and tri. secondly, this study has mainly focused on combining these two models in the consumer context. previous studies that had the same notion of combining models have mainly focused on studying tri in the work context. thirdly, this study empirically tested the proposed model and achieved reliable findings, which can be generalized to the target population. it also reports results that contradict the expected results, which provides scope for future research and further investigations on the target group. fourthly, the choice of centennials as the population for this study is one of its main contributions due to this group's special characteristics. for example, centennials are described as techno-savvy and experts in technology, in addition to being an experience-and efficiency-oriented cohort. virtual try-on technology provides a means to enhance online fashion and apparel retailing. hence, fashion retail businesses should consider adopting this technology, which in turn means that they should focus on understanding the factors that will lead to customers adopting this technology. this study is of great practical importance because it provides retailers with a guide to the factors that affect the consumer adoption process for this new technology, and it also sheds light on the importance of centennials' personality traits and their effect on the adoption of virtual try-on technology. the special nature of apparel as a high-involvement product means that customers need to have direct experience (touching, feeling, and trying) with the item before purchasing. try-on technology, by providing customers with a sensory-like experience, is one solution to the problem of online retailing in the fashion and apparel sector. providing more realistic information about fashion items using virtual try-on technology will also lead customers to make more reliable decisions, which will in turn reduce the number of returned items (joshi, ). an additional benefit of this technology is that it allows customers to access a wider variety of clothes than they would find in physical stores. all of the advantages of virtual try-on technology discussed above incorporate utilitarian benefits such as saving time and effort, which is of great importance to centennials. the results of this study show a relationship between performance expectancy and the intention to adopt try-on technology. hence, this study highlights the importance of retailers creating websites that incorporate try-on technology most efficiently. this technology has other benefits that enable customers to try on clothes in the comfort of their own homes, and that reduce the cost of returning items that do not fit due to inadequate product evaluation before purchase (li & xu, ) . this not only saves effort but also reduces the costs of transportation, parking, and other expenses. the results of this study show that, among centennials, there is a relationship between perceived price and intention to adopt try-on technology, which can be linked to centennials' price sensitivity. therefore, e-retailers may want to focus more on creating promotional activities that encourage centennials to visit e-stores, since such activities will add to the perceived value. the results of this study support the importance of hedonic factors provided by try-on technology. therefore, it is recommended that retailers incorporate playful and fun elements in their websites to enhance centennials' willingness to adopt try-on technology. although this study presents important insights into the area of adoption and use of virtual try-on technology in fashion and apparel e-retailing among centennials, it nevertheless has several limitations. for example, the sample for this study was collected in jordan. although centennials generally share the same generational cohort characteristics, this study did not consider cultural differences that might affect the generalizability of the findings to western countries. this limitation suggests that there is a potential to expand this research to western countries. a second limitation relates to the fact that try-on technology has not, to the best of our knowledge, been used yet in jordan; hence, most of the participants had not previously used virtual try-on technology and were basing their answers on their general knowledge using a survey. therefore, in our future agenda, we intend to use experiments to revalidate the findings of this study. finally, future research could, in accordance with the literature, incorporate other variables, such as risk, in the model because of their significant ability to explain intention to adopt new technologies. virtual try-on technology represents an attractive area of research, particularly because of its potential to help a booming field such as apparel and fashion e-retailing. taking into account the novelty of this topic and its strong ties to centennials, a generation that is native to technology, this study has revealed the necessity of investigating factors relating to systems and to personal traits that could shape centennials' intention to adopt virtual try-on technology. this research is especially important because, to the best of our knowledge, few, if any, studies have focused on all three aspects (virtual try-on technology, factors related to the system, and personal traits) and their effect on adoption among centennials. furthermore, two models were selected as the theoretical foundation of this study. utaut (venkatesh et al., ) was extended by incorporating the positive factors from tri. performance expectancy, hedonic motivation, and price value were demonstrated to be significant predictors of the behavioral intention to adopt virtual try-on technology among centennials. however, the influence of effort expectancy on centennials' intention to adopt virtual try-on technology was found to be insignificant. positive personal traits (optimism and innovativeness) were found to have a significant effect on centennials' intention to adopt new technology by influencing their perception of performance expectancy, hedonic motivation, and price value. this is to state that i am zainah qasem the only author of this paper. therefore, i was responsible for all roles related to writing this manuscript. hybridizing an extended technology readiness index with technology acceptance model (tam) to predict e-payment adoption in ghana a conceptual and operational definition of personal innovativeness in the domain of information technology mobile food ordering apps: an empirical study of the factors affecting customer e-satisfaction and continued intention to reuse examining factors influencing jordanian customers' intentions and adoption of internet banking: extending utaut with risk factors influencing adoption of mobile banking by jordanian bank customers: extending utaut with trust acceptance of electronic health record system among nurses: the effect of technology readiness some methods for respecifying measurement models to obtain unidimensional construct measurement robust cloth warping via multi-scale patch adversarial loss for virtual try-on framework analyzing