A practical framework for developing a virtual reality-based anatomy education application: key content and technical requirements (2025)

The healthcare system requires medical education to train specialists and enhance their skills, competencies, and clinical experience, in which anatomy is a prerequisite^1,2. Anatomy is a fundamental part of medical education but is often viewed as a traditional and memory-based discipline^3,4. For medical courses and effective clinical practice, anatomical knowledge must be acquired through discipline-specific courses or medical-specific training sequences (combined human anatomy, clinical/operative skills, and surgical anatomy)^5,6.

The COVID-19 pandemic has caused most undergraduate anatomy education to shift online or combine virtual and face-to-face instruction. Moreover, cadaveric shortages have influenced the requirement for different methods of anatomical education⁷. During the pandemic, anatomy educators quickly embraced online technologies, platforms, and creative teaching approaches to ensure engaging and effective student learning experiences. Nevertheless, there is a consensus that an optimal approach involves blending online and in-person instruction for effectively imparting knowledge on this three-dimensional subject^8,9,10.

Medical education has changed over the years, mainly due to technological advancements¹¹. Electronic tools have become increasingly crucial in education and training, and new technology-based pedagogical approaches have emerged as complementary to traditional methods¹². In studying anatomy, instead of relying on physical skeletons and bone models, educators now use advanced three-dimensional (3D) anatomy platforms and software as visual aids. In addition, technology has provided healthcare providers with various methods to study anatomy, including video lectures, 3D printing materials, and ultrasound¹³.

Innovative pedagogical approaches, specifically the integration of virtual reality (VR), augmented reality (AR), and gamification present auspicious avenues for advancing anatomy education across all tiers of instruction. VR and AR offer immersive experiences that can captivate audiences, while the incorporation of gamification enhances engagement and interaction¹⁴. Furthermore, innovative teaching methods like VR and AR can address obstacles like a lack of corpses and inadequate laboratory resources for anatomy education in low-resource settings¹⁵.

Among the several innovative 3D teaching modalities in medical education, VR has emerged as a promising innovative pedagogical tool complementary to lectures, textbooks, and anatomical specimens¹². VR technology is a valuable educational tool for increased physical interaction with subject matter and improved learning. Learners’ control over experiences and the potential for gamification can enhance motivation, while the immersive environment aids information retention^16,17,18. VR can have diverse applications in medical education. It has been most commonly used for surgical technique training, developing the ability to visualize anatomy in 3D and teach anatomy across health sciences courses, and training for procedures such as cardiopulmonary resuscitation (CPR)^5,17,19,20.

VR in smart devices refers to VR modalities designed for touch-screen smartphones. While solving all the mentioned challenges, VR can teach abstract ideas, illustrate real-world phenomena, and motivate students²¹. VR-based anatomy applications provide interactive simulations and virtual dissections, allowing students to actively engage with virtual objects and perform procedures in realistic scenarios. This immersive experience enhances hands-on learning and practical skill development²². The first step in designing and developing a mobile VR modality for teaching anatomy is identifying VR software’s content and technical requirements for musculoskeletal anatomy training.

In 2019, Pohlandt et al.²³ conducted a study to develop a VR-based software with a puzzle-solving approach to learn the names and locations of the body’s bones. In their study, some requirements were extracted through a review of VR-based education articles and discussions with two anatomy experts. These requirements include "frame rate above 50″, "existence of feedback," "no worries for the user about hitting walls and obstacles during use," "natural and sensory interaction," "easy learning to use the system," "greater engagement and immersion in the system," "use of medical terminology," "possibility of adding a 3D model by the instructor", "use of performance-based interaction techniques and the ability to freely select accessible and distant models," "accuracy of model placement," "supportive mechanisms for solving puzzles," "software support for learning stages," and "attractiveness and the possibility of repetition”.

Mansouri et al.²⁴ conducted a study in 2020 to explore the features of an anatomy mobile application. Semi-structured interviews and note-taking were used to collect the data and found features. These features were categorized into eight main themes: “visual richness”, “scientific comprehensiveness”, “auditory richness”, “affordability”, “user-friendliness”, “self-assessment”, “interactive content” and “user support”. Rezayi et al.'s²⁵ study (2024) sought to determine the essential features and design specifications of a 3D simulation program for physiotherapy students’ clinical training in neurology departments. Based on the literature review, curriculum analysis, and medical record review results, the primary elements for creating the instructional software for physiotherapy were determined in this work. To improve the capabilities of simulation software and determine its main purposes, a questionnaire was developed by the researcher to survey physiotherapy professors.

