Painting a false picture of ourselves

In the quest for improving our health, we're on the path to capturing more data about us, and what we do, and what happens to us. It's no longer sufficient to capture data about our health when we visit the doctor. Sensors are popping up all over the place, even in pills that help others determine whether we are actually taking our medication. Today, the most prevalent sensors are the ones in those wristbands and smart watches that track how many steps we've taken and how much we've slept. We're likely to end up at some point in the future where many, if not all of us, will be monitored 24 hours a day. Recently, Target in the USA, announced it will be offering a Fitbit activity tracker to each of its 335,000 employees.

There are already insurers in the US & UK that are offering rewards if you share data from your wearable, and the data from the wearable proves you are being active enough. In Switzerland, a pilot project by health insurer, CSS, is monitoring how many steps customers are walking every day, with one implication being, "people who refuse to be monitored will be subject to higher premiums." In that same article, Peter Ohnemus of Dacadoo, believes "Eventually we will be implanted with a nano-chip which will constantly monitor us and transmit the data to a control centre."

Well, if pills with ingestible sensors are already here, then the vision of Ohnemus may not be that far fetched. En route to the nano-chip, I note that Samsung's new Sleepsense device that sits under your mattress and tracks your sleep (and analyses the quality of your sleep), offers a feature where a report about your sleep can be emailed daily to family members. You might use it to track how your elderly parents/grandparents/children are sleeping. At the 5th EAI International Conference on Wireless Mobile Communication and Healthcare in London next month, there is a keynote titled, "The car as a location for medical diagnosis." There is so much data about us that could be captured and shared with interested parties, it's an exciting new era for many of us. 

SLEEPsense was launched when I visited IFA earlier this month

Not everyone is excited though. It's truly fascinating to observe how people might respond to the introduction of these new sensors in our lives. We're going to see many developments in 'smart home' technologies, and maybe Apple's HomeKit will be the catalyst for people to make their homes as smart as possible. Given aging populations, maybe older people, especially those living alone are the perfect candidates for these sensors and devices. Whilst their children, doctors and insurers may find the ability to 'remotely monitor' behaviour quite reassuring, what if the older person being monitored doesn't like being monitored? What strategies might they employ to hack the system? The short film below, 'Uninvited Guests' shows an elderly man and his smart home, and where the friction might occur. 

Then you have 'Unfit Bits' which pokes fun at the growing trend of linking data from your activity tracker with your insurance. "At Unfit Bits, we are investigating DIY fitness spoofing techniques to allow you to create walking datasets without actually having to share your personal data. These techniques help produce personal data to qualify you for insurance rewards even if you can't afford a high exercise lifestyle." Check out their video. 

These videos are food for thought. Our daily choices and behaviour are going to come under increased scrutiny, and just because it's technically possible, will it be socially desirable? Decisions are increasingly being made by algorithms, and algorithms need data. There is a call for healthcare to be more of a data driven culture, but how will we know if the data coming from outside the doctor's office can be trusted? There is huge concern regarding the risks of health data being stolen, but little concern regarding how health data may be falsified. 

In the case of employers tracking employees, "Instead of feeling like part of a team, surveilled workers may develop an us-versus-them mentality and look for opportunities to thwart the monitoring schemes of Big Boss", writes Lynn Parramore in her post examining the dystopia of workplace surveillance.  As these new 'monitoring' technologies and associated services emerge and grow, at the same time, will we also observe the emergence of technologies that will allow us to paint a false picture of ourselves?

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

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Can technology get us moving again?

Our bodies were designed to move. In today's world, many of us are moving less. According to the WHO, insufficient physical activity is a significant risk factor for heart disease, cancer and diabetes. They also state that more than 80% of the world's adolescent population is insufficiently physically active. You might expect this issue to be in societies designed around the car, such as the USA, but it's a concern around the world. In fact, according to data compiled by the Economist, rates of physical inactivity in adults from 2010 showed that countries such as Japan, Malaysia, South Africa, and Britain have higher rates of physical inactivity than the USA. A 2012 study looking at time use and physical activity in 5 countries (USA, UK, Brazil, China and India) and forecasting trends to 2030, concluded with "These forecasted declines in physical activity and increases in sedentary behaviour will have significant implications for the health outcomes, healthcare costs and overall functional well-being of societies across the globe." It makes for bleak reading and is a global call to action. As the world continues to modernize, is the price we pay for progress? 

