Smart watches, fitness trackers and the NHS: Are wearables just what the doctor ordered?
Tracking steps, measuring heart rate, counting calories, monitoring sleep: wearables have become part of everyday life for a surprisingly large portion of the UK. According to researcher YouGov, nearly one in five of us own a wearable, and one in 10 actively use them. So could the interest in keeping fit that wearables have inspired, and the data they collect, be something the NHS can use to its advantage?
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Other private healthcare providers around the world have started making use of consumer wearables. In the US, for example, insurer Aetna has subsidised the cost of Apple Watches for customers to "improve healthy outcomes", while in the UK private health insurer Vitality subsidises them for people undertaking a certain amount of exercise. Other health and wellness companies offer reward points or even cash to members who hit certain healthy milestones, such as regular step counts or gym visits.
The idea behind such schemes is that prevention is better than cure: it might cost a few dollars to give customers a new fitness band or smart watch, but if it encourages them to exercise more -- and thus reduces their need for medical treatment in the long term -- then there's a saving for the company and better health for the individual.
But, while the NHS has its own prevention-is-better-than-cure programmes; some doctors can prescribe free gym visits, for example, don't expect the health service to begin offering free fitness trackers any time soon.
"The value equation isn't really there yet," says James Moar, smart devices analyst at Juniper Research. Even the cheapest devices cost at least £10 or £15 per device per consumer, plus you'll need a smartphone; still too much for the NHS to be spending per consumer on something that may or may not pay off in terms of improving health outcomes
"Added onto the cost, there's the question of whether wearables can effectively and reliably drive [health] behaviour change. We're not at the point of saying that's definitely the case yet," he says.
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There are also concerns over accuracy. A recent study found that in some metrics, like heart rate, health trackers tended to be largely accurate, but for other measurements, including calories burned, they were significantly off. While measurements that vary by five percent from the actual reading might be fine for consumers keeping tabs on their workouts, that level of variation is too great for a lot of medical purposes.
Nevertheless, early-adopter NHS trusts are showing interest in wearables' potential: one has even begun to allow people to upload data from their wearables to their patient record.
The CIO of the Salford Royal NHS Foundation Trust, which began piloting wearable data-sharing last year, said data on patients' heart rate, sleep and exercise could be used to help clinicians adjust medication based on a patient's metabolism. That may be overly optimistic, however -- doctors are more likely to adjust medication based on liver and kidney function, as well as any interactions with the other medications a patient is taking -- all of which are beyond the scope of today's wearables.
There are a number of technical challenges ahead before the NHS can get greater numbers of people sharing their wearable data with their medical record, however, including a lack of interoperability between various vendors' devices.
"Unfortunately we have discovered a lack of interoperability with digital health tools such as devices, wearables and integrated apps which need to be addressed," Dr Indra Joshi, clinical lead for NHS England's digital experience programme, wrote in a recent blog post. "What has become clear is that the market has pushed on ahead in creating high cost health IT systems, with little focus on building application programming interfaces (APIs) or allowing smaller digital health players to integrate clinically effective tools into those larger electronic health records and IT systems".
That integration challenge may be particularly difficult with wearables. There are many devices and few standards, so any software the NHS developed would need to connect to multiple ecosystems. In a market driven by fashion as much as tech there's no guarantee which products remain popular in the long term, so it's not immediately clear where NHS developers should focus their attention.
Another problem: the people that buy fitness trackers are typically richer, younger, and interested in maintaining good health -- not the people that necessarily need to be encouraged by the health service to adopt good habits. Using wearables to monitor these people's heart rates or blood pressure is not hugely valuable, as they're more likely to be within the normal range. Gadgets that create volumes of quasi-medical data from healthy people also risks generating a wave of false positives, or incidentalomas as they're known in medical parlance.
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Anyone monitoring their pulse, for example, might find episodes of atrial fibrillation (AF). For some older people, symptomatic chronic AF might put them at risk of a stroke and so needs treatment. A young person detecting a brief episode of irregular pulse following a boatload of coffee after a heavy night out might take themselves to their GP for unnecessary testing -- and worry -- that they wouldn't have otherwise had, thanks to their health tracker.
"You can measure all sorts of things on a continuous basis and remotely, but it's whether it's useful to the clinician or the patient. Just because you can monitor something, doesn't necessarily mean you need to," says Dr Sarah Cook, biomedical policy analyst at health thinktank the PHG Foundation.
The risk is that the 'worried well' will be able to track things that might be medically relevant without a doctor's supervision, which could increase their anxiety. "When you're looking at ECGs, you might panic and think 'I've got a heart attack and might drop dead in the next few minutes'. That puts increased pressure on the health service," she says.
For Juniper Research's Moar this means wearables makers will need to explain how the data they generate can be translated for the healthcare professional, and there will need to be more training for the doctors who will end up interacting with the data from these devices. "Both of those aren't really there yet," he warns.
