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? 

Will the online job application of the future also request access to the health & fitness data from your #wearables? #privacy

— Maneesh Juneja (@ManeeshJuneja) June 26, 2015

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.

My Apple watch told me to stand up as I sat down on the toilet from Maneesh Juneja

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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The Apple watch is dead. Long live the Apple watch.

I've had the Apple watch for just over a week now, and in this post, I'd like to share my experience and my thoughts about the future. I've examined many aspects of the functionality of the device, but also its potential for playing a role in health. It appears to be a device that polarises opinions, before it has even hit the market. I've met people who ordered one, not because they like it, or because they want some kind of 'smartwatch', but simply because it is a new product from Apple. Others have told me they would never purchase such a watch, because of the cost, and also they don't see a use for it given they already have an iPhone. 

There have been multiple attempts at 'smartwatches' to win over consumers. I use the term, 'smartwatch' very loosely, simply to group these wearables together. I'll be sharing more in this post about why these watches are still not particularly smart. Last summer, Android Wear launched, and I wrote about my initial experience and thoughts on health & social care. Android Wear hasn't been as successful as Google had hoped. I've actually been using a number of 'smartwatches', and for me, the closest existing rival to the Apple watch is the Samsung Gear S, which released late 2014, and didn't sell very well (I only know one person on Earth who has also purchased one). It overlaps in functionality with the Apple watch, with two big differences. It has its own SIM card inside the watch, with its own phone number, and it only works with an Android phone. I've been using the Gear S since November 2014, and the user experience is very different. Whilst the Samsung seemed to have just tried to miniaturise a computer/phone into a watch, It is clear to me that Apple have put considerably more thought into the design of the watch. A clear example of this difference in design thinking is the fact that the Gear S offers both a QWERTY keyboard on the watch such as when you write a text message, and also a web browser. Just because it is technically possible to do something on a device as small as a watch, doesn't mean it should be included as a feature. Thankfully, Apple have not added those two features. 

Some people say to me if the Apple watch is not replacing the iPhone, then what's the point? Why use an app on a tiny screen on your wrist when you could just use the same app on your iPhone? A perfectly sensible question to ask. To answer, I'll give you a real life example of why having the Apple watch made me feel safer as I navigated the streets of a foreign city at night. I flew from London to Milan on Tuesday evening, and after dinner in the city, I wanted to walk back to my hotel. I didn't know the route, so I used my Apple watch. I opened the Maps app, dictated the name of the hotel (which the watch recognised despite me being on a busy street), and chose the walking (vs driving) option for navigation. Why did the Apple watch make me feel safer walking back to my hotel at night? Well, you can keep your iPhone in your pocket, and you don't even need to glance at your Apple for instructions on when to turn left or right. You just walk normally, except that when you do have to turn left or right, the watch 'taps' your wrist in different ways. To anyone observing you, they wouldn't know you had an expensive phone and watch. Bear in mind that GPS is not always accurate, especially in cities with tall buildings. On one walk in London, the watch tapped to indicate that I turn right, into a clothing store. The street I actually had to turn right into was 50 yards up ahead. However, I'm not sure if the driving mode on the watch would be safe. Would you really want to navigate using your watch whilst you drive? 

One of the standard notifications is to alert you once an hour to stand up and move. Sounds like a useful concept given how many of us work in jobs that keep us sitting in a chair all day long. These notifications are simple, not smart, as they appear at the strangest of times. You'd think the notifications could have made use of data from sensors in your watch to be more relevant and timely.

@BSchuler @pmarca my Apple watch told me to "stand up & move" just as I sat down on the toilet

— Maneesh Juneja (@ManeeshJuneja) April 28, 2015

Using the Gear S has changed how I use my Android phone. I typically keep my phone on silent, and use the Gear S to notify me of emails/calls etc. I find it particularly useful if I'm charging my phone at home or in the office, and I want to wander away from the phone, without missing any notifications. All these devices need to be paired with your phone via Bluetooth in order to work. Since the Gear S has its own SIM card, as soon it loses the Bluetooth connection with my phone, it forwards calls from the phone to the Gear S. So, if I left the phone at home to visit the gym, and someone rang my phone's number, the call would be forwarded to the Gear S. Since the Gear S has a speaker you can answer the call (or alternatively, you can connect the Gear S with bluetooth earphones, which is a lot better). Incidentally, I found the speaker on the Apple watch is competent, but not as loud as the speaker on the Gear S. 

When the Apple watch loses the Bluetooth connection with the iPhone because you've walked out of the house, the watch isn't completely useless. You can use it to track your workouts and it will continue to monitor your activity (move, stand & exercise). You can listen to music that's stored on the watch, and use Apple Pay to buy stuff (Apple Pay only available in the USA right now). Oh, and you can still use it as a watch to tell the time, set alarms and use the stopwatch feature! If you're at home or in the office and you wander around so that the Bluetooth connection is lost between your iPhone and the Apple watch, if your iPhone is also connected to a wifi network, you can also use Siri on the watch & send and receive iMessages. 

Which menu of apps do you prefer? Gear S (left) or Apple Watch (right)?

When it comes to learning to use the Apple watch, it should be intuitive, given Apple's previous products. Tell me something, if the Apple watch was intuitive, why would the user guide be nearly 100 pages long? (For comparison, the manual for the Gear S is also of a similar length!)

For example, the Apple watch features something called 'Force Touch', which can distinguish between you tapping the screen and pressing the screen. Pressing the screen brings up new menus or options within apps. For example when you open up the Maps app, in order to search for a destination, you have to press firmly on the screen, and two options then appear, "Search" & "Contacts." If you were unaware of "Force Touch" or had not read the User Guide, you might be bamboozled. When the Apple watch has a bunch of notifications you wish to clear, you have to press firmly on the screen for a "Clear All" option to appear. On the Gear S, when browsing the notifications, you simply swipe up to see the "Clear All" option. It seems the user interface on the Apple watch leaves many users confused, leading to 9to5mac creating a quick start user guide. Whilst browsing and choosing the apps on the Apple watch, I sometimes find myself starting the wrong app, because the screen and the icons are so small. In that respect, I do prefer the larger screen and traditional menu of the Gear S. For clarity, I purchased the larger of the two Apple watches, 42mm, rather than the 38mm. I do wonder how difficult or easy it would be for someone with Arthritis to use the Apple watch (or any wearable device with a touch screen)?

When it comes to health, one of the first apps I tried was one called Sickweather. It uses crowdsourced data for forecasting and mapping sickness. It is the same notification that would appear on the iPhone, but if you have the watch, it will appear there instead. Now it might seem of limited or no value to many, but for some people, it is useful. After I put out the tweet showing how the cough alert looked, it led to an interaction on Twitter with a guy called Jarrod, who has Cystic Fibrosis, and said the app would be useful for him. Sickweather has a Sickweather score that is only available on the Apple watch. 

@westr I already got a cough alert tonight! pic.twitter.com/0hxN6GnUbE

— Maneesh Juneja (@ManeeshJuneja) April 24, 2015

I also tried an app called DocNow that provides instant access to doctors 24/7 from the Apple watch. A tap on the watch will initiate a HD video call with a doctor via the iPhone. Unfortunately, being in England, it didn't work for me when I tried it. That's being resolved I believe. 

There are also a number of apps on the watch for Medication reminders. Medication reminders on a watch are not new, I tested the MediSafe version for Android Wear last year. For the Apple watch, I tested an app from WebMD, and one good thing I noticed was it even includes a picture of the medication you are supposed to take. In the WebMD app on the iPhone, you can even use your own picture, if your pills look different from the stock image. It all sounds great, doesn't it? However, once I shared via Twitter, I got valuable feedback. Is the screen size too small for older people and/or people with poor eyesight? So, rather than on a watch, perhaps medication reminders for older people taking multiple medications are better delivered via a personal companion robot? (more on that in a future post as I have some updates in that arena) 

The Deadline app that shows my predicted life expectancy

Another interesting app I tested was Deadline. This is an app that asks you questions about your lifestyle, and family history as well as reading some of your health data from the iPhone to then determine your life expectancy. It displays it on the watch as a tip on how to improve your life expectancy. The science behind this app is probably unvalidated, but as a concept, but it does make me wonder. In the future, If the science was accurate, and the app was validated, how comfortable would you feel with tailored health advice via your watch that was based upon the state of your health there and then? Would it be too intrusive if your watch nudged you to eat a salad instead of a burger?

