The workshop opened with an overview presentation by Ted Vickey, founder and president of FitWell, Inc. He began his talk by recounting how his passion for digital health was born out of his experience as the executive director of the White House Athletic Center charged with helping to manage the health and fitness of the President and his staff. During this assignment, White House staff repeatedly requested that he travel with the President, but his answer was always that he could not because he needed to stay in Washington to help the entire staff, not just those who traveled with the President. “I needed to find a way to eliminate the four physical walls of our fitness center and to become virtual,” Vickey explained. As his physical fitness consulting business grew, other clients approached him about managing distance facilities and this increased his interest in and passion for digital health tools.
Turning to the subject at hand, Vickey asked the following question: “Can consumer-facing digital health technology really help people live healthier lives?” Before answering this question, he noted the number of workshop attendees whom, like him, were wearing activity-tracking devices and commented that certain people fear using this technology. He also remarked that “this area is so new and in flux that here is a great opportunity and an even greater potential to leverage this technology to help people lead healthier lives.”
1 This section is based on the presentation by Ted Vickey, founder and president of FitWell, Inc., and the statements are not endorsed or verified by the IOM.
Vickey pointed out that academic research suggests that there are more than 200 definitions for consumer-facing digital health technology, including eHealth and mHealth, gamification of health, and big data. He considers consumer-facing digital health technology to focus on applications (apps), wearables, and websites. He discussed some examples, starting with Fooducate, an app that enables a smartphone user to scan a food product’s barcode while shopping and to receive a health score for that item. This app can be useful for providing teachable moments that can lead to purchasing decisions when parents are shopping with their children. A fitness tracking app called Runkeeper, which he used as part of his Ph.D. research project, tracks time and distance for a run and enables the user to share these data with his or her social network. A similar app from Nike connects to Facebook and enables friends and family to remotely cheer and even provide voice encouragement to runners as they make progress.
Recently, Vickey began using the iHeadache app to track his migraine headaches, including symptoms and preceding events that may have triggered the migraine. “What I was able to do with this app was then go in and have a more educated discussion with my physician about the headaches,” explained Vickey.
One wearable device that he highlighted is a tattoo that sticks to the upper arm and monitors glucose levels in real time for diabetic individuals. Another device, from a company called Fitlinxx, is a heart monitor that resembles a Band-Aid and is meant to replace a bulkier chest-strap heart rate monitor. This device, which is placed over the heart, transmits heart rate both to a mobile phone app and to exercise equipment so that the user can monitor his or her heart rate while exercising. Vickey also mentioned the recently released Apple Watch as being part fitness device, but pointed out that its $350 price point is one that many people will be unable to afford and that its complexity may be beyond the abilities of some potential users. “What can we do to help them?” he asked.
Informational websites such as WebMD and Doctor Google, as well as government websites, are becoming an important avenue for patients to get health-related information, Vickey said. Health-related websites include PatientsLikeMe, which provides a means for patients to share real-world health experiences and to help similar users to connect with organizations that focus on specific health conditions. “If I had a rare disease and lived in San Diego and there were others in Boston with similar symptoms, I could now have this interface for connecting,” said Vickey. “I realize that some physicians, some health groups may be nervous about what this does to the quality of health care, but it’s happening. So how can we be part of that solution?”
Vickey then quoted Unity Stoakes, co-founder of StartUp Health, to illustrate one of the paradoxes of consumer-facing technology. “Digital
health innovation takes longer than you think and happens faster than you think at the same exact time,” said Stoakes. His organization is aiming to address this paradox by helping 1,000 health start-ups to reimagine and transform health care over the next decade based on the belief that entrepreneurs have the collective power to build the future of health care. Vickey also noted that other start-up incubators across the country and around the world are coming together and trying to figure out how to create a better approach to health care.
