Globally, nearly 28 million wearable devices were sold in the second quarter of 2018 – a 5.5 per cent increase on the previous year – according to the International Data Corporation. That’s $US4.8 billion ($6.7 billion) worth – an 8.3 per cent rise. The IQVIA Institute of Health Data Sciences says there are more than 310,000 health apps now available. The business of keeping well is booming. In October, the Global Wellness Institute reported that the wellness industry, covering everything from spas to apps, was worth $US4.2 trillion in 2017 – a growth of 12.8 per cent over two years which, it says, now represents more than 5 per cent of global output.
Instant genetic information
Diabetes is an area of intense activity in health tech. Between 1980 and 2014 the global population of diabetics nearly tripled to 422 million. For those with type 2 diabetes – the form of the disease that affects 90 per cent of diabetics – which a change of diet can fix the problem. If people can change their food buying behaviour it makes sticking to a healthful diet easier. That’s where entrepreneurs like Professor Chris Toumazou come in.
Not long before I met him, Professor Toumazou wanted a chocolate. “I’m not going to not have a chocolate,” he says. So at the shop counter, he waved his wristband over his two preferred options: a Snickers and a Mars bar.It flashed green on the Snickers. Based on his DNA, it had determined the bar to be the healthier option. (He has the hypertension gene, not the obesity one).
The wristband and analysis are developments from the Imperial College biomedical engineering professor’s company, DnaNudge. The London-based company has developed palm-sized micro-labs which do on-the-spot DNA analysis for key risk factors – including diabetes and hypertension. It also looks for genetic markers that reveal how well substances including carbohydrates, proteins, saturated fat, caffeine and sodium are metabolised. The data is encrypted and uploaded to the user’s app and wristband. They then scan or photograph foods to find out if an item is healthy for them.
The object is to help people gradually change how they shop by being able to quickly tell which food options are best for them. For example, someone with a poor ability to break down fat will be guided away from foods high in fats.
In October, the company announced a year-long trial of the technology with a group of 1000 pre-diabetic customers of British supermarket chain Waitrose who will try to reduce their risk of developing the disease. Toumazou hopes to be rolling the technology out commercially in key global markets, including Australia, by the end of 2019.
There are a number of startups using DNA to direct eating behaviour but large companies are also getting in on the act. Nestle in Japan has a Wellness Ambassador programme. Subscribers to the programme upload pictures of their meals onto photo-sharing app Line, the food image is then analysed for its nutritional content. Users can also submit their DNA to a third party for analysis. On the basis of all this data, Nestle makes tailored diet and recipe recommendations. It also proposes particular supplements or kale and fruit smoothies for use in the Nestle Dolce Gusto machine.
DnaNudge says that when the technology is fully commercialised, the company will have booths in every supermarket where a shopper could swab their cheek and pick up a wristband complete with their genetic information 15 minutes later. The micro-lab cartridge with the DNA sample would be destroyed immediately afterwards. Toumazou is intent on making the technology affordable; he says the hardware will retail for tens of dollars and there will be a small subscription fee for the app – which could branch into monitoring inactivity levels, offering meal plans and building social networks of people with similar conditions.
Toumazou says decades of healthy eating advice has failed to stem a global obesity epidemic. Something needs to disrupt that tide. “It’s got to be very simple so people make small changes, without really affecting their behaviour too much in the short term,” he says.
Chronic condition management
By taking a long-term approach, Australian tech start-up Perx is hoping to crack chronic condition management. According to the Australian Institute of Health and Welfare, half of the Australian adult population has one of eight chronic conditions – arthritis, asthma, back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes and mental health conditions – and 39 per cent of potentially preventable hospitalisations were due to these eight conditions.
Through a cluttered bookshop on Bourke Street, Surry Hills, in Sydney, and up a winding staircase, old high school friends Scott Taylor and Hugo Rourke have set up an office for Perx, an app that encourages people to stick to clinical treatments through gamification. The young co-founders are bright-eyed, wearing matching branded T-shirts, Apple Watches and physiques that suggest participation in amateur rowing or rugby union teams. They sit in their sparse, small meeting room, a blank white board against one wall.
Users of Perx have to upload evidence that they have taken their medication, a photo perhaps. They are then sent a simple game to play which offers the possibility of winning a prize such as movie tickets or a donation to their favourite charity.
The start-up is partnering with the NSW Health Sydney service, Diabetes NSW and ACT and Novartis, among others, which pay a licence fee for the technology; for the end user, the app is free. Data from the users is encrypted and aggreggated and general reports are sent to the participating organisations about the level of the groups’ adherence. They have several thousand users.
Perx began as a side project when Taylor was working in private banking and Rourke was a consultant across a number of consumer industries. Both men had family members struggling to manage different chronic conditions and they realised how few behavioural economics tactics were being used in the health sector. Two years after they started, the team now numbers seven (who are hard at work in a small room adjoining the meeting room) and a further three people are about to join the company.