21st century lifestyles

Where is modern technology taking us? Take online shopping, which continues to grow, and whilst convenient, and cheaper for many, I do wonder what the impact will be on physical activity levels? There is rising interest in 'smart home' technologies. How about eliminating the walk from your bed to the kitchen to make coffee in the morning? That's right, control your coffee maker from the comfort of your bed using an app on your phone.

Saying 'Good Night' in bed will never be the same again

Perhaps tapping buttons on our phones is still too physically taxing for us. In the future, we may be speaking to our homes. At IFA (one of the leading shows in consumer electronics and home appliances) in Berlin last Friday, I wandered around the Samsung hall to explore their new products. One new feature seems to be the ability to adjust your 'smart home' from bed at night with just one phrase. I can see this technology could be tremendously useful for some people, but is this another modern convenience that ends up promoting an inactive lifestyle? 

Eventually, will we all control our cars from our watches?

Samsung launched their new smartwatch, the Gear S2, and showed an application where you can control your car directly from the watch. That's right, turn on the air conditioning, stop/start the charging process, check if the doors are locked, from the comfort of your sofa. Take a look at the language used in the marketing material, "You don't need to walk back because you aren't sure you had locked the car doors." I can't help but think that a potential side effect of the Internet of Things is further reducing opportunities for us to move, because we can we do much more from the bed or the sofa. Perhaps this world of reducing activity from our lives is what we really want? A survey in 2014 by Lowe's found that 70% of Americans who own a smartphone/tablet wish they could control something in their home from their mobile device without getting out of bed. 

Remotely controlling your robot vacuum cleaner

Whilst housework may not be considered 'exercise', take a look at this robot vacuum cleaner I spotted at IFA. Control it using the app or the remote control. I'm not picking on Samsung particularly, but they did have a large presence at IFA with a focus on connecting various devices in our life, so it's interesting to see what they are pushing as the future of consumer electronics. Maybe this appeals to us at our very core? A study in Canada suggests that we are biologically wired to be lazy, although this is very early stage research.

Given the global call to action to get people moving again, how might policy makers regulate use of these new connected technologies? We hear about banning sugary drinks or placing extra taxes on foods and drinks associated with a rise in obesity, what if technologies that lead to you being less physically active are taxed at a higher rate?

Or maybe you can only buy them if you have a specific medical condition, and being able to control your home whilst lying in bed would improve your quality of life? 

Sensoria app showing data from the socks as you run

Now, there are two sides to every coin, and technology is also out there to get us moving again and to make being active a more enjoyable and engaging experience. We are starting to see our clothes getting smarter, equipped with sensors and connected to the internet. Do you run a lot? What if your socks could speak to you and offer real time coaching on improving your running style so you can avoid knee and back injuries? I don't run anymore due to an knee injury, but I was curious about the socks from Sensoria. The socks feel like regular socks, but contain textile sensors which relay data on your foot pressure as you run up to a plastic anklet that clips onto the top of the sock. The anklet transmits that data by Bluetooth to your phone, and you'll get real time feedback as you run from the app on the phone. I did try the socks out, and go out for a short run, and I found it quite remarkable. I had set my desired foot landing to 'ball', but I deliberately ran landing on my heel, and through my earphones, the 'virtual coach' reminded me to land on the ball of my foot or take a break. Whilst the socks are aimed at distance runners, it's interesting to note that Sensoria have a vision of 'The garment is the computer' and that they are exploring the world of healthcare. For me the socks don't just collect data about your activity, but are offering real-time feedback based upon that data, which I think is what we need more of.