The Apple watch searches for Bluetooth devices

Within the Bluetooth menu on the watch, I found that it shows two types of devices it can connect to, devices & health devices. I understand that it is possible to pair the watch to an external heart rate monitor, if you wanted to use that to monitor your heart rate rather than the sensor within the watch itself (I plan to test this connectivity). It is not clear what other health devices you could connect to the watch, but its a feature worth keeping track of. 

The watch comes with a sensor that will normally record your heart rate every 10 minutes, and store that data in the health app on the iPhone. That sensor could also act as a pulse oximeter, allowing measurement of oxygen content of your blood. However, this feature has not been activated yet. 

Now if you choose the Workout app, and select one of the workouts (such as Outdoor walk or Indoor Cycle), it will track your heart rate continuously. I did try that out with an Outdoor walk, and I also compared how the Gear S was measuring my heart rate compared with the Apple watch. Bear in mind that the positioning of both devices may have affected the results, and I'll have to repeat the test, with the devices in different positions, on different arms. 

HR on Gear S almost double that of Apple watch (I was sitting on a bench as a I rested during my walk) 

How do steps/distance walked compare against other devices? Well, this picture illustrates the challenge with these consumer devices. For the picture, the Apple watch & Gear S were worn on my left hand, and the Microsoft Band was worn on my right hand. Same walk, different devices, different results. Note, I entered my age, gender, height and weight were entered exactly the same in the app for each device. Why does the Apple watch show more steps walked than the Microsoft band, but a longer distance? Why does the Gear S show more steps & more distance but fewer calories than the Apple watch? BTW, since the Apple Watch doesn't track sleep, I'm using the Microsoft band to track my sleep. Will we ever have one device that can serve every purpose or do we have multiple wearables?

Apple Watch (left), Microsoft Band (top right), Gear S (bottom right) 

Health app on my iPhone

I was curious about the data from my watch being recorded in the Health app on my iPhone, and I found something quite puzzling. The Outdoor walk I had selected on the watch, had captured my heart rate continuously but something didn't make sense.

The app shows 6 entries for 8.21am, two of them for 128bpm, two more for 127bmp, one at 78bpm, and one at 69bpm. The date stamp only shows the hour and minute not the second. How will it be possible to make sense of this data in any analysis if I have 6 different heart readings at 8.21am? (Update: 18th May - I got a response from Apple about this issue. They told me the watch will measure HR multiple times in a minute, but that the data in the health app is only in hours and minutes.)

Now that my heart rate is being captured with the watch, could that data ever be used with other personal data to tailor advertising messages to me? I'm outside Starbucks, having not slept well, woken up late, missed by usual bus to work, and voila, my watch gets a coupon offering me a discount off coffee within the next 10 minutes at THAT particular Starbucks. Would that be creepy or cool? I envisioned this scenario after reading a brilliant post by Aaron Friedman, on the future of search engines, which he says is all about context. Delivering information to your watch at the right place and the right time was the plan behind Google's Android Wear. A great idea, but their implementation last year was not optimal. Additionally, many of the first Android Wear watches didn't look very fashionable either. Their new strategy for Android Wear in response to the Apple watch may win them more consumers, but I'm not convinced.

I have been examining the role of the Apple watch in health primarily from a consumer perspective. What about people working in healthcare? Is the watch helpful for them? Well, Doximity, a professional network for physicians in the USA thinks so. An article about their app for the watch highlights, "They think the Apple Watch can enable medical professionals to share information easily, securely, and quickly — and perhaps most importantly, hands-free."

There is a hospital in the USA, Ochsner Health System, that is trialling the use of the Apple watch with patients with high blood pressure. Then you've got one of the biggest hospitals in Los Angeles, Cedars-Sinai has now added support for Apple's HealthKit, allowing data from a patient's phone to be added to their medical record. That's where I see the biggest advantage of the Apple watch over any other makers of smartwatches.  

• Interface - Whilst not perfect, and probably too complex, once you get the hang of it, the Apple watch is a more polished user experience than its current rivals 

• Integration - Whilst I capture health information with the Gear S, it doesn't really go anywhere from the Samsung S-health app. This is where Apple really shines. 

• Ecosystem - With around 3,500 apps already available for the Apple watch (including many popular iPhone apps), and around 1,000 apps for the Samsung Gear watches, once again, Apple are ahead. I downloaded very few apps for the Gear S, as I didn't find many good ones.

The Bump is an app for pregnant women - this is the screen you see for several seconds as the app loads 

Since I've mentioned apps, thanks to Tyler Martin for reminding me to mention some of the issues I faced with installing & using apps on the Apple watch. Maybe it is because the ecosystem is so new, but the apps can be buggy. You expect a tiny device like a watch to respond swiftly, it is not like a computer with a hard drive. Yet, there are times, when the watch does take a relatively long time to install/open apps, or the app crashes whilst you're using it. Those are the moments when you feel like you've purchased a product that is still a work in progress. I would hope these bugs get ironed out as more people start using these apps and report issues to the developers. The source of these problems may be that developers have had to create apps for the watch without actually having access to the watch prior to launch. Maybe those consumers waiting for Apple Watch 2.0 or 3.0 are the sensible ones?

Dr Eric Topol highlights in a tweet how the Apple watch may be of benefit to diabetics wishing to monitor their blood glucose levels when using a Dexcom CGM.

Glucose glances, trend taps + notifications on a now medicalized #smartwatch #diabetes pic.twitter.com/QacIzXnR5g

— Eric Topol (@EricTopol) May 4, 2015

One thing I was reminded of this week was that we might have the latest technology such as an Apple watch, but the infrastructure around us was designed for a different era. For example, I travelled from London to Milan and Paris this week with British Airways. As a result, I was able to use their mobile boarding pass on my Apple watch. I checked-in online using the BA app on my iPhone, and then retrieved my boarding pass, which I added to Passbook. The passes in Passbook on your iPhone get transferred to Passbook on your Apple watch, so you could even board a plane using your Apple watch alone, if your phone was off or left at home. There are two parts to the boarding pass on the watch, one is the text information about your flight and the other part is the QR code which airport machines will scan. On the iPhone, you'd see both parts at once, on the watch, due to the small screen, you have to swipe up to see the QR code.

Instead of waiting by the screens in departures at Heathrow airport, I wandered around the airport at my leisure, and got a notification on my watch when the gate for my flight was announced. However, when I was at the gate, and was asked for my boarding pass, I had to take the watch off my wrist so the boarding pass could be scanned. The machine which scans boarding passes had been designed to scan paper boarding passes, and so didn't have a gap large enough to accommodate someone's arm wearing a watch. Where I wished I had a paper boarding pass was at Milan airport, where on departure, passport control wanted to see my boarding pass. The officer was in a kiosk fronted by a glass screen, and I had to take off my watch and slide it across the counter. However, when I did that, the screen of the watch went off, and as I leaned over the counter to tap the screen for the boarding pass to reappear, a bunch of notifications pinged to the watch, which then confused the officer in the kiosk. I had to then clear all the notifications from the watch, open Passbook on the watch, and bring up the boarding pass again.

When you Apple watch notifies you, it uses the new 'Taptic engine' to tap your wrist rather than the traditional vibration I get on devices such as the Gear S and Microsoft Band. I found these taps to be too weak. After reading the User Guide, I found within the watch, a menu that offered 'Prominent Haptic', which I switched on. It is better than before, but I still prefer the more noticeable vibration from the Gear S and Microsoft Band. 

