My review of the first Scripps Health Digital Medicine conference

In this post, I'm going to be sharing my thoughts regarding the first Scripps Health Digital Medicine event hosted by Scripps Translational Science Institute (STSI) that I attended a few months ago. What was excellent, and still rare to see in many Digital Health events across the globe is that both days started with patients sharing their stories on stage, and not just a few minutes, but 30 minutes for each patient story. These were really powerful reminders of why we were gathered there. 

I wasn't enamored by the first two talks on Day 1. I still remain skeptical of Deepak Chopra's work, even after listening to his talk on the 'Future of Wellbeing'. I found Paul DePodesta's talk on 'Moneyball for Healthcare' to be quite dry and didn't engage with me at all. Thankfully, Anna McCollisterSlip's talk followed on patient centered healthcare which was a highlight and I'm looking forward to the future launch of Vitalcrowd, which aims to crowdsource the design of clinical trials and involve patients. 

Talking to other attendees in the breaks got me thinking, where is everyone? Whilst the speakers were from different parts of the USA, almost every attendee I spoke to was local to the San Diego area (Note: I did meet 3 people who had travelled from Europe) This was the first event of its kind by Dr Eric Topol and Dr Steve Steinhubl by STSI, and when registering, I imagined people would be attending from around the world. Especially given how influential Topol's work has become in recent years, I find it surprising that nobody from the UK's NHS was there. After all, UK Health Secretary, Jeremy Hunt, cited Dr Topol's book, 'The patient will see you now' in his annual HSJ lecture in October 2015.

One of the most energetic talks during the entire event was delivered by Dr Henry Wei, and really hit home for me because he actually talked about the challenges of evidence generation in Digital Health, and he shared Aetna's experience from piloting health apps. 

Adam Pellegrini, from Walgreens, shared that they had seen improved outcomes as a result of patients using wearable devices, in terms of medication adherence and the results were unexpected. They seem to have big plans for incorporating digital technologies in their offerings, so it will be worth keeping an eye on what they do next. 

What was interesting was that the second half of Day 1 had 5 talks on the theme of 'What the patient wants and needs.' Walter de Brouwer from Scanadu, made some bold predictions including that within 2-3 years there will be a lab in every bathroom. His talks are always very engaging, as he is definitely focused on the patient first. He also made a point that consumers will have agents like Siri, Artificial Intelligence like Watson, and so what will happen to doctors? 

All this talk about transforming medicine, and it made me aware of my own health. Sadly, this event seemed to suffer from the same issues I have observed at similar events around the world. To be fair, someone must have listened, because on Day 2, fruit was available in every break. 

John Sculley, the former CEO of Pepsi & Apple, pointed out that the American Medical Association says that 70% of procedures could be done remotely, in his talk, on 'Telehealth Care to Just Health Care.' I do think more people need to consider virtual doctor visits, and whether in some areas, it becomes the default method for interacting with a healthcare provider. I was intrigued to hear Babak Parviz speak, (who invented Google Glass) but has moved to Amazon, where they are exploring new spaces including healthcare. I wonder, what if our experience of healthcare were as efficient as our experience of using Amazon? 

Since the event was located in California, which is considered by many to be the most progressive and forward thinking state in the USA, I was surprised to see find that the panel discussion at the end of Day 1 was absent of women. On top of that, out of 11 formal talks on Day 1, just 2 were delivered by women. 

What I found particularly valuable was the chance to network and spend time with people who are normally really difficult to get hold of. After the talks had finished on Day 1, I remember having a wonderful extended conversation with Professor Rosalind Picard, who is at the MIT Media Lab, and I got the chance to have a look at the wearable technology she is currently developing. One of the benefits of having a relatively small event in a compact venue. I went to the mHealth Summit in Washington, DC a few years ago, and felt like I was in a small town, since 4,500 attendees were there. 

Whilst I'm on the topic of the venue, the location, which was the Scripps Institution of Oceanography in La Jolla is the best setting for a conference that I've ever attended. Having flown 11 hours to attend, and then driving 2 hours from Los Angeles in rush hour, I suspect the ocean views and laid back atmosphere had an impact in reducing the effects of my jet lag during the 2 days. 