A smarter wardrobe

Live data from the sensors in the Hexoskin shirt

What about 'smart shirts'? I have tried out one from Hexoskin, which captures an array of biometric data on your activity (and your sleep). It's amazing to be able to capture that depth of data about your physical performance from a shirt (42,000 data points a minute!), and I could even see live data streaming from my shirt to my Apple watch. They are quite a snug fit as the fabric needs to be close to your skin for the sensors to work. Recently announced was a 'smart shirt' for men from Ralph Lauren, which won't just capture data as you exercise, but the app will also process the data in real-time to suggest workout options to you. At IFA, Samsung launched their platform brand for wearables, 'the humanfit' (which stands for Human Fashion in Technology). They demonstrated a research project, Body Compass, their take on a 'smart shirt' for fitness tracking & coaching. An interesting video demonstrating this shirt and associated coaching app can be viewed here. It appears inevitable that one day, all of our clothes will have some form of technology within them, especially now that Google have started Project Jacquard. I wonder, could we end up living in a world, where we are willing to pay MORE for a piece of clothing that isn't going to be monitoring us?

Body Compass - part of 'the humanfit' 

These advanced technologies are not cheap either. The Sensoria socks are $199, the Hexoskin shirt is $399, and the Ralph Lauren shirt is $295. Today, such inventions are the preserve of the rich but we easily forget that once upon a time, mobile phones were originally the preserve of the rich, but are now ubiquitous. On the plus side, you can chuck the socks and shirts in the washing machine like regular clothes. 

What about 'smart hats'? In case you don't want to wear a chest strap to track your heart rate whilst you exercise. You know it's 2015 when you can connect your Lifebeam hat to your Apple watch and see your heart rate displayed on the screen of the watch. A lot of products produced so far that can track your activity levels seem to be great for walking, running or cycling. What if you want to track other forms of activity? Kudos to Misfit who just launched the Speedo Shine, a wrist worn device that can count your swim laps and swim distance. 

The LifeBeam hat connected by Bluetooth to my watch and the heart rate data gets synced from the watch into Apple's health app on my iPhone

The app detected 13 reps, when I'd performed 20

Maybe you want to track how many push ups you do? An app called Fitocracy launched for the Pebble Time watch, which can automatically track how many repetitions of an exercise you do. I did try it in the gym, attempting both Russian Twists and Push Ups. I found in my test that the app consistently under recorded how many repetitions I did. I understand apps aren't perfect on the day of launch, evolve quite rapidly and I do think they are going in the right direction. Focus Motion who provide the algorithm used in the Fitocracy app do have a bold vision, "We're like Siri for human movement" is mentioned in their new video, and they are "building the world's most sophisticated database in human movement analysis." If they achieve what they are aiming to do, it would impact not just fitness, but physical therapy and corporate wellness too. I recommend viewing their video. 

There are a plethora of fitness apps and wearables with features aimed at getting us active and keeping us active, and there is hope that these new tools are the solutions to many of our problems. We might believe that apps and wearable technology can't really do much for us. However, there are fascinating stories out there of how these new tools have transformed lives. For example, Dan Ziehm, who lost 126 lbs over 13 months with the help of an app called MyFitnessPal, or Federico Viticci who after being diagnosed with Hodgkin Lymphoma, turned to his iPhone to help him get in shape. The post covering his usage of different digital tools makes for compelling reading, and he writes, "Tracking my life with my iPhone makes my commitment real and the effects directly measurable. Being able to open an app and be coached through workout sessions or use my phone to track steps and runs is empowering. iPhone software has enriched my lifestyle and it has allowed me to be more conscious in my daily choices."

Another example is Graham Bower, who opens his series of posts with, "I was diagnosed with cancer in 2007. Technically, it was chemotherapy that saved my life, but fitness gadgets helped me put my life back together again afterward." These stories are not just occuring in rich countries like the USA, but elsewhere too. Take Deepak Abbot, in India, who used a combination of tools to lose weight, and mentions "Goqii is not just an App, but a combination of fitness band, tracking App & a personal coach for guidance. It has a big hand to play in my current weight/inch loss."

After completing a 46 minute workout at the gym, I got this notification on the watch. 