There are some features of the Apple watch which seem rather frivolous. One of them is that you can press both buttons on the side of the watch, and a screenshot of the watch's display is then added to your iPhone's photo library.

You're probably wondering about battery life. Well, Apple claim 18 hours, and I did get close to that on the second day. After 16 hours, the battery was down to 14%. Another day, after 12 hours it was down to 12%. When it comes to charging the Apple watch, it's a magnetic dock that has a 2 metre long USB cable. You can't use your iPhone charging cable to charge the watch. I understand it's an engineering challenge that means currently every wearable has its own charging connector or charging dock. It's annoying, another cable to carry around. Don't lose it, a replacement isn't cheap at £29.

There are countless other reviews based upon a week's usage of the Apple watch. One week's usage won't always reveal the flaws, especially design defects. I'll give you a very real example. My Gear S has a charging dock that clips onto the watch, and you plug the micro USB charging cable into the charging dock. After 4 months of usage, the charging dock no longer clips onto the watch, meaning I can't charge it (unless I keep the dock in place with an elastic band). The exact same thing also happened after a few months with my Samsung Gear Fit. I went to the Samsung store in London yesterday, who told me that my warranty wouldn't cover this problem, as it was a cosmetic fault. I would have to purchase a new charging dock, which they didn't have in stock, as they don't sell many Gear S devices. I'm not the only one, as Gear S owners in the USA have the same problem, and a received a similar response from Samsung USA. Knowing how the Apple watch performs over a longer period of time is critical, as well as observing how Apple will respond to problems as they occur.

Charging docks, special adaptors, and unique cables all make living with wearable technology, more challenging than it needs to be. Just yesterday I came across a company called Humavox in Israel working on wireless charging which would include wearables. I really hope they succeed in making wearables easier to live with. In the meantime, one advantage of the Gear S is the charging dock also doubles as a supplementary battery, so if you are away from home and low on battery, you can just clip on the charging dock. Nothing like that with the Apple watch, apart from an aftermarket 'Reserve strap' coming out later this year. It promises to charge your watch as you wear it, but costs $249. An expensive fix for an already expensive watch.

The futuRE

The Apple watch is a good first attempt, and if Apple invest in refining the product, it may become a successful product line for them in the long term. Like many of its rivals, it is primarily an extension of the smartphone, another screen, on our wrist. Look around you, and most people aren't wearing a 'smartwatch.' Samsung has launched so many models, yet none of them have really gone mainstream. Apple may not succeed immediately with this first version of their watch, but simply because they are Apple, they may shift the culture and make consumers more interested in purchasing (and regularly using) a 'smartwatch' of some kind, even if it's not made by Apple. 

How much value will the Apple watch add to to our daily lives? Will it make a difference only to the young, or will it benefit the old too? Apart from making life more convenient, will it actually play a role in improving our health, or saving us money? It is too early to answer those questions as it has only just hit the market, but those are key questions to answer.

I'd personally want to get my questions about the accuracy of my heart rate data answered, especially if data from my watch could one day be added to my medical records. Even the differences in steps/distance walked/calories burned between the Apple, Samsung & Microsoft devices make me think twice about unvalidated data ending up in the system of my doctor or insurer. 

Genuine advances are needed in battery life, how much information is the Apple watch not able to capture about my health because it has to be charged whilst I sleep? If I'm travelling, I don't want to interrupt my routine to find somewhere to charge my watch. 

Today, based upon my experience so far,  I believe the Apple watch is the best 'smartwatch' available. It has got fewer flaws than other devices, such as the Gear S, but it still has got flaws that Apple needs to deal with. I have to admit I didn't really like it at first, but as I learnt how to use the features, it grew on me. Now tomorrow, it could be someone else, or a new form of technology, not even necessarily in form of a watch. Some people tell me they view the Apple watch as technology that is already redundant, good for loyal Apple customers, but not a genuine innovation in this arena. 

You've got the Pebble Time watch with the concept of 'smart straps', which could allow new possibilities. Then there is the Bluetooth 4.2 specification which just got finalised in Dec 2014, featuring low power IP connectivity. What would that mean for future devices? Bluetooth smart sensors that could connect directly to the internet, without having to be paired to a smartphone or tablet. 

Yi Tuntian, a former Microsoft official in China claims that wearables will replace mobile phones soon. I find that claim hard to believe. 

How about the new chip developed in Taiwan, which integrates sensors for tracking health as well as data transmission and processing. This chip is so small so that "people could wake up in the morning to the voice of a microcomputer in a headset informing them of the state of their health and things to look out for in their lifestyle."

It may be the case that the Apple watch ends up being of significant value for particular applications in healthcare & clinical trials for those who can afford it, but does not have long term success as a general smartwatch with the average consumer. Here in the UK, with the NHS hunting down the back of the sofa looking for extra pennies, experimenting with the Apple watch may be a pipe dream at best. 

I did find a wonderful story of how the Apple watch has changed someone's life, in just 5 days. Molly Watt, a 20 year old woman in England who has Usher Syndrome Type 2a. She was born deaf and has only a very small tunnel of vision in her right eye. In her blog, she describes how the different taps for turning left and right that helped me feel safer walking in Milan at night, allowed her to feel more confident when walking down the street, without relying upon hearing or sight. We might not see much benefit from Apple Pay on the watch for mobile payments, but could this feature be tremendously useful to someone with learning difficulties?

Without giving it a try and without generating evidence, it would premature to dismiss the Apple watch completely. As these consumer technologies evolve at an increasing rate, what actually is evidence, and how do we collect it?

You may see wearables as just a fad, a passing phase, and you'd never wear any of these devices. Well, what if you had to wear a device on your wrist, just to get insured? Nope, it is not science fiction, it iss the view of Swiss Re, a reinsurance giant whose executives believe it will be impossible to get life insurance in 5 to 10 years without a wearable device. 

A really fascinating article from Taiwan discusses the profitability of smartwatches in healthcare, and mentions, "Service platforms that integrate medical care organizations with insurance companies will produce the greatest value." 

Fitness is touted as one of the immediate applications for the Apple watch, yet Gregory Ferenstein's review suggests you won't gain much from the Apple watch in the fitness arena over and above simply using an iPhone. 

Or maybe we are misguided in pursuing the idea of 'smartwatches' entirely? Below is a great talk given by Gadi Amit recently at WIRED Health talking about the concept of wearable tech under our skin, and he states, "The biggest issue that I see… is the idea that if we load more and more functionality on our wrists, things will get better. In many cases, it does not."

I'm not surprised that Apple have sold so many watches, as they have a well oiled marketing machine. How many of today's purchasers will still be using the watch in 12 months time, or will it go the way of Google Glass? And how many people would be willing to upgrade to a newer version of the watch in 12-18 months? These are the hard metrics that we need to pay attention to, once the initial enthusiasm dissipates.

In my opinion, the single biggest improvement Apple could make is finding a way to extend the battery life, and also offer wireless charging. I'd happily have fewer features in exchange for not having to charge it every day. Come to think of it, current engineering limitations on battery life impacts the use of many portable devices, whether it is wearable tech, phones, tablets or laptops. We need a breakthrough in battery technology. 

So, will people wearing an Apple watch been treated with the same disdain as those who wore Google Glass? Users of Google Glass got branded, "Glassholes" and so will users of the Apple watch get branded, "Glanceholes?" 

The Apple watch is dead. Long live the Apple watch.

