Managing our health: One conversation at a time

If you've watched movies like Iron Man, featuring virtual assistants, like JARVIS, which you can just have a conversation with and control your home, you probably think that such virtual assistants belong in the realm of science fiction. Earlier this year, Mark Zuckerberg, who runs Facebook set a personal challenge to create a JARVIS style assistant for his own home. "My personal challenge for 2016 is to build a simple AI to run my home and help me with my work. You can think of it kind of like Jarvis in Iron Man." He may be closer to his goal, as he may be giving a demo something this month. For those that don't have an army of engineers to help them, what can be done today? Well, one interesting piece of technology is Amazon's Echo. So what is it? Amazon describes it as, "Amazon Echo is a hands-free speaker you control with your voice. Echo connects to the Alexa Voice Service (AVS) to play music, provide information, news, sports scores, weather, and more—instantly. All you have to do is ask." Designed for your home, it is plugged into the mains and connected to your wifi. It's been on sale to the general public in the USA since last summer, and was originally available in 2014 for select customers.

This week, it's just been launched in the UK and Germany as well. However, I bought one from America 6 months ago, and I've been using it here in the UK every day since then. My US spec Echo does work here in the UK, although some of the features don't work, since they were designed for the US market. I've also got the other devices that are powered by AVS, the Amazon Tap, Dot and also the Triby, which was the first 3rd party device to use AVS. To clarify, the Echo is the largest, has a full size speaker and is the most expensive from Amazon ($179.99 US/£149.99 UK/179.99 Euros). The Tap is cheaper ($129.99, only in USA) and is battery powered, so you can charge it and take it to the beach with you, but it requires that you push a button to speak to Alexa, it's not always listening like the other products. The Dot is even cheaper (now $49.99 US/£49.99 UK/59.99 Euros) and does everything the original Echo can do, except the built-in speaker is good enough only for hearing it respond to your voice commands. If you want to use it for playing music, Amazon expect you to connect the Dot to external speakers. A useful guide comparing the differences between the Echo, Dot and Tap is here. The Triby ($199.99) is designed to be stuck on your fridge door in the kitchen. It's sold in the UK too, but only the US version comes with AVS. Amazon expect you'd have the Echo in the living room, and you'd place extra Dots in other rooms. Using this range of products has not only given me an insight into what the future looks like, but I can see the potential for devices like the Echo (and the underlying service, AVS) to play a role in our health. In addition, I want to share my research on the experiences of other consumers who have tried this product. There are a couple of new developments announced this week which might improve the utility of the device, which I'll cover towards the end of the post. 

Triby, Amazon's Tap, Dot & Echo

Triby, Amazon's Tap, Dot & Echo

You can see in this 3 min video, some of the things I use my Echo for in the morning, such as reading tweets, checking the news, weather/my Google calendar, adding new events to my calendar or turning my lights on.  For a list of Alexa commands, this is a really useful guide. If you're curious about how it works, you don't have to buy one, you can test it out in your web browser, using Echosim (you will need an Amazon account though) 

What's really fun are experimenting with the new skills [i.e apps] that get added by 3rd parties, one of which is how my Echo is able to control devices in my smart home, such as my LifX lights. I tend to browse the Alexa website for skills and add them to my Echo that way. You can also enable skills just by speaking to your device. At the moment, every skill is free of charge. I suspect that won't always be the case. 

Some of the skills are now part of my daily routine, as they offer high quality content and have been well designed. Amazon boast that there are now over 3,000 skills. However, the quality of the skills varies tremendously, just like app stores for other devices we already use. For example, in the Health & Fitness section, sorted by relevance, the 3rd skill listed is one called Bowel Movement Facts. 

The Echo is always on, it's 7 microphones can detect your voice even if the device itself is playing music and you're speaking from across the room. It's always listening for someone to say 'Alexa' as the wake up word, but you have a button to mute the Echo so it won't listen. I use Siri, but I was really impressed when I started to use my Echo, it was felt quicker than Siri in answering my questions. Anna Attkisson did a 300 question test, comparing her Echo vs Siri, and found that overall, Amazon's product was better. Not only does the Echo understand my London accent, but it also has no problem understanding me when I used some fake accents to ask it for my activity & sleep data from my Fitbit. I think it's really interesting that I can simply speak to a device in my home and obtain information that has been recorded by the Fitbit activity tracker that I've been wearing on my wrist. It makes me wonder about how we will access our health data in the future. Whilst at the moment, the Echo doesn't speak unless you communicate with it, that may be changing in the future, if push notifications are enabled. I can see it now, having spent all day sitting in meetings, and sat on my smart sofa watching my smart TV, my inactivity as recorded by my Fitbit, triggers my Echo to spontaneously switch off my smart TV, switch my living room lights to maximum brightness, announce at maximum volume that I should venture outside for a 5,000 step walk, and instruct my smart sofa to adjust the recline so I'm forced to stand up. That's an extreme example, but maybe a more realistic one is that you have walked much less today than you normally do, and you end up having a conversation with Echo because your Echo says, "I noticed you haven't walked much today. Is everything ok?"

We still don't know about the impact on society as our homes become smarter and more connected. For example, in the USA, those with GE appliances will be able to control some of them with the Echo. You'll be able to preheat the oven, without even getting off your sofa. That could have immense benefits for those with limited mobility, but what about our children? If they grow up in a world where so much can be done without even having to lift a finger, let alone walk a few steps from the sofa to the kitchen, is this technology a welcome advance? If you have a Hyundai Genesis car, you can now use Alexa to control certain aspects of your car. When I read this part of the Hyundai Genesis article, "Being able to order basic functions by voice remotely will keep owners from having to run outside to do it themselves" it made me think about a future where we just live an even more sedentary lifestyle, with implications for an already over burdened healthcare system. Perhaps having a home that is connected makes more sense in countries like the USA and Australia which on average have quite large houses. Given how small the rooms in my London home are, it's far quicker for me to reach for the light switch than to issue a verbal command to my Echo (and wait for it to process the command)

Naturally, some of us would be concerned about privacy. Right now, anyone could walk into the room and assuming they knew the right commands, could quiz my Echo about my activity and sleep data. One of the things you can do in the US (and now in Europe) is order items from Amazon by speaking to your Echo, and Alex Cranz wrote a post saying, "And today it let my roommate order forty-eight Cadbury Creme Eggs on my account. Despite me not being home. Despite us having very different voices. Alexa is burrowing itself deeper and deeper into owners’ lives, giving them quick and easy access not just to Spotify and the Amazon store, but to bank accounts and to do lists. And that expanded usability also means expanded vulnerability.", he also goes on to say, "In the pursuit of convenience we have to sacrifice privacy." Note that Amazon do offer the ability to modify your voice purchasing settings, so that the device would ask you for a 4 digit confirmation code before placing the order. The code would NOT be stored in your voice history. You can also turn off voice purchasing completely if you wish.

