1.1 Introduction

Advances in technology directly affect our lives and behaviors. On one hand, it enhances our learning abilities effectively when integrated with our curriculum to alleviate submissive experiences of lectures for large number of students in the class. On the other hand, it acts as a tool for students to gain knowledge in a meaningful environment [52]. Therefore, the goal is to create a powerful interactive learning environment for students where they can use their inborn capabilities of learning to clutch intricate notions and acquire knowledge through participation, observation and simulation [28]. The term student is taken generally in this chapter for medical students, doctors, and various types of medical professionals, medical trainers and all those who are directly or indirectly using health care services and applications in society or in any organization for learning and training purposes.

Simulation technology is now being increasingly used to improve the student’s learning abilities in a variety of domains like marketing, engineering, education and most importantly in health care which is one of the biggest adopters of VR/AR like simulated surgery, treatment of phobia, robotic based surgery, skill based training, dentistry and disabled treatment are some of the examples. It is generally recognized that VR and AR are in the forefront having strong potential to lead health care for impactful change in society [10]. Nowadays, this can be possible with the development and provision of multimedia information delivery tools such as apps, pod-casts, medical and educational software and screen casts which can be easily used on personal computers and mobile devices specifically on smart phones [30, 51]. In addition, numerous visualization technologies have been released such as Oculus Rift, Gear VR and Head Mounted Displays (HMD) to incorporate VR in giving intuitive feeling of actually being engrossed in the simulated world [21]. AR is also known as mixed reality that has lined a possibility to understand the concepts in a novel way which was not ever possible in the past.

VR and AR can be viewed in Figure 1.1. Although there is a very slight difference between both concepts which will be discussed later in the chapter, but today, AR (mixed reality) shown in Figure 1.2, supersedes VR because of the collaboration of real world and virtual objects rather than the whole computer generated virtual world. Therefore, VR is now being transformed into AR in the near future gradually. Taking the advantage, we schematically unfold rest of the chapter by briefly discussing VR/AR, their formats and design elements, relationship among presence, reality and realism in context with VR/AR, features of VR/AR technologies and in detail the implications of VR/AR applications related to enhance health care issues using AI and IoT for impactful change in the society and organization. To end this chapter, challenges and limitations of the technology along with conclusion are finally discussed.

1.2 Virtual Reality and Augmented Reality

The following section will explain VR/AR and how both differ from each other. Further, Table 1.1 will summarize standard terms and definitions related to the simulating environment.

1.2.4 Formats and Design Elements of VR/AR Technology

This section reflects general understanding about the available formats of VR/AR and which one is best accepted for health care. In addition, Table 1.2 summarizes the design elements for implementing VR/AR. The contents of Table 1.2 are taken from Lemheney et al., 2016.

Elements	Description
Situated Learning	Familiar circumstances that can be recognized by a user or participant.
Debriefing	Opportunity to interact and focus by a participant on health care analysis and reflections.
Navigation	Components which can guide and sequence the directions.
Identical Elements	Visual representation of health care artifacts accurately.
Stimulus Variability	Range of relevance indicating objects found in health care settings.
Feedback	Prompts to facilitate progression through an activity.
Social Context	Collaborative environment to synchronize contribution of participants.

Formats of VR: VR systems have three formats namely non immersive, semi-immersive and fully immersive. The main concept which is frequently used is ”immersion” with VR. ”Immersion” refers to the sense of being involved in task environment without considering the time and real world and up to which extent high fidelity important inputs (e.g. sound waves, light samples) are supplied to diverse sensory modalities (touch, audition, vision) for the purpose of building powerful illusion of realism [36, 39]. The three formats also refer to the level of immersion:

1. A non immersive VR system utilizes usual graphics terminal with a monitor typically desktop system to view VR environment using some portal or window. This format imitates a three dimensional graphics environment on television or flat panel within which the user can interact and navigate. Hence, this format is less popular [49, 60];
2. A semi immersive VR system is relatively a new implementation which comprises of comparatively high performance graphics computing system together with an outsized projection plane to display scenes [49];
3. A fully immersive system gives a sense of presence but the level of immersion depends on various factors like the field of view of resolution, contrast, update rate and illumination of display. Generally, an immersive VR system clubs computer, body tracking sensors, specialized interactive interface such as head mounted display or an outsized projection screen encasing the user (e.g. CAVE–Cave Automatic VEs where VE is projected on a concave surface) and real time graphics to immerse the participant in a computer generated world of simulation to perform alterations in a natural way with body and head motion [56, 60]. Thus, this format leads us to adopt immersive learning environment for health care services and applications presently and also for future. Figure 1.3 presents some snap shots of various immersion levels.