online reviews to measure technology acceptance at the point of scale: the case of ikea i virtually try it… i want it! virtual fitting room: a tool to increase on-line and off-line exploratory behavior, patronage and purchase intentions fashion shopping in multichannel retail: the role of technology in enhancing the customer experience back-translation for cross-cultural research model of adoption of technology in households: a baseline model test and extension incorporating household life cycle scouting the centennials: millennials must move over as the new kids start shopping adaptive hypermedia and adaptive web-based systems: international conference incorporation of health consciousness into the technology readiness and acceptance model to predict app download and usage intentions i like your product when i like my photo: misattribution using interactive virtual mirrors fastest growing online retail sectors unveiled state of the art and future developments of the augmented reality for measurement applications user acceptance of computer technology: a comparison of two theoretical models a generalised adoption model for services: a cross-country comparison of mobile health (m-health) exploring the effectiveness of an augmented reality dressing room everything social marketers need to know about generation z evaluating structural equation models with unobservable variables and measurement error multivariate data analysis the technology acceptance model: its past and its future in health care the effect of consumer innovativeness on perceived value and continuance intention to use smartwatch a study of online virtual fitting room adoption based on utaut. may consumer acceptance of retail service robots retailers have a lot to gain from ar and vr. forbes information technology adoption across time: a cross-sectional comparison of pre-adoption and post-adoption beliefs adoption of virtual try-on technology for online apparel shopping an acceptance model for smart watches: implications for the adoption of future wearable technology the effect of airport self-service characteristics on passengers' technology acceptance and behavioral intention the virtual dressing room trend: what retailers need to know the role of personal traits and learner's perceptions on the adoption of e-learning systems in higher learning institutions consumer need for mobile app atmospherics and its relationships to shopper responses including subjective norm and technology trust in the technology acceptance model: a case of e-ticketing in china a study of chinese consumers' adoption behaviour toward virtual fitting rooms online shopping drivers and barriers for older adults: age and gender differences integrating technology readiness into technology acceptance: the tram model social media communications and festival brand equity: millennials vs centennials how do technology readiness, platform functionality and trust influence c c user satisfaction modeling factors explaining the acceptance, actual use and satisfaction of nurses using an electronic patient record in acute care settings: an extension of the utaut exploring merchant adoption of mobile payment systems? connecting with consumers using ubiquitous technology: a new model to forecast consumer reaction a cross-cultural study of the intention to use mobile banking between lebanese and british consumers: extending utaut with security, privacy and trust self-service technologies: understanding customer satisfaction with technology-based service encounters technology readiness of teenagers: a consumer socialization perspective psychographics of comparison shoppers antecedents of export venture performance: a theoretical model and empirical assessment tendency to use the virtual fitting room in generation y: results of qualitative study msci frontier markets index understanding the purchase intention characteristics of gen y and gen z and introspecting the modern demand variables in fashion industry proposed trutaut model of technology adoption for lapor moderator roles of optimism and weight control on the impact of playing exergames on happiness: the perspective of social cognitive theory using a randomized controlled trial interest in virtual reality and augmented reality usage while shopping us the state of the ecommerce fashion industry: statistics, trends and strategy role of optimism in the well-being of undergraduate students in goa augmented reality platforms for virtual fitting rooms enhancing the online decision-making process by using augmented reality: a two country comparison of youth markets d virtual prototyping traces new avenues for fashion design and product development: a qualitative study can d virtual prototype conquer the apparel industry technology readiness index (tri): a multiple-item scale to measure readiness to embrace new technologies an updated and streamlined technology readiness index: tri . optimism in relation to resilience and perceived stress understanding the generation z behavior on d-learning: a unified theory of acceptance and use of technology (utaut) approach digital sensory marketing: integrating new technologies into multisensory online experience technology readiness and customer satisfaction in luxury hotels: a case study of vietnam virtual reality, real reactions? comparing consumers' perceptions and shopping orientation across physical and virtual-reality retail stores personality factors in human-computer interaction: a review of the literature consumer acceptance of rfid-enabled services: a model of multiple attitudes, perceived system characteristics and individual traits generation z consumers' expectations of interactions in smart retailing: a future agenda the role of website experience in building attitude and intention towards online shopping healthcare professionals' acceptance electronic health records system: critical literature review (jordan case study) how augmented reality apps are accepted by consumers: a comparative analysis using scales and opinions consumer innovativeness: concepts and measurements diffusion of innovations in-store experience: digital technologies retailers deploy in europe in data visualization in dashboards through virtual try-on technology in fashion industry ieee colombian conference on applications in computational intelligence (colcaci) the impact of trust, risk and optimism bias on e-file adoption effects of optimism on psychological and physical well-being: theoretical overview and empirical update help welcome or not: understanding consumer shopping motivation in curated fashion retailing understanding the generation z: the future workforce new trends in retailing and services using multivariate statistics a review of technology acceptance and adoption models and theories an analysis of the factors influencing the adoption of online shopping personal computing: toward a conceptual model of utilization a theoretical model proposal: personal innovativeness and user involvement as antecedents of unified theory of acceptance and use of technology user acceptance of hedonic information systems when brands come to life: experimental research on the