Matt Novak filed a FOI request to ask if the FBI had ever wiretapped an Amazon Echo. The response he got, "we can neither confirm nor deny."

If you don't have an Echo at home, how would you feel about having one? How would you feel about your children using it? One thing I've noticed is that the Echo seems to work better over time, in terms of responding to my voice commands. The way that the Echo works is that it does record your voice commands in the cloud, and by analysing the history of your voice commands, it refines its ability to serve your needs. You can delete your voice recordings, although it may make the Echo less accurate in future. Some Echo users whose children also use the device say their kids love it, and in fact got to grips with the device and it's capabilities faster than the parents. However, according to this Guardian article, if a child under 13 uses an Echo, it is likely to contravene the US Children’s Online Privacy Protection Act (COPPA). This doesn't appear to have put off households installing an Echo in the USA, as research suggests Amazon have managed to sell 3 million devices. Another estimate puts the installed user base significantly lower, at 1.6 million. Either way, in the realm of home based virtual assistants, Amazon are ahead, and probably want to extend that lead, with reports that in 2017 they want to sell 10 million of these speakers. 

Can the Echo help your child's health? Well a skill called KidsMD was released in March that allows parents to seek advice provided by Boston Children's hospital. After the launch, their Chief Innovation Officer, John Brownstein said, "We’re trying to extend the know-how of the hospital beyond the walls of the hospital, through digital, and this is one of a few steps we’ve made in that space." So I tested Kids MD back in April, and you can see in this 3 minute video what it's like to use. What I find fascinating is that I'm getting access to validated health information, tailored to my situation, simply by having a conversation with an internet connected speaker in my home. Of course, the conversation is fairly basic for now, but the pace of change means it won't be rudimentary forever. 

I was thinking about the news last week here in the UK, where it was announced that the NHS will launch a new website for patients in 2017. My first thought was, what if you're a patient who doesn't want to use a website, or for whatever reason can't use a website. If the Echo (and others like it) launch in the UK, why couldn't this device be one of the digital channels that you use to interface with the NHS? Some of us at a grassroots level are already thinking of what could be done, and I wonder if anyone in the NHS has been formally testing an Echo to see how it might be of use in the future? 

The average consumer is already innovating themselves using the Echo, they aren't waiting years for the 'system' to innovate. They are conducting their own experiments, buying these new products with their own money. One man in the USA has used the Echo to help him care for his aging mother, who lives in a different location from him. 

In this post, a volunteer at a hospice asks the Reddit community for input on what the Echo could be useful for with patients. 

How about Rick Phelps, diagnosed back in 2010 at the age of 57 with Early Onset Alzheimer's Disease, and now an advocate for Dementia awareness. Back in Feburary, he wrote about his experience of using the Echo for a week. What does he use it for? To find out what day it is, not knowing what day it is because of Dementia.

For many of us, consumer grade technology such as the Echo will be perceived as a gimmick, a toy, of being of limited or no value with respect to our health. I was struck by what Rick wrote in his post, "To many, the Amazon Echo is a cool thing to have. Some what of a just another electronic gadget. But to a dementia patient it is much, much more than that.It has afforded me something that I have lost. Memory. I can ask Alexia anything and I get the answer instantly. And I can ask it what day it is twenty times a day and I will still get the same correct answer." Rick also highlights how he used the Echo to set medication reminders.

I have to admit, the Echo is still quite clunky, but the original iPhone was clunky too, and the 1st generation of every new type of technology is usually clunky. For people like Rick, it's good enough to make a difference to the outcomes that matter to him in his daily life, even if others are more skeptical. 

Speaking of medication reminders, there was a 10 day Pymts/Alexa challenge this year, using Alexa to "to reimagine how consumers interact with their payments and financial services solutions providers." What I find fascinating is that the winner was DaVincian Healthcare, and they created something called DaVincianRX, an “interactive prescription, communication, and coordination companion designed to improve medication adherence while keeping family caregivers in the loop." You can read more and watch their video of it in action here. People and organisations constantly ask me, where do we look for innovation and new ideas? I always remind them to look outside of healthcare. From a health perspective, most of the use cases I've seen so far involving the Echo are for older members of society or those that care for them. 

I came across a skill called Marvee, which is described as "a voice initiated voice-initiated concierge application integrated with the Alexa Voice service and any Alexa-enabled device, like the Amazon Echo, Dot or Tap." Most of the reviews seem to be positive. It's actually refreshing to see a skill that is purpose built to help those with challenges that are often ignored by the technology sector. 

In the shift towards self-care, when you retire or get diagnosed with a long term condition for the first time, will you be getting a prescription for an Amazon Echo (or equivalent)? Who is going to pay for the Echo and related services? Whilst we have real world evidence that shows the Echo is making a positive impact on people's lives, I haven't been able to find any published studies testing the Echo within the context of health. That's a gap in knowledge, and I hope there are researchers out there who are conducting that research. Like any product, there will be risks as well as benefits, and we need to be able to quantify those risks and benefits now, not in 5 years time. Earlier I cited how Rick who lives with Alzheimer's Disease finds the Echo to be of benefit, but for other people like Rick, using the Echo might lead to harm rather than benefit. We don't know yet. However, not every application of the Echo will require a double blinded randomised clinical trial to be undertaken. If I can already use my Echo to order an Uber, or check my bank balance, why can't I use it to book an appointment with my doctor?