“It’s pretty rapid growth given that this time last year it was three guys in a room in Bondi,” says Taylor. “We’re super excited about it.”
There is plenty of room to grow since 230,000 hospitalisations a year in Australia are because people fail to take their medications as prescribed. In Europe the problem is the cause of 190,000 avoidable deaths.
“Healthcare has traditionally suffered from top-down direction, not treating the patient as a person who can manage their own care,” says Rourke. “If we can empower people, health will be in a better place.”
The invisible doctor
At the Consumer Electronics Show conference in Las Vegas, run by the Consumer Technology Association, wellness and health technology formed a large part of this year’s new products. There were lots of cutting-edge devices making huge claims: E-vone smart shoes can detect a fall and call an emergency contact; a magnetic attachment for Motorola phones, which can measure respiratory rate, blood pressure, body temperature and blood oxygen levels; a Somnox robot pillow which glows and contracts as the user cuddles it in bed, all the while detecting carbon dioxide, sound and movement.
But in terms of the leading edge, few companies scrape it so closely as Emerald Innovations. It isn’t in the business of wearables, but “invisibles”.
Emerald Innovations, a Boston start-up led by MIT professor and Macarthur “genius” prize winner Professor Dina Katabi, has already put hundreds of its Wi-Fi-like boxes in homes in the United States. The Emerald is able to detect a user’s posture, gait, heart beat and breathing without ever touching them. Without even being in the same room. Katabi says the technology could herald a new era of independence for people with serious conditions or older people, and could transform the way we conduct clinical trials, with pharmaceutical companies able to take continuous readings from trial participants to assess a drug’s efficacy. In a TED talk, Katabi said the device has even been deployed in homes of people with depression and anxiety.
“Every single move that we make – even when we take a breath, or the pulsing of our blood – changes the electromagnetic waves around you,” Katabi tells AFR Weekend. “Our idea is to have a sensitive device that can detect changes in electromagnetic waves, and use the advances in machine learning to interpret those changes so we can refer the physiological signal to the end user.”
The end user may be a clinician monitoring a patient’s condition remotely, an adult child concerned about an elderly parent or a drug company conducting a clinical trial.
Trials in the US for people with Parkinson’s have been able to detect when a patient’s medication has started to wear off by assessing their movement, and has helped doctors adjust doses accordingly. The traditional alternative has been sporadic visits to doctors who assess movement visually within a consultation.
Katabi says that the device use is based on the consent of the person monitored, that they can determine who gets what data. However, she says, just like you don’t have to inform your house guests if you have a baby monitor or security camera, she expects that the user would not have to notify any guests that an Emerald box was in use, despite the fact that it could monitor their vital signs too (though their information won’t be stored).
“Getting information on anyone is getting information that they may consider private,” she says. “But at the same time, you compare it to the alternative. For an older person who lives alone, what are their options? Putting a camera in the home would be way more invasive of privacy – as would asking a carer to live with them. It’s really about trying to find the right trade-off to deliver something that can provide a lot of gain, while managing the privacy issue in the proper way.”
Public health implications
A study published in the Digital Medicine journal, which analysed studies and trials of the efficacy of mobile health apps for things such as managing weight or mental health, found evidence that while some worked, overall the quality of the studies were too poor to reach any conclusions.
Professor Tim Shaw of the Digital Health Co-operative Research Council, which launched this year with $55 million worth of federal government funding, agrees.
“It’s a bit like where pharmacy was in the 1800s. It was totally unregulated. You could buy a drug for just about any condition and it was largely financially driven. At the moment, people are building apps for $3, just as I’m sure you could buy a pill for leprosy for $3 back in the 1800s, and there’s not a lot of evidence as to how that actually impacts on health,” he says. “That’s changing.”
The US Food and Drug Administration has just cleared two Apple Watch medical apps – one that can take an electrocardiogram by the user touching a button on the series 4, and another that can detect signs of atrial fibrillation and warn the wearer. In Britain, the National Health Service has its own apps library, which recommends apps for everything from managing panic attacks to blood clots, and indicates which of these are undergoing NHS testing. Here in Australia, the CSIRO and Therapeutic Goods Administration are looking into how to regulate the emerging medical devices industry.
“As apps become part of how we deliver care – because we are heading towards prescribing apps – we will have a smaller number of evidence-based apps and devices that have impact,” Shaw says.
The Digital Health CRC is investigating how all these data sets being created by personal apps and devices, and in clinical environments, can be utilised to improve individual and public health. The infrastructure supporting this is lacking, says Shaw. “It’s like we have well and truly made it to Mars, but we dragged the rocket to the launch pad with a horse and cart,” he says. “We have these fundamental failures in the underpinnings about how data is connected together.”