Formats of AR: Since the advent and extreme usage of smart phones in recent times, most of AR applications are based on this new invention. Hence focusing the smart phones, there are two major AR formats. According to Pence, 2010:

1. Marked or mark based AR system utilizes two dimensional barcode normally QR code (quick response code) to connect a mobile phone and/or personal computer for overlaying information digitally on real world object or usually on a website;
2. Mark less AR system employs location based services like GPS (Global Positioning System) used by cell phone to serve as a platform of adding native information on a camera vision [11].

Figure 1.4 shows snap shots related to formats of AR.

1.3 Features of VR/AR Technology in Health Care

The most emerging feature of VR/AR technology in health care is E-Health with many enlightening features to support health care like patients can explain their symptoms in a better way; nurses can easily find veins, pharmaceutical companies can supply innovative drug information, surgeons can get assistance, invoking empathy, treatment for post therapeutic stress disorder, support for physical therapy, pain management, doctor or hospital visits, surgical trainings with the help of visualization and maintenance of labs etc.

1.3.3 Health Care Applications

In addition to health care services, there are numerous health care applications which can help to revolutionize not only the society but organizations as well. It has been noticed that health care services (see above section) are the basis for health care applications whereas these applications are directly used by patients and users. Hence, services are developer centric and applications are user centric. Moreover, there exist lot of gadgets, wearable devices and other health care devices to work with some health care application. Figure 1.5 shows some of the gadgets used in health care applications.

Electrocardiogram monitoring: Electrocardiogram (ECG) is the measure of electrical activity of heart recorded using electrocardiography on the basis of heart rate, focusing of basic rhythm and diagnosis of myocardial ischemia, extended QT intervals and versatile arrhythmias [3, 16, 75]. The ECG monitoring system can be formed using portable wireless acquisition transmitter and wireless receiving processor. Both together search out automation methods to notice abnormal data in order to identify cardiac function on real time basis [35].

Rehabilitation systems: Rehabilitation represents vital branch of medicine. It means that physical medicine can improve and overcome the working ability and quality of life of people having some sort of physical injury or disability. The intelligent and IoT based smart rehabilitation systems and upper limb rehabilitation systems are given by many profound researchers [20, 47, 67]. This design successfully demonstrates all essential resources to offer real-time information connections. Other rehabilitation systems such as prison rehabilitation system, smart city medical rehabilitation system, language training system for childhood autism and rehabilitation training for hemiplegic patients have been addressed in the past but require advancements to meet today’s requirements.

Blood pressure monitoring: Monitoring blood pressure (BP) is a fundamental aspect in our daily life. Now it is possible to monitor BP remotely with the involvement of AI and IoT. To accomplish this notion, there exists a remote communication between health post and health center which is responsible to monitor the BP of patients. A device is used for collecting and transmitting BP data to BP apparatus having communication module along with location intelligent terminal for monitoring BP gradually on real time basis [19, 31, 72]. However, advances are necessary to overcome upcoming flaws to incorporate with recent research.

Glucose level sensing: Diabetes (blood glucose or sugar) is a common metabolic disease and prime health care application. It is necessary to make it our habit to monitor blood glucose on daily basis. Diabetes monitoring for an individual discloses changes in blood glucose patterns and helps to adjust activities, medication and meal timings [50]. A utility model reveals the transmission of somatic blood glucose data on a device comprised of a mobile phone, a computer, a blood glucose collector and a background processor [32]. The whole setup is a combination of AI and IoT features.

Medication management: One of the serious threats to society is non compliance of medication as a result of which the patient has to bear enormous financial loss. To overcome this issue, an AI based packaging method is introduced in medicine boxes for medication management, for example IoT based iMedBox is proposed by [55]. The packaging method has controlled sealing based on delaminating control by wireless communications.

Body temperature monitoring: Monitoring body temperature is a vital habit in health care service because body temperature is a critical indicator for monitoring and maintenance of homeostasis. Therefore, m-IoT has the successful solution which uses body temperature sensor embedded in TelosB mote to attain body temperature variations in an effective manner [37].

Smart phones and health care solutions: Recently, smart phone has become the driver and rise of health care applications because this device has smart phone controlled sensor. Smart phone is now considered a popular health care device because of the invention of multiple types of hardware and software (apps) which can be easily and freely available for download and can be used by any user for his/her personal health care and satisfaction. Table 1.3 summarizes some of general smart phone health care apps in detail.

