The hype around wearables is deafening. I say this from the perspective of someone who saw their application in chronic illness management 15 years ago. Of course, at that time, it was less about wearables and more about sensors in the home, but the concept was the same.
Over the years, we’ve seen growing signs that wearables were going to be all the rage. In 2005, we adopted the moniker ‘Connected Health’ and the slogan, “Bring health care into the day-to-day lives of our patients,” shortly thereafter. About 18 months ago, we launched Wellocracy, in an effort to educate consumers about the power of self-tracking as a tool for health improvement. All of this attention to wearables warms my heart. In fact, Fitbit (the Kleenex of the industry) is rumored to be going public in the near future.
So when the headline, “Here’s Proof that Pricey Fitness Wearables Really Aren’t Worth It,” came through on the Huffington Post this week, I had to click through and see what was going on. Low and behold this catchy headline was referring to a study by some friends (and very esteemed colleagues) from the University of Pennsylvania, Mitesh Patel and Kevin Volpp. Other authors were Meredith Case and Holland Burwick. Also notable was that the study was published in JAMA. In this research letter, the authors compared several fitness wearables to smartphone-based apps as tools to track activity. They asked healthy volunteers to walk either 500 steps or 1,500 steps on a treadmill, and compared step counts on multiple devices as well as on smartphone pedometer apps. It is worth spending some time reviewing their data tables.
The first take-home for me was that steps counted on the wearable devices and the mobile apps, when walking on a treadmill, are pretty accurate. I was somewhat chagrined to learn this. I have a treadmill desk and this time of year spend many evenings walking while reading email. It always seems like I’m walking farther than the Fitbit tells me, but now I know I’m probably just tired at that hour.
Their main point, however, is that smartphone apps are as accurate as these wearable devices. This makes sense intuitively, as we’ve known that smartphones have embedded accelerometers, which can be used to track the movement of the phone. For years, there have been apps that can take this data and, by applying some software algorithms, show activity that the phone has traveled as steps walked by the owner. I believe they were initially not so accurate. However, a bigger problem in the early days was that these apps drained the phone’s battery because the processor always needed to be on while tracking the accelerometer’s activity. This has been remedied in the most recent generation of mobile phones, as they now have separate processors dedicated to this sort of continuous tracking.
Thus, we have plentiful pedometer apps (a search on the Apple App store produced too many to count). We’ve also solved how to run these apps in the background without disrupting the phone tasks or draining the battery. So, is it time to ask, “do we really need fitness wearables anymore”?
I’d frame the question a different way. Is the future of patient-generated data migrating to the mobile phone (the proverbial digital Swiss Army Knife of life) or will it be migrating to the realm of micro-sized wearable seeds, ingestibles, injectables, bandaids and the like? I was a fellow panelist with tech guru and futurist Nicholas Negroponte, and in an off-handed comment, he said that wearables are just a temporary fad and that the future is in ingestibles.
On the one hand, it’s tempting to think about a world where all of your health-related data are generated on and analyzed by software resident on your mobile device. One big challenge to this vision is that we don’t always have our phones on our person. Some folks carry them in a bag, etc. This latter point calls into question the experiment that our friends at Penn did and, more impressively, that JAMA chose to publish it. The quality of the science is quite high but the applicability is questionable.
Also, there are many other health sensing applications than just pure activity tracking. What about continuous heart rate or blood pressure monitoring. It’s hard to imagine getting those done without some sort of sensor.
Going back to the eye-catching headline from the Huffington Post and channeling Mark Twain, I’d have to say that reports of the death of wearables have been greatly exaggerated. The power of sensor-generated data in personal health and chronic illness management is simply too powerful to ignore.
The last point to be made, however, is that wearables and their attendant feedback loops are relatively weak motivators on their own. In fact, the same group from Penn came out with an opinion piece, also in JAMA one week earlier, thoughtfully talking about this point. Our Connected Health research team at Partners HealthCare has shown repeatedly that the motivational messaging that puts these feedback loops in context is the true driver of behavior change.