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

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The Tyranny of The Should

Many of us lament at the paternalistic attitudes and behaviours, we both witness and experience, when dealing with healthcare systems. We hope that this is now the era when we can really transform healthcare, wearables may play a role in that transformation, or perhaps not. Now, one of the aspects of Digital Health I find most fascinating is the potential to change our behaviour, both at an individual level and a population level. So many firms have already launched some form of wearable technology which can monitor activity levels, heart rate and sleep. Many more are about to jump in this year. There are increasing levels of interest, excitement and expectation from these devices. Can simply tracking how much we walk, run or sleep really be the panacea to all our problems in healthcare? I don’t believe so, but some do. “The future of the NHS is in Apple’s hands”, is the headline of a post, by David Claire. He believes that the soon to be launched Apple watch will have a fundamental impact on the way the NHS runs. He even goes as far as to predict, “If self-awareness is the first step to kicking bad habits then the preventative care factor alone of the Apple Watch and similar devices will save the NHS billions.”

During 2014, I personally tried so many different pieces of wearable technology, hoping I could gain new insights about myself and use them with their apps to support my desire to live a healthier life. The truth is that none of them really worked for me. None of them engaged me for more than a few weeks, and also I just didn’t find anything that truly integrated with my life.

Two of my most recent purchases, in December 2014, have been the Samsung Gear S, and the Basis Peak. I had high hopes about the Basis Peak, as it can automatically detect when you fall asleep and when you wake up. I stopped using it to track my sleep after 3 nights. Why? I just didn’t feel comfortable wearing a watch whilst I slept. Apparently, we “should” be walking at least 10,000 steps a day. So I set my daily goal with the Samsung Gear S at 10,000 steps. A message pops up when you’ve achieved 50% of your daily goal, and how much time you’ve got to achieve your goal. Samsung’s website says the Gear S provides a “smart wearable experience.” Surely, if was a genuinely smart wearable, it would know that it’s about to going to rain all afternoon, and I’m unlikely to meet my goal?”

The Samsung Gear S highlights how much time I have left to complete my goal of 10,000 steps

There have been headlines recently about “sitting disease”, and how being inactive is dangerous to our health. Hence, I’ve programmed my Gear S to bleep if I’ve been inactive for 30 minutes. Not particularly useful when you’re in the middle of eating lunch with a friend, despite the device itself knowing I was at lunch because it popped up a calendar reminder 10 minutes before the lunch meeting. Still a way to go before we can truly regard these devices as smart.

What also bothers me about these devices is that currently we’re simply digitising flawed messages. Does simply being told to be more active, or eat less, or sleep more actually make a difference? There is now scrutiny on the recommendations of 150 minutes a week of physical activity. I “should” walk 10,000 steps a day, and when my watch informs me that I haven’t, then I don’t feel that good. We hear lots of talk about “Gamification”, the idea that gamifying health can make a difference. I was chatting with Dr Pritpal S Tamber a few months ago, and he mentioned the term, “Shamification.” Is making us feel shame or guilty about our behaviour really the way to improve health, both of individuals and populations?

I’m not surprised that research shows wearables being are not being used after 6 months. You get called into a series of meetings, or your child is sick, and suddenly, life gets in the way of maintaining a healthy lifestyle. At present, the device or app won’t take that into context, it will still ominously display that you haven’t met your goal.

In the US, wearables are getting on people’s wrists from employer wellness programs. In the UK, a survey found 55% of business leaders would look at the health data from an employee’s smartwatch or health app, if that employee called in sick. Employees calling their boss and pretending to be sick could become a thing of the past. However, in the same survey, just 6% of employees would want their boss to have access to the health data from the watch or phone.

You might believe that it’s easy to deceive the system, because you could put the device on your dog, cat, or even another person. Yes, that’s true right now, but that could be impossible after 2018, if research in Australia is successful. Researchers at the University of New South Wales are embarking on a 3 year study to develop an algorithm that can verify who generated the data, so that the data could be fed back into mainstream health systems.

So many are hoping that these emerging technologies can integrate into our lives and provide the “Digital Nudges” to that will empower us to live healthier lives. The Internet of Things promises smart homes with all our devices connected to each other. Mitsubishi of Japan have showed their concept of a smart home. In their vision of the future, your fridge would connect the data from the sensors on your body with the data on the contents of the fridge, and display recipes on the fridge door. Is this concept dystopia or utopia?

Today, childhood obesity is of growing concern, around the world. A fascinating use of technology may be tested in schools in Dubai this year. Using a payment system linked to the child’s phone and an app that contains information on the nutritional content of food in the school cafeteria. So if the child tries to buy a burger at school, and that burger would take them beyond their daily nutritional allowance, the payment is declined, and the app suggests something healthier. Now that system is under the control of parents, but is this the route to dealing with obesity with adults too? In an increasingly connected world, do you want machines and algorithms limiting your choices, or would you prefer the freedom and autonomy to eat what you want, when you want?

What if the government offered you a way of paying for public transport using wearable technology that would also monitor your health status, provide suggestions, and even reward you if you decided to walk than take public transport? Such a scheme just launched in Beijing, with a plan to roll out to 400 cities across China. 

In the UK, it appears the NHS will have a “huge rollout” of wearable technology as part of a “revolution in self care”. Being able to monitor patients remotely, especially those with a chronic condition, is admirable. If entities in healthcare will be able to monitor us remotely, surely that’s always going to be a good thing? Perhaps not. Given the huge financial pressures facing the NHS over the next 20 years, we may have to ration access to care. In the future, could all this data collected about our behaviour be used to ration or even deny care? I’m not the only one who is asking that question.

Will we ever be refused #healthcare because the data says we ignored govt health guidelines? @AndrewDMurray #nhs pic.twitter.com/cW5vi61397

— Maneesh Juneja (@ManeeshJuneja) February 28, 2015

In a great article by Hamza Shaban examining the impact of sensors collecting data about our health on the pricing of health insurance, one sentence stands out, “Imagine a pricing scheme that would punish sleep-deprived single parents or the dietary habits of the working poor.” A world where our health insurance premiums decline when we behave within the guidelines, and rise when we deviate from the guidelines. Will you avoid watching late night movies on TV because sleeping less would increase your health insurance premium next month?

Should doctors “Google” their patients? A really fascinating BBC podcast highlights the potential for the impact on the trust between patient and medical provider. There is a huge need to understand what happens to you in between visits to the healthcare system. In this new world of monitoring, if your healthcare provider has recommended you cut down on alcohol consumption, but can then obtain data on how much alcohol you’re continuing to drink, is that too intrusive? Today, the National Institutes of Health announced it's searching for a wearable or otherwise discreet device capable of measuring blood alcohol level in real time.

There is a fine line between “Digital Nudges” and “The tyranny of the Should” – and it’s not clear to me that we’re having the right conversations in the right places. Will we be nudged into living healthier lifestyles because we want to or because we should? Is everyone a winner or will there be losers? Is there really a place for autonomous decision making within the context of improving our health?

Hugo Campos, a patient in the USA, concludes his recent interview with a critical question, "Will WE have autonomy over ourselves and the data WE create?" Progress of technology can be easy to predict, what we can’t predict very well are the consequences of technologies. In the realm of Digital Health, some believe that power is moving away from the healthcare systems into the hands of consumers and patients, but over the long term, is the power going to move full circle? This year celebrates the 800th anniversary of the Magna Carta, an ancient symbol of justice over tyranny and protecting individual liberties. In 2015 and beyond, do we need a Magna Carta for Digital Health?

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

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Robots as companions: Are we ready?

Nao

Some people on Earth seem to think so. In fact, they believe in the concept so much, they are actually building the world's first personal robot that can read & respond to human emotions. A collaboration between French robotics firm, Aldebaran, and Softbank mobile from Japan. You may already know one of Aldebaran's existing robots, Nao. The new robot is called Pepper, is due to launch in Japan in February 2015, and is priced at 198,000 Yen. Using today's exchange rates, that's approximately $1,681 and £1,074, although only the Japanese launch has been confirmed for now. Pepper may be sold in the USA through Sprint stores at some point. The notion of a robot in your home that can interact with you, and even tell you a joke if you're feeling sad, attracted my curiosity. So much so, that in September 2014, I hopped on a train from London to Paris. 