This was the view of the Pacific Ocean from the venue when we had breaks

This was the view of the Pacific Ocean from the venue when we had breaks

Day 2 opened strongly, with D.A Wallach speaking about the need to create a company that is the Apple of healthcare, a one stop shop for consumers. Dr Jess Mega from Google Life Sciences [now known as Verily] gave a insightful talk on the technology that Google is pursuing in healthcare, including the contact lens that aims to monitor glucose levels in people living with Diabetes. Their vision she shared on the 'machine intelligent' landscape in healthcare has convinced me to pay much more attention to technology trends such as machine learning. Professor Picard's talk on what wristband sensors can tell us about brain health also gave tremendous insights into the future, asking how could we use sensors to predict seizures in those living with Epilepsy. She also asked us to work together to use tech to save lives. One of the metrics I use to judge if a speaker has made the audience think is how many queue up to ask questions once the talks are over. 

Virtual Reality is tipped to be an area of increasing interest in 2016 with the launch of new consumer headsets. We might think it's brand new technology but Brenda Wiederhold from the Virtual Reality Medical Center, highlighted how the evaluation of virtual reality as a form of therapy has been around for some time. 

I enjoyed listening to Donna Spruijt-Metz from the USC mHealth Collaboatory share some of her research in Obesity, and made me think about the 'just-in-time' interventions we may be receiving in the future.

Dr Zubin Damania from Turntable Health, delivered a very entertaining talk which tackled a very serious topic about reforming primary care, including his vision for the future, where instead of evidence enslaved medicine, we have evidence informed medicine. He also gave the audience a preview of his latest video, EHR State of Mind, which the audience loved so much, he received a standing ovation. As I too stood up, smiling and clapping, it hit me how humour can be utilised to get an entire group of people thinking hard about something that bothers many in healthcare today. 

Wendy Nilsen, from the National Science Foundation, spoke about Precision Medicine as a National Initiative: The Role of mHealth. I've admired her efforts for many years, and it was great to get to hear her speak in person. 

In the final session on Day 2, the theme was 'Individualizing care via Big Data', which is a growing area of interest right now. This was the first time I'd seen a talk about the newly formed Watson Health, and Robert Merkel, certainly shared a bold vision for what they hope to use their technology for. 
 

It was unfortunate that at the end of Day 2, the panel discussion was devoid of women, again. 

After the event formally concluded at the end of Day 2, there was a long queue of people patiently waiting to speak to Merkel about Watson Health. I reckon that given their strengths in big data and their bold visions for future, competition between interlopers such as Watson Health and Google Life Sciences may lead to a paradigm shift in the application of data in our everyday life to optimise our health. 

It was my first time hearing in person about MD2K, which aims to lay the scientific foundations for turning the wealth of mobile sensor data available through new and rapidly evolving wearable sensors into reliable and actionable health information, and contribute to the vision of predictive, preventive, personalized, participatory, and precision (P5) medicine.  However, the speaker, Santosh Kumar, spoke far too fast, and I had trouble keeping up with the pace of the presentation. It was enlightening to learn about their mHealth Training Institute (applications open Jan 15th 2016)

There was also a small marquee outside of the auditorium where breakfast, lunch & breaks took place, which also had a very small selection of exhibitors. That was a good decision. Sometimes, there can be so many exhibitors that you use most of your breaks visiting booths, which makes the day quite hectic. 

I left the event feeling somewhat confused. The cost of registration was $345, which is less than the price of some of the latest smartwatches, so a veritable bargain, in my opinion. STSI did a great job bringing some brilliant speakers together in one place. However, they need to work out exactly what this event is about in order for it to justify a place in the increasingly crowded space of Digital Health events. It has the potential to be a brilliant event, but because it didn't deliver content that consistently met the objectives stated in the brochure, it's a major failing in my eyes. I expressed this view in my earlier post. Neither the low cost of admission or the beautiful location can offset that. The brochure opened with this statement under course description, "A thoughtful exploration of the clinical evidence necessary to drive the widespread uptake of mobile health solutions will be the focus of the first Scripps Health Digital Medicine conference", and whilst there were elements during some of the talks with this explicit focus, by and large it felt like existing events I've been to which discuss in general terms, the future of emerging technologies that are hoping to transform medicine.