That will no doubt be delivered via your smartphone!
I’m often asked, ‘If you could snap your fingers and do some things to accelerate the adoption of connected health, what would they be?’ I’ve resisted responding, thinking that things are not so simple and reducing the keys to adoption to a list is unrealistic. However, I have been thinking lately about the cultural and business phenomena that are currently shaping and accelerating the adoption of connected health and, in that context, came up with five accelerants. The best part of the story is that four of the five are already going on and we can see their early-stage effects.
So, at the risk of ‘dumbing down’ adoption, here is my list of five accelerants. If we could make these go faster, the adoption of connected health would accelerate too.
1. Increase value-based reimbursement for providers.
The more providers are financially rewarded for outcomes/quality and efficiency, the more they will be receptive to virtual care. This is more acute in situations where providers take on downside risk, i.e., they lose money if they do not achieve the targets mentioned above. Virtual care enables improved efficiency by allowing us to scale our human resources across more individuals/patients. It enables improved quality by enhancing ‘just-in-time’ decision-making. And, patients are almost universally in favor of it. For instance, a recent survey showed that 64% of consumers were receptive to virtual visits with their doctor.
2. Create more mechanisms for provider reimbursement for non face-to-face care (like the new CMS CPT code that just took effect).
This may seem counterintuitive given the first accelerant, but even when providers go at risk, they still need ways to document their effort. We could just put everyone on a salary, but even then, it seems administrators need evidence of actual units of work. The Centers for Medicare and Medicaid Services’ newest CPT code includes reimbursement for telemedicine services, which is exciting because it enables clinicians to envision a mechanism where they can be financially rewarded for providing chronic care management. More codes like this would be a tremendous accelerant.
3. Accelerate consumer choice in the marketplace as well as ‘consumer-driven health care’ (i.e., high deductible plans, health savings accounts (HSAs), etc.).
It’s been fun to watch how health insurance exchanges have affected the dynamic between insurers and consumers. Insurers were used to selling to employers (human resource professionals) and having the employers do the work selling the plans. Health plans must now go direct to consumer, forcing them to explain in plain English what health insurance means and how it works. On the consumer side, it has put the cost of health care in the consciousness of consumers. The cost-conscious consumer will likely prefer virtual care because it keeps care out of the high cost part of the system. High deductible plans and health savings accounts (HSAs) draw consumers into the conversation of health care costs. If we offer a virtual service for two-thirds the cost of a face-to-face service, you can bet consumers will flock, if they have a deductible to spend down or if it’s coming out of their HSA.
4. Make the consumer-facing technology truly frictionless.
This includes a mix of wish-list items, all designed to make it effortless for consumers to participate in connected health. We’ve found that even the effort to find an app in the app store, download it and create an account can impede adoption. It seems that people will do it for Snapchat or Trivia Crack, but not to improve their health. Likewise with all of the effort required to set up wearables and sensors so that their data flows to the right place. This needs to be simplified. Standards have a role to play here. My favorite example of this is USB. If you lived through the time where printers had one cable, your mouse/keyboard had another and other peripherals still another, you appreciate how powerful standards can be. USB allows us to easily connect and plug them in without extra effort. Bluetooth Low Energy is becoming that important connection for wearables, but it has a ways to go.
5. Create a universal privacy/security technology and make it a public good.
This is the most pie-in-the-sky idea. I believe it is important to solve the problem of privacy and security within that same envelope of frictionless technology. There are products on the market today that add layers of security in connected health, but they require the consumer to take extra steps and they are expensive. The scandals with the NSA, the multiple credit card breaches and the periodic stories on how Facebook is secretly manipulating your data are all a big setback for the adoption of connected health. We have to create a system in which consumers can share their health data with minimal extra effort, but also with minimal worry about whether it will be hacked.
I came up with these five accelerants in a moment of creativity. Do you agree? What did I miss?