In the earlier use case, a son looked through the data from his mother's usage of her Echo to spot the signs when something is wrong. Surely, Amazon could parse through that data for you and automatically alert you (or any interested person) that there could be an issue? Allegedly, Amazon is working on improvements to the service where Alexa could one day recognise our emotions and respond accordingly. I believe our voice data is going to play an increasing role in improving our health. It's going to be a new source of value. At an event in San Francisco recently, I met Beyond Verbal, an emotions analytics company. They are doing some really pioneering work. We already have seen the emergence of the Parkinson's Voice Initiative, looking to test for symptoms using voice recordings.

How might a device like the Echo contribute to drug safety? Imagine it reminds you to take your medication, and in the conversation with your Echo, you reply that you're skipping this dose, and it asks you why? In that conversation, you have the opportunity in your own words to say why you have skipped that dose. Throw in the ability to analyse your emotions during that conversation, and you have a whole new world of insights on the horizon. Some of us might just be under the impression that real world data is limited to data posted on social media or online forums, but our voice recordings are also real world data. When we reach a point when we can weave all this real-world data together to get a deeper understanding of our health, we will be able to do things we never thought possible. Naturally, there are immense practical challenges on that pathway, but progress is being made every day. Having all of this data from all of these sources is great, and even if it's freely available, it needs to be linked together to truly make a difference. Researchers in the UK have demonstrated that it's feasible to use consumer grade technology such as the Apple watch to accurately monitor brain health. How about linking the data from my Apple watch with the voice data from my Amazon Echo to my electronic health record?

An Israeli startup, Cordio Medical has come up with a smartphone app for those patients with Congesitve Heart Failure (CHF) that captures voice data, analyses it in real-time, and "detects early build-up of fluids in the patient’s lung before the appearance of physical symptoms", and deviations found in the voice data would trigger an alert, where "These alerts permit home- or clinic-based medical intervention that could prevent hospitalisation." For those CHF patients without smartphones, could they simply use an Echo at home with a Cordio skill? Or does Amazon offer the voice data directly to organisations like Cordio for remote monitoring (with the patient's consent)? With devices like the Echo, if Amazon (or their rivals) continue to grow their user base over the next 10 years, they could have an extremely valuable source of unique voice based health data that covers the entire population. 

At present, Amazon has surprisingly made rather good progress in terms of the Echo as a virtual assistant. However, other tech giants are looking to launch their own products and services. For example, Google Home, that is due to arrive later this year. This short video shows what it will be able to do. Now for me, Google plays a much larger role in my daily life than Amazon, in terms of core services. I use Google for email, for search, for my calendar, and maps for navigation. So, Google's Home might be vastly superior to Echo, simply because of that integration with those core services that I already use. We'll have to wait and see. The battle to be a fundamental part of your home is just beginning, it seems. 

The battle to be embedded in every aspect of our lives with extend beyond the home, perhaps in our cars. I tested the Amazon Dot in my car, and I reckon it's only a matter of time before we see new cars on sale with these virtual assistants built into the car's systems, instead of being an add-on. We already have new cars coming with 4G internet connectivity, offering wifi for your devices, from brands like Chevrolet in the USA. 

For when we are on the move, and not in our car or home, maybe we'll all have earphones like the new Apple Airpods, where we can discreetly ask our virtual assistants to control the objects and devices around us. Perhaps Sony's product, the Experia Ear, which launches in November, and is powered by something called Sony's Agent, which could be similar to Amazon's AVS, is what we will be wearing in our ears? Or maybe none of these big tech firms will win the battle? Maybe it will be one of us, or one of our kids who comes up with the virtual assistant that will rule the roost? I'm incredibly inspired after watching this video where a 7 year old girl and her father built their own Amazon Echo using a Raspberry Pi. This line in the video's description stood out to me, "She did all the programming following the instructions on the Amazon Github repository." Next time there is a health hackathon, do we simply invite a bunch of 7 year old kids and give them the space to dream up new solutions to problems that we as adults have created? Or maybe it should be a hackathon that invites 7 year olds with their grandparents? Or maybe we have a hackathon where older adults are invited to co-design Alexa skills with younger people for the Echo? We don't just have financial deficits in health & social care, but we have a deficit of imagination. Amazon have a programming tutorial where you can build a trivia skill for Alexa in under an hour. When it comes to our health, do we wait for providers to develop new Alexa skills, or will consumers start to come together and build Alexa skills that their community would benefit from, even if that community happens to be a community of people scattered around the world, who are all living with the same rare disease?

You'll have noticed that in this post, I haven't delved into the convergence of technologies that have enabled something like the Echo to work so well. This was deliberate on this occasion. At present, I'm really interested in how virtual assistants like the Echo make you feel, rather than the technical details of the algorithm being used to recognise my voice. For someone living far away from their aging parents/grandparents, does the Echo make you feel reassured? For someone living alone and feeling social isolated, does the Echo make you feel not alone? For a young child, does it make you feel like you can do magic, controlling other devices just with your voice? For someone considering moving out of their own home into an institution, does the Echo make you feel independent again? If more and more services are becoming digital by default, how many of these services will be available just by having a conversation? I am using my phone & laptop less since I've had my Echo, but I'm not yet convinced that virtual assistants will one day eliminate the need for a smartphone, but some of us are convinced. 50% of urban smartphone owners around the world believe that smartphones will be no longer be needed in 5 years time. That's one of the findings when Ericsson Consumer Lab quizzed smartphone users in 13 cities around the globe last year. The survey is supposed to represent the views of 68 million urban citizens. In addition, they also found, "Furthermore, a third would even rather trust the fidelity of an AI interface than a human for sensitive matters. 29 percent agree they would feel more comfortable discussing their medical condition with an AI system." I personally think the consumer trends identified have deep implications for the nature of our interactions with respect to our health. Far too many organisations are clinging on to the view that the only (and best) way that we interact with health services is face to face, in a healthcare facility, with a human being. Despite these virtual assistants at home not needing a smartphone with a data plan to work, they would need fixed broadband to work. However, looking at OECD data from December 2015, fixed broadband penetration is rather low. The UK is not even at 40%, so products such as the Echo may not be accessible for many across the nation who might find it beneficial with regard to their health. This is an immense challenge, and one that will need joined up thinking, as we need everyone included in this digital revolution.