Me & Pepper in Paris

Why Paris? Well, the world's first home robot store opened in Paris this summer, called Aldebaran Atelier, and they had Pepper in the store. You can't buy any of the robots in the store just yet, it's more a place to come and learn about these robots. 

So what's Pepper like? You have to bear in mind that the version I interacted with in Paris is not the final version, so the features I saw are not fully developed, especially the aspects of recognising who you are, and getting to know you and your needs. The 3 minute video below shows some of the interaction I had. For now, Pepper understands English, French and Japanese. 

A bit more about how Pepper works. In the final version, Pepper will be able to understand 5 basic emotional expressions of the face: smiling, frowning, surprise, anger & sadness. Pepper will also read the tone of your voice, the verbage used, as well as non verbal communication such a tilting your head. So for example, if you're feeling sad, Pepper may suggest you go out. If you're feeling happy, Pepper may sing a song and do a dance for you (more on that later). According to a Mashable article, "Pepper has an 'emotional engine' and cloud based artificial intelligence". The article also states, "The cloud AI will allow Pepper to share learnings with cloud-based algorithms and pull down additional learning, so that its emotional intuition and response can continually improve. It's either a technological breakthrough or the most terrifying robot advancement I've ever heard of."

Some facts and figures for you; 

• 4 feet tall, and weighs 61 lbs/28kg

• 12 hour battery life - and automatically returns to charging station when battery is low

• 3D camera which senses humans and their movements up to 3 metres away

In the press kit I was given at the store, it's stated that "Pepper's number one intention is about being kind and friendly. He has been engineered to meet not functional but emotional needs." 

It's not just speech and movement that Pepper responds to, it's also touch. There are sensors on the upper part of his head, upper part of his hands and on the tablet attached to his chest. Pepper may be talking to you, and if you place your hand on his head, the way that you would with a child, Pepper will go quiet. Although, when I tried it, Pepper responded by saying something about sensing someone was scratching his head! 

The creators anticipate Pepper being used to care for the elderly and for baby sitting. What are your thoughts? Do YOU envisage leaving your elderly parent or young child with Pepper for company whilst you do some chores or dash to the supermarket? I told Shirley Ayres, Co-Founder of the Connected Care Network, about Pepper. Her response was; "I'd prefer a robot companion to 15 minutes of care by a worker on minimum wage struggling to provide quality care on a zero hour contract."

Given aging populations, and the desire for many to grow old in their own home, rather than an institution, are household companion robots the answer to this challenge? As technology such as Pepper evolves, will a robot at home be the solution to increasingly lonely societies? Will we really prefer the company of a household robot versus another human being? Will we end up treating the purchase of Pepper the same way we treat the purchase of an Ipad? Will your children buy you a Pepper so they don't have to visit you as often as you'd like? The CEO of Aldebaran, Bruno Maisonnier, believes they will sell millions of these robots. Apparently, they'll be able to make a profit from the sales of robot related software and content. Apps for robots?

Pepper does have all sorts of sensors so it can understand humans as well as understand the environment it's operating within. I understand it will collect data, but it's not clear to me, at this stage, exactly what would be collected or shared. Just because Pepper seems kind and friendly, doesn't mean we should not consider the risks and benefits associated with any data it collects on us, our behaviours and intentions. There could be immense benefits from a robot that can 24 hours a day remind an older person when to take their medications, and potentially collect data on when doses are being skipped and why.

An Institute of Medicine panel has just recommended that "Physicians should collect more information about patients' behaviour and social environment in their electronic health records." Some of the information the panel recommends collecting include "whether they are experiencing depression; their social connections and sense of social isolation." Is technology such as Pepper the most effective route to collecting that data? Do we want a world where our household robot sends data to our doctor on how often we feel sad and lonely? Perhaps for those of us too afraid to reach out for help and support, that's a good thing?

My brief interaction in Paris with Pepper was fun and enjoyable, a glimpse into a possible future. With it's childlike gestures and ability to monitor and respond to our emotions, could we as humans one day form emotional attachments to household robots? Here is the video of Pepper wanting to play some music for me in the Paris store. 

One does wonder how the introduction of these new robots might impact jobs? What does technology such as Pepper mean for human carers? A recent report from Deloitte forecasts that 30% of jobs in London are at high risk from automation over the next 20 years. It's low paid, low skill jobs that are most at risk. Microsoft is trying out a different robot called K5 from Knightscope as security guards in their Silicon Valley campus. In Japan, Pepper has been used by Softbank to conduct market research with customers in a Tokyo store. Nestle is planning to use Pepper to sell coffee machines in 1,000 of it's stores across Japan by the end of 2015. Here is the video showing how Pepper might work in selling to consumers in Nestle's stores. 

Now, some of us may dismiss this robot technology as crude and clumsy, with little or no potential to make a significant impact. I personally think it's amazing that we've reached this point, and like any technology, it won't stand still. Over time, it will improve and become cheaper. We are at a turning point, whether we like it or not. Does Pepper signify the dawn of a new industry, or will these household robots be rejected by consumers? How are household robots treated by the law? Do we need to examine how our societies function rather than build technology such as Pepper? Are we becoming increasingly disconnected from ourselves that we need Pepper in our homes to connect with ourselves as humans? Does the prospect of having a robot like Pepper in your own home with your family, excite you or frighten you?

Given the intense pressure to reduce costs in health & social care, it would be foolish to dismiss Pepper completely. So in the future, will we also see companion robots like Pepper stationed in hospitals and doctor's offices too? Can personal robots that connect with our emotions change how we 'deliver' and 'receive' care?

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

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Sensors: What value do they add?

That was the underlying question throughout the Body Computing conference (BCC) last Friday in Los Angeles. The conversation in Digital Health is maturing, and the question facing all parties is, what's in it for me? Investors want to know if there are significant returns to be made, entrepreneurs want to know if they will be rewarded for taking risks, physicians want to know if clinical decision support will be helped or hindered, and consumers want to know if they can prevent disease or better manage an existing disease. That's just a few of the interested parties. Many more are curious about the potential value of sensors that could collect data about each of us in real-time. 

8 recent #wearable / #digitalhealth tech acquisitions: http://t.co/TB1NzWBzh1 several on panel here at #USCBCC8 http://t.co/nt5zdeEc43

— Sonny Vu (@sonnyvu) October 3, 2014

Doctors don't want more data, they want more insight says @DrDave01 #USCBCC8 pic.twitter.com/pgGIyHPdkz

— Maneesh Juneja (@ManeeshJuneja) October 3, 2014

I really enjoyed listening to the talk by Dr David Beiser during the session on virtual visits. When we think about sensors and the type of data we might be able to collect on people and how frequently, he really made me stop and think with this one question.

What if we could understand how quality of life changes for a patient on a daily basis? #USCBCC8 pic.twitter.com/CrhQZJemlz

— Maneesh Juneja (@ManeeshJuneja) October 3, 2014

Do we need to be collecting more data on people? Even though we have lots of data already, it's sometimes not enough to answer questions that arise in pharmaceutical research. For example, I regularly use a database with the health insurance claims for 100+ million Americans. It sounds like a huge database, right? Well, if I have to answer a question which involves a rare disease and/or a rare event, even this seemingly giant database sometimes doesn't have enough patients available to analyse. Could we one day have a database which captures health data in real-time on the health of not just an entire country, but multiple countries? Is that going to be the made possible by existing organisations? Or will be it be done by new organisations that bypass traditional infrastructures and develop new methods of both collecting, sharing and making sense of these data? New organisations such as British startup, uMotif, whose founder & CEO, Bruce Hellman spoke at BCC and announced their plans to create the world's largest health self-management dataset. 