Sharing some statistics about smartphone use, Vickey noted that smartphone users keep their device within arm’s reach 91 percent of the time, a transformation he considers remarkable given that the iPhone was first released in 2007. “What I find interesting now is that the computing power in the smartphones that we all have is more powerful than the computer used to put a man on the moon,” he said, “so can we use that technology to move our agenda forward?” He also noted that many more people now use fitness apps than belong to health clubs, a worrisome trend for the health and fitness industry. Even more alarming to that industry is the fact that 73 percent of app users say they are healthier today because of those apps. Other statistics Vickey cited included
- Sixty-nine percent of mobile health users think that tracking their health and fitness on their smartphone is more important than using it for social networking or online shopping;
- Forty-six percent say that tracking has changed their overall approach to maintaining their own health or the health of another, suggesting that people are now using smartphone apps to manage the care of family members;
- Forty percent of people who use tracking devices say that doing so has led them to ask a health professional new questions or to get a second opinion; and
- Thirty-four percent say that it has affected a decision about how to treat an illness or a condition.
“These stats are impressive, and the technology is persuasive, but how can we make the connection and leverage these advancements in technology to impact chronic disease and to improve health? Because the world suggests a different story,” Vickey said.
That different story starts with the fact that obesity levels continue to rise across the country, as does the prevalence of diabetes (see Figure 2-1). An increasing number of Americans with chronic diseases now account for 84 percent of the nation’s health care dollars and 99 percent of Medicare spending (Anderson, 2010), with projections suggesting that this situation is likely to worsen. Nearly half of the U.S. population suffers from one or
NOTE: BMI = body mass index.
SOURCE: Centers for Disease Control and Prevention’s Division of Diabetes Translation. National Diabetes Surveillance System. http://www.cdc.gov/diabetes/statistics (accessed March 24, 2015). Vickey presentation, March 24, 2015.
more chronic diseases, and by 2020 the number of Americans suffering from multiple chronic diseases is expected to rise significantly (Bodenheimer et al., 2009), Vickey noted.
The other aspect of this different story is that while users report loving apps, health care professionals are still hesitant about using the data those apps generate. A recent survey, for example, found that 16 percent of health care providers are using mobile health apps in their own practices with their patients, and half of the health care providers surveyed expect to use these types of devices in their practice within the next 5 years. “So while the health care providers are well aware of the benefits, most are still reluctant to jump in, which begs the question of why,” said Vickey. Consumers, he said, report that they are using these apps and devices to track their health goals, become aware of health issues, and become motivated. Regarding this last point, he said a major reason why people hire a personal trainer is for motivation and accountability. He also mentioned that he has a scale at home that not only reports his weight via the Internet to his physician via his electronic health record (EHR), but it also Tweets his weight to his
followers, which makes him accountable to a large group of people. “That’s where we can leverage this technology,” he said.
The Pew Mobile Health Report (Fox and Duggan, 2012) suggests there are many different groups that use smartphones to gather health information, particularly Latinos and African Americans ages 18 to 49, and those with college degrees. To be specific, though, Vickey spoke about his father as someone who has a smartphone and could benefit from the health information it could collect, yet has trouble typing on his smartphone and loses connection to the Internet when he leaves his house. “Is there a way that we can help him manage his high blood pressure and the medications he takes?” asked Vickey. “I think the answer is yes.” To illustrate that point, he recounted an experience he had in the Bronx, the poorest U.S. congressional district, when he was speaking with a nutritionist about what she was doing with the community to improve eating habits there. Given the widespread use of smartphones by people living in that community, he expected that she would teach residents to use the smartphone as a readily available means of keeping a food journal. That would be too complicated, she said, so Vickey suggested having her clients use their phones’ camera function to create a picture album of the foods they were preparing and eating. That idea appealed to the nutritionist and is being tested.