You might be thinking right now that building a virtual assistant is your next startup idea, it's going to be how you make an impact on society, it's how you can change healthcare. Alas, it's not as easy as we first thought. Cast your mind back to 2014, the same year that the Echo first became available. I was one of early adopters who pledged $499 for the world's first social robot, Jibo [consider it a cuter or creepier version of the Echo with a few extra features] They raised almost $4 million from people like me, curious to explore this new era. Like the Echo, you are meant to be able to talk to Jibo from anywhere in the room, and it will act upon your command. The release got delayed and delayed, and then recently I got an email informing me that the folks behind Jibo have decided that they won't be shipping Jibo to backers outside of the USA, and I was offered a full refund.

One of the reasons that cited was, "we learned operating servers from the US creates performance latency issues; from a voice-recognition perspective, those servers in the US will create more issues with Jibo’s ability to understand accented English than we view as acceptable." How bizarre, my US spec Echo understands my London accent, and even my fake ones! It took the makers of Jibo 2 years to figure this out, and this too from people who are at the prestigious MIT Media Lab. So just how much effort does it take to make something like the Echo? A rather large amount, it seems. According to the Jeff Bezos, the CEO of Amazon, they have over 1,000 people working on this new ecosystem. A very useful read is the real story behind the Echo explaining in detail how it was invented. Apparently, the reason why the Echo was not launched outside of America until now, was to so it could handle all the different accents. So, if you really want to do a hardware startup, then one opportunity is to work on improving the digital microphones found not just in the Echo, but in the our smartphones too. Alternatively, Amazon even have an Alexa Fund, with $100m in funding for those companies looking to "fuel voice technology innovation." Amazon must really believe that this is the computing platform of the future. 

Moving on this week's news, the UK Echo will have UK partners such as the Guardian, Telegraph & National Rail. I use the train frequently from my home into central London, the station is a 15 minute walk from my house, so that's one of the UK specific skills I'm most likely to use to check if the train is delayed or cancelled before I head out of the front door. Far easier and quicker than pulling out my phone and opening an app. The UK version will also have a British accent. If you have more than one Echo device at home, and speak a command, chances are that two or more of your devices will hear you and respond accordingly, which is not good, especially if you're placing an order with Amazon. So now they have updated the software with ESP (Echo Spatial Perception) and when you talk to your Echo device, only the closest one to you will respond. It's being rolled out to those who have existing Echo devices, so no need to upgrade. You might want to though, as there is a new version of the Echo Dot (US, UK & Germany), which is cheaper, thinner, lighter and promises better voice recognition than the original model. For those who want an Echo in every room, you can now buy Dots in 6 or 12 packs! In the UK, given that the Echo Dot is just £49.99, I expect this Christmas, many people will be receiving them as presents. 

Amazon's Alexa Voice Service is one example of a conversational user interface, and at times it's like magic, and other times, it's infuriatingly clumsy.  I'm mindful that my conversations with my Echo are nowhere near as sophisticated as conversations I have with humans. For example, if I say "Alexa, set a reminder to take my medication at 6pm" and it does that, and then I immediately say "Alexa, set a reminder to take my medication at 6.05pm", and so forth, it currently won't say, "Are you sure? You just set a medication reminder close to that time already." Some parents are concerned that the use of an Echo by their kids is training them to be rude, because they can throw requests at Alexa, even in an aggressive tone of voice, with no please, no thank you, and Alexa will always comply. Are these virtual assistants going to become our companions? Busy parents telling their kids to do their homework with Alexa, or lonely elders who find that Alexa becomes their new friend in helping them cope with social isolation? Will we end up with bathroom mirrors we can have conversations with about the state of our skin? Are we ever going to feel comfortable discussing the colour of our urine with the toilet in our bathroom? When you grab your medication box out of the cupboard, do you want to discuss the impact on your mood after a week of taking a new anti-depressant?

Could having conversations with our homes help us to manage our health? It seems like a concept from a science fiction movie, but to me, the potential is definitely there. The average consumer will have greater opportunities to connect their home to the internet in years to come. Brian Cooley, asks in this post if our home becomes the biggest health device of all.

A thought provoking read is a new report by Plextek examining the changes in the medical industry by 2020 from connected homes. I want you to pause for a moment when reading their vision, "The connected home will be a major enabler in helping the NHS to replace certain healthcare services, freeing up beds for just the most serious cases and easing the pressure on GP surgeries and A&E departments. It will empower patients with long-standing health conditions who spend their life in and out of hospitals undertaking tests, monitoring, rehabilitation or therapy, and give them freedom to care for themselves in a safe way."

Personally, I believe the biggest barrier to making this vision a reality is us, i.e people and organisations that don't normally work together will have to collaborate in order to make connected homes seamless, reliable and cost effective. Think of all the people, policies & processes involved in designing, installing, regulating, and maintaining a connected home that will attempt to replace some healthcare services. That's before we even think about who will be picking up the tab for these connected homes.

Do you believe the Echo is a very small step on the path towards replacing healthcare services, one conversation at a time?

[Disclosure: I have no commercial ties with the individuals or organisations mentioned above]

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Promise doesn't equal proof

I've just returned from California, where I attended these 3 conferences;

For this post, I'm going to focus on what I observed at these events regarding the quest for evidence in Digital Health. I'll be writing separate blog posts in the future relating to my overall experience at each of these events.

Starting with the first event which was hosted by Scripps Translational Science Institute, I was excited about the event. The opening sentence in the brochure said, "A thoughtful exploration of the clinical evidence necessary to drive the widespread uptake of mobile health solutions will be the focus of the first Scripps Health Digital Medicine conference." When booking my place, Three of the educational objectives of the event which sounded tremendously useful to me as a participant were;

  • "Assess the quality of clinical trials of mobile health in terms of providing the evidence necessary to support implementation"
  • "Discuss the implementation of mobile health technologies into clinical practice based on clinical trial evidence"
  • "Identify innovative trial methodologies for use in digital medicine"

Having attended, I don't really feel those three objectives were met. Whilst some of the sessions were very interesting and thought provoking, it wasn't because the speakers were discussing evidence generation or clinical trials in this arena. Often they were talking about the future of Digital Health, and where we are heading. I walked away feeling confused and disappointed. Only on the second day, when Jeff Shuren, Director of the Center for Devices and Radiological Health at the FDA spoke, did I see a session which specifically related to the objectives listed above.