That's not to say that the data from wearables might not still have its uses for the health service. Even the fittest and healthiest among us will eventually get old and ill, and the data from wearables can be useful showing when there are changes to a person's baseline health: a doctor seeing a patient who has had the same blood pressure for years won't be called for further tests; a patient who has a blood pressure that has suddenly gone up or down may well need further investigation.
And, taken in aggregate, data from wearables could eventually help further research into the impact of general lifestyle factors, such as exercise, sleep, or diet, on the general health of the population. The usefulness of such correlations will likely be small for now due to the self-selecting nature of those who use fitness tracking, and so any results couldn't be extrapolated out to the wider population at large. It won't be until the penetration of such devices reached the same levels as smartphones that it could potentially be used to analyse the population as a whole.
Nonetheless, there are signs the NHS is investigating how to better address the wearables users that are already out there. The health service is already laying the foundation for greater use of wearable tech: it's making overtures to developers under its Health Developer Network and has a beta apps library.
Despite this, there are no indications that the NHS will be building dedicated software for wearables any time soon. The NHS Health Check site, for example, has a page dedicated to health and fitness trackers, but the health apps it suggests are aimed at mobile devices, or simply websites. "These [wearable] gadgets, which come in the form of wristbands, watches and earphones, can be a good option if you need a nudge and want information about your wellbeing -- but they do come at a cost," it says.
A more targeted use of wearables is likely to prove much more fertile ground for the NHS. Back in 2015, for example, health software company EMIS gave a patient in Leeds an iPhone-connected blood pressure cuff to show how her high blood pressure was down to 'white coat syndrome' rather than medical reasons. While that's a relatively unsophisticated use of the technology, the information was valuable in directing the patient's healthcare and in saving the patient visits to the doctor -- good for the patient, and freeing up appointments within the NHS.
It also shows the direction of travel for NHS and wearables: using devices to help monitor long term conditions, and increase patients' ability to self-manage such conditions.
"One of the benefits is that if patients want to be more involved in their health, there's an aspect of patient empowerment to it -- people can feel more in control. You don't want to be making everyone manage their conditions that way, because you would leave some people in the lurch, but it could be seen as beneficial to have more patient choice," the PHG Foundation's Cook says.
Early pilots are ongoing. In late 2017, as part of the NHS Diabetes Prevention Programme, a pilot was launched to give diabetics extra support in monitoring their condition and controlling their condition through digital services, including online group support and health-coach apps, as well as exercise tracking wristbands. The 12-month long trial was aimed at discovering whether such support would help deter the onset of diabetes in people with 'pre-diabetes' -- those whose level of blood sugar suggested they might develop the condition unless they moved to a healthier lifestyle.
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While such trials involve off-the-shelf fitness trackers, the real benefits of wearables are likely to come from the next generation of devices designed specifically for a particular condition. The NHS is already funding wearable glucose monitors for diabetics. Instead of having to check their blood sugar levels by drawing a drop of blood from their finger and checking it on a glucose strip, the wearable monitor gives diabetics a real-time insight into their blood glucose level, helping them avoid episodes of hypoglycaemia, which can land them in the hospital, or hyperglycaemia, which can damage their blood vessels over the long term.
Medical device companies are already working on more highly targeted medical wearables: for example, MC10 has made wearable patches that can be used to monitor heart rate and muscle activity, as well as patches that measure UV-A and UV-B exposure, while Omron Healthcare has built a wrist-worn blood pressure monitor. There's also a watch device called Embrace, made by startup Empatica, can be used to monitor epilepsy sufferers for electrical activity in the skin that indicates a seizure and alert the epileptic's caregivers.
The current generation of wearable health hardware is best characterised as monitoring devices. Devices that simply take readings are far easier to gain regulatory approval for, whereas devices that offer any kind of treatment are subject to far greater scrutiny from watchdogs -- which is why commercial companies are focusing on the former.
Take the difference between wearable glucose monitors and 'artificial pancreases' for example. Wearable glucose monitors simply record the diabetic's blood sugar level, letting them know if it's high or low; the actual administration of insulin is down to the person wearing the device, not their hardware.
Artificial pancreases, which both measure glucose levels and administer insulin directly as needed, are gradually coming onto the market. However, they'll take longer to get the necessary approvals, and so won't be available through the NHS for some considerable time.
Part of what's holding back the greater use of medical wearables is that the tech companies don't really understand how the medical space works yet, says Moar. "You're seeing very few with a background in medical devices or medical systems, and that's a stumbling block because they're not used to how medical procurement works, and the regulation."
The NHS may not be a particular focus either, he says, compared to markets like the US or Singapore, where there are many health insurers and a variety of different systems, which means gadget makers can shop around until they find the one that best fits their business model.
Still, sooner or later, wearables will be something that the NHS has to reckon with, and certainly the medical-grade wearables offer clear, measurable ways to improve users' health, allowing them to manage their conditions more themselves. Just what the doctor ordered.
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