Vertual and VERT (Virtual Environment for Radiotherapy Training)
Submitting InstitutionUniversity of Hull
Unit of AssessmentComputer Science and Informatics
Summary Impact TypeTechnological
Research Subject Area(s)
Physical Sciences: Other Physical Sciences
Medical and Health Sciences: Neurosciences, Oncology and Carcinogenesis
Summary of the impact
VERT is a multiple award-winning virtual environment training simulator
for radiotherapy education, developed during a six year research
collaboration with Hull and East Yorkshire Hospitals (HEYH) NHS Trust. A
National Radiotherapy Advisory Group (NRAG) Report (2007) and the
Department of Health (DoH) NHS Cancer Reform Strategy (2007) identified
the potential for VERT to address a skills shortage and improve the
radiotherapy workforce. The UK government provided £5M capital funding to
implement VERT at 40 hospitals and 10 universities in England from
The company Vertual Ltd was created to commercialise VERT. It now has an
annual turnover of £2M and has created 10 new high-skilled jobs since
2008. With 92 VERT systems installed across 16 countries, it has delivered
a quantum change in radiotherapy education in the UK. An active
international VERT user group has been established and its impact is
The research underpinning VERT was conducted from 2001 to 2008 by the
University's Computer Science Department in collaboration with the Medical
Physics Department at the HEYH NHS Trust. The researchers involved were
Andy Beavis (Honorary Professor, 2008 to 2011), Roger Phillips (Research
Professor, 1990 to 2011) and James Ward (Research Lecturer, 2001 to
The objective was to investigate innovative and beneficial applications
of immersive environment technologies in Radiotherapy treatment of cancer.
Radiotherapy (RT) aims to maximise therapeutic radiation dose to the
tumour whilst minimising collateral damage to neighbouring organs.
Improved delivery techniques are being developed such as IMRT (Intensity
Modulated RT), IGRT (Image Guided RT), and adaptive therapy. These achieve
improved outcomes but demand higher precision. Excellent 3D visualization
and spatial awareness of the treatment in terms of dose, beams, anatomy,
equipment and potential variations from the planned treatment is
fundamental to planning and reviewing RT treatments.
Using advanced computer graphics technology, the University of Hull
developed a sophisticated and highly realistic training simulator for
Radiotherapy [5,6]. This provides a life-sized virtual simulation of the
treatment room with all its equipment, controls and a simulated patient.
VERT uses stereoscopic 3D projection to create a high sense of presence
for trainees. Novel head-tracking technology enables a user to literally
walk around the virtual treatment room , with life-sized visualization
of the equipment. It provides highly detailed and realistic simulations of
Linac treatment machines from major manufacturers (Varian, Elekta and
Siemens). Authentic hand controls have been interfaced to control the
Linac, enabling trainees to develop psychomotor skills in VERT. Training
can be carried out without risk to the patient or access to the real
VERT provides training tools to teach safety critical skills, including
detailed simulation of the calibration and quality assurance processes for
the treatment machine [1,2].
Actual patient anatomy and treatment plans can be imported into the
simulation, which enables the use of real patient cases for training. VERT
provides a full body patient model for skin apposition treatment training
 and includes examples of prostate, breast, and head and neck treatment
plans and paediatric cases.
VERT provides visualizations that go beyond what the trainee would see in
the actual treatment room. In this sense, virtual environment training
improves on reality. For example, the patient can be rendered transparent
to reveal the location of the tumour and neighbouring organs. Similarly,
the normally invisible radiation beam can be made visible, to better
understand its spatial relationship to other structures. VERT also
provides numerous visualizations of radiation dose distributions, to
illustrate the benefits of different treatment techniques.
Together, these visualization tools make VERT an effective platform for
teaching the technical skills and fundamental principles of radiotherapy
References to the research
1. The Development of a Virtual Reality Dosimetry Training Platform for
Physics Training, A Beavis, J Ward, Medical Physics 06/2012; 39(6):3969.
2. Calibrating an Ionisation Chamber: Gaining Experience Using a
Dosimetry `Flight Simulator', A Beavis, J Saunderson, J Ward, Medical
Physics 06/2012; 39(6):3970. DOI 10.1118/1.4736201
3. Virtual Reality Training for Radiotherapy becomes a Reality. R
Phillips, JW Ward, L Page, C Grau, A Bojen, J Hall, K Nielsen, V
Nordentoft, AW Beavis. Studies in health technology and informatics
4. The Development and Evaluation of a Virtual Radiotherapy Treatment
Machine using an Immersive Visualization Environment. Bridge P, Appleyard
RM, Ward JW, Phillips R, Beavis AW, Computers & Education, 49 (2), pp
481-494, 2007. DOI:10.1016/j.compedu.2005.10.006.