So onto Health 2.0, where I was expecting validation and evidence to be discussed at two sessions. The first was "Validating Performance in Healthcare and Turning the Dial on Credibility" and the second was "Arc Fusion: Getting real about the convergence of health IT and biomedicine." In the first session, Vik Khanna from Quizzify made a number of good points.

I didn't manage to attend the second session, but the talk was captured on video, and can be found here. Having watched the 40 minute video, there wasn't much exploration of evidence or validation.

However, before either of those two sessions took place, it was useful to hear about validation at the session on "Health Data Exploration Project-Personal Data for the Public Good." It's good that they are pursuing this research, and I look forward to seeing what they discover.

I also noticed this tweet during Health 2.0, but I can't find a link on the web that shows what the American Medical Association is doing here.

At Body Computing, there was a panel discussion on "Building a virtual healthcare system" and I asked the panel about whether we need some kind of new institute that can validate & certify these new digital interventions. Andy Thompson, the CEO of Proteus Digital Health replied, and said that we don't need new institutions, and that industry needs to collaborate with regulators to improve regulatory science, as the regulators can't do it alone. At some level, I think he has a good point, and later in this post, I'll explain why we might actually need a new institute.

I've tried a lot of wearable technology, especially smart watches, and there still isn't any real evidence showing that these are making an impact on our health. Whilst a watch that can remind you to walk more or workout at the gym in the best heart rate zone is of some use, many who work with patients every day, are asking, "What's the medical benefit?" There is a huge unmet need out there for wearable technology developed with medical grade sensors that doctors and patients can trust and use with confidence.

At Body Computing, I witnessed the first public viewing of the AliveCor ECG for the Apple watch. You can see a demo by Dr Dave Albert, founder & CMO of AliveCor, in my video below.

I must mention that this new AliveCor product is a prototype and has not been FDA cleared yet. I personally expect it to be a roaring success when it is launched. I note that at the Scripps conference, when both patients and doctors were commenting on what Digital Health product had impacted their life, AliveCor was cited nearly every time. The fact that the AliveCor app on the watch records the patient's voice, links it to the location, takes us a step forward on the path to a single patient view, the marriage of hard and soft data. We need more of this science driven innovation in Digital Health, where gathering of evidence is not an afterthought, and where the product/service has a clearly defined medical benefit. 

I am witnessing increasing use of algorithms in healthcare, especially since we're collecting more data than we ever have before. Algorithms are like the invisible hand that guides many of our decisions, and since they are programmed by humans, how do we know what bias is incorporated into them? The recent scandal which involved Volkswagen's cars and an algorithm that was cheating the system makes me think about the need for greater transparency in healthcare.

I appreciate that in the modern era, algorithms are closely guarded secrets by companies just like Kentucky Fried Chicken guards its secret recipe. I'm not saying that private corporations should make their algorithms open source and lose their competitive advantage, but maybe we need an independent body that can be monitoring these algorithms in healthcare, not just once when the product is approved, but all year round, so that we can feel protected? I found a fascinating post by Jason Bloomberg, who in response to the VW emissions scandal, asks if this is the death knell for the Internet of Things?  Bloomberg cites 'calibration attacks' as the possible cause of the VW scandal, and goes on to highlight how this may impact healthcare too. In my opinion, each of the three conferences I attended should have had a session where we could have a healthy debate about algorithms. I keep hearing about how artificial intelligence, big data and algorithms will lead to so many amazing things, but I never hear anyone talking about calibration attacks, and how to prevent them. Zara Rahman closes her wonderful post on understanding algorithms with, "Though we can't monitor the steps of the process that humans decide upon to create an algorithm, we can - or should be able to - monitor and have oversight on the data that is provided as input for those algorithms."

I don't think it's alarmist to examine a range of different future scenarios and to consider updated regulatory frameworks to reflect threats that never existed before. It's wonderful to hear speakers at conferences show us how the future is going to be better due to technological advances, but we also need to hear about the side effects of those new technologies too.

I recognise that not every digital intervention will need clinical trials and a whole body of evidence before it can be approved, accredited and adopted. For example, medication reminder apps that are a twist on the standard reminder app. Or it could be argued that even these simple apps should be regulated too? What if the software developer makes a mistake in the code and when a patient actually uses the app, their medication reminders in the app are switched around, leading to patient harm? A recent article highlights research that showed that most of the NHS approved apps for depression are actually unproven. Another related post by Simon Leigh, points out, "are apps forthcoming with the information they provide? It's easy enough to say this app beats depression, but do they offer any proof to turn this from what is essentially marketing into evidence of clinical effectiveness?"

Many people are so angry with the state of healthcare that they want this digital revolution to disrupt healthcare as quickly as possible. Asking for evidence and proof is often seen as slowing down this revolution, a sign of resistance to change. Just because something is digital doesn't mean we can trust it implicitly from the moment it's developed. Hype, hope and hubris will not be enough to deliver the sustainable change in healthcare that we all want to see. We are at a crossroads in Digital Health, and we have to be very careful going forwards that the recipients of these digital interventions aren't led to believe that promise equals proof.

[Disclosure: I have no commercial ties to any of the individuals or organizations mentioned in this post]

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Data or it didn't happen

Today, there is incredible excitement, enthusiasm and euphoria about technology trends such as Wearables, Big Data and the Internet of Things. Listening to some speakers at conferences, it often sounds like the convergence of these technologies promises to solve every problem that humanity faces. Seemingly, all we need to do is let these new ideas, products and services emerge into society, and it will be happy ever after. Just like those fairy tales we read to our children. Except, life isn't a fairy tale, neither is it always fair and equal. In this post, I examine how these technologies are increasingly of interest to employers and insurers when it comes to determining risk, and how this may impact our future. 