While so many folks were writing about their impressions of 2014, I was enjoying the holidays with my family. During that time I was thinking about the notable events of 2014 in connected health, but more importantly how they will set the stage for 2015, which is poised to be a breakout year.
One year ago, Gregg Meyer, MD rejoined the Partners HealthCare network as Chief Clinical Officer. One of his initial moves was to bring the Center for Connected Health under his jurisdiction. For 19 years we were part of the IT apparatus at Partners. We thrived under that leadership, but the perception within our system and of the rest of the world was that we offered a set of IT tools. I had said some years ago that as connected health matured, our leadership would adopt the vision that connected health is really about changing the way that care is delivered. Technology plays a supporting, not a leading role. Gregg shares that vision and after consultation with our CEO, Gary Gottlieb, brought connected health into the clinical fold. Connected health now shares the stage along with his other major initiatives, namely, QSV (Quality, Safety and Value), Population Health, and Partners eCare. It has been tremendously rewarding for me to work with Gregg over this year as well as with my colleagues in these other areas. We are creating a strategy that will integrate connected health into the fabric of everyday care delivery in multiple ways over the next several years.
Supporting this strategy, and underscoring the increasingly important role connected health will play at Partners and throughout health care, Partners made the decision to create a new position on the executive team, Vice President, Connected Health, and asked me to fill it. It is with humility and excitement that I look out at 2015 and the opportunities these developments bring.
It’s clear connected health has turned a corner, making the transition from ‘curiosity’ and ‘future’ to everyday use. Provider organizations large and small are spending energy on how to integrate sensors, mobile devices and virtual visits into their care delivery. Some are doing so because they are entering into value-based payment relationships, or are more motivated to think differently after seeing their Medicare readmissions penalties. Some are simply realizing they have to be part of the 21st century, responding consumers and patients asking for more virtual care.
On the commercial side we saw large companies moving into the connected health space. Big announcements, especially from Apple, but also from Samsung, Microsoft and others portend a big push in consumer involvement. As you cruise through Staples, Best Buy or the Apple Store, you can’t help but notice the plethora of consumer connected health devices and their prominent placement in these stores. We’ll be sensing everything, all of the time, before long.
Of course sensing is only part of the magic. Particularly when addressing the chronically ill, a focus on motivation, engagement and behavioral health is key. This is much harder, it turns out, than sensor performance, connectivity, etc., and something our research team is actively working on. Our designs need to incorporate personalization, integrate into everyday life and reinforce social connections.
In 2014, we also saw the first concrete evidence that the pharmaceutical industry is serious about incorporating connected health into therapeutic offerings. In fact, we’re proud that we are executing a collaborative research and development agreement with Daichi Sankyo that will bring a bundled connected health/therapeutic product to market. Others will surely follow suit.
Topping the year off was the announcement by CMS that they will begin to reimburse for chronic care management (CCM) in 2015. This is the first acknowledgement from CMS that connected health is mainstreamable. The interesting thing about the new CCM code is that it acknowledges the value of care management that is not face-to-face and that is delivered by non-physician providers. While it does not specifically call out remote monitoring as a tool, remote monitoring is an ideal use case for this new code. It will enable us to engage with providers, particularly primary care physicians who have modernized their practices using a team-based (or patient-centered medical home) approach. This code enables us to approach this market with an ROI-based business proposition rather than some of the hand-waving we’ve employed in the past. It is still early going and I plan to write a more lengthy post on this development soon, but I predict this will bring a big lift to connected health as a tool for chronic illness management.
As I look back at my previous 20 years worth of New Year thoughts, I can’t remember a year where we saw more tangible movement toward mainstream adoption. Those of us who deliver services into this market had better strap on our safety belts because 2015 promises to be a fast ride – unlike any we’ve seen to date.
My dad was a wonderful guy who could fill the room with his personality. He grew up during the Great Depression and was a World War II veteran. I was thinking of him recently while considering how much health care delivery has changed in the last 100 years.