What about my own story? I have become more active this year, and given I work in front of a computer at a desk, then my Apple watch reminding me to stand up once an hour has probably been a useful tool. An app called Deadline, has shown me the impact on my life expectancy based upon the physical activity data captured by my Apple watch and stored in my iPhone. I understand it's not a regulated medical app with clinical validation, and we don't know how exactly it works, but the point is, that linking my activity with a perceived extension to my life expectancy was a feedback loop that made me feel really good about my choice to exercise at the gym that evening. Behavior change is complex, so rather than generic messages encouraging us to be more active, why aren't we using new technologies to enable 'personalised prevention'?

Furthermore, for me, the key factor this year has been my family & friends who care enough to have kept asking me, when are you going to get into shape, Maneesh? If a machine like the Apple watch kept asking me that question, I'd probably have thrown it out of the window pretty swiftly. Humans genuinely care, but machines are programmed to care. 

The need for systematic evidence

Now these stories are inspiring and a form of evidence, but what does the latest research say about these new digital tools? A recently published study evaluated 30 free iPhone fitness apps, and compared the content against guidelines from the American College of Sports Medicine. One of the study's conclusions was, "Nearly all the apps, although technically well designed, did not meet the basic recommendations of the ACSM for exercise prescription, and therefore, would not be suitable for beginning exercisers." A small clinical trial in New Zealand tested two fitness apps to see they would increase fitness and physical activity levels in 14-17 year olds. They didn't find that these two apps made a difference as standalone instruments.

Some people rely on data from activity trackers to understand how many calories they are burning. Another recently published study found that some of the popular trackers are not as accurate as they could be. It's early days yet in the world of digital fitness and we desperately need more research to understand what actually works in the real world. The challenge is that many of these devices are evolving at such a rapid pace, that by the time research gets published, the technologies they evaluated may have moved on a version or two. Just like in the world of healthcare, methods of generating evidence need to adapt to the the blistering pace of change in the 21st century. 

Having the option to collect all of this data about our activity is likely to be useful, but we must be mindful of the purpose they have been designed for, despite boundaries appearing to be blurred. I'm concerned that ordinary people could start relying upon the growing abundance of data from these fitness tools to medically self diagnose. 

Marketing departments might position many of these latest technologies as the next big thing in getting us active, but we have to remember that promise does not equal proof. I'm hopeful that a greater focus on science driven innovation in years to come will lead to improvements in this arena. 

Gyms & technology

Interesting to see how I felt when seeing my heart rate in comparison to others also in the group class

One of the screens when setting up the CustomFit app

When faced with the need to exercise, some of us turn to gyms & health clubs. I am curious to know if these organisations are taking these new trends seriously as I believe their revenue streams are at risk by some of these ‘disruptive’ technologies. I was invited by Fitness First (the largest privately owned health club group in the world, operating in 16 countries) to check out what they are doing in the area of Digital Fitness. I attended the Charing Cross branch and took part in a new form of group class, called BEAT, which uses heart rate based training. I was asked to put on a Polar chest strap before the demonstration, and whilst the class was on, I could see live data about my heart rate (as well as others) on the wall mounted screen.  When the class finished, I got an email with a report summarising my activity, showing how long I spent in each of the 5 training zones. David Perrin, CustomFit Fitness Manager, told me that the BEAT classes have been well received by members. The BEAT concept is in 2 UK clubs right now. David also showed me their CustomFit app (in 8 UK clubs right now), which is powered by a clever fitness algorithm that can give members a bespoke workout. FitnessLogic is the “brain” that powers CustomFit.  It builds workouts based on a member’s training goal, experience level and preferred training style through a combination of human expertise and smart technology. What I find interesting is that it’s device agnostic, so in future, Fitness First would be able to incorporate data from any device that you are wearing. These new products are part of a journey for Fitness First, which is expected to evolve and mature over time. 

David Langridge, digital lead at Fitness First, told me, “There’s no doubt technology is changing the fitness  and health world, but we believe tracking activity in isolation will not keep people motivated to stay active – already a lot of people stop using wearables and apps soon after purchase. Through working with behavioural psychologists at Fitness First we have developed a good understanding of how motivation is created and habits are formed, and evidence suggests devices on their own are not enough. People also need support and an emotional connection, sharing of the accountability for the data with someone else. This can be shared with family, friends or peers or dedicated fitness professionals. All of these people provide social recognition, a vital part in the creation of motivation and forming long term habits. “This is not the time to be cautious, it’s the time to embrace the disruption to our industry which is providing us with opportunities for growth in the coming years – we already think beyond the bricks and mortar of our clubs. We should welcome digital health with open arms, shaping our products and services ready to support the digital health users of tomorrow.” When I think about gyms, and my own experiences using them, cutting edge technology doesn't come to mind, so I was pleasantly surprised to hear that Fitness First are actively thinking about Digital Health.  