Let's take the job interview. There may be some tests the candidate undertakes, but a large part of the interview is the human interaction, and what the interviewer(s) and interviewee think of each other. Someone may perform well during the interview, but turn out to under perform when doing the actual job. Naturally, that's a risk that every employer wishes to minimise. What if you could minimise risk with wearables during the recruitment process? That's the message of a recent post on a UK recruitment website,  "Recruiters can provide candidates with wearable devices and undertake mock interviews or competency tests. The data from the device can then be analysed to reveal how the candidate copes under pressure." I imagine there would be legal issues if an employer terminated the recruitment process simply on the basis of data collected from a wearable device, but it may augment the existing testing that takes place. Imagine the job is a management role requiring frequent resolution of conflicts, and your verbal answers convince the interviewer you'd cope with that level of stress. What if the biometric data captured from the wearable sensor during your interview showed that you wouldn't be able to cope with that level of stress. We might immediately think of this as intrusive and discriminatory, but would this insight actually be a good thing for both parties? I expect all of us at one point have worked alongside colleagues who couldn't handle pressure, and their reactions caused significant disruption in the workplace. Could this use of data from wearables and other sensors lead to healthier and happier workplaces? 

Could those recruiting for a job start even earlier? What if the job involved a large amount of walking, and there was a way to get access to the last 6 months of activity data from the activity tracker you've been wearing on your wrist every day? Is sharing your health & fitness data with your potential employer the way that some candidates will get an edge over other candidates that haven't collected that data? That assumes that you have a choice in whether you share or don't share, but what if every job application required that data by default? How would that make you feel? 

What if it's your first job in life, and your employer wants access to data about your performance during your many years of education? Education technology used at school which aims to help students may collect data that could tag you for life as giving up easily when faced with difficult tasks. The world isn't as equal as we'd like it to be, and left unchecked, these new technologies may worsen inequalities, as Cathy O’Neil highlights in a thought provoking post on student privacy, “The belief that data can solve problems that are our deepest problems, like inequality and access, is wrong. Whose kids have been exposed by their data is absolutely a question of class.”

There is increasing interest in developing wearables and other devices for babies, tracking aspects of a baby, mainly to provide additional reassurance to the parents. In theory, maybe it's a brilliant idea, with no apparent downsides? Laura June doesn't think so, She states, "The merger of the Internet of Things with baby gear — or the Internet of Babies — is not a positive development." Her argument against putting sensors into baby gear is that it would increase anxiety levels in parents, not reduce them. I'm already thinking about that data gathered from the moment the baby is born. Who would own and control it? The baby, the baby's parents, the government or the corporation that had made the software & hardware used to collect the data? Furthermore, what if the data from the baby could impact not just access to health insurance, but the pricing of the premium paid by the parents to cover the baby in their policy? Do you decide you don't want to buy these devices to monitor the health of your newborn baby in case one day that data might be used against your child when they are grown up? 

When we take out health and life insurance, we fill in a bunch of forms, supply the information needed for the insurer to determine risk, and then calculate a premium. Rick Huckstep points out, "The insurer is not able to reassess the changing risk profile over the term of the policy." So, you might be active, healthy and fit when you take out the policy, but what if your behaviour changes and your risk profile changes during the term of the policy? This is the opportunity that some are seeing for insurers to use data from wearables to determine how your risk profile changes during the term of the policy. Instead of a static premium at the outset, we have a world with dynamic and personalised premiums. Huckstep also writes, "Where premiums will adjust over the term of the policy to reflect a policyholder’s efforts to reduce the risk of ill-health or a chronic illness on an on-going basis. To do that requires a seismic shift in the approach to underwriting risk and represents one of the biggest areas for disruption in the insurance industry."

Already today, you can link your phone or wearable to Vitality UK health insurance, and accumulate points based upon your activity (e.g. 10 points if you walk 12,500+ steps in a day). Get enough points and exchange them for rewards such as a cinema ticket. A similar scheme has also launched in the USA with John Hancock for life insurance

Is Huckstep the only one thinking about a radically different future? Not at all. Neil Sprackling, Managing Director of Swiss Re (a reinsurer) has said, “This has the potential to be a mini revolution when it comes to the way we underwrite for life insurance risk." In fact, his colleague, Oliver Werneyer, has an even bolder vision with a post entitled, "No wearable device = no life insurance," in which he believes that in 5 to 10 years time, you might find not be able to buy life insurance if you don't have a wearable device collecting data about you and your behaviour. Direct Line, a UK insurer believe that technology is going to transform insurance. Their Group Marketing Director, Mark Evans, has recently talked about technology allowing them to understand a customer's "inherent risk." Could we be penalised for deviating away from our normal healthy lifestyle because of life's unexpected demands? In this new world, if you were under chronic stress because you suddenly had to take time off work to look after a grandparent that was really sick, would less sleep and less exercise result in a higher premium next month on your health insurance? I'm not sure how these new business models would work in practice. 

When it comes to risk being calculated more accurately based upon this stream of data from your wearables, surely it's a win-win for everyone involved? The insurers can calculate risk more accurately, and you can benefit from a lower premium if you take steps to lower your risk. Then there are opportunities for entrepreneurs to create software & hardware that serves these capabilities. Would the traditional financial capitals such as London and New York be the centre of these innovations? 

One of the big challenges to overcome, above and beyond established data privacy concerns, is data accuracy. In my opinion, these consumer devices that measure your sleep & steps are not yet accurate and reliable enough to be used as a basis for determining your risk, and your insurance premium. Sensor technology will evolve, so maybe one day, there will be 'insurance grade' wearables that your insurer will be able to offer you. These would be certified to be accurate, reliable and secure enough to be used in the context of being linked to your insurance policy. In this potential future, another issue is whether people will choose to not take insurance because they don't want to wear a wearable, or they simply don't like the idea of their behaviour being tracked 24/7. Does that create a whole new class of uninsured people in society? Or would their be so much of a backlash from consumers (or even policy makers) to this idea of insurers accessing this 24/7 stream of data about your health, that this new business model never becomes a reality? If it did become a reality, would consumers switch to those insurers that could handle the data from their wearables? 

Interestingly, who would be an insurer of the future? Will it be the incumbents, or will it be hardware startups that build insurance businesses around connected devices? That's the plan of Beam Technologies, who developed a connected toothbrush (yes, it connects via Bluetooth with your smartphone and the app collects data about your brushing habits). Their dental insurance plan is rolling out in the USA shortly. Beam are considering adding incentives, such as rewards for brushing twice a day. Another experiment is NEST partnering with American Family Insurance. They supply you a 'smart' smoke detector for your home, which "shares data about whether the smoke detectors are on, working and if the home’s Wi-Fi is on." In exchange, you get 5% discount off your home insurance. 