The brochure also stated it would be an interactive conference. Sorry chaps, but a conventional format where in each session, the audience sits and passively receives information from 3 talks over 90 minutes followed by a panel discussion, and Q&A time with the audience doesn't count as interactive for me. Fewer talks, more audience participation/practical workshops would be a step towards being able to describe it as interactive. The brochure also listed, "After attending this activity, participants should be able to: Identify global needs for mobile health and potential technologies to address those needs." Sadly, this didn't actually translate into reality, since the speakers including the patients were all from the US, and most of the examples cited in talks were in reference to the American healthcare system or research initiatives set in the US. .

I'm not sure that having a theme of mHealth is the best thing for the future. We assume that smartphones are cutting edge and with us for some time. However, a recent survey by Ericsson Consumer Labs found that 50% of smartphone users believe that smartphones will disappear within 5 years [Note: they surveyed urban smartphone users in 13 major cities around the world]. 

To conclude, I see that STSI are now showing online that the event will repeat in 2016. I also note that the overview and conference objectives for 2016 are identical to 2015. I sincerely hope that they will make changes to the structure, content and format of the next event. Artificial Intelligence and the Internet of Things are likely to be two buzzwords that are thrown around in 2016 from many claiming to have solutions that might impact the lives of many people around the globe. "There is a clear need for a forum to present, discuss and debate clinical trial evidence and how to best obtain it in order to accelerate change" states this conference brochure. Moving forwards, I believe this need will become even more acute, let's hope this annual event can become the forum that the everyone eager to change healthcare is awaiting.

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

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Unexpected findings

It's fascinating to meet people in healthcare and hear them dismiss the potential value of a tool like Twitter. Despite an increasing amount of noise, I do find it a great place to listen and learn. For me personally, it's been a very powerful tool, and has taken me to places I've never imagined. One of those places is Cedars-Sinai Medical Center in Los Angeles, California. By chance, I'd come across Dr Brennan Spiegel on Twitter earlier this year, and through our online interactions, discovered that we had common interests in Digital Health, especially in the context of understanding whether these new digital tools and services being developed are actually having an impact in healthcare.

Dr Spiegel is Director of Health Services Research at Cedars-Sinai Health System, Director of the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), and Professor of Medicine and Public Health in Residence at UCLA. I was particularly intrigued by the work he does at CS-CORE, where he oversees a team that investigates how Digital Health technologies, including wearable biosensors, smartphone applications, and social media, can be used to strengthen the patient-doctor bond, improve outcomes, and save money. So whilst I was out in California, I popped into Cedars-Sinai Medical Center to spend some time with him and his team to understand their journey so far in Digital Health.

With Dr Spiegel and the CS-CORE team - the picture was taken remotely using Dr Spiegel's Apple watch! 

With Dr Spiegel and the CS-CORE team - the picture was taken remotely using Dr Spiegel's Apple watch! 

To give you some context, Cedars-Sinai Medical Center is a non-profit, has 958 beds, over 2,000 doctors and 10,000 employees. It's also ranked among the top 15 hospitals in the United States, and is ranked first in Los Angeles by US News and World report. In addition to Dr Spiegel, I met with Dr Christopher Almario, Garth Fuller, and Bibiana Martinez. 

What follows is a summary of the Q&A that took place during my visit. 

1. What is the big vision for your team?
"The big vision is value of care. Value is our true north. It puts patients first while also reminding us to be judicious about the healthcare resources we use. Take Cedars-Sinai, a traditional volume based center of excellence. How do we transform our hospital, that has excelled in the fee-for-service healthcare environment for so long, and transform it into a value-based innovation center while maintain our top-notch quality of care? It seems like a magic trick to transform from volume to value in healthcare. How do we do it at scale, and how do we keep people out of hospitals when healthcare systems have  been designed to take people in? Our mission is to figure out how to do that. This could be a blueprint for how other health systems could do this and which doctors could do this. How do we align incentives? How do we create a Digital Health strategy that works within the existing clinical workflow? How might we use an E-coordination hub? These are all open questions ready for rigorous research. 

