Wearables are fast moving out of the consumer realm and becoming an important clinical tool for health and wellbeing.
Smart wearable health devices, colloquially known as wearables, have become intrinsic in many Australians’ daily lives with a reported 1.2m smart wrist devices sold in the first half of 2019 and are forecast to become the second most sold consumer electronics product in 2020 after smartphones.
Wearables have come a long way from the humble beginnings of the iconic Casio Databank calculator watch from the early 1980s, to the latest Apple Watch, which is many times more powerful than the Cray-2, the most powerful supercomputer of the Databank’s era.
Although wearables are synonymous with smart watches, there is a burgeoning industry of clinical devices that go beyond purely wrist-based devices, potentially offering improved provision of health care via artificial intelligence algorithms and predictive analytics based on real-time metrics of wellbeing and vital signs.
From a connectivity standpoint, smart wearables will benefit from the proliferation of 5G wireless networks that should significantly reduce latency and exponentially faster download and upload speeds when compared with the current 4G networks.
However, the ‘smart’ or digital technology aspect of wearables may be new, especially in the context of clinical applications, but when viewed through a historical lens, wearable technology has been around for centuries. From the invention of eye glasses in the 13th century to the advent of digital hearing aids in the 1980s, we have been wearing innovative health solutions for a long time.
Their success has been based on convenience to the user and a clinical solution to a health need. For nascent wearable devices to reach clinically efficacy, demand needs to be driven from clinicians, and engineers who are focused on the benefit to the end-user.
Medical Forum spoke to people at the forefront of wearable health care design and application in Australia to explore what wearable technology is being developed here and what impact will it have in primary health care.
New world order
Cuff-based systolic blood pressure measurement (BPM) has been one of the staples of medicine for almost a century, thanks to the sphygmomanometer, yet this method of capturing vital signs is rudimentary, uncomfortable and non-continuous. Continuous BPM requires an invasive arterial line inserted into an artery, but this is not practical nor common for non-critical cases.
Finger-based blood pressure monitors can provide continuous BPM but the findings can be variable depending on the movements of the finger and the body, which is a similar limitation of the cuff-based sphygmomanometer.
A device that can produce reliable, non-invasive, continuous beat-to-beat BPM, regardless of body movements, could soon be the new normal thanks to a team of engineers and clinicians in Melbourne that has developed a wireless device that measures real-time BP based on pulse arrival time, pre-ejection period and pulse transit time.
The devices have undergone real-world testing in a clinical trial at Cabrini Hospital, Melbourne, with the published results demonstrating proof-of-concept. Medical Forum spoke with the study’s lead author, Associate Professor Mehmet Yuce, from Monash University.
A/Prof Yuce has garnered a reputation for developing innovative wearable devices, designed for health care applications, over the past decade.
He said clinicians would regularly approach him with ideas for devices that would help them in their day-to-day practice. A recurring theme in these conversations was the need for a non-invasive BPM that could provide real-time readings while not being subject to the variability of body movements. Based on this feedback, Mehmet and colleagues set to work five years ago on a cuff-less BPM.
The resulting small wearable device, which is fixed to the sternum, features world-first technology, the first being a sensor that utilises continuous wave radar to transmit frequencies that penetrate through the chest to measure the blood flow timing from the heart. Another sensor uses bioimpedance, which sends a weak electric current through the chest to extract the pulse wave. The next sensors are placed at different locations on the body and use electrocardiography (ECG) to measure the duration it takes for blood to flow from the heart.
An algorithm then processes the output from the sensors into accurate, real-time blood pressure readings. A unique aspect of these monitors is they can take measurements while a user is actively moving, even exercising for hours at a time, and still provide reliable readings.
A/Prof Yuce envisages the two devices designed by his team will eventually go to market.
He believes they could be particularly beneficial for patients in nursing homes or remote areas, so doctors can wirelessly access their patients’ vital signs from hundreds or thousands of kilometres away. Paramedics could use the device to measure a critical patient’s blood pressure from pick-up to drop-off, sending the measurements to the emergency department in real time.
A/Prof Yuce predicts wearable devices will become commonplace in health care settings, especially with the possibilities of 5G, but not without collaboration between clinicians and engineers, who can co-design and develop practical solutions to real-world problems.
GPs & wearables
The wearables on our wrists may not be ready for critical clinical data capture but they can provide clinicians and patients with useful information such as longitudinal heart rate data, which can be collected from a wrist-based wearable such as an Apple Watch then sent to an app, which a GP can view.
For this type of technological integration to be adopted, the benefits need to be immediately obvious to patients and clinicians alike, from an efficiency and efficacy perspective. However, this type of disruptive technology requires patients, GPs and medical practices to change the architype of primary health care from a face-to-face consultation to an interconnected, data sharing relationship.