The world's largest health self-management dataset - 100k people tracking for 100 days @umotif #USCBCC8 pic.twitter.com/QjyT9F2vXl

— Maneesh Juneja (@ManeeshJuneja) October 3, 2014

As mentioned in my last blog post, my slot to speak at the conference was on Consumer Wants & Needs, and I shared the results of my survey. Over the course of 4 days, 886 people had opened the survey, but only 86 had responded, giving me a response rate of 9.7%. Not bad for an impromptu survey over a couple of days. The slides below reflect responses one week after the conference, now with 94 responses. Looking at the geodemographics of responders.

• 62% were outside the USA

• 60% were men

• 92% were between 25-55

I acknowledge the results are not representative of the population as a whole, given that I didn't get anyone aged 65 or older responding (and that group is likely to contain the heaviest users of health & social care). 

I asked 7 questions about sensors, and the answers to these 4 questions in particular were of most interest to me.

• Would you wear a smartwatch if it could improve your health? 81% said Yes

• Would you considering implanting a sensor under your skin if it could improve your health? 49% said Yes

• Would you want a smartphone to diagnose illness without having to visit a doctor? 74% said Yes 

• Would you share data from your body if you got paid to share the data? 57% said Yes

I deliberately allowed only an answer of Yes or No to my questions when designing the survey. As it turns out, I received feedback from people who told me they didn't respond to the survey, as there wasn't an option to answer 'Maybe' or 'It depends'. Especially regarding the question on sharing data from your body if you were paid for that data. For example, their answer might change depending upon whether it's Google vs their hospital wanting to buy their data. Including a 'Maybe' option in future surveys is something I will definitely do, I wonder how many of the people who answered 'No' in my survey were actually 'Maybe'. Some people even emailed me to request that there be a option to answer each question with free text, as they had many questions and concerns that they wanted to share. This experience only serves to remind me that understanding the wants & needs of consumers is not cut & dried. 

I was surprised at how many people said Yes for the smartwatch question, given that the smartwatches already in the market are not particularly good, and it's such a new market too. I know of organisations developing sensors that would be implanted underneath our skin, and I'm also surprised to see almost half of people would consider the implanted sensor. When it comes to the idea of a smartphone diagnosing illness without having to visit a doctor, I'm not surprised at all. Using the healthcare system can often be 'disruptive' to your life. Making an appointment, waiting a week or more for the appointment, taking time off work for the appointment, and so on. When it comes to being paid to share data from your body, I wonder if I had made that a two part question, with the second part of the question asking which organisation you would be most willing to share your data with for payment. 

As I said before. this survey was an experiment, and the combination of user feedback and the initial results compel me to undertake more surveys in the future. It appears to me that consumers may be more open to sensors than we think. I'd also like to drill down deeper over time to ask how people feel about sensors in particular settings or scenarios. Interestingly, the questions I asked relate to future of medicine as envisioned by Dr Eric Topol, whose recent talk at AHIMA centred around the 'rebooting' of medicine, in which he sees access and ownership of medical data shifting from physicians to consumers through the proliferation of smartphones and health apps. I love this powerful statement from Topol's talk, "You are your data but more importantly each individual needs to own their data. That’s where we need to be."

What do you think of the results of my survey? What question(s) do YOU think I should be asking next time?

Sensors in Digital Health: What do consumers want & need? from Maneesh Juneja

Big Pharma & Sensors

The pharmaceutical industry is often one of the most risk averse groups in healthcare. However, I found a talk (video is below) given in April 2014 by Professor Patrick Vallance, President of R&D at GSK to be very illuminating. The talk was about looking ahead to 2025. Now, when Vallance talks about monitoring of patients in clinical trials, he believes the future will be "Invisible, wearable devices with real-time data collection."  At BCC, Stuart Karten's session was on "Design: The Future is Not Wearable…It’s Invisible" with a great recap of Karten's session here. 

When Vallance speaks about patients, he remarks that "patient influence will become much more evident". Mentioning sensors in the context of drug safety, Vallance also talks about a future which involves, "Instant feedback in terms of surveillance of medicines post-launch, with various sensing devices/monitors, and listening to patients in real-time, much more than we are able to do at the moment". Why would the President of R&D at the world's 4th largest pharmaceutical company be talking this way publicly if sensors have limited value both now and in the future? Perhaps it's the work that GSK has been doing with McLaren Applied Technologies that is behind these perspectives on the future?

Moving forwards

This coming week, there are two events which are relevant to this conversation. Kaiser Permanente, is hosting an event in Washington, DC where they discussing a future where we could receive care anywhere. The event looks at both current & emerging technologies. 

The second event is Cisco's Internet of Things World Forum in Chicago. I attended last year, and found it useful to understand what Cisco and their partners are doing in this space. 

It really is incredible to see how sensor technology is evolving, and to see organisations working towards a future where billions of devices might be connected together. These converging forces could potentially impact health & social care. However, there are barriers to unlocking this value, and one of the biggest is standards (or lack of them). Today, within health & social care, we already suffer from systems that don't talk to one another, even in the same building. It's extremely frustrating for everyone involved. Then we hear about these new sensors, new devices and new software interfaces and we wonder, where are the standards? How will all these different devices talk to one another? Will I be forced to be buy all my products from one vendor in order for everything to work seamlessly? Actually, there are multiple standards emerging. A great article from Joe McKendrick highlights these different standards being proposed for the Internet of Things. It's early days and it's not clear which will become the preferred standard. 

With the consumerisation of health & social care, who will be the organisations that will serve our needs over the next decade and beyond? Will it be the existing players in health & social care, or will it be the 'interlopers' as Don Jones (who helped conceive the Qualcomm Tricorder XPRIZE) mentioned in his talk at BCC on 'The bleeding edge of mobile'? Or will it be a combination of these different types of organisations working together? Will this shift happen primarily in the USA or will it take place in other countries too? Which country will lead the world with research and development of sensor technology? Will it be a different nation that leads the world in the deployment of these sensors in real-life settings?

We are all hopeful of what sensors might do for us, but ultimately, like so many new technologies in health & social care, we're going to need to see evidence of it's value, as well as finding someone willing to pay for this innovation. This is likely to be easier in some markets than others, given the impact of austerity measures on budgets across Europe. Your appetite for risk as well as how much trust you have built with consumers could determine whether you're part of the future or left behind in the past. The choice is yours. 

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

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Sensors: What do consumers want & need?

[Link to the survey is here]

We keep hearing more about developments in the world of sensors which hope to be able to monitor our health in between visits to the doctor. Some of the most prevalent sensors in 2014 are those in wearable technologies such as wrist based trackers which monitor how far you've walked or how much you've slept. In 2015, Apple's watch is due to launch, offering more of that but in a sleeker design. Will they add further sensors to the watch over time? There is much excitement about these technologies, but what problems do they actually solve? Are we building the right technology for the right people at the right price? Is this a sustainable market or merely a bubble? Is all of this technology socially desirable? What do consumers around the world actually need?

Many of us forget to take our medications, especially as we get older. This causes problems not just for us as patients, but for the people that are caring for us. What if we could have a smart pill that could tell notify others automatically that we have taken our medication? It's already been invented by Proteus Digital Health. I still find myself in awe when thinking about how far we have come, and wondering where we might go next?

Socks that measure how much pressure we place on different parts of the foot, cars that can monitor our health, even our homes. The dream of the Internet of Things is that we will move to a world where tens of billions of devices are connected powered by machine to machine communication. At the moment, it is a dream but companies are entering this space, and exploring how to build the ecosystem that allows this dream to become a reality.

Now, our bodies generate data 24 hours a day, 7 days a week. Imagine a world where sensors on our bodies, in our environment or even inside of our bodies could harness this data stream and use it to improve not just our individual health but the health of the world. 