Who else in that industry is thinking about the future? Virgin Active is another international health club group, and their CIO, Andy Caddy sees data playing a crucial role in their future. In an article, he says, "They will have with them what I call the ‘database of you', this thing that defines you, and it will be up to [companies like Virgin Active], health insurance providers and hospitals to think about how they are going to interface and use that data. "People will arrive at the door of a business towing this information, and they'll be expecting companies to be able to work with it. If [companies] can't they will go somewhere else."

As patients become more empowered through data we are moving from the "Internet of Things" to the "Internet of You" - @DrDave01 #IoTEast15

— Lea Armstrong (@LeaArmstrong) September 10, 2015

Whilst today, data about us and our health may be scattered around the globe, held in different databases by multiple providers, the status quo is overdue for disruption. Leonard Kish & Dr Eric Topol's bold commentary outlines the case for people owning their medical data, and outlines the path needed to create a very different future from today's world. 

I'm writing this post during European week of Sport, which is working on building an active Europe. On their website, they've got some brilliant infographics which I found enlightening. Some of the highlights;

59% of Europeans never or seldom exercise or play sport

Where are Europeans active? 15% in a health or fitness centre

42% of Europeans don't practice sport due to lack of time

I didn't realise that so few people use health clubs & gyms, and I wonder how the industry will play a role in increasing physical activity, when so many people don't have time. The future poses huge challenges for health clubs & gyms, who may have to convince their senior leadership to foster a data driven business culture. Just as pharmaceutical companies are being forced to think ‘beyond the pill’, health clubs will have to think ‘beyond the gym’. They will have to offer a basket of digital services around their core product in order to survive and prosper. It will be interesting to see how organisations like Fitness First and Virgin Active adapt to changes in digital health over the coming years. As our world becomes more connected, I see numerous opportunities;

a)    What if your health club had access to the data from the sensors monitoring your health at home? Imagine you had a group class scheduled at 6pm, but because the club knew you slept badly the night before, they sent you a message suggesting you reschedule the class, as you are at increased risk of an injury?

b)    When you’re at the gym and lifting free weights, imagine there are sensors that can monitor how you are lifting the weights. A member of staff might get alerted that you’re using poor technique, and be prompted to walk over and suggest advice to reduce your risk of injury with that exercise. 

c)    With all that data available about members, could health clubs offer tiered analytic services to help you get insights about what that means for you and your training goals?

d) If doctors prescribed a patient a series of classes at a health club, the health club (with your consent) could insert data collected about you from each of your visits into your electronic medical record to prove to the doctor that you had adhered to the prescription which could also serve to record the intensity of your activity too. 

e) Maybe you prefer to exercise when the gym is quieter. So why couldn't the gym use data from members swiping in and in out of the gym to monitor capacity levels, and send you a text message letting you know it's quiet, and it's a good time to come in?

I recently heard Misha Patel, an Experience Designer, give a great talk at Wearables London on the use (and non-use) of wearable technology in gyms. I asked her, What could gyms do with tech & data to retain members? She told me, "Gyms need to provide a more connected and tailored experience for their customers to allow people to achieve a holistic and comprehensive view of their fitness activity, both inside and out of the gym. Physical activity informatics acquired at the gym should integrate seamlessly with the individual’s fitness data history; exercise machines should be able to connect to personal devices to access individual’s fitness achievements and aims in order to suggest realistic and personalised training programmes and goals."

I'm curious, if you don't currently use a gym, would all of this new technology, data and connected devices convince you to start using one? If you've stopped using a gym, would these advances persuade you to start going again? Or maybe by embracing these new technologies, gyms will lose members who perceive all of these new technologies as distractions and disruptions? 