Investments in consumer-facing health information technologies continues to rise, he then noted, increasing from $1 billion in 2011 to $4.6 billion in 2014. UnderArmour, for example, just acquired makers of two of the more popular mobile fitness apps: MyFitnessPal for $450 million and Endomondo for another $85 million. These two apps combined have a user base of 120 million people, compared to the fitness industry with 58 million health club members. They provide examples of how the convergence of technology and health care is helping to change how consumers get health care information and use it to change their behaviors. Four out of five Americans now own a smartphone and are using it more and more on a daily basis, said Vickey. Moreover, smartphone users are becoming more technically savvy, particularly seniors who want to use technology to access information about their health care. For example, more than two-thirds of seniors prefer to use self-care technology to independently manage their health, and more than 60 percent are willing to wear a health-monitoring device to track vital signs, such as heart rate and blood pressure. Sixty percent of seniors are somewhat or very likely to turn to online communities for health information, and one-quarter of them now regularly use their smartphones for managing their health, a figure that is expected to grow to 42 percent over the next 5 years as the number, variety, and utility of consumer-facing tools increases, Vickey said.
Researchers from the Pew Research Center have talked about peer-to-peer health care, when the Internet is giving patients and caregivers access
to both information and each other, creating a forum of sorts where patients can talk about their ailments and treatments. Vickey believes the clear intentions of Apple, Google, and Microsoft to move into the digital health space is a good thing, though not everyone agrees with this sentiment. Apple, for example, has released a research kit that allows researchers to collect information easily and even recruit people for clinical trials. He said that within a day of announcing that there was a Parkinson’s disease research kit, some 10,000 people applied to be part of a clinical trial. “How many researchers would love to have that sample set of 10,000 people?” asked Vickey.
Development of these kinds of tools presents challenges. Privacy and data ownership are two issues that need to be addressed. For example, Vickey conducted a research project in which he collected more than 7 million Tweets in which people shared their running workout routines for more than 1 year. From some of these Tweets he could find out a person’s routine, the distance run, time and heart rate, and any music listened to during exercise. He could also identify an individual’s running routes and the time of day that person ran, which may not be ideal information to share. “We need to help educate developers and users about what is being shared,” said Vickey. Another challenge arises from a lack of standards. Last year, he noted, the IOM issued a discussion paper on designing health literate mobile apps (Broderick et al., 2014).
The London School of Economics has created an app called Mappiness that occasionally asks smartphone users how happy they are feeling and where they are at a particular moment, which enables the developers to monitor in real time how people across the United Kingdom are feeling. Mappiness, then, is a tool for monitoring one aspect of well-being on a national level, and it enables a new sort of measurement that was not possible before. As management expert Peter Drucker said, “You can’t manage what you can’t measure.”
Vickey then presented additional examples of what could be considered boundary-pushing consumer-facing technology. GoBe is a combination wrist-worn sensor and a smartphone app that measures, through the skin, calorie intake, nutritional intake, and calories burned. Whether this claim is accurate or not (Vickey said he believes it is not), this wearable’s developers raised $1 million through the crowdfunding site Indiegogo because as Vickey put it, people want this type of technology to work.
Another smartphone app called PlushCare enables “face-to-face” appointments with a physician—but only in California because current law does not allow a physician in one state to treat patients in another state. The U.S. Food and Drug Administration (FDA) and Congress are aware of this issue and are working on a solution, Vickey said. “But sometimes, innovation in digital health is faster than what we are used to and the regulatory path is still a little confusing.”
Concluding his remarks, Vickey called digital health a most interesting space for health literacy. “This area of technology is rapidly growing and changing, but there remain problems with access and equity. There seems to be real potential here to make a difference in the lives of people, lots and lots of people, so that they can live healthier lives, but this technology still remains unproven and the lack of scientific proof puts sustained growth of this consumer-facing health technology at some sort of risk. People will ask if this is just another fad,” Vickey said, adding that he hoped this workshop would start a discussion about how health literacy can help create sustained behavior change in people’s lives through these technologies.