In 2021, Jirarattanawan et al.²⁶ conducted a study to create a prototype for a mobile learning app named "Laryngo-App." This app features 3D computer models and animations of the larynx. To develop this application, researchers considered factors such as providing a summary of knowledge about the larynx, using 3D models to demonstrate the musculoskeletal structures of the larynx, using 3D animation to demonstrate the functions of intrinsic laryngeal muscles and movements of the vocal cords, and taking a quiz for self-development in learning as required functions and compartments. Gupta et al.’s²⁷ study investigated the creation of a successful VR–based medical simulation environment to introduce the BUILD REALITY framework (begin with a needs assessment, use, identify, leverage, define, recreate, educate, adapt, look, identify, test, amplify). They identified certain factors to consider in a needs assessment that may promote creating a VR-based medical environment over another teaching modality. These factors include location, time, accessibility, assessment, personnel, software, diversity, and learning environment.

A review of the existing literature indicates that, to our knowledge, no comprehensive dataset of content and technical requirements has been developed in Iran, a developing country, for designing VR-based software to teach musculoskeletal anatomy. Educational needs in anatomy may differ due to variations in curricula, teaching methods, and institutional requirements in Iran compared to other countries. Previous studies have focused on similar software’s general design and effectiveness but have not explicitly identified the content and technical requirements tailored to Iran’s context. This study aims to bridge this gap by identifying these requirements, ultimately contributing to improving educational quality and facilitating learning and memorization in anatomy education for healthcare students.

This descriptive-analytical study was conducted in 2023–2024 at the Tehran University of Medical Sciences to determine VR software’s content and technical requirements for musculoskeletal anatomy training.

Data collection and sampling

The process of collecting data consisted of two phases:

• Phase 1: Extracting technical and content requirements based on literature and software review.

• Phase 2: A survey on technical and content requirements based on experts’ opinions.

The initial phase comprised three steps:

• In the first step, a comprehensive literature review was conducted to identify technical requirements for VR-based anatomy education. Searches were performed in Medline (via PubMed), Scopus, and Google Scholar using a combination of keywords related to virtual reality (e.g., “virtual reality,” “virtual environment,” “spatial,” “3D,” “immersive”), education (e.g., “learning,” “teaching,” “education,” “training”), and anatomy (e.g., “anatomy,” “dissection,” “cadaver,” “atlas”). The inclusion criteria consisted of original articles published between 2017 and 2024 in English and Persian that focused on the design and evaluation of VR-based software for teaching human anatomy. Studies that did not align with the research objectives, were in languages other than English and Persian, or were review articles, meta-analyses, conference abstracts, or book chapters were excluded. A total of 25 studies (20 international and five domestic) were reviewed, and data regarding existing VR software—including software name, required hardware, number of users (single/multiple), development tools, 3D modeling methods, anatomical content, and key features—were extracted.

• In the second step, VR software stores such as Steam, Meta, and SideQuest were examined to identify software with the most comprehensive technical features. A selection of similar anatomy-related applications, including 3Dorganon²⁸, Sharecare_YOU_VR²⁹, ImmersiveView³⁰ and Human Anatomy VR³¹ was installed and systematically evaluated. Each software was examined based on predefined criteria, including functionality, user interface, interactive features, and anatomical coverage. These criteria were established through a combination of literature review and expert consultation. The evaluation process involved testing the software in a VR environment, exploring its capabilities, and assessing its usability for anatomy education. The insights gained from this analysis helped define the technical and educational requirements that the proposed software needed to fulfill, ensuring that it met both usability and instructional effectiveness standards.

• In the third step, the curricula of the anatomy course for seven undergraduate paramedical fields (including medical laboratory sciences, surgical technology, radiation therapy, radiology, health information technology, emergency care, and anesthesiology) were analyzed to determine the essential content for the software. Based on these curricula and in consultation with an anatomy professor, a list of anatomical positions that needed to be included in the software was compiled.