A personal trainer in your pocket

What if you don't want to visit a health club or gym, or you can't afford it, or you travel a lot for work? Just like in healthcare where a multitude of apps offer access to a doctor from your smartphone, what if you could access a personal trainer from your smartphone? 

There is Fitmo, an app that allows you to connect to a trainer and help meet your goals. Create a custom program using your activity history with the Fitstar app. 5 minute personalised mobile fitness is what the Fitnet app promises. An 'Uber for personal training', Handstand, offers a workout when you want it, with on demand personal training, where the trainer can meet you where you want!

It's fascinating to see how wearables are trying to get smarter, and do more than just collect data about you. Microsoft offered 'Guided workouts' with their wrist band, so you can turn the band on your wrist into a 'pro trainer and coach.' What about a wearable device that could track your activity but also coach you in real-time? That's what Moov plan to offer with their 2nd generation product. If this is what's here in 2015, imagine what we're likely to see in the decade ahead. Will personal trainers become unemployed by 2025? It would be unwise for people in this industry to believe their work is immune from rapidly changing technologies. Some people may prefer training with a 'virtual coach' or even a companion robot, because they know the machine would never judge them like humans sometimes can. Or will this smarter technology be the trigger to help 'inactive' people become 'active' again?

What about Virtual Reality? Widerun's use of VR is interesting. Bringing the outdoors to indoor cycling. Perhaps it's snowing in Scotland, yet you can from home, use Widerun to cycle in sunny San Francisco? How about a strenous workout at home using VR and some basic equipment? A prototype from Icaros in Germany shows us what might one day be possible. Maybe the use of VR to offer 'immersive fitness' will make group classes at gyms more attractive? Given Oculus Rift VR is set to launch in 2016, will we be adding VR headsets to our bags when visiting gyms in the future?

What if we could understand the best type of physical activity based upon our genes? Or how our genes impact our ability to recover from exercise? That's what DNAFit offers, and even allows you to get reports by linking to the data about you already captured by 23andMe. 

As we technology plays a bigger role in physical activity, we may find us postponing taking part in an activity because our wearables need to be recharged first. Will a simple walk in the park be considered boring and unattractive if we're not monitoring, measuring and scanning every minute aspect of the walk? In the future, some of us may not have that choice if it becomes compulsory for others to know what we are doing 24/7. Should parents have the right to access activity data on their children? Would you want a daily email with details on the activity levels of your spouse? The ability to remotely track activity levels of family members in real-time may be reassuring for many. For example, if you have an elderly parent/grandparent living alone or in care. You might be halfway around the world, but you'll be able to find out if they've gone for their daily walk, simply by opening an app on your phone.

What lies ahead

I'm cautiously optimistic about the use of emerging technologies to get us moving again, and that collectively we can work with these new tools to enable as many of us to live healthier lifestyles. We have to ensure that these new digital tools don't inadvertently widen health inequalities. Perhaps we should focus on building technology to get specific groups of people active? Next month, Sport England is hosting a sports technology hackathon with the aim of developing apps to get a specific demographic more physically active. It makes me think, given ageing populations, are we doing enough to cater for the needs of people 65 years and up? Are we blinkered by stereotypes that old people are always weak and frail? How do we help the 'sandwich' generation to stay active? I believe time is going to be increasingly cited as a barrier to staying active.  Maybe technology can evolve to help more people be active on their terms and conditions.

@ManeeshJuneja 4 me the biggest obstacle to exercise is time. With a job, a family, & lots of related responsibilities, time mgmt is tough

— Lygeia Ricciardi (@Lygeia) August 30, 2015

Whilst the focus of this post has been looking at technology and physical activity, I fully appreciate that technology alone cannot meet all the challenges that lie ahead of us. There are structural changes that are likely to be required across society with regard to how we live, work and play. On the other hand, redesigning how our cities are planned, reformulating public health policy and revising incentives in healthcare systems can take a long time, and technology is relatively easier to develop and implement. It's encouraging to read in NHS England's Five Year Forward View the recognition that more needs to be done in preventing people getting sick. This week at the National University of Singapore, during an event discussing the future of healthcare, there was also a call to shift focus onto preventative strategies, with a great analogy from Professor Wong, "It’s much better to build a fence to prevent people from falling into the river, rather than fishing everyone out to do CPR." Can simple changes reframe the entire conversation? It's remarkable to read about Dr David Sabgir, who couldn't seem to get his patients to be more physically active. In the end, he started going for walks with them, which prompted him to start a nonprofit, Walk with a Doc. 

