Part 2: Health apps, wearables, and sensors: The advancing frontier of digital health

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With the increasing proliferation and sophistication of mobile phones, wearable devices such as smart watches, and sensors that can measure and gather a variety of data, public interest is growing in using consumer electronics to take ownership of personal health and wellness. A 2015 survey found that 66% of Americans age 66 and older want to use mobile technologies to improve their health by receiving medication reminders and tracking diet and nutrition, physical activity, and symptoms.[1


Health apps and wearables
Health apps and wearables can unobtrusively gauge physiological and emotional states and collect, quantify, and monitor data regarding a user’s day-to-day behaviors. This “quantified self” can increase users’ self-awareness regarding their behavior and encourage positive changes to their overall health and well-being.[2] These commercially available devices also integrate an array of features to provide motivation through reward systems, opportunities for social in-teraction, tools for self-improvement, and prompts. The novelty, affordability, practicality, and ease of use have resulted in increased consumer enthusiasm and the pervasiveness of these devices.[3,4] With this growing interest in personal health, members of the general public are becoming more involved in monitoring and improving their own health habits.[5-10

Undoubtedly, merely tracking data through a device is not enough to maintain good health-related behaviors long-term, and the software must also incorporate motivational constructs important for the adoption and habituation of behaviors. For instance, a systematic review of studies that considered the use of electronic activity monitor systems found short-term changes in physical activity with self-monitoring, but no demonstration of superiority when the systems were compared with other interventions.[11] Another review of studies on the viability of using mobile technology for measuring and influencing physical activity found that most apps allow users to document their activity, set goals, review real-time feedback, connect to a social support network, and access online expertise.[12] However, less common among these apps were prompts to act and opportunities for problem solving and action planning, which are crucial constructs that translate intention into long-term behavior change.[13]

Sensor technologies
Sensor technologies have begun to enter the telehealth landscape and are primarily focused on continuous monitoring and precise diagnostics to inform management of various health conditions and diseases.[14-17] Sensors can be integrated into a watch or arm band or adhesive bandages and clothing, and then programmed to collect data on cardiac rhythm, heart rate, blood pressure, respiration, oxygen saturation, galvanic skin response, glucose levels, body temperature, body motions, ambient temperature, and global positioning. For health care providers, sensor inputs can permit remote monitoring, real-time teleconferencing, and timely care for patients with chronic diseases. For both patients and clinicians, telehealth supported by sensors can have profound implications. Clinicians can provide timely and patient-centred care to those living at a distance with chronic disease and can coordinate care when multiple providers are involved, reducing costs to the health care system.

A current clinical example is the management of paroxysmal atrial fibrillation with a mobile ECG and app that monitors the patient’s electrical rhythm to detect frequency and patterns of arrhythmias, and may even allow patients to share ultrasound and electrocardiogram data with their health care provider.[18-20] Telemonitoring with sensors can also support self-management of chronic diseases and detect early signs of deterioration in health requiring immediate treatment and advice.[21] Studies to date have demonstrated some clinical promise for the use of home telemonitoring in the context of heart failure and diabetes. A recent Cochrane review found that telemonitoring was an effective way to lower levels of glycated hemoglobin and low-density lipoprotein.[22] Although several studies on heart failure have produced conflicting results regarding the overall benefits of home monitoring,[23-26] systematic reviews have suggested that home telemonitoring reduces all-cause mortality and hospitalizations, and improves quality of life compared with usual care.[22,27] In addition, features such as automated and mobile telemonitoring appear to be more effective compared with other forms of home telemonitoring.[27]

Further studies are needed to determine how home health monitoring can improve patient safety during the transition from acute care to community care, and to examine the impact of home monitoring on health care costs. TEC4Home (Telehealth for Emergency-Community Continuity of Care Connectivity via Home Tele-monitoring), an initiative of the University of British Columbia and Vancouver Coastal Health, is seeking to do this with prospective trials designed to uncover how telemonitoring can support the safety of heart failure patients discharged from hospital to home.[28]

Mobile apps, wearables, and sensors in the clinical setting
Even though mobile apps, wearables, and sensor technologies are promising, further research is needed to validate their use and long-term impact.[29] This research will require the collaboration of clinicians, health researchers, engineers, and computer scientists.[30] Understanding the possible risks of using these technologies, from physiological harm to breaching of privacy and confidentiality with insecure devices, and how to mitigate any risks is also important. Other important issues to consider include patient anxiety with overuse of technologies, health data piracy, self-diagnosis resulting from overreliance on self-monitoring, and patients not seeking help appropriately. These technologies should be used only as complementary tools in the treatment and prevention of health conditions and disease and should not be used in isolation by patients who self-diagnose and self-manage without consulting a health professional. 