In the second phase, a survey was conducted on the necessity of technical and content requirements using two researcher-made questionnaires. Using the census sampling method, the survey involved 35 participants chosen for their expertise and qualifications in relevant fields. We ensured that our approach included participation from pertinent fields, such as anatomy, health information management (HIM), health information technology (HIT), and medical informatics (MI). The process of selecting participants was guided by criteria including their professional expertise, work experience, and engagement in anatomy, HIM, and MI to guarantee a diverse and thorough viewpoint. Two researcher-made questionnaires were designed to identify technical and content requirements:

1. 1-

   Technical Requirements Questionnaire (TRQ),

2. 2-

   Technical and Content Requirements Questionnaire (TCRQ).

The technical section was identical in both questionnaires. However, they were completed by different participants. The TRQ consisted of two main sections:

• The first section collected demographic information about the participants, including gender, age, academic level, field of study, and work experience.

• The second section focused on technical requirements, covering eight main aspects: virtual environment (eight questions), 3D model (six questions), interaction (15 questions), metadata (three questions), multi-user functionality (five questions), evaluation (five questions), account management (seven questions), and other technical considerations (eight questions). The full version of this questionnaire is provided in Appendix 1.

The TCRQ also consisted of two sections:

• The first section covered demographic details, similar to the first questionnaire.

• The second section addressed both technical and content-related requirements. The content section included two main areas: the skeletal system (14 questions) and the muscular system (nine questions). The technical section remained the same as in the first questionnaire. The full version of this questionnaire is provided in Appendix 2.

Each question in both questionnaires had three response options: "Necessary," "Useful but not necessary," and "Not necessary." Additionally, an open-ended question was included at the end to gather expert feedback and insights, allowing for a deeper understanding of the subject and identifying potential areas for improvement.

Data analysis

In the data analysis process, experts’ ratings were used to assess the significance of each item. If a specific item received “necessary” responses from 75% or more participants, it was classified as a main term. If 50–74% of the participants have chosen the “necessary” options, the item will be deemed recommended. The final recommendations did not include items that received less than 50% of expert support for the “necessary” options. The data analysis considered anatomy, HIM, HIT, and MI experts’ viewpoints.

The qualitative content validity was assessed using the content validity ratio (CVR)³². According to the Lawshe table³³, with 35 experts responding to questions about technical requirements and 10 experts addressing questions about content requirements, their CVR thresholds are 0.31 and 0.62, respectively. In addition, Cronbach’s alpha was utilized to assess the internal reliability of the tool, with a threshold of 0.7 considered high³⁴. The reliability of the technical and content requirements questionnaires was confirmed, with average scores of 0.94 and 0.72, respectively. Descriptive statistics were used for the analysis with SPSS software version 27 (SPSS, IBM Corp., Armonk, NY, United States).

Ethical approval

This study was approved by the ethics committee of Tehran University of Medical Sciences with the ethics code IR.TUMS.SPH.REC.1402.060 and with 1402-1-102-64856 proposal code.

The research team in this study discovered the technical and content requirements by reviewing 34 related literature and software. After removing duplicates, we identified 80 technical and content requirements, categorized into eight and two axes, respectively. Afterward, the participating experts determined the necessity of each identified requirement through a researcher-made questionnaire (Fig.1).

Characteristics of participated experts

The technical and content requirements assessment questionnaires were distributed among 124 experts (40 anatomy professors of medical sciences universities in Tehran and 84 HIM and MI professors and other majors). The TCRQ was completed by ten anatomy professors at Tehran University of Medical Sciences, while the TRQ was completed by 35 experts (~ 28%) (including ten anatomy professors from Tehran University of Medical Sciences, as well as 25 HIM and MI professors from medical sciences universities in Iran). The demographic characteristics of them are illustrated in Fig.2. The number of females was greater than that of males, with the HIM experts having the highest percentage (43%). Furthermore, the average age and work experience of the experts who participated in the study were 44.5 and 15.1, respectively.