5. A Hybrid Virtual Environment for Training of Radiotherapy Treatment of
Cancer, Phillips R, Ward JW, Bridge P, Appleyard RM, Beavis AW,
Proceedings of SPIE and IS&T Electronic Imaging: Stereoscopic Displays
and Applications, San Jose, USA, Jan 2006, SPIE Vol 6505, pp 6055008 1-12.
6. Immersive Visualization Training of Radiotherapy Treatment, Phillips
R, Ward JW, Beavis AW, Proceedings of Medicine Meets Virtual Reality 13,
Studies in Health Technology and Informatics, 111, pp 390-396, January
2005, IOS Press.
1. 6/2007 - 5/2009, £50,000, Virtual Environment Radiotherapy Training,
University of Ulster, R Phillips, A Beavis, J Ward.
2. 3/2007 - 2/2009, £166,225, Immersive Visualization of Radiotherapy
Planning, CMS, A Beavis, R Phillips, J Ward.
3. 3/2007 - 2/2009, £50,000, Virtual Environment Radiotherapy Training,
University of Central England, R Phillips, A Beavis, J Ward.
4. 1/2007 - 12/2008, £50,000, Virtual Environment Radiotherapy Training,
Aarhus University Hospital, Denmark, R Phillips, A Beavis, J Ward.
5. 1/2006 - 8/2007, £5,500, VR Studies, Sheffield Hallam University, J
Ward, R Phillips, A Beavis.
6. 11/2005 - 12/2006, £124,116, Immersive Visualization of Radiotherapy
Planning, CMS, A Beavis, R Phillips, J Ward.
7. 4/2005 -10/2005, £10,480, Immersive Visualization of Radiotherapy
Planning, CMS, A Beavis, R Phillips, J Ward.
Awards and Prizes
1. First Prize winner of 2011 Eurographics Medical Prize — Dirk Bartz
Prize for Visual Computing in Medicine. €400 prize money.
2. Medilink Innovation award for Virtual Environment for Radiotherapy
Training (VERT), 2008
3. Finalist for Health and Social Care Awards, 2008.
4. Service Improvement Day, Local NHS Combined Trusts Award, 2008.
5. BCS IT Industry Awards, Winner of 2007 Project Excellence Awards for
BT Flagship Award for Innovation and Social Contribution Project.
6. BCS IT Industry Awards, Runner-up for 2007 Project Excellence Awards
for Social Contribution.
7. First prize winner of the Medipex 2006 Yorkshire and Humber NHS
Innovation Competition 2006 under the Innovation category. £2,000 prize
8. National finalist for Healthcare Service Journal Award 2006, Skills
9. A Beavis awarded IPEM's 2009 Manufacturers Award, for contribution to
10. A Beavis awarded Dept. Of Health's Chief Science Officers Innovation
and Technology Award in recognition of his contribution to VERT.
Details of the impact
In 2007, an NRAG report recognised the need to reduce the attrition rate
of radiography students and identified a potential crisis in England for
training staff and students for RT treatment of cancer.
The report identified the potential impact and benefits of VERT in this
context, and recommended the introduction of Hybrid Virtual Environment
(HVE) skills training facilities, to be rolled out across 10 educational
providers and over 40 clinical sites to support first year students and
Assistant Practitioners. This was reinforced by the DoH's Cancer Reform
Strategy 2007 which recommended the introduction of VERT as part of a
national programme, supported by £5M of capital funding from the UK
VERT was rolled out to 40 clinics and 10 universities in the UK from
February 2008, effectively covering all RT trainees in England. The main
beneficiaries were students, teaching staff and health trusts. An
independent evaluation of the impact of the exploitation of VERT
recruitment and retention, and on students' knowledge and understanding
was undertaken. It also made recommendations for future curriculum design
and teaching. The Final Project Report was published in June 2010 (see
Section 5 [C1]). Overall feedback was positive; pre-placement experience
with VERT was thought to enhance basic practical skills and enhance
confidence, including improved confidence operating hand pendant controls.
Skills developed in VERT were found to transfer well to the clinical
environment. 90% of students responding to a questionnaire agreed or
strongly agreed that VERT contributed to their enjoyment of learning and
teaching scenarios. There was a perception that use of VERT had a positive
impact on: development of understanding of radiotherapy concepts (82%
agreed or agreed strongly); enhancement of practical skills (72% agreed or
strongly agreed); and motivation (70% agreed or strongly agreed?).