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Instant Heart Rate by Azumio.[31] A free app downloadable to both Apple and Android operating systems that measures heart rate and displays a monitoring strip. As well as helping users accurately track their heart rates, the app is capable of detecting irregular rhythms when palpitations occur. 

Sleep Time by Azumio.[32] A free app that monitors sleep patterns, sleep efficiency, and also acts as an alarm clock. Users can know how often they go into light and deep sleep, and recognize how much of these types of sleep will be necessary for them to feel rested, thereby quantifying the amount of true sleep they need and not just how long they should stay in bed. 

Bellybio Interactive Breating by RelaxLine.[33] A free app that helps users pace their breathing to achieve calmness. Placing the mobile phone against the abdomen, users can follow the sounds emitted to practise deep, abdominal breathing using this simple yet surprisingly effective tool. 

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Discernment to determine whether a particular app, wearable, or sensor can be effective.
Expertise and experience to guide patients on the use of technology.
Partnership with patients in pursuit of optimal health through technology use.
Trials to closely monitor benefits and drawbacks.
Humility to recognize that patients may know and invest much more time than physicians in looking for these tools.34

Based on today’s rapid pace of development and public enthusiasm for the technology marketplace, health apps, wearables, and sensors will soon become integral to our patients’ pursuits of good health and will need to be integrated in clinical practice. Physicians must be active agents in these evolutionary times, guiding patients, advocating for evidence to support the use of technologies, and participating in the development and incorporation of technology in patient wellness journeys. Through clinical stewardship and partnership with patients, physicians can use their expertise and experience to guide the growth of innovations into mainstream health care.

Competing interests
Dr Ho receives no personal financial compensation as the principal investigator of TEC4Home (Telehealth for Emergency-Community Continuity of Care Connectivity via Home Tele-monitoring), a project funded by a Canadian Institutes of Health Research grant. This grant is matched by the Michael Smith Foundation for Health Research and the BC Ministry of Health, with additional support provided by TELUS Health and Sentrian. TELUS Health, Cisco, and Avizia have also provided equipment for display in Dr Ho’s Demonstration and Simulation Studio for Health (DaSSH) at UBC. Mr Yao and Dr Lauscher have no competing interests to declare.

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1. Cision PR Newswire. Fifth annual Pulse of Online Health survey finds 66% of Americans eager to leverage digital tools to manage personal health. Posted 24 February 2015. Accessed 28 August 2017.

2. Swan M. Emerging patient-driven health care models: An examination of health social networks, consumer personalized medicine and quantified self-tracking. Int J Environ Res Public Health 2009;6:492-525.

3. Gao Y, Li H, Luo Y. An empirical study of wearable technology acceptance in healthcare. Ind Manag Data Syst 2010;115:1704-1723.

4. Kim KJ, Shin DH. An acceptance model for smart watches: Implications for the adoption of future wearable technology. Internet Res 2015;25:527-541.

5. West JH, Hall PC, Hanson CL, et al. There’s an app for that: Content analysis of paid health and fitness apps. J Med Internet Res 2012;14:e72.

6. Abroms LC, Padmanabhan N, Thaweethai L, Phillips T. iPhone apps for smoking cessation: A content analysis. Am J Prev Med 2011;40:279-285.

7. Cowan LT, Van Wagenen SA, Brown BA, et al. Apps of steel: Are exercise apps providing consumers with realistic expectations? A content analysis of exercise apps for presence of behavior change theory. Health Educ Behav 2013;40:133-139.

8. Azar KM, Lesser LI, Laing BY, et al. Mobile applications for weight management. Am J Prev Med 2013;45:583-589.

9. Breland JY, Yeh VM, Yu J. Adherence to evidence-based guidelines among diabetes self-management apps. Transl Behav Med 2013;3:277-286.

10. Lyons EJ, Lewis ZH, Mayrsohn BG, Rowland JL. Behavior change techniques implemented in electronic lifestyle activity monitors: A systematic content analysis. J Med Internet Res 2014;16:e192.