vividness effect of virtual reality in transformational marketing communications user acceptance of information technology: toward a unified view consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology the effect of service employees' technology readiness on technology acceptance technology readiness and customer satisfaction with travel technologies: a cross-country investigation dynamic processes of territorial embeddedness in international online fashion retailing try it on! contingency effects of virtual fitting rooms augmented reality marketing: consumer preferences and attitudes toward hypermedia print ads incorporating technology readiness (tr) into tam: are individual traits important to understand technology acceptance? the role of uncertainty avoidance and indulgence as cultural dimensions on online shopping expenditure is augmented reality technology an effective tool for e-commerce? an interactivity and vividness perspective structural equation modelling with heavy tailed distributions research on virtual roaming technology of urban scene based on multi-mode human-computer interaction the role of virtual try-on technology in online purchase decision from consumers' aspect key: cord- -t xh authors: goodman, christopher w.; brett, allan s. title: accessibility of virtual visits for urgent care among us hospitals: a descriptive analysis date: - - journal: j gen intern med doi: . /s - - -x sha: doc_id: cord_uid: t xh nan complex regulations and limited reimbursement have hindered telehealth. however, increasing experience with telehealth during the covid- crisis represents an opportunity to facilitate its use more generally after this crisis. while telehealth has the potential to expand access to care, disparities in access are an ongoing concern. many hospitals now offer real-time "virtual visits" for common urgent care through their websites, which offer an opportunity to assess the accessibility of a typical telehealth service. we assembled a geographically representative sample of hospitals in the usa, according to previously published methodology. in brief, we selected hospitals according to an algorithm that involved gross receipts, geographic diversity, and bed size; at least one hospital in each state was included. hospitals are often part of multi-hospital systems with web portals for the entire network of hospitals. in our estimation, websites of sampled hospitals represented about hospitals, one-fifth of all us hospitals. many hospitals have begun offering virtual visits for urgent care with real-time connectivity through their websites. we chose to focus on virtual urgent care with both audio and visual connectivity. hospitals used different names for these services such as "e-visits," "virtual urgent care," and "virtual visits." we included links to primary care visits if the website clearly indicated quick access for urgent care. we excluded other versions of urgent care including online algorithms (e.g., "symptom checkers") or audio-only services. we examined hospital websites and their virtual visit sites, focusing on three accessibility characteristics: general availability, language accommodations, and affordability. general availability included the presence or absence of virtual visits and relevant exclusions. navigation started from the main hospital system website, with attempts to proceed logically to virtual urgent care, or "virtual visits." if that failed, a separate search was conducted with the hospital's name and "virtual visits." we included virtual visits with real-time, audio-visual connectivity for urgent care. websites were accessed march -april , . table ); however, restrictions were common: about onefifth of virtual visits were not publicly accessible. even among hospitals with publicly accessible virtual visits, further limitations included geographic limitations (i.e., accessing care across state lines) and exclusions for chronic health conditions. ease of navigation was variable. some virtual visit links were advertised on the main page, while others required more thorough searches. language accessibility was poor. among hospitals with virtual visits, % made language accommodations easily identifiable on navigation (usually only spanish translation). only hospital clearly noted interpreter options for virtual visits. most hospitals charged a flat fee for virtual visits (median charge, $ ). payment was usually required upfront; no hospital made accommodations for ability to pay (although % temporarily waived fees in relation to covid- ). virtual visits were not easily or equitably accessible; in general, navigation of hospital websites was challenging. most hospitals required navigation in english, and only one clearly offered interpreter services, which are considered best practice and legally required. exclusions for new patients or patients with chronic medical conditions suggest that clinicians and hospitals may be hesitant to care for new or complex patients without physical examinations; however, such exclusions favor healthier, insured patients. the requirement of up-front payment, albeit modest, reinforces bias towards higher income patients. other limitations such as the reading level of websites and internet bandwidth requirements were not assessed and deserve further investigation. broadband access is a welldescribed limitation for rural and low-income communities. the pattern that emerges in this survey is all too familiar: access favors generally healthy, well-off, english-speaking patients. we suspect this pattern results from a combination of telehealth policy constraints (e.g., limited reimbursement) and neglect on the part of clinicians and hospitals. public policy committee of the american college of physicians. policy recommendations to guide the use of telemedicine in primary care settings: an american college of physicians position paper virtually perfect? telemedicine for covid- telemedicine and the next decade in-person health care as option b charity care characteristics and expenditures among us tax-exempt hospitals in broadband access as a public health issue: the role of law in expanding broadband access and connecting underserved communities for better health outcomes publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. charges transparent ( %) accommodations for low income || *restrictions included the following: access only for "established" patients, exclusion of patients on federal insurance programs, and requirement to purchase additional telehealth equipment †generally, geographic limitations were state-based, requiring the patient to be physically located in a given state at the time of the visit ‡some websites alluded directly or indirectly to excluding patients with chronic conditions; however, language was often too vague to allow formal quantitation § language support included hospitals with any link or visual aid that indicated translation of the website or interpretation of virtual visits || while none of the hospital websites made general accommodations for income status, hospitals waived fees temporarily due to covid- or specifically for visits related to covid-