Sales of VERT worldwide have grown from 2008 to the present, and the
beneficiaries have been:
- Health trusts, students and patients: VERT offers a safe and effective
training environment with the potential to reduce training costs,
increase training capacity, provide more effective training and
ultimately improve patient safety, as detailed in sections 3-5.
- Vertual Ltd and its shareholders: 92 VERT systems have been installed
worldwide in 16 countries, with economic impacts including an
accumulated gross profit over 3 years of £965k and typically £2M annual
- Employees of the company, with employment/economic impacts in terms of
10 new jobs created since 1st January 2008, with an average salary of
£30k. This includes 4 full-time software developers.
- A network of 12 distributors worldwide, with economic impacts in terms
of profits from distributing VERT.
- Significant economic benefits to other UK industry, including
equipment suppliers and local manufacturing. Vertual partner with a UK
based VR system supplier to provide over £400k annual hardware sales,
including installation and support services. Vertual also use UK based
companies for electronic printed circuit board manufacture and assembly,
electronic components, manufacture of enclosures, printing, graphic
design and exhibition services.
- Benefits to the educational, medical and research community: Vertual
is a Diamond Partner of the UK College of Radiographers, providing
financial support for research and educational projects. Vertual
regularly sponsor student graduation awards and prizes in the UK, US and
Canada, and fund student / staff attendance at conferences.
VERT is an established and recognised tool for training radiotherapy
professionals at over 90 institutions worldwide. VERT has been
continuously used for RT training at Aarhus University Hospital from 2008
to present, resulting in a doubling of the training capacity [Ref. C3]. A
training centre has been established where VERT is a key facility,
reducing the demand for training in the real clinic. Following the same
model, three other VERT simulation centres have been established at
Birmingham City University, Michener Institute and City University.
A VERT user community was established from the outset which continues to
actively conduct and publish research and studies evaluating VERT,
expanding its scope and application, and sharing best practice. The
beneficiaries are users of VERT, evidenced by the International User
Meetings in Bristol (March 2010), London (September 2011) — where 70
delegates from UK, Europe, USA and Canada attended — and Hertfordshire
(April 2013). An annual user meeting is held in the USA, to cater for the
increasing number of US users (15 VERT installations in the USA and
Canada, and growing).
Impact is evidenced by the adoption of VERT under nationally funded
training programmes. Following on from its uptake in the DoH (UK), in 2011
the Australian Department of Health funded the installation of 5
state-of-the-art VERT systems throughout Australia to improve radiographer
training. This was followed in 2013 by the first installation in New
Zealand at the University of Otago, which was opened by the Minister of
Health. VERT has also been adopted for training by Varian Medical System,
the global market leader for radiotherapy linear accelerators.
The scope of the use of VERT includes graduate and postgraduate RT
training, continuing professional development, anatomy training, skills
assessment, patient awareness, nurse training, staff training and
research. VERT has an important role to play in improving patient safety
and in 2010 was adopted by the prestigious MD Anderson Cancer Centre
(Texas, USA) where it has been used to reconstruct RT treatment errors and
identify remedial actions with trainees (several institutions in the UK
use the system in the same role).
In summary, VERT is increasingly used worldwide for RT education and
training. Radiotherapy professionals are identifying innovative
applications far beyond its initial scope. VERT is continually under
development to improve its effectiveness for training, to keep abreast of
improvements in techniques and technology and cater for its expanding
diversity of use.
Sources to corroborate the impact
- Virtual Environment for Radiotherapy Training (VERT) Final Project
Report, Appleyard R., Coleman C, Society of Radiographers, 2010
(available online at http://doc-lib.sor.org/vert-final-project-report)
— corroborating the impact on RT training (including students' knowledge
and understanding) and recruitment and retention.
- Financial and sales information on Vertual (available on a
confidential basis on request) — corroborating sales of and revenue from
- 3D Accelerator in Radiation Therapy Training — From Apprenticeship to
Virtual Reality Training, Boejen A., European Oncology Nursing Society
Newsletter, 24-25, Summer 2010 (available online at http://www.cancernurse.eu/documents/newsletter/2010summer/EONSNewsletter2010summerPage24.pdf)
— corroborating the doubling of RT training capacity at the hospital.
- Head of Radiotherapy Research, Aarhus University Hospital, Denmark -
corroborating the increase in training capacity at the hospital,
consequent cost savings and shorter waiting times for RT patients.
- Programme, presentations and survey results from International VERT
User Community Meetings (available on request) — corroborating the
benefits to the VERT community of evaluating and developing VERT.