Maybe the biggest change required is changing our attitudes, beliefs and mindsets. "My doctor is not responsible for my health, I am" is emblazoned onto the t-shirt worn by personal trainer, Shawn McClendon. Not everyone thinks that way though. For example, a UK survey asked adults who was responsible for their health and wellbeing. The results are fascinating, with 14% believing they have little or no responsibility for it, 19% believing it's the duty of the government and 39% believing their GP is responsible. Is Canada moving in the right direction given the federal government is launching an app that will reward Canadians for making healthier lifestyle decisions? 

I sincerely believe it's critical to ask ourselves, how do we prevent the children of today from becoming the patients of tomorrow? Our leaders will need to find the courage to plan for a better future, even if that means making changes today which make some of us uncomfortable. As Dr David Agus said back in 2013 on the danger of our sedentary society, "Yet we've engineered our society to sit. We need to change that." 

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

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Data or it didn't happen

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

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

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

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 Internet of Things World Forum

I recently attended the inaugural Internet of Things (IoT) World Forum in Barcelona, Spain which was hosted by Cisco.  For those that have not heard of IoT, it could even be bigger than the Internet. Check out this infographic from Cisco. John Chambers, CEO of Cisco reckons IoT as a market could generate $14 trillion in profits over the next decade. Yes, you read correctly, $14 trillion! Mr Chambers certainly seems to be one of the most forward thinking CEOs of a large organisation that I've heard speak in 2013.

if you don't keep up with change, you will get left behind, not just as company but as a country! #iotwf pic.twitter.com/YpiWJHdMdm

— Maneesh Juneja (@ManeeshJuneja) October 30, 2013

Reading through the attendee list, I did not see any pharmaceutical companies, neither anyone from the NHS. Oh wait, during the event, I did bump into someone from Eli Lilly. I have no idea why their were so few healthcare organisations at the event, despite a closing keynote delivered by Jay Walker, chairman and curator of TEDMED (more on that later).

Cisco are so excited at the prospect of IoT as the next big thing, they are setting up a new business unit. After coming back from the event, I learnt that Intel, the chipmaker, is also setting up an IoT business unit.

When I imagine IoT and our health, I'm envisioning sensors embedded in everyday objects that are wirelessly connected to the net. An example might be that my sofa, TV, fitness tracking wristband, and my smartphone are all connected. So, I've been sitting on the sofa watching TV for hours, despite my goal being to walk 1 mile every day. My sofa senses my inactivity, knows it's going to rain in 2 hours, and then switches the TV off and sends me a text message saying, it's time to go for a walk before it starts raining. I didn't see anything like this at the event. To be fair, there was one fascinating session on IoT & healthcare, featuring some pioneering work shown by Bill Kennedy, who has been using in IoT technology in telehealth.

The first video at the bottom of this post is of Steve Lucas from SAP and includes a demo of a smart vending machine that can suggest food options based upon your sleep & physical activity [actual demo starts from 4 mins onwards] 

The second video is of the closing keynote from Jay Walker. I've included a 10 min video from his speech [unfortunately, ran out of space on my iPhone, so didn't record all of it]

Easier said than done

There was a Smart City Walking tour, to showcase what the city of Barcelona is doing to embrace IoT. Initiatives such as parking sensors that let citizens know where an empty parking spot is located, location analytics that allow the city to understand where pedestrians are walking, sensors in waste bins that inform when the bin is full and free public wifi. All to be applauded. However, when flying back to London from Barcelona airport, and looking to get online, I was in a different Barcelona from the glitzy forum. Not a single power socket at the gate (phone was running out of juice), and 15 minutes free wifi (fee required for >15 mins). So much for a smart city!

@ManeeshJuneja Fully agree, such a shame!! Airport is managed by central government in Madrid though...