When asked about his health, my dad would always say, “I feel great. I don’t have any aches or pains.” This is telling. His generation equated pain with the need to seek care from an expert. After all, he grew up before Penicillin was discovered. During that time, given what we knew about health and disease and what we could offer for treatment, it makes sense that people sought the care of a physician when they ‘weren’t feeling well.’
We’re now in an era where chronic illness management and prevention accounts for 70% of health care costs. Of the forces responsible for illness — bad luck, bad genes and lifestyle — lifestyle is the predominant cause of chronic illness.
Our public health officials understand this important change, but consumers by and large still do not. They still mostly seek care when there is some symptom or acute need. This is problematic because so much lifestyle-driven illness is silent for years (hypertension, pre-diabetes, obesity) and only generates symptoms when things are pretty far along.
The other interesting aspect of my father’s adage is the denial underneath it. He was really saying, at some level, “If I don’t have any symptoms, I’d just as soon avoid the doctor so I won’t get any bad news.” This psychology too is quite prevalent among consumers today, adding to the challenge of raising awareness of lifestyle-driven illness. It is easy and human nature, to live in denial.
Another childhood memory I have is how kind my mom was whenever I was under the weather. She gave us extra love, as if that would help the illness improve more rapidly. Given that most childhood illnesses are viral infections, I suspect her added affection didn’t change the course of any illness, but she made it tolerable to be sick.
We all want to be cared for. This enables a child-like approach to the health care system. It is common for patients to come to see us joking about non-compliance and begging, “Don’t yell at me.” Likewise, they boast about their doctors, implying that they can put all of their worries aside: “She’ll make sure I am ok. I trust her.”
This triad of not thinking about health until symptoms arise, not wanting to hear bad news and abdicating responsibility for care to a health care provider accounts for a big part of why it is so difficult for physicians to get folks’ attention before they get sick.
Connected health can help us counteract these challenges. The vast array of sensors now available and their attendant feedback loops make it hard to ignore when we’re not on track with our health. Even if we don’t feel symptoms, we can be reminded several times per day of how we’re doing with respect to a given health parameter. When these data are shared with a health care provider, it becomes more difficult for individuals to ‘abdicate responsibility,’ something we’ve called the sentinel effect. When patients know their objective health data is being shared with a provider, they naturally up their game to appear to be compliant and interested in their health. No one wants to look like a slacker in front of their doctor.
But we still have challenges when it comes to denial and individuals abdicating responsibility for their health. This is magnified because we live in a libertarian society. It is our right to ignore our health if we choose to; and because our politicians want to offer us ‘coverage,’ we can still get our bills paid in the face of unhealthy lifestyle and behaviors.
What tools do we have to deal with this challenge?
- Incentives/rewards. We can offer individuals rewards for achieving health goals. Our connected health sensors can be the source of objective data to automate decision-making around those goals.
- Penalties. As a colleague recently said to me, “There is a continuum. You start with encouraging your workforce not to smoke and offering them rewards for not smoking. Next, you give them notice that those who continue to smoke will pay a higher insurance premium. Finally, you institute a policy to not hire smokers.”
Should we follow this approach with other lifestyle/habits such as physical activity and diet? Does it seem to invasive? What do you think?
Have you ever thought about how we evolved and the implications for health care? For millennia, we sought the help of a physician when we sensed something awry in our daily sensations. Sometimes this is as subtle as ‘I just don’t feel right,’ but sometimes it is as dramatic as an athletic injury or a tooth ache. Those latter circumstances are strong motivators to seek health care services because of the associated pain. Somewhere along the evolutionary road, we developed a nervous system with pain receptors, vital sensors that can help prevent injury. These benefits are most obvious in people with various forms of neuropathy. It is common for them to develop serious burns that they aren’t aware of; pressure ulcers, etc.