This data, when combined with augmented intelligence, could shift the way the healthcare system works. Shaw says that at present, for instance, Sydney’s Royal North Shore Hospital can predict that on the weekend it might have five people show up with a broken leg, four with influenza and 53 heart attacks. “What we can’t predict is who those 53 people are that will have those heart attacks and reach out to them two months before and stop it happening. This is the really interesting piece that AI can contribute to; our predictive ability to make decisions on people’s trajectories.”
It might be, Shaw says, that a patient on a trajectory to a heart attack on the basis of data such as their heart rate, activity levels and other information might pop up on a doctor’s computer. The doctor might then call in their patient to prescribe lifestyle changes and potentially medication that could prevent a catastrophic event.
Meanwhile, for healthy people and those with chronic conditions alike, having access to personal and continuous data about their health and wellbeing will see them more empowered in their relationships with clinicians.
“You’re almost getting the emergence of expert consumers that understand their own data best, and can start to work much more collaboratively with the clinician in terms of what matters to them,” he says.
New roles may be created within medicine, says Shaw. People can manage their lifestyle and chronic conditions largely on their own, when supported by technology. The remote monitoring of these things could mean the creation of a something like a virtual coach, who may co-ordinate different aspects of an individual’s health and wellbeing and call in consultants or doctors when needed.
Dr Harry Nespolon, president of the Royal College of Australian General Practitioners, says the role of the GP will evolve, and become more central. The GP could monitor a thousand patients at once as they upload their data about sugar levels, heart rate and the like, but only need to call in a few for consultations. The lower-value consultations will start to disappear; managed by patients themselves, nurses or even pharmacists.
“It’s exciting,” he says. “It will help patients understand what they’re doing better – whether they do anything about that is going to be their choice.”
Privacy and data
The implications of this personal health data go beyond healthcare. It could change the way some industries do business.
For a few years now, MLC has been offering discounts on life insurance premiums for policy holders who agree to share their steps data with the insurer. In return for demonstrating that they are walking at least 37,500 steps a week for 30 weeks out of 40, the policy holders get a 5 per cent annual discount on their premium; if they don’t meet the target, the premium rises the following year. Just under 5000 people are enrolled in the programme. The data from their Fitbits, Apple Watches or other activity trackers is sent to a third party, encrypted and then the step count alone is passed on to MLC for verification. For the insurer, it’s a way to not only make their customers healthier – and therefore lower risk – but also to build a closer relationship with them.
Last year, MLC’s head of retail, Sean McCormack, broke his sternum in a car accident on the way to Tullamarine Airport in Melbourne. He went from averaging about 15,000 steps a day, to nothing. In the future, McCormack would like the insurance company to notice such a change and make contact. They could say: ‘Hey Sean, we’ve noticed you’re really inactive. Something seems to have happened. Is everything all right? Is there anything we can do to help you?'” And then signpost things such as recovery tools or programmes. “This positive customer engagement I think is the real opportunity for us in the future,” he says.
Technologies such as the in-development contact lens that monitors blood glucose levels or heart-rate monitors are also of interest. It could change the way companies underwrite customers, able to show that while an individual has a chronic condition, it is well managed and therefore a lower risk. “It’s really, really exciting,” he says.
For Dr Lisa Carver, a sociologist at the Queens University in Canada, the scenario put forward by MLC sounds terrifying.
Dr Carver has raised concerns that the multiple sets of health and wellness data that stream into the ether from our devices, phones, apps, watches could be used to create a wellness score report – much like the financial credit reports held on every individual. And just like credit reports, they would be compiled without the participation or notification of individuals, she says, and potentially used to restrict access to various services, such as health insurance (in countries where insurers can charge or refuse policies to individuals who present high risk), or even medical procedures in public health systems.
“These programmes can become gatekeepers,” she says. “Just like credit reports, they may be full of errors.” Carver paints a hypothetical picture of a wine enthusiast, who spends time researching fine wine, enjoying a moderate amount but not drinking beyond limits. Perhaps this person’s data is skewed because they’re wearing their heart rate monitor wrong, or they break their leg and are rendered sedentary. And say that person also ended up requiring a liver transplant in a public health system. “What concerns me is if your app, browser and credit card history linked to wine is added to health data, all of these factors combined could end up with you being told you don’t get a liver transplant because you’re labelled by your ‘health report’ data profile as an alcoholic.
“We’re sitting here like it’s our birthday. We have all these apps we’re opening up and we’re just jumping right in there,” says Carver. “It’s too easy for this technology to just become part of life. They’ll be ingrained so completely that it’ll be impossible for any government to step in and clean it up, because they’ll be so integrated into everything. And that really worries me.”
Greg Williams, lead author of the CSIRO’s Future of Health report, says he is optimistic about the role of technology in supporting individual health and wellbeing, but many things need to be got right. Ensuring equal access to the technology is critical. On privacy, he says: “The funny thing is that none of us have much privacy at all, really. It’s just a matter of how aware of that you are.”
And on that note, my Apple Watch has beeped. It’s time for me to focus on breathing for one minute. I can relax now.