— Júlia López Ventura (@jlopezventura) November 1, 2013

Even when departing London Gatwick airport for Barcelona, I spent ages wandering around the terminal hunting for a place to plug my laptop in before my flight. I finally found a power socket, in between two chairs. Plugging in my laptop revealed the socket was not functioning.

More recently, attending the Health Tech Summit by Silicon Valley Comes to the UK, held at University of Cambridge. An illustrious panel flown across from the USA to share their vision on the future of healthcare. Exciting stuff! Oh wait, I struggled to live tweet during the event. No public wifi in the venue. On top of that, my mifi device had no signal, and my mobile phone's signal was often too weak for a data connection. These incidents make me feel like I'm living in a real-life Dilbert cartoon!  

As inspired and excited as I am by the vision of a hyper connected & programmable world, the on the ground reality in healthcare is very different. I remember a business trip when I worked at GSK. I took the Eurostar train from London to Brussels one morning to visit the Vaccines division. A taxi had been booked for me at Brussels station. Upon arrival, I found my taxi driver waiting for me, with my name and the GSK logo on a card he was holding up. Actually, there were many drivers around him, all holding up cards for GSK staff. So, same train from England, with employees from different divisions, all heading to the same GSK building in Belgium, each with their own taxi. Hmmm. We frequently can't get people to talk to one another and share information, and yet, we expect those same people will enable  50 billion devices to talk to one another. Technology seems to be progressing at an exponential pace, leaving many leaders and their organisations struggling to keep up.  

I don't see a prosperous future for many organisations in health & social care unless they wake up. I was talking to a friend in the US about IoT and the NHS. He told me "a true IoT means we wouldn't need the NHS at all. It is not about innovating within current structures but innovating and being willing to change the physical geography of healthcare and beyond!!" 

@czb_oracle says it's not about #bigdata but fast data! In health and IoT, how to analyse & act! #iotwf pic.twitter.com/Qhpv4k6rYi

— Maneesh Juneja (@ManeeshJuneja) October 31, 2013

Beyond IoT  

Yes, whilst IoT is yet to hit the radar screens of many organisations, visionaries such as Alice Rathjen are already thinking beyond IoT. Alice is a good friend of mine, and spoke at Silicon Valley comes to the UK a few days ago. Her vision of the future is the Internet of Human Beings. Truly fascinating stuff!  

Forget #IoT - @dnatimes believes the future is the Internet of Human Beings #svc2uk #digitalhealth pic.twitter.com/lx5YQwlABm

— Maneesh Juneja (@ManeeshJuneja) November 8, 2013

@tedmedjay says in the future, each of your internal organs will have an IP address!! #iotwatch #digitalhealth pic.twitter.com/N5TNdyyums

— Maneesh Juneja (@ManeeshJuneja) October 31, 2013

So what next?

I applaud Cisco for hosting this pioneering event, and it was a privilege to be there and witness what felt like a turning point in history. Naturally, there will be tremendous hype surrounding the potential of IoT, just like the hype we are forced to navigate in 'Big Data' & 'Digital Health' for example. The dreamer in me wants to believe IoT will solve many of the challenges we face in health and social care. However, looking at recently released data about internet usage in Europe. 100 million people in Europe have NEVER used the internet. Take Greece, where 65% of residents have never used the internet.

60 million Americans don't use the internet, according to Pew research. Many of the people who don't use the internet are poor, disabled or elderly. However, the Greek government have promised to roll out free wifi across Greece in 2014. Looking at the bigger picture, social inequalities in health do exist. Amazing developments in technology including IoT seem to have the potential to either widen or reduce those inequalities around the world. I really hope it will be the latter. As Jay Walker said in his closing keynote, "our biggest challenge is lack of imagination".

Can you and your organisation imagine what a hyper connected world would look like?  What will the IoT mean for you? Does the IoT frighten or excite you?

[Disclosure: I have no commercial ties with any of the companies mentioned above] 

Steve Lucas from SAP at Internet of Things World Forum - 31st Oct 2013 

Jay Walker, chairman of TEDMED delivering closing keynote at IoT World Forum - 31 Oct 2013