What does innovation mean at Cedars-Sinai? We see ourselves as a hub of innovation and are now developing a new 'Value Collaboratory' under the guidance of our visionary leader, Scott Weingarten, who directs Clinical Transformation at Cedars-Sinai. We offer a set of tools to help value-based innovators make a difference. We're going to be doing a lot over the next 5 years. Digital Health is just one small part of that. The Value Collaboratory will be the centre for ideas within Cedars. For example, if innovators seek internal funding for a project, then they can work with the collaboratory to refine their idea, evaluate its health economic potential, and create a formal case for its support."

2. Tell me more about the team, what types of people work in CS-CORE
"There are 12 of us in CS-CORE, and we have a combination of health system and statistical expertise. We have social scientists, behavioural scientists, mobile health experts and more. It's a multi-disciplinary team. For example, Dr Almario is a gastroenterologist, who has always been interested in health services research, and was awarded a career development award from the American College of Gastroenterology, which is very rare, in Digital Health to pursue research. Garth Fuller with a background in health policy and management has been working with us for the last 5 years and has a strong interest in medication adherence, and conducts research to understand how we can show that 'Beyond the Pill' strategies in the pharma industry are working. Bibiana Martinez with her background in Public Health is hands on, and works with our patients. Bibiana helps filter the real world barriers faced in Digital Health research and bring them back to our team. We have an all-hands-on-deck research crew."

3. What has surprised you during your research in Digital Health?
"We've had some unexpected findings. For example, we had a patient who reported less pain, and our original expectation was that the data from her wearable would report that she had been walking more, as the pain was subsiding. However, that wasn't the case, as her pain decreased, she was walking less. It turns out the patient was an author, and being free of pain meant she could sit for hours on end and finish writing her book. Completing the book was the outcome that mattered to the patient. What should we do when a patient's steps fall from 1,500 a day to almost 0? Do we give them a call, simply because we perceive it as unhealthy? How often does your doctor ask you what your goal is for your visit? I show these charts of pain vs steps when I teach my health analytics class at UCLA, to challenge how my students think."

4. How else have your assumptions about how patients use Digital Health tools been challenged?
"In healthcare, we often make a lot of assumptions about the needs and wants of patients. We have been fitting Virtual Reality goggles with hospital patients, so that we can transport them from their hospital bed to far away places such as Iceland. One patient asked if we could transport him somewhere more tropical, as the hospital is cold, and having a VR experience in Iceland made him feel even colder. 

We had an instance where a patient wasn't able to charge her Fitbit. We tried to explain over the phone, but it actually required a house visit in order for this patient to understand how to charge the device. We thought we could put sensors around the ankle joint of patients to measure steps, and some patients felt like they were under house arrest when wearing our sensor on their ankle."

5. What are some of the most exciting projects you're working on today?
"Well, we create our own technologies and sensors. We find out soon if our first sensor is approved by the FDA. Also, with the vision of our hospital Enteprise Information Services (EIS) team, our hospital's EHR is now connected to Apple's HealthKit, it's a great achievement, we now have 750 people pouring in real-time sensor data into our EPIC Electronic Health Record. We've also developed My GI Health, a patient provider portal which by gathering information on symptoms in advance of a visit to the doctor, helps us learn more about a patient's GI symptoms. The computer doesn't forget to ask questions, but sometimes the doctor forgets to ask questions. Although much of our research is in GI, we are working across healthcare. We are now building a version of My GI Health for rheumatology, for example. We are also interested in testing whether the first visit to a specialist doctor should be virtual or in person? What would patients & doctors actually want? We are putting a study design together now that will compare both types of visits."

6. What are some of the challenges you face in your research?
"The research we do is often challenging for the IRB because it’s so different.  We work closely with our IRB to explain the nature of our work. As more academic groups conduct Digital Health research, it will be important that medical centers develop regulatory expertise around this type of work.

There is also an urgency to test quickly, fail quickly and succeed quickly. What we need is a high level discussion to understand what risk means in the context of Digital Health research. Can we generate evidence faster?"