Expert opinions on technical requirements

Table 1 demonstrates the technical requirements and mean score of experts’ responses to the necessity of each of these items. In addition, the CVR of each item is presented. The total CVR of the technical requirements questionnaire was calculated as 0.48. Furthermore, the technical requirements such as "The possibility of teleportation to another place in the virtual environment (to avoid side effects and move faster)," "The ability to switch between light and dark environment, "Tactile feedback: vibration in the controller, "The presence of virtual avatars of users, "Voice communication between users, "Age, "Gender," "Mobile number, "Student number, "Video recording of the user’s view (screen record)," "Tool for painting or changing color, "The ratio of organs selected by the user to total organs report, "User usage time report, "and "Selected organ report" were considered not necessary, since they received less than the threshold (0.31) (written with orange ink).

Expert opinions on content requirements

Table 2 presents the content requirements, mean score, and CVR. The total CVR of the content requirements questionnaire was calculated as 0.54. Moreover, the content requirements include "Head and face bones," "Elbow," "Head and face muscles," "Chest muscles," "Back muscles," "Trunk muscles," "Upper limb muscles," and "Lower limb muscles," which were identified as unnecessary since they received less than the threshold (0.62).

Table 3 indicates the content and technical requirements that were excluded. A total of fourteen technical requirements and eight content requirements were excluded.

This study aimed to identify the technical and content requirements for creating VR-based software designed to teach musculoskeletal anatomy. The identification of technical requirements resulted from a comprehensive library and software review. Moreover, some content requirements were determined by collecting the anatomy course curriculum for the undergraduate degree in paramedical fields. The identified technical and content criteria were distributed among experts in relevant fields in a researcher-made questionnaire format. As a result, we identified 57 technical requirements categorized into eight axes and 23 content requirements categorized into two axes.

The VR-based anatomy teaching software can offer an immersive, interactive, and collaborative learning experience that transforms students’ understanding of anatomical concepts by fulfilling these technical and content requirements. Our strategy for teacher knowledge transfer, particularly in anatomy, offers fresh approaches to evaluating learning objectives and tailoring instruction to the needs of each student, thereby enhancing engagement and comprehension. Combining VR with well-known e-learning platforms that teachers and students are familiar with enhances transparency and streamlines course administration, making academic learning more engaging and successful.

Numerous studies have underscored some valuable technical requirements for these kinds of software. Farajpour et al.²² conducted a study to investigate the creative application of VR as an interactive and immersive approach to anatomy education. This study illustrated that the instructor and the students were using VR headsets simultaneously and experiencing the same virtual environment. They believe VR-based software should enable students to manipulate and study virtual anatomy. This manipulation includes rotating, zooming in and out, and dissecting organs and systems. Also, 3D models of anatomical structures should be accurately generated using information obtained from MRI and CT scans. These results are consistent with ours. In this study, experts have emphasized the significance of students and professors being able to simultaneously be in the virtual environment. Furthermore, they think that in addition to the capability to resize, rotate, and zoom in and out of the model, it is important to take, hold, move, group select, and highlight the model. They also suggest considering models based on 3D scanning of real organs.

Górski et al.'s³⁵ study identified the visualization, human tissue data form, animations, object manipulation and interaction methods, collisions and force feedback, full immersion (HMD), required tracking and force accuracy, required computing power, and participation of specialists/medical doctors as features and requirements necessary for educational VR applications for medicine at different knowledge levels. These results are consistent with ours.

Falah et al.³⁶ developed a VR medical system to enhance the anatomy system process. The system includes a quiz interface with 25 questions designed to evaluate students’ understanding of the anatomical functionalities provided. The questions aimed to evaluate the capacity to accurately recognize the heart’s anatomical components, the anatomical connections between different elements, and a comprehensive comprehension of this vital organ’s organization. Additionally, the user interacts with the VR heart model by choosing various functions from the toolbar. For example, they can rotate, enlarge, mark, or minimize structures, and make them visible or invisible, similar to our results. In our study, a text-based multiple-choice test allows the user to assemble the parts and complete the system, similar to a puzzle.

Pedram et al.'s³⁷ study identified 92 requirement statements across 11 essential areas for VR‑HMD training systems for medical education. This study indicated that freedom of movement is a critical requirement, and the equipment should not restrict the typical range of physical motion needed to complete a task. Moreover, the study of Fairén González et al.³⁸ suggested that a tracking device could be integrated to allow for natural movement and interaction in the virtual environment. Similarly, our study identified the ability to take, hold, and move the model as a critical requirement.