Switching back to work, employers are increasingly interested in the data from employee's wearables. Why? Again, it's about a more accurate risk profile when it comes to health & safety of employees. Take the tragic crash of the Germanwings flight this year, where it emerges the pilot deliberately crashed the plane, killing 150 passengers. At a recent event in Australia, it was suggested this accident might have been avoided if the airline were able to monitor stress in the pilot using data from a wearable device.

What other accidents in the workplace might be avoided if employers could monitor the health, fitness & wellbeing of employees 24 hours a day? In the future, would a hospital send a surgeon home because the data from the surgeon's wearable showed they had not slept enough in the last 5 days? What about bus, taxi or truck drivers that could be monitored remotely for drowsiness by using wearables? Those are some of the use cases that Fujitsu are exploring in Japan with their research. Conversely, what if you had been put forward for promotion to a management role, and a year's worth of data from your wearable worn during work showed your employer that you got severely stressed in meetings where you had to manage conflict? Would your employer be justified in not promoting you, citing the data that suggested promoting you would increase your risk of a heart attack? Bosses may be interested in accessing the data from your wearables just to verify what you are telling them. Some employees phone in pretending to be sick, to get an extra day off. In the future, that may not be possible if your boss can check the data from your wearable to verify that you haven't taken many steps as you're stuck in bed at home. If you can't trust your employees to tell the truth, do you just modify the corporate wellness scheme with mandatory monitoring using wearable technology?

If it's possible for employers to understand the risk profile for each employee, would those under pressure to increase profits, ever use the data from wearables to understand which employees are going to be 'expensive', and find a way to get them out of the company? Puts a whole new spin on 'People Analytics' and 'Optimising the workforce'. In a compelling post, Sarah O'Connor shares her experiment where she put on some wearables and shared the data with her boss. She was asked how it felt to share the data with her boss, "It felt very weird, and actually, I really didn't like the feeling at all. It just felt as if my job was suddenly leaking into every area of my life. Like on the Thursday night, a good friend and colleague had a 30th birthday party, and I went along. And it got to sort of 1 o'clock, and I realized I was panicking about my sleep monitor and what it was going to look like the next day." We already complain about checking work emails at home, and the boundaries between work and home blurring. Do you really want to be thinking about how skipping your regular session at the gym on a Monday night would look to your boss? Devices that will betray us can actually be a good thing for society. Take the recent case of a woman in the USA who reported being sexually assaulted whilst she was asleep in her own home at night. The police used the data from the activity tracker she wore on her wrist to prove that at the time of the alleged attack, she was not asleep but awake and walking. On the other hand, one might also consider that those with malicious intent could hack into these devices and falsify the data to frame you for a crime you didn't commit. 

If these trends continue to converge, I see enterprising criminals rubbing their hands with glee. A whole new economy dedicated to falsifying the stream of data from your wearable/IoT device to your school, doctor, insurer or employer, or whoever is going to be making decisions based upon that stream of data. Imagine it's the year 2020, you are out partying every night, and you pay a hacker to make it appear that you slept 8 hours a night. So many organisations are blindly jumping into data driven systems with the mindset of, 'In data, we trust,' that few bother to think hard enough about the harsh realities of real world data. Another aspect is bias in algorithms using this data about us. Hans de Zwart has written an illuminating post, "Demystifying the algorithm: Who designs our life?" Zwart shows us the sheer amount of human effort in designing Google Maps, and the routes it generates for us, "The incredible amount of human effort that has gone into Google Maps, every design decision, is completely mystified by a sleek and clean interface that we assume to be neutral. When these internet services don’t deliver what we want from them, we usually blame ourselves or “the computer”. Very rarely do we blame the people who made the software." With all these potential new algorithms classifying our risk profile based upon data we generate 24/7, I wonder how much transparency, governance and accountability there will be? 

There is much to think about and consider, one of the key points is the critical need for consumers to be rights aware. An inspiring example of this, is Nicole Wong, the former US Deputy CTO, who wrote a post explaining why she makes her kids read privacy policies. One sentence in particular stood out to me, " When I ask my kids about what data is collected and who can access it, I am asking them to think about what is valuable and what they are prepared to share or lose." Understanding the value exchange that takes place when you share your data with a provider is critical step towards being able to make informed choices. That's assuming all of us have a choice in the sharing of our data. In the future, when we teach our children how to read and write English, should they be learning 'A' is for algorithm, rather than 'A' is for apple? I gave a talk in London recently on the future of wearables, and I included a slide on when wearables will take off (slide 21 below). I believe they will take off when we have to wear them or when we can't access services without them. Surgeons and pilots are just two of the professions which may have to get used to being tracked 24/7.

Will the mantra of employers and insurers in the 21st century be, "Data or it didn't happen?"

If Big Data is set to become one of the greatest sources of power in the 21st century, that power needs a system of checks and balances. Just how much data are we prepared to give up in exchange for a job? Will insurance really be disrupted or will data privacy regulations prevent that from happening? Do we really want sensors on us, in our cars, our homes & our workplaces monitoring everything we do or don't do? Having data from cradle to grave on each of us is what medical researchers dream of, and may lead to giant leaps in medicine and global health. UNICEF's Wearables for Good challenge could solve everyday problems for those living in resource poor environments. Now, just because we might have the technology to classify risk on a real time basis, do we need to do that for everyone, all the time? Or should policy makers just ban this methodology before anyone can implement it? Is there a middle path? "Let's add in ethics to technology" argues Jennifer Barr, one of my friends who lives and works in Silicon Valley. Instead of just teaching our children to code, let's teach them how to code with ethics. 

There are so many questions, and still too few places where we can debate these questions. That needs to change. I am speaking at two events in London this week where these questions are being debated, the Critical Wearables Research Lab and Camp Alphaville. I look forward to continuing the conversation with you in person if you're at either of these events. 