That's the vision behind the Center for Body Computing at USC. It's the home of the Body Computing conference (BCC), set up by Dr Leslie Saxon in 2007. That's the same year that the first iPhone was launched. We need visionaries like Dr Saxon to challenge our thinking, and to create environments which enable us push the boundaries of what we believe is possible, even if that does upset some of the traditional thinking in health & social care. I first attended the conference in 2012, and it's one of my favourite events to attend. I wrote about my 2013 experience.

This Friday, Dr Saxon once again hosts BCC, only this year, I'm not just attending, I'm speaking there! A privilege and an honour. 

I'm on a panel titled "The State of Venture Investment in Digital Health and the State of Consumer Wants and Needs". I'm speaking on consumer wants and needs. I believe the patient/consumer voice is still not heard as frequently as it could be, which is what drives me in my research to refine my understanding of what people around the world really want from all this new technology.

Do people feel comfortable with a world where machines know more about their health than their doctor? Do people feel comfortable with sensors that are implanted under the skin or even swallowed? What aspect of their health do people want to monitor the most? Do people want a world where sensors embedded in their cars, homes and offices monitor the state of their body? Do people worry about how these new sources of data may be used against them?

I want to be able to capture the pulse of the world and share those opinions at BCC. This is where I would like your help. From San Diego to Sydney, from New York to New Delhi, from Accra to Abuja, I want to understand your needs, desires and concerns. I want your voice to count!

I want to harness the insights of the crowd through an online survey I'm launching today. 

The link to the survey is here.

Please could you share the link to the survey via your networks. I've never done this before, so it's an experiment. I hope to get responses from as many different countries as possible. 

I'll be sharing the results of the survey at BCC, and I'll be publishing the results in a blog post next week. My hope is that I can repeat this survey at regular intervals to see how consumer wants & needs evolve.  

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

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Finding a signal within the noise

Apple's new iPhones and their new watch. That's what dominated the technology headlines last week. More firms are planning to enter the smartwatch space. In health & social care, what value do these smart watches actually add? The Apple watch claims to be able to track our activity levels, with new fitness and workout apps. Sounds great for those who want to monitor their activity or monitor their workouts in the gym or whilst jogging. I wasn't blown away by the keynote and I began to wonder how useful are these health & fitness features for someone whose job involves sitting for the entire working day? Bus drivers, taxi drivers, truck drivers? How useful is the Apple watch for someone confined to a wheelchair? Add a price of $349 for the watch and that you need your iPhone nearby the watch to use all the functions, and I wouldn't blame you for concluding that the reality of the Apple watch doesn't match the hype. Has it been designed by the 'worried well' for the 'worried well'? Are the primary beneficiaries those of us with above average income/education, who are digital savvy and already engaged with our own health? What value Apple's watch will add to health & social care? Only time will tell. 

Technology for Parkinson's disease

For me, what's remarkable, is that last week, there were three advancements in the development of technology for Parkinson's disease (PD) that didn't grab the headlines the way the Apple watch did. The main symptoms of PD are tremor, rigidity and slowness of movement, and it's estimated that between 7-10 million people around the world are living with PD. There are no lab tests to diagnose PD, no cure, and we don't know what causes PD. 

The first advancement was at the British Science Festival, where Dr Max Little gave an update on his work for the Parkinsons Voice Initiative. He'd already developed the technology to test for symptoms using voice recordings alone, more in his TED talk. He's gone one step further now, by using smartphones to track how the disease progresses in those that have PD, collecting data on voice, location & movement every 20 microseconds. He is now conducting larger trials to evaluate the technology, and he has said, "This new kind of remote data analysis will help patients monitor their conditions on a minute-by-minute basis from the comfort of their own homes".

We often hear talk about bringing the hospital into the home, and it's encouraging to see someone actively working on that. What I find particularly fascinating is Dr Little is interested in developing a tool "that could potentially provide specific feedback to people on symptoms that matter to them". The research has been going on for 8 years, and it reminds me that every problem in health & social care can't be solved with a weekend hackathon.

The second advancement is an activity tracker from Australia called the Parkinson's KinetiGraph Data Logger that allows automated reporting of a PD patient's movements. It's just been approved by the FDA in the USA. The device is prescribed to a patient, who wears it on their wrist, and it can collect data for 10 days, after which it's downloaded by the physician. This wearable technology offers physicians the ability to know much more about changes in a PD patient's movements outside of the doctor's office. The device even vibrates and reminds patients to take their Levodopa medication, and records data on when the patient took the medication. Remember that in my testing of the new Android Wear smart watches, an app already exists that allows me to get medication reminders on the watch, and to record when I have taken or skipped my dose. For many in the world of health, wearable technology is just a buzzword with little or no value, and I can understand their perspective. It's easy to dismiss this emerging area of computing, but dismissing it entirely might be foolish.

The third advancement was that Google X bought Lift Labs, joining the Life Science division. What do Lift Labs make? Their product, Liftware, is a spoon that vibrates to stablise tremors, which makes it much easier for people with PD to eat. The founder of Lift Labs, Anupam Pathak, "sees the technology being extended to other everyday objects, as well as extending the diagnostic capabilities to be able to monitor tremors over time." Google X is the part of Google that runs their most ambitious projects. Many of the people I meet who are experimenting with new technology in health & social care, are driven because of personal experience or a family member's experience. The mother of Sergey Brin (one of Google's co-founders) has PD, so I find this acquisition of Lift Labs most fascinating. Once again, time will tell what they bring out in the future. You can see more in the video below.

Finding the signal

Finding the signal within the noise of Digital Health is increasingly a challenge. The three advancements I listed above could both improve the quality of life for PD patients as well as enable a deeper understanding of this disease. They are not just cool technologies, but designed to solve real problems associated with different aspects of PD. 

Now, Apple's watch might offer extra features once it's launched, but for now, it's health features leave people wondering, "Is that it?". What problems does it solve that existing technology does not? 

How do we evaluate and test emerging technologies in Digital Health? This fledgling industry is evolving so rapidly that many organisations I speak to are struggling to keep up with the pace of change. How do we determine what offers sustainable value? One of the steps that seems to be missed is about understanding needs. Do we truly understand what doctors, nurses and other frontline staff want? Do we truly understand what patients want? Do we truly understand what the ordinary consumer wants?

Is the Digital Health industry at times trapped in the dogmatic perspective that the system is always wrong, and startups are always right? 

On top of that, do we actually have a genuine understanding of the underlying problems facing us in health & social care? I meet so many organisations that believe by making services 'Digital', everything will be transformed. I challenge that mindset. Have you stopped to examine whether the underlying process or service is flawed? Merely 'digitising' an existing process or service isn't going to help in the long term. It makes your process looks shiny and modern, but it's fundamentally still a flawed process. 

This week, it was announced that two US hospitals are working with Apple to trial the use of the new HealthKit platform with patients that have diabetes and other chronic diseases. Apple have built up amazing levels of trust with consumers around the globe by delivering a simple but great user experience. Could they do the same with health & social care? Many of us are excited by the possibility that companies with no track record in health, such as Apple, could transform aspects of healthcare delivery, but it's too early to tell. As Dan Diamond points out, an unsustainable hype cycle built up for the Apple watch, and another is building up in advance of the iPhone 6 release this Friday with regard to what the new iPhone can do for our health. 

In a thought provoking article by Darius Tahrir, which questioned the benefits of Digital Health, Julia Adler-Milstein, a professor in the School of Information at the University of Michigan said “There’s a risk of backlash against the technology: we were promised all these benefits, and we’re not seeing them”.

Evidence based medicine is the bedrock of modern healthcare systems, so how can we practice evidence based Digital Health? What evidence do we need to help us find the signal within the noise? Is the health of the Digital Health industry at risk if we don't take steps to generate, evaluate and share the evidence?

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

"healthcare delivered at home" is part of Samsung's vision #digitalhealth #IFA2014 pic.twitter.com/ruRLd3iFO0

— Maneesh Juneja (@ManeeshJuneja) September 5, 2014

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. 