By contrast, we did not develop sensations for some equally serious health-related phenomena. For instance, the elevation of blood pressure is virtually undetectable until it gets to acute-crisis levels (hence the term ‘the silent killer’). Most folks can tolerate a blood glucose level of 150 to 200 (normal is around 100) or even higher without having much in the way of symptoms. This is why so many cases of type II diabetes go undetected years before they are picked up because of some other downstream symptom.
When you get into the realm of preventative care, it is even more curious. Though current evidence overwhelmingly supports daily cardiovascular exercise, most of us feel a very strong pull toward the easy chair or the sofa. Likewise, we can overeat slightly or overtly for years and ‘suddenly’ notice that we’ve gained 10 lbs. There is no symptom of high cholesterol, though we now know it to be a precursor of serious cardiac disease. Somehow our knowledge of pathophysiology seems to be ahead of our evolutionary development.
These latter challenges have become the bane of health care policy makers. We can’t get people to pay attention to diet, exercise and other preventative tasks because there is no symptom associated with unhealthy behavior — until it’s often too late. In fact in many cases, it seems that the unhealthy behaviors are in themselves psychologically rewarding so we are really swimming upstream here.
Enter the modern era of wearables and sensors. Sensor technology is going through a sort of Moore’s law type period, with personal health technologies experiencing exponential improvements. The technology is becoming cheaper, smaller, easier to power, etc. The most mainstream example of how this can affect health care are the systems that combine continuous glucose monitoring with insulin pumps in type I diabetes (so-called artificial pancreas).
The sensor industry is exploding with interesting innovations. Boston-based MC10 can put sensors and associated electronics into a flexible substrate allowing for devices the size and thickness of a postage stamp to be employed in vital sign sensing.
OMsignal is weaving sensors into fabrics enabling a t-shirt that can sense all manner of vital signs.
With all of the attention to nano technologies, it is not farfetched to imagine sensing of phenomena such as the level of cholesterol in the blood.
Are there examples of products on the market today that bring this vision to life? I can think of three. The Muse, by InteraXon, is a wearable EEG device that enables biofeedback and enhanced mindfulness training.
BioBeats senses your heartbeat and uses software algorithms to create music that relieves stress.
HeartMath uses a wearable sensor to give you biofeedback on your heart rate and improves focus, mindfulness and stress response.
So what if high blood pressure was like a broken arm? Think how health care delivery and prevention would change. With the evolution of new sensors, we will be finding out in our lifetimes. Imagine, with me, how this is going to change health and wellness in the future.
The 2014 Connected Health Symposium (our 11th) promises to be a feast for those hungry for knowledge on the subject. This year we have content focused on connected health at scale, the patient voice, new ways of sensing health and the latest policy updates – just to name a few of the topics we’ll cover during this two-day event.
We continue our rich history of outstanding keynoters delivering TED-style talks on the main stage. Don’t miss Eric Dishman. There is no one who tells the story of how connected health can make a difference in a more genuine manner.
Nir Eyal is both giving a workshop on October 22 and speaking on October 23. His recent book Hooked: How to Build Habit Forming Products has made lots of news. He’ll tell us how to make healthy behaviors habit forming.
Additional examples of some of our thought provoking panels include, The Evolution of the Patient, Pioneers at the Intersection of Primary and Behavioral Health, and Lessons Learned from Large Scale Telehealth Interventions.
There will be a themed section on Sensing Aspects of Health That are Normally Silent, which includes a performance by the design firm Sensoree highlighting their innovative clothing that changes color according to the wearer’s mood.
Top it off with book signings and networking breaks. Day one is a can’t miss day.
Day two kicks off with two great speakers: Robin Farmanfarmaian and Clive Thompson. Following that are some terrific panels including one on International Perspectives on Scaling Connected Health. Our themed section for day two is on Patient Voice, and includes both a thoughtful keynote (Sarah Krug) and panel on the topic, as well as a rendition by the comedy group Damaged Care giving us a lighter take on the topic.
Once again, we have more book signings and networking on day two.