11. Lewis ZH, Lyons EJ, Jarvis JM, Baillargeon J. Using an electronic activity monitor system as an intervention modality: A systematic review. BMC Public Health 2015;15:585.

12. Bort-Roig J, Gilson ND, Puig-Ribera A, et al. Measuring and influencing physical activity with smartphone technology: A systematic review. Sports Med 2014;44:671-686.

13. Rhodes RE, Yao CA. Models accounting for intention-behavior discordance in the physical activity domain: A user’s guide, content overview, and review of current evidence. Int J Behav Nutr Phys Act 2015;12:1-14.

14. Chen M, Gonzalez S, Vasilakos A, et al. Body area networks: A survey. Mob Networks Appl 2011;16:171-193.

15. Appelboom G, Camacho E, Abraham ME, et al. Smart wearable body sensors for patient self-assessment and monitoring. Arch Public Health 2014;72:28.

16. Chan M, Estève D, Fourniols JY, et al. Smart wearable systems: Current status and future challenges. Artif Intell Med 2012;56:137-156.

17. Alemdar H, Ersoy C. Wireless sensor networks for healthcare: A survey. Comput Networks 2010;54:2688-2710.

18. Haberman ZC, Jahn RT, Bose R, et al. Wireless smartphone ECG enables large-scale screening in diverse populations. J Cardiovasc Electrophysiol 2015;26:520-526.

19. Ferdman DJ, Liberman L, Silver ES. A smartphone application to diagnose the mechanism of pediatric supraventricular tachycardia. Pediatr Cardiol 2015;36:1452-1457.

20. Baquero GA, Banchs JE, Ahmed S, et al. Surface 12 lead electrocardiogram recordings using smart phone technology. J Electrocardiol 2015;48:1-7.

21. Wootton R. Twenty years of telemedicine in chronic disease management—An evidence synthesis. J Telemed Telecare 2012;18:211-220.

22. Flodgren G, Rachas A, Farmer A, et al. Interactive telemedicine: Effects on professional practice and health care outcomes. Cochrane Database System Rev 2015;(9):CD002098.

23. Mortara A, Pinna GD, Johnson P, et al. Home telemonitoring in heart failure patients: The HHH study (Home or Hospital in Heart Failure). Eur J Heart Fail 2009;11:312-318.

24. Dar O, Riley J, Chapman C, et al. A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: Results of the Home-HF study. Eur J Heart Fail 2009;11:319-325.

25. Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring in patients with heart failure. N Engl J Med 2010;363:2301-2309.

26. Koehler F, Winkler S, Schieber M, et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: The Telemedical Interventional Monitoring in Heart Failure study. Circulation 2011;123:1873-1880.

27. Kitsiou S, Pare G, Jaana M. Effects of home telemonitoring interventions on patients with chronic heart failure: An overview of systematic reviews. J Med Internet Res 2015;17:e63.

28. TEC4Home Healthcare Innovation Community. Supporting heart failure patient transitions from acute to community care with home telemonitoring technology: A protocol for a provincial randomized controlled trial (TEC4Home). JMIR Res Protoc 2016;5:e198. 

29. Yao C, Ho K. Mobile sensors and wearable technologies. In: Amelung VE, Stein V, Goodwin N, et al., editors. Handbook integrated care. Cham, Switzerland: Springer; 2017.

30. Ho K, Borycki E, Kushniruk A, et al. The health perspective in using digital media for health and wellness. Presented at the IEEE International Digital Media Industry Forum, Boston, MA, 4-6 July 2016.

31. Azumio Inc. Instant heart rate. Accessed 28 August 2017. 

32. Azumio Inc. Sleep time. Accessed 28 August 2017. 

33. RelaxLine. BellyBio. Accessed 28 August 2017.

34. Ho K. How health information technologies are enhancing health of patients and their doctors. Presentation at the Alberta Medical Association 2015 Spring Representatives Forum, Edmonton, AB, 13 March 2015.

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Kendall Ho, MD, FRCPC, Christopher Yao, MSc, Helen Novak Lauscher, PhD. Part 2: Health apps, wearables, and sensors: The advancing frontier of digital health. BCMJ, Vol. 59, No. 10, December, 2017, Page(s) 503-506 - Clinical Articles.

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