In another study, Fairén et al.³⁹ introduced VR-based software for anatomy teaching. The software features a menu displaying all available anatomical structures for exploration. Users can choose a specific structure to explore, at which point the virtual environment transforms to represent the selected anatomical structure, similar to our results. This software also could support multiple languages (Catalan, Spanish, and English), making it easy to configure additional languages. Bilingual support, which enables smooth transitions between Persian and English, is one of our primary software design needs. This feature guarantees that all textual material and messages are presented in the chosen language and features a bilingual user interface with the ability to switch the language via a menu or settings.

Some studies have identified important content requirements for this software. Fairén González et al., in a study³⁸, selected ten distinct anatomical regions of the human body for students to investigate using VR. The selected anatomical parts included the heart, encephalon, eye, ear, lung, circulatory system, digestive system, reproductive and urinary system, chest, and aneurysm. In another study, Fairén et al.³⁹ developed a VR-based application that represented seven 3D anatomical models, including the heart, eye, ear, circulatory system, digestive system, lungs, and brain. Conversely, our study did not consider the internal organs; only musculoskeletal anatomical parts were included for 3D visualization.

Abundez Toledo et al.⁴⁰ conducted a study investigating the potential application of VR as an innovative tool for learning anatomy. They visualized the skeletal system (head to toe), cardiovascular system (heart, main arteries, and veins), and lymphatic and nervous systems (such as cervical lymph nodes, inguinal lymph nodes, vagus, and sciatic nerves) in their VR-based anatomy teaching system. In contrast, experts in our study deemed the anatomical parts related to the musculoskeletal systems essential for this software.

Limitations

Our study’s limitation is the lack of cooperation from some participants in completing questionnaires. One hundred twenty-four questionnaires were distributed among the experts, of which only 35 cooperated. To address this issue, the researcher provided detailed oral explanations to the participants about the study’s goals, benefits, and significance to persuade them to cooperate. Additionally, the questionnaire was distributed electronically via the Porsline platform to facilitate accurate and efficient data collection.

Implication for practice

The education industry has undergone many changes in recent years. The purpose of VR is that the user enters a virtual world with his/her physical body and senses, and his/her movements in the real world can be seen and understood by others and himself. In this way, his/her hardware is responsible for translating his/her movements, words, and feelings in the virtual world. Every person in VR has a personality or character that can be designed or prepared in advance. We are all familiar with the benefits of virtual education. Reducing time and financial costs, ease of communication, and removal of location restrictions are among the significant benefits that policymakers in the field of education can pay for. However, as we know, this method of education has a fundamental challenge, which is the reduction of sensory and physical communication. The use of VR in education was initially created to solve this problem, but after some time, its other added values ​​were also identified. A VR platform for educational purposes can take many forms to be useful.

Author notes

1. Erfan Esmaeeli and Amir Soleimani as co first author

Authors and Affiliations

1. Department of Health Information Management and Medical Informatics, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran

   Erfan Esmaeeli,Amir Soleimani&Leila Shahmoradi

2. Department of Health Information Technology and Management, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

   Mohadeseh Sadat Khorashadizadeh

3. Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

   Saeid Nekoonam

4. Department of Health Information Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran

   Sorayya Rezayi

Contributions

Amir Soleimani, Leila Shahmoradi ,and Sorayya Rezayi: Conceptualization, Methodology, Software. Erfan Esmaeeli, Amir Soleimani, Mohadeseh Sadat Khorashadizadeh, Sorayya Rezayi: Data curation, Writing- Original draft preparation. Amir Soleimani, Sorayya Rezayi, Leila Shahmoradi, Mohadeseh Sadat Khorashadizadeh, and Erfan Esmaeeli: Visualization, Investigation. Leila Shahmoradi and Saeid Nekounam: Supervision and consultation.

Corresponding authors

Correspondence to Leila Shahmoradi or Sorayya Rezayi.

Ethics approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations. The methodology for this study was approved by the Ethics committee of Tehran University of Medical Sciences with the ethics code IR.TUMS.SPH.REC.1402.060 and with 1402–1-102–64856 proposal code. All participants (or their legal guardians) were provided verbal informed consent for all stages of study and the Ethics committee of Tehran University of Medical Sciences approved this procedure.

Competing interests

The authors declare no competing interests.

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