[Disclosure: I have no commercial ties to any of the individuals or organisations mentioned in the post]

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Will the home of the future improve our health?

According to BK Yoon, that would be one of the benefits in their vision of the 'home of the future'. Who is BK Yoon? He's President and CEO of Samsung Electronics. Last Friday, I listened as he delivered the opening keynote of IFA 2014, which is the largest consumer electronics and home appliance show in Europe.

Whilst many talk of bringing healthcare out of the hospital/doctor's office into the home, Samsung, in theory, have the resources and vision to make this a reality at a global level. Samsung Group, of which Samsung Electronics is the biggest subsidiary, have just invested $2 billion in setting up a biopharmaceuticals unit. Christopher Hansung Ko, CEO at the Samsung Bioepis unit. said in an earlier interview, “We are a Samsung company. Our mandate is to become No. 1 in everything we enter into, so our long-term goal is to become a leading pharmaceutical company in the world.” 

Is South Korea innovative?

My views on Samsung (and South Korea overall), changed when I visited Seoul, the capital of South Korea during my round the world trip in 2010. I had only scheduled a 3 day stopover, but ended up staying over 3 weeks. I was impressed by their ambitions, their attitude towards new technology and their commitment to education. Their journey over the last half century is truly amazing. "Fifty years ago, the country was poorer than Bolivia and Mozambique; today, it is richer than New Zealand and Spain." Bloomberg released their Global Innovation Index at the start of this year. Guess which country was top of the list? Yup, South Korea. The UK was ranked a lowly 16th.

After my visit, I left South Korea with a different perspective, and have been paying close attention to developments there ever since. I believe many people in the West underestimate the long term ambitions of a company like Samsung. Those wishing to understand the future, would be wise to monitor not just what's happening in Silicon Valley, but also in South Korea. 

Aging populations worry policy makers in many advanced economies. Interestingly, recent data shows that South Korea's population is aging the fastest out of all OECD countries. Maybe that's one of the drivers behind Samsung's strategy of developing technology that could one day help older people live independently. 

We've been hearing about smart and connected homes for many years, and one wonders how this technology would be integrate with our lives. How easy would it be to set up and use? How reliable would it be? Would I have to figure out what to do with all these data streams from the different devices? I used to believe that Apple was unique in really understanding the needs and wants of the consumer, but it seems Samsung have been taking notes. They have conducted lifestyle research with 30,000 people around the world. The results of that research were shared after they keynote. Whilst reading the reports, one feels like Samsung Electronics is now trying to position itself as a lifestyle company, not a technology company. Whether it's one of the opening statements, "The home of the future is about more than technology and gadgets. It's about people." It's about responsive homes that adapt to our needs, homes that protect us, homes that are empathetic. How much is all of this going to cost us, right? Is it only going to be for the rich? Is it only going to work with new homes, or can we retrofit the technology?

Data driven homes - is that what we truly want?

Their research also says, "Technology will promote eating and living right. Devices around the home will inspire us to make decisions that are right for our bodies, taking an active role in helping us achieve better health by turning goals into habits." So in Samsung's vision, the fridge of the future will inform you that some of the food inside has expired and needs to be thrown away. Where do we draw the line? What if you come home from work hoping to grab a beer from the fridge, but the fridge door is locked, because the home of the future knows you've already consumed more than your daily allowance of calories?

Do we actually want to live in data driven homes? Our homes are often an analogue refuge in an increasing digital & connected world. We have the choice to disconnect and switch off our devices and just 'be'. What if part of our contract with our energy provider or home insurer is having smart home technology installed?

In a recent survey of Americans aged 18+ for Lowe's, 70% of smartphone/tablet owners want to control something inside their home from their bed via their mobile. Obesity is already a public health issue not just in the USA, but in many nations. Will being able to switch on the coffee pot, adjust the thermostat and switch on the lights by speaking into your smartphone whilst lying in bed lead to humans leading even more sedentary lives in the future? 

However, there is a flip side. Rather than just dismiss this emerging technology as silly or promoting inactivity, these advancements may be of immense benefit to certain groups of people. For example, would the home of the future enable someone who is blind, disabled or with learning difficulties a greater chance to live independently? Would the technology be useful when you're discharged from hospital after surgery?

Is it just about the data?

One of the byproducts of these new technologies for our homes, are data. Sensors and devices which track everything we do in the home are going to be collecting and processing data about us, our behaviour and our habits. Samsung to mention in their research "Our home will develop digital boundaries that keep networks separate & secure, protecting us from data breaches, and ensuring that family members cannot intrude on each other's data." It all sounds great in a grand vision, but turning that into reality is much harder than it appears.

We expect to hear about Apple's HealthKit later today. Who will you trust with the data from your home in the future? Apple, an American corporation or Samsung, a South Korean corporation? Or neither of them? Is the strategy of connecting our homes to the internet simply a ploy to grab even more data about us? Who will own and control the data from our homes? Where will it be stored? 

Despite the optimism and hope in BK Yoon's keynote, I can't help wonder about the risks of your home's data feed getting hacked, and what it means for criminals such as burglars, or even terrorists. Do we want machines storing data on the movements of each family member within our own home? Or will tracking of family members who are very young or very old, in and around the home, give families peace of mind and reassurance?

Ultimately, who is going to pay for all of this innovation? Even today, when I talk to ordinary hard working families about new technologies, such as sleep tracking, I'm conscious it's out of the reach of many. For example, the recently launched Withings Aura system allows you to track and improve your sleep. It's priced at $299.95/£249.95. If given the choice, how many ordinary families would invest in the Withings Aura to improve their sleep vs buying a new bed from Ikea for the same price?

The video below was played during the keynote, and gave me a glimpse into Samsung's vision of the home of the future. BK Yoon claimed that the future is coming faster than we think. He seemed pretty confident. Only time will tell. 

How does this video make you feel? Does Samsung's vision make you excited and hopeful, or does it frighten you? Do you look forward to a home that aims  to protect you and cares for your family? How comfortable do you feel with your home potentially knowing more about your health than you or your doctor? How will the data about our health collected by our home integrate with the health & social care system? Will the company that is most successful in smart homes be the one that consumers trust the most?

[Disclosure: I have no commercial ties with the individuals and organisations mentioned in this post]

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