I have the honor of closing the conference with my talk asking the question: Will 2015 be mHealth’s Coming Out Party?
Year after year, attendees give us great feedback on the Symposium. It has become a signature event for Partners HealthCare, for the Center for Connected Health and an event which promotes industry growth and cohesion.
It’s a can’t-miss event and I look forward to seeing you there.
I saw another exciting news story on a mobile health intervention the other day. I honestly don’t remember the company or product, but what stuck with me was the declaration of success based on 10 patients using the product for three months. Success was touted in terms of cost reduction and resource utilization reduction in a before/after analysis. This inspired me to collect some thoughts on some of the challenges around evaluating success in mHealth.
mHealth represents the collision of two interesting worlds — mobile, which changes on what seems to be a daily basis, and health care, which changes infrequently, only after significant deliberation and usually much empirical analysis. In the tech (mobile) world, companies are talking about creating a minimally viable product (MVP), getting it out in the market, assessing adoption through metrics such as downloads and customer feedback, and iterating accordingly. This would seem to make sense in the consumer world where the goal is to sell a game, an information app or productivity app. If people use it and are willing to pay, that proves its utility, right?
There is something to this line of thinking. Empiric market success is in some ways the ultimate success, at least for those who want to make a big difference in how humanity benefits from technology.
But does this work in health care? I’m not so sure. As clinicians, we’re trained to turn our noses up at this sort of measure of success. But maybe we’re the ones who are wrong. Let me use the 10-patients-for-three-months example to illustrate some issues.
- Selection bias. Virtually all pilots and trials of any sort suffer from this to some extent. These days, it seems that patient/consumer engagement is the holy grail and we all must realize that people who show up to enroll in any sort of study are already engaged to an extent. What about the people who are great candidates for an intervention (conventional wisdom says the disengaged are sicker and more costly) but are too unmotivated even to show up to enroll? Does anyone know how to handle this one?
- Regression to the mean. This is a pesky and annoying one — and a favorite of folks trained in public health — but unfortunately it is a real phenomenon. This is the stake in the heart of virtually all before/after studies. If you follow a group of people, particularly sick ones, a certain percentage of them will get better over time no matter what you do. The more sick the starting sample, the more dramatic the effect. This is why some sort of comparison group is so helpful and why before/after studies are weak.
- Small sample size bias. This one can go either way, meaning you can exaggerate an effect or miss one. If you want to run a proper study, find someone who has training in clinical trial design to estimate the size of the effect of your intervention, and thus the size of the sample you need, to show its efficacy. Lots of technical jargon here (power calculations, type I error, type II error, etc.), enough to make your head spin. But bottom line, you can’t really say much about the generalizability of data based on 10 patients.
- Novelty effect. I made that up, and there is probably a more acceptable scientific term for it. But what I’m referring to is, when you take that same group of people that was motivated enough to enroll in a study and apply an intervention to them, the newness will drive adoption for a while. We see this all of the time in our studies at the Center for Connected Health. The novelty always wears off over time. In fact, I’d say the state-of-the-art in understanding the impact of connected health is one of cautious optimism because we haven’t yet done long term studies to show if our interventions have lasting effects over time. There is room for argument here, I guess, but three months is awfully short.
Why is health care tech different than finding the MVP in the rapidly-changing, market-responsive world of mobile tech? One reason may be that we’re dealing with health and sickness which are qualitatively different than sending a friend the latest snapshot from vacation. It is cliché to say it, but lives are at stake. So we’re more careful and more demanding of evidence. Is this holding us up from the changes that need to occur in our broken health care non-system? Possibly.
It is true that a well designed trial with proper sample size is expensive and takes time. Technologies change faster than we can evaluate them.
One thing we’ve done at CCH is design studies that use a large matched data set from our electronic record as a comparator. This speeds things up a bit, eliminating the need to enroll, randomize and follow a control group. Results are acceptable to all but the most extreme purists.
What ideas do you have on this dilemma?