7. What are you doing to help ensure that no patient gets left behind in Digital Health?
"We are soon going to start a community-based study in partnership with African American churches in Los Angeles. We will work with these 'mega churches,' which have up to 10,000 congregants, and will distribute healthy living experiences delivered by Virtual Reality goggles using Google Cardboard.  We will also use an app for obesity and diabetes management. We observe that many families from minority backgrounds are mobile first, and we see that the next digital divide is opening up over mobile. Healthcare isn't built for mobile. We are also researching the mobile usability of hospital websites across America."

8. What message would you like to share with others also on the same journey as you?
"Listen to the patients, get used to Digital Health being dirty and difficult, it may be harder than you think. We can say that with some authority now, that it can sound easy, but in reality it's been very hard. Our team has developed devices and applied them directly to patients; what happens next is often unexpected and challenges our assumptions. Digital Health is really hard to do. We have to focus on the how of Digital Health. We understand why it's valuable, but not as much about how we will be doing it. Value is another big theme - we need to improve outcomes and reduce costs of care. It takes time to do it right. We also try to never forget the end user, both the physician and the patient. 

This work is 90% perspiration, and 10% inspiration. You need to have a sense of humor to do this because, you’re going to get a lot of unexpected bumps and failures. It’s a team sport to figure it out. Defining the problem in terms of the health outcomes and costs is the key, and generating a solution that has value to patient and providers is paramount.. 

Finally, the 'cool test' is so seductive. Don’t been fooled by the 'cool test' in Digital Health. What may be cool to us may not be cool to the patient. Don’t be seduced by the 'cool test' in healthcare."

I really enjoyed my time with Dr Spiegel and his team, not only because of the types of research they are doing, but also because of their vision, values and valor. Their unexpected findings after putting new devices on patients has subsequently made me think at length about health outcomes. I was reminded about the human factors in healthcare, and that both patients and doctors don't always do what we expect them to do. I'm glad CS-CORE are not just thinking from the perspective of medicine, but through the lens of public health too, and how to ensure that no patient is left behind. I'm not the only one who is admires their work. David Shaywitz, has recently written a post about the research conducted by CS-CORE, and mentions, "they are the early adopters, the folks actually in the arena, figuring out how to use the new technology to improve the lives of patients." 

Dr Spiegel did admit they've been under the radar so far, focusing on putting “one foot in front of the other” in research mode while working with a wide variety of partners from industry and academia. The team is also looking for collaborators who want to road test their digital health solutions in a “real world” laboratory of a large health system. Their team is equipped to conduct stem-to-stern evaluations with an eye to rigorous research and peer-reviewed publications. I see that Dr Spiegel is one of the speakers at the Connected Health Symposium later this week, as part of a panel discussion on Measuring Digital Health Impact & Outcomes. I won't be there but I hope to be part of the live Twitter discussion. 

Since my visit, I note that Cedars-Sinai and Techstars have partnered to launch a Digital Health focused accelerator. What does this accelerator aim to do? The website states, "We are looking for companies transforming health and healthcare.  Companies that are creating hardware, software, devices and/or services that empower the patient or healthcare professional to better track, manage, and improve health and healthcare delivery are eligible to apply." Techstars is one of the world's most highly rated startup accelerator programs, the other being Y Combinator. It's fascinating to see the marriage of two very different worlds, and who knows what unexpected findings will result from this partnership. In the 21st century, when we think of radically different models of care, startups and emerging technologies, large traditional hospital systems are not the first place we think of looking for them. Maybe the lesson here for large healthcare institutions is to "disrupt or be disrupted?"

In the world of Digital Health, the trend of moving healthcare out of the hospital into the home, virtual visits and telemedicine may be causing concern to hospital executives. If all of these converging technologies (often coming from startups) really are effective and become widely adopted, then surely we will need smaller hospitals, or perhaps in certain scenarios, we may one day not need to have that many hospitals at all? Perhaps the hospitals that survive and thrive in the 21st century will be the ones that boldly explore the unknown in Digital Health, rather than the ones that hide and hope that the world of Digital Health will just be a passing fad? 