During the brief discussion period following this presentation, Bernard Rosof asked Vickey what he thought consumer-facing technology would look like over the next 10 to 15 years and what effects it will have on health, chronic disease, and improvement of health in general. Vickey responded that he believes the field is at a great place today. “I’ve been in the health and fitness industry for 20 years, and I’ve never been as excited as I am today about the potential of where we’re going,” he said. Apps, wearables, and websites are getting easier to use, which is a positive, but he fears that without good science behind them, they will not enable behavior change. “That’s why I think the next step is coming together, creating a set of standards, and creating opportunities to bring Apple, Google, and Microsoft to the table so they can be part of the solution,” he said.
Michael Paasche-Orlow, associate professor of medicine at the Boston University School of Medicine, voiced his concern that these technologies will drive an increase in disparities because the most avid users are the “wealthy, worried, and well,” as he put it. He asked Vickey if had any ideas on how to address this situation. Vickey agreed that this was indeed a problem and one of his main concerns as well. “The people that need the technology may not be using the technology because they can’t afford it.” However, tracker devices, for example, are now available for less than $20, and it may be possible to capitalize on the fact that smartphone use seems to span all socioeconomic levels so they can be used as health-monitoring devices. Rosof commented that while the literature supports the notion that smartphones are becoming ubiquitous in American society, the issue may be one of health literacy and the transfer of appropriate information rather than whether someone can acquire a smartphone. Terry Davis, professor of medicine and pediatrics at the Louisiana State University Health Sciences Center, added that in her research with new mothers coming into a very low-income clinic, all of the women had smartphones and all had downloaded an app for pregnant mothers that provided a wealth of information
on what they should do during pregnancy to have a healthy baby. Her concern, though, was that many of these women had low literacy, and she wondered if they were able to use the information in those apps.
Laurie Francis, senior director of clinical operations and quality at the Oregon Primary Care Association, agreed that the problem was not so much about the affordability of a smartphone, but the fact that apps need to speak to where people are in their lives rather than where they need to be with regard to their health. “Controlling A1C when you’re working three jobs or trying to get shoes for your kids or living on the street is not your top priority,” she said. “So how do we build apps that are respectful and connecting?” Regarding the latter, she wondered if apps can eliminate the provider team from the behavior change equation given that the behavior change needed to overcome many chronic diseases often has little to do with the physician or care team. “We always turn to the doctor to help us with chronic care, which is often not generated by a lack of medical care, but a history of many challenges,” said Francis. Vickey noted that consumer-facing technology can play an important role without the involvement of the physician and that it can also help connect individuals with others who can help them, such as the nutritionist, personal trainer, mental health specialist, and other members of a wellness team. The key to realizing this potential, he added, is to involve the user in these discussions. “We need to understand what they want and how they want it and bring them to the table and say ‘help us design these apps and these wearable devices,’” he said.
Jennifer Dillaha, medical director for immunizations and medical advisor for health literacy and communication at the Arkansas Department of Health, noted that this presentation helped her think of a connection that might offer a way to help overcome learned helplessness, which often plagues those with chronic illnesses who seem unable to make the necessary changes to improve their health (Seligman, 2012). “When you were talking it made me wonder if some of these apps could be used in such a way as to help people who don’t believe they can have control or make a change to overcome that sense of learned helplessness and manage their current conditions,” she said. Vickey agreed that apps could help with that aspect of managing chronic disease, but his main concern is that there are tens of thousands of apps and no good way for the average person to pick those that provide good information. “People can create apps and then can claim to be health experts or health literacy experts, but they may not be,” said Vickey. He hopes that someday there will be a stamp of approval for apps as well as a means to measure the effectiveness of apps at changing health behavior.
Rosof remarked that this last comment seemed to be a call for standardization, and Vickey said it was. “This is the new version of snake
oil salesman, and we need to have those standards,” he noted. The question is who will create the standards, and he wondered if the roundtable could play a role by creating the momentum needed to bring together the appropriate stakeholders to establish standards. Workshop participant Robert Logan, communications research scientist at the National Library of Medicine (NLM), commented that in his role as a federal official, standards mean FDA. “Do you really want FDA to take charge of this? What about having the industry itself take charge of this?” he asked. He said he doubted that the broadcast industry, if it had to do it all over again, would have asked the government to create the Federal Communications Commission to end the confusion that reigned over airwave rights, and he implored this community to think hard before asking a federal agency to get involved in creating standards.