Fascinating that Samsung CEO wants home of the future to help older people live independently #ifa2014 @clarkmike pic.twitter.com/nvDMOOoWB3

— Maneesh Juneja (@ManeeshJuneja) September 5, 2014

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?

"The future home is not about being smart & connected, it's about the right options at the right time" #ifa2014 #IoT pic.twitter.com/Xhvk5PbYwK

— Maneesh Juneja (@ManeeshJuneja) September 5, 2014

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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How do we measure health?

I saw a tweet which made me really think about our existing approaches to measuring our health. 

Why don't doctors ever ask patients what "healthy" means to them? I measure it by whether I'm able to ride my horse. What about you? #hcldr

— Morgan Gleason (@morgan_gleason) August 12, 2014

Morgan Gleason is a 15 year old girl who lives in the USA. She was diagnosed with a rare disease, Juvenile Dermatomyositis (JDM) at the age of 11. From her website, "The main symptoms of JDM are weak or painful muscles, skin rash, fatigue and fever." I wonder how many other Morgans are out there? How many feel that their voice as a patient needs to be heard?

I speak to patients regularly as part of my research in Digital Health, and many of them tell me when they visit their doctor, what they want is health. Not Health IT, Digital Health, Health Outcomes, but plain and simple Health. There is too often a tendency for those in health & social care, in whatever function, to prioritise on what makes their lives easier, what makes the system more efficient or even what allows them to increase profitability.  

We're hearing more and more talk about data driven health. For the last decade, I've worked with epidemiologists and health economists in the pharmaceutical industry to use patient data the USA, UK, France & Germany to help decision makers understand how drugs are used in the real world. My work has contributed to speeding up drug development and helping to make drugs safer. So, what kind of data on patients? Typically, data from 'real world settings', i.e. the doctor's office or the hospital. One of the most common types of research projects I've worked on, has been to use these databases to help researchers understand the natural history of a particular disease.  For example, when I look at the data, I can answer questions such as;

• When were patients diagnosed?

• What the patients were diagnosed with?

• Were the patients treated after diagnosis?

• If so, what kind of drug?

• Were lab tests ordered?

• If so, what were the results?

• When patients were hospitalised?

• How long the patients were hospitalised for?

What's frustrating for me and others is that the existing data collected from doctor's offices and hospitals doesn't show the full picture of a patient's health. If I have to look at medication adherence, and if the database shows that some patients don't have a repeat prescription for their medication when they're supposed to, why is that? 

The transactional data currently available from healthcare systems doesn't tell me WHY. With 'Big Data' being frequently part of  conversations about innovation in health & social care, collecting even more of the same type of data doesn't seem logical. There are major gaps in existing 'Big Data', and for me, that's patient generated health data (PGHD). It's the marriage of 'hard' data from the system and 'soft' data from the patients that could be the key to meeting the challenges ahead of us.

How do individuals measure their health?

What value might be unlocked if we understood how different people measure their health? The system might currently measure someone's health based upon clinically validated instruments, i.e. blood pressure, blood glucose, cholesterol, and so forth, but how do people measure their own health? More importantly, how can the system accommodate data such as whether Morgan is able to ride her horse or not? 

More and more people have been using activity trackers such as Fitbit to track how active they are, and even using the social elements of the app to compete with their friends and family. Some are even sharing the data & insights gained from their Fitbits with their doctors. For many medical professionals, the data from consumer devices such as Fitbit has limited or no clinical value, even if they had systems which could incorporate such data into the patient's record. The array of hardware and software increasingly becoming available to consumers to monitor aspects of their health is largely unproven. So what to do? 

It's fascinating to read about Dr Josh Umbehr, a doctor in the USA who not only welcomes patient generated data from devices such as Fitbits, but has built his own computer system in his practice which can accept data from a patient's Fitbit. “We don’t know what all this data means, yet,” Umbehr said, “but I can discuss it with the patients and we can both follow it.” 

I have much sympathy for over worked doctors who are apprehensive about dealing with these new streams of data. Whilst patients collecting all sorts of (unvalidated) data about themselves sounds great in theory, it could be dangerous if used and interpreted in isolation. I even ran a Health 2.0 London event in 2013 entitled, "Information Obesity: A possible side effect of Digital Health?" Having to deal with patient generated health data could even put physicians at risk, as Sue Montgomery points out, "providers could be held liable if they don’t review all information in the patient’s record—if this lack of review leads to misdiagnosis or other patient harm."

However, do patients wishing to share data from their Fitbit signify the emergence of a new era where patients can themselves choose to capture (and share) data that is important to them? Thinking back to the patient databases I work with, if I observe that a patient doesn't visit the doctor for 6 months, does that mean during those 6 months they were healthy, they were well? 

What new discoveries might happen if patients were able to bring data into the system that measured health based upon their own experience? Would that future involve having to reboot Health IT infrastructure as we know it? There is already the pioneering personal health record system called Patients Know Best developed in the UK, which in March 2014 had the ability to integrate data from 100 devices and apps.

However, should we limit patient generated data to structured data like number of steps or number of hours slept? In a thought provoking post about patient generated health data, Dr Scott Nelson says, "Unstructured data gathering tools like Apple’s Siri could be used to capture and store patient verbal input and feedback on regular basis. This unstructured data could be parsed into structured formats that could then be automatically organized, analyzed, and visualized for doctor’s use at the time of care." 

If patients like Morgan were able to use Siri to measure their health simply by speaking into the phone, why aren't we offering that to patients today? Would you feel comfortable sharing how healthy you are feeling by speaking into your phone? Who is thinking about the patient data in the form of digital diaries, video, audio, pictures? Are we heading towards a world where the data on your smartphone will reveal more about your health than the data collected during your visits to the doctor?

Understanding human health

If medicine revolves around disease, what if we could measure and maximise wellness? Dr Lee Hood in the USA aims to see if we could with his 100K Wellness Project. It's an ambitious study that aims to enroll 100,000 people over the next 20 years (subject to funding). What I find fascinating is that Dr Hood wants to quantify "wellness". 

Do we have to reboot the entire system of medicine to truly understand human health? New research suggests people with friendly neighbours and strong community ties are less likely to suffer heart attacks. When was the last time your doctor asked you how friendly your neighbours are? When was the last time your doctor asked you if you feel like you belong to a community? Even if they did ask you these questions, where on the paper form do they record such information?

Where have you lived? In Bill Davenhall's TEDMED talk in 2009, he shows how where have lived can impact our health. Yet, our place history is not in our medical records. Now, an electronic health record (EHR) is defined as a systematic collection of electronic health information about an individual patient or population. Ironically, when EHRs are being developed, how many stop to ask patients how THEY measure their health? 

It's encouraging to read of a system that is building technology today which allows us to understand what's important to a patient. For example, the Hudson Center for Health Equity & Quality have developed a "system that captures patient data on who the patient actually is, what is important to the them and what’s preventing the patient from getting the necessary care." We need more institutions to take these bold leaps forward. 

The future

Whilst it's clear that health & social care systems are being stretched beyond their limits, what's not clear is how we prepare our people, policies & processes to be able to cope with an increasingly complex and uncertain future. Just because we've measured our health in a certain way up till now, do we keep doing the same in future years? Can we really accommodate the needs of all stakeholders? Who will be the winners and losers in this new era? Technology is merely the tool here, and probably the simplest factor in the equation. Ultimately, it's the combination of people, policies and processes moving in tandem that will trigger the change many of us are hoping will occur. 

Moving forward won't be simple or easy. Yes, change is typically tough to navigate and often downright terrifying. However, the inspiring Sir Ken Robinson reminds us that "imagination is the source of all human achievement". Yet, the most dangerous words I keep hearing from decision makers in health & social care are "We've always done it this way". Is your organisation tapping into the imagination of your employees?

I'm curious to know what health means to YOU, and how YOU measure your own health? Feel free to leave a comment below, reply to me via Twitter or email. 

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

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