The positive outcomes from integrating disruptive technologies in general practice are something that Dr Simon Kos, CEO of Next Practice, is familiar with. Before his role with Next Practice, Dr Kos was the chief medical officer of Microsoft and has worked in digital health for almost two decades.
According to Dr Kos, Next Practice is aiming to improve the patient journey in general practice through digital innovation to enhance, rather than reduce, the patient-centric focus of the medical clinics.
“We’ve really thought about how the patient experience flows through the clinic experience and how aspects of the doctor-patient relationship can then flow back into tools that the patient can take away and use to self-manage aspects of their own care,” he said.
By using a digitally innovative approach, Dr Kos believes that this will break the traditional paradigm of general practice.
“We think a lot of general practices have historically been episodic and we’re trying to create more of a continuum of health information.”
Alongside their general practice management system, Next Practice also has a patient application, all of which has been developed in-house, which will capture aspects of patient data such as cardiovascular metrics from consumer grade wearable devices, such as the Apple Watch, and collate the information so that it can be discussed at the patient’s next GP consultation.
As far as the efficacy of using consumer grade devices in a clinical context, Dr Kos said there had always been some contention, but their proliferation necessitated a change in how the clinician thinks about that data.”
“While two different pedometers might not accurately report the same number of steps, if someone hasn’t walked for the past three days and that person is elderly, that trend level information is absolutely clinically relevant, even if there’s variance between different models.”
“So that’s what we’re thinking about now. Not how we use consumer devices as a replacement for the data we would ordinarily capture from clinical devices, but more, how do you use consumer devices to establish trends of activity between consultations? That’s really important.”
Person-centred design
To ensure a wearable will be beneficial for the end-user, person-centred design is fundamental. As counterintuitive as this may seem, it is not always the case for the design of innovative technologies, according to Dr Leah Heiss, from the Royal Melbourne Institute of Technology and co-director of the RMIT Wearables and Sensing Network.
“Many companies have a technology-first approach that is focused on fast turnaround pitches, investment, and getting products to market very quickly. This does not allow for meaningful engagement with the people who we hope will actually wear our technologies. If we are going to design devices that will change people’s lives, we need to make sure that the devices are integrated into those lives,” she said.
Dr Heiss emphasises that good design is paramount to the functionality and aesthetics, but more important is the cohort for which the device benefits.
“So many resources are committed to the aesthetics of devices to count the steps of healthy people, yet so few are allocated to improving devices for people who are really unwell. The attitude seems to be that if you have a disability, you suddenly have no interest in aesthetics. This is crazy.”
The Conversation as Therapy (CaT) pin is among one of Dr Heiss’s more prominent collaborative wearable design projects, which, at first glance, is a personalised brooch yet inside is a microphone, microprocessor and Bluetooth transceiver. The CaT pin detects loneliness by monitoring ambient sound to identify the presence or absence of speech by counting words over time. If a wearer of a Cat Pin has not spoken for a day, a text message can be sent to a contact to alert them.
According to Dr Heiss, the CaT pin was designed with a fundamental understanding of the end-user and not only their need for the device but their emotional response to the device.
To ensure use-case and end-user applicability, the CaT pin team, co-led by Dr Heiss, was a multidisciplinary collaboration of designers, engineers and Bolton Clarke, a not-for-profit aged care and health care provider.
“I focus on creating wearable health technologies that resonate with us emotionally but also keep us healthy. I call these, ‘emotional’ technologies. Central to creating emotional technologies is engaging deeply with the people who are going to use the device – understanding what they would really like in their lives, and tailoring the technology around that.
“While smart watches are fine, many wearable health technologies such as cardiac Holter technology or falls monitors are created with efficiency and hygiene as paramount concerns, with little regard for how the wearer will feel using it, said Dr Heiss.
“This leads to devices that have little resonance with the emotional experience of users. I am particularly focused on humanising wearable health technologies and this requires that I work in an interdisciplinary way across design, health and technology. At the core of my practice is collaboration and the challenge to create communication between disciplines who do not have a shared language.
“By working laterally across design, health and technology we can start to address the complex needs of people in the healthcare system. A technology-only approach is not sufficient, neither is a design-only approach.”
The clinical application of a device such as the CaT pin may not, at first glance, seem as obvious as a cuff-less blood pressure monitor, yet upon closer inspection social isolation is a key risk factor for an older cohort.
Dr Heiss believes the CaT pin can bring awareness of the health implications from loneliness to clinicians.
“It also requires a mindset shift so that clinicians realise that the work of keeping people well is distributed, rather than isolated, with caregivers. This means that a network of family, friends, neighbours and support workers can help to keep people well, before a situation deteriorates that then needs support from clinicians.”