“It is the tension between creativity and skepticism that has produced the stunning and unexpected findings of science.” - Carl Sagan

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

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Promise doesn't equal proof

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

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

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

  • "Assess the quality of clinical trials of mobile health in terms of providing the evidence necessary to support implementation"

  • "Discuss the implementation of mobile health technologies into clinical practice based on clinical trial evidence"

  • "Identify innovative trial methodologies for use in digital medicine"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The quest for evidence

There is an abundance of excitement and enthusiasm in the world of Digital Health. One example is the growth in venture funding, another is the announcement of new partnerships between incumbents and the technology companies, such as Astrazeneca's partnership with Adherium to develop a 'smart inhaler.' We see more accelerators, more incubators, and more hackathons. It really is an incredible era. One of the major challenges is that the world of healthcare requires more than excitement and enthusiasm, it requires evidence. Apps may be cool and fashionable in the modern age, but apps that are proven to save lives are what decision makers in healthcare are seeking. News articles may cite that 165,000 health apps now exist, but that’s a headline statistic, as it’s simply evidence of increased activity. If we don’t start seriously thinking about validating these new technologies, chances are that the industry will fail to make the impact it hopes to. Even worse, widespread use of digital interventions that have not been validated may cause unnecessary harm to patients.

Now, evidence means different things to different people. In the world of startups, evidence might be $1 million in seed funding and 5,000 active users of an app. In the world of healthcare, evidence might be a randomised clinical trial with results published in a peer reviewed journal. I have observed a gulf between these two worlds, and that's a problem. How many startups have evidence generation in their business plans given that half of Digital Health startups fail within 2 years? Generating evidence is expensive when you're trying to get your business off the ground. Omada Health is cited as one of the leading examples of a startup that has worked hard to generate evidence, and they state, "Omada’s commitment to generating, analyzing, and sharing clinical data is central to our identity."

What is evidence in the 21st century?  This is a critical question, and one not being asked enough. Maybe if healthcare systems eventually start collecting patient outcome data in real-time, evidence may be easier to obtain? Perhaps as we collect different types of data, the evidence that is gathered could change? The time and costs needed to gather evidence using traditional methods may not be suitable to enable the swift development of Digital Health. Even when we have schemes for validating Digital Health, it’s not always plain sailing. Take the NHS example, and the news that some accredited health apps were found to be putting users' privacy at risk. My fear is that traditional organisations, under pressure to be seen to ‘accelerating innovation’ or ‘transforming healthcare with digital’ act in haste with regard to these new tools, and throw caution to the wind. Changing the world of healthcare is going to be a relatively slow moving process when done properly, no matter what you hear about the next disruptive idea. Maybe we mistakenly assume that a digital intervention is always going to be brilliant, which is quite a dangerous assumption to be carrying around. Again, that’s where evidence is useful, as maybe the evidence will show that a particular digital intervention does not offer any additional benefit over existing non-digital interventions.  

There are people out there starting to look at validating new ideas in Digital Health. It's interesting to note how a new startup accelerator, Rockstart, from the Netherlands has quite a strong focus on validation and evidence generation, which is a step in the right direction. There is also Evidation Health, which has a focus on, "Defining and demonstrating value in Digital Health." Also, the Global Consortium for Digital Medicine has been established, with a focus on Evidence based Digital Health.

This is good news, and quite frankly, we need more people working on this. I am so curious about trends in generating evidence that I've flown out today to California to attend the inaugural Digital Medicine conference at Scripps, where the focus of the 2 day event will be, "A thoughtful exploration of the clinical evidence necessary to drive the widespread uptake of mobile health solutions." There seems to be a growing momentum for pushing this conversation forward. I note that the Hacking Medicine Institute will be hosting their first "Measuring Digital Health Outcomes Summit" next week. I'm excited that the Institute has the aim of "convening healthcare leaders around the world to accelerate data, evidence and adoption of effective new medical technologies." I suspect those organizations building Digital Health products that have not thought enough about evidence are likely to be viewed differently in 2016 and beyond.

The quest for evidence in Digital Health is underway, and hopefully, we'll soon be able to sort out the wheat from the chaff. 

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

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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

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

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?

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

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

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

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' 

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 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

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. 

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

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

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."

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.

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? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.

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)?

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. 

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

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

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) 

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) 

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

Health app on my iPhone

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 

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.

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

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.

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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