Apps	Description
Finger Print Thermometer	It is used to determine body temperature with the help of finger print.
iOximeter	Calculates oxygen intake that is SpO2 and pulse rate.
Calorie Counter	Keeps track of user food intake and his/her weight and relationship among them.
Eye Care plus	Monitors and tests eye vision.
Period Tracker	Helps to track periods and forecasts fertility.
Blood Pressure Watch	Tracks, analyzes, shares and collects blood pressure data.
Cardiomobile	Remotely monitors cardiac rehabilitation on real time basis.
On Track Diabetes	Helps to monitor and track blood glucose for medication to manage diabetes.
Noom Walk	It acts as pedometer to count user’s steps in daily routine work.
Monitoring Heart Rate	Used for real time heart rate monitoring and tracking.
Google Fit	It is used to hack cycling, walking and running for the user.
Asthma Tracker and Log	Used to track asthma for patient.

The current section discussed in detail some of health care services and applications. However, few other health care services such as wearable devices access (WDA), the internet of m-Health things (m-IoT), embedded context prediction (ECP) and embedded gateway configuration (EGC) require more implications and advances to overcome future health care issues. In the same manner, certain health care applications need to be addressed vigorously like wheel chair management, imminent health care solution and oxygen saturation monitoring for potential resolution and integration of new ideas [37].

1.4 Future Assessments in VR/AR Technology

This section introduces some of the prominent implications and applicable researches made by researchers for the sake to transform their ideas into VR/AR applications which not only offer an immense change in an organization but will become useful for the society as well. Mostly, these researches are based on medical imaging and its related areas under the domain of image processing and computer vision. This will help the novice VR/AR professional to build new VR/AR applications that can specifically run on mobile devices for the betterment of health care issues. Following are some of the research ideas available for transformation.

Glaucoma detection is a vital task in eye care especially when fundus imaging is available for glaucoma. This could be handled using implications and ideas proposed by [13] while detection of lung nodule [53], lung cancer [24], brain tumor [5], diabetic retinopathy [6], skin cancer [22] and extraction of cotton wool from retinal images [64] can also become smart applications in future to improve health.

An important property is the colorization of medical images in order to retrieve required medical image from a database. This idea and technique has been proposed and available for developing VR/AR applications [54, 76]. VR/AR environment has an ability to absorb diversified domains hence we can have applications to classify facial expressions [66], simulation based facial recognition [22] and biometric based person re-identification [65] on our mobile devices for enhancing ourselves not only as an individual but also as a society. Despite all that, potential research has been proposed to build numerous intelligent systems in future for improving health care services and applications [22, 25].

1.5 Key Challenges for Adopting VR/AR Technology

In recent times, no doubt there is no comparison of any kind of technology with VR/AR technology. Nevertheless, there still exist certain challenges and gaps in adopting such diversified technology in this modern era. In this section, some challenges are mentioned for the reader interest to provide baseline in overcoming these in future:

1. Funding and monetary issue, which means the organization must have enough funds for product development, research and coping marketing cost;
2. Technical limitations is a broad spectrum which reflects that VR/AR systems limit their use in certain clinical settings and mobile VR/AR systems limit to the pocket size computer which can be enhanced to take out from constraints. Moreover resolution, memory and processing are challenging in this aspect;
3. Organizational issues concerns about having an infrastructure to adopt technology like blue tooth connectivity, platform compatibility, provision and usage of health care software and hardware, networking, privacy issues, provision of digital medical data, vendor relationship and above all the prime factor is acceptability of technology within the organization;
4. Lack of knowledge is a primary challenge because most of the people are unaware with the use of VR/AR technology in health care domain rather than using it as an entertaining medium. Disseminating knowledge will be an important goal to make the people aware in using these technologies in health care domain;
5. Lack of research studies around VR/AR. It has been observed that there may only be a handful of useful research studies. So, this needs to be enhanced in future.

Some other additional challenges also need to be focused and emphasized like market issues and cultural obstacles; regulation and insurance policies, resistance from end user, lack of interest about concerned side effects etc. which are significant in adopting these technologies.

1.6 Conclusion

The foremost purpose and objective of this review is to discuss the implications of VR/AR technologies in health care services and applications for improving societal and organizational change. This chapter highlights diversified priorities in health care services and applications and efforts made by researchers in this respect taking AI and IoT as baseline. Further, it also emphasizes on definitions, formats, differences, features, design elements, cognitive aspects and challenges to VR/AR as a part of discussion.

Unlike VR which is accomplished through a complete virtual environment, AR limits itself to involve certain virtual elements to merge them with physical world. Although both technologies are being considered competent for the last two decades in view of some professionals and researchers but another thought exists that these are still in their initial phases. Therefore, research is needed to identify finest practices, determine optimal solutions to implement these technologies and facilitate for rapid adoption in society.

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