Christopher Dezii, director of Healthcare Quality and Performance Measures at Bristol-Myers Squibb, wondered if the field should start working on interoperability with respect to the feedback that consumer-facing technology can provide to physicians. Vickey agreed and said there needs to be a discussion about how to create interoperability that does not dictate actions, but rather provides feedback and advice. “I was reading an article a couple of months ago that said these technologies won’t work until they tell us what to do, and I don’t think I want a technology to tell me what to do,” he said.
Winston Wong, medical director for community benefit disparities improvement and quality initiatives at Kaiser Permanente, asked if consumer-facing health technology can facilitate public health, citing the recent outbreak of measles as a public health failure and wondering if an app or other health technology could facilitate the advancement of public health in a health literate manner. Vickey responded that software is already being used to track influenza outbreaks by monitoring Twitter posts in which people tweet about their symptoms. “This technology is opening up with so many new ways of looking at things that we may not have done before,” said Vickey. “I go back to the Mappiness example that sends out push notifications to find out where people are and how they feel. Can we do the same thing when it comes to health? I think we can, and while we don’t have all the answers now, I think by having organizations such as the IOM and others bring together all of the stakeholders to the table to find consensus, that we can find a way to do that.”
Rosof added that he is working on a program with the American College of Physicians (ACP) called I Raise the Rates that aims to increase the rates of immunization. “I think that it requires more than an iPhone or something digital, it requires an education process around that,” he said, adding that champions, in addition to social media, are needed to encourage public education about these issues.
Michael Villaire, chief executive officer of the Institute for Healthcare Advancement, worries that these devices and apps might be disempowering in the long run, citing the food score app that Vickey described in his talk. “That’s a great tool, but when it replaces our own ability to look at food and make a choice, is that a good thing?” What happens, he said, when a person is in the grocery store without his or her smartphone and cannot access food information? “How are we able to make those decisions if we’ve been relying on the app to make those decisions for us?” he asked. Another problem, added Vickey, is what to do with all of the information that these technologies generate. His FitBit, for example, has recorded more than 7 million steps since he started wearing it. “So what?” he said. “I think what happens now is that a lot of these data are in a data silo. So I have my step information here, I have my blood pressure information here, I have my food journaling here. But what I’m seeing now in the industry is finally some interoperability of people coming together and being able to see that information as one.”
Vickey commented that consumer-facing technologies may eventually serve as a diagnostic tool for physicians in much the same way that a modern car’s onboard computer provides diagnostic information for an auto mechanic. He noted that he is working on a project with a San Diego middle school that will outfit everyone with a FitBit to monitor heart rates when the students take tests and to monitor how well they sleep the night before a test. The goal is to use the resulting data as part of a wellness program.
Alicia Fernandez, professor of clinical medicine at the University of California, San Francisco, commented that most of her primary care patients are poorly educated and have a hard time learning how to use even a simple pedometer, let alone a FitBit. Many have a smartphone, but have no idea how to download an app, she said. She wondered if there was some new position—a medical assistant informatician or a pharmacist informatician—whose job could be to help patients download apps and set them up, then teach patients how to use these new technologies in much the same way that she has someone on her staff who reviews medication information with a patient. “I think you just created a new job that I would love to have,” said Vickey in response to her suggestion. He noted that he has been advising health clubs, fitness centers, and personal trainers to offer people who get a FitBit or other device to bring it to the club for help setting it up. “I think that there’s an opportunity to be able to have someone in a doctor’s office, in a health club, in a Walgreens to be able to download these apps and educate people on the wearables,” said Vickey in concluding the discussion period.