503bc medical journal vol. 59 no. 10, december 2017 bcmj.org

Kendall Ho, MD, Christopher Yao, MSc, Helen Novak Lauscher, PhD

Health apps, wearables, and sensors: The advancing frontier of digital healthAs public interest in consumer electronics for improving personal health grows, physicians have an important role to play in guiding patients and advocating for evidence to support the use of these technologies in clinical settings.

ABSTRACT: The proliferation of mo-

bile technologies that can measure

and gather a variety of data has in-

creased public interest in using

consumer electronics to take own-

ership of personal health and well-

ness. Apps, wearables, and sensors

can unobtrusively gauge physiologi-

cal and emotional states and collect,

quantify, and monitor data regarding

a user’s day-to-day behaviors, can

provide timely and patient-centred

care to those living at a distance

with chronic disease, and can be

used to coordinate care when mul-

tiple providers are involved, reduc-

ing costs to the health care system.

In all cases, merely tracking data

is not enough to maintain health

behaviors long-term, and the soft-

ware must also incorporate motiva-

tional constructs important for the

adoption and habituation of health-

related behaviors. Even though all of

these technologies are promising,

further research is needed to vali-

date their use and long-term impact

and to identify possible risks, from

physiological harm to breaching of

privacy and confidentiality with in-

secure devices, and how to mitigate

any risks. Before recommending de-

vices or platforms to patients, phy-

sicians should experiment with the

technologies themselves so they

understand the functions and limi-

tations. As well, physicians should

be active agents in these evolution-

ary times, guiding patients, advocat-

ing for evidence to support the use

of technologies, and participating in

the development and incorporation

of technology in patient wellness

journeys.

W ith the increasing prolif-eration and sophistication of mobile phones, wear-

able devices such as smart watches, and sensors that can measure and gather a variety of data, public inter-est is growing in using consumer elec-tronics to take ownership of personal health and wellness. A 2015 survey found that 66% of Americans age 66 and older want to use mobile tech-nologies to improve their health by receiving medication reminders and tracking diet and nutrition, physical activity, and symptoms.1

Dr Ho is an emergency physician at Vancou-

ver General Hospital. He is also a professor

in the Department of Emergency Medicine

at the University of British Columbia, lead

of Digital Emergency Medicine, and execu-

tive director of iCON (interCultural Online

Health Network), a community engage-

ment initiative funded by the BC Ministry

of Health to support chronic disease pre-

vention and self-management. Mr Yao is a

research associate with Digital Emergency

Medicine at the University of British Colum-

bia. Dr Novak Lauscher is research man-

ager for Digital Emergency Medicine at the

University of British Columbia.This article has been peer reviewed.

504 bc medical journal vol. 59 no. 10, december 2017 bcmj.org

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

How is this growing phenomenon going to affect health service deliv-ery? More importantly, will personal health technology lead to better man-agement and outcomes for our pa-tients, and if so, how can clinicians support this approach and promote it with patients?

Health apps and wearablesHealth apps and wearables can un-obtrusively gauge physiological and emotional states and collect, quantify, and monitor data regarding a user’s day-to-day behaviors. This “quan-tified 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, afford-ability, practicality, and ease of use have resulted in increased consumer enthusiasm and the pervasiveness of these devices.3,4 With this growing in-terest 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 be-haviors long-term, and the software must also incorporate motivational constructs important for the adoption and habituation of behaviors. For in-stance, 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 demonstra-tion of superiority when the systems were compared with other interven-tions.11 Another review of studies on the viability of using mobile technol-ogy 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 How-ever, less common among these apps were prompts to act and opportunities for problem solving and action plan-ning, which are crucial constructs that translate intention into long-term be-havior 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 cloth-ing, 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, tele-health 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 in-volved, reducing costs to the health care system.

A current clinical example is the management of paroxysmal atrial fi-brillation with a mobile ECG and app that monitors the patient’s electrical rhythm to detect frequency and pat-terns of arrhythmias, and may even allow patients to share ultrasound and electrocardiogram data with their health care provider.18-20 Telemonitor-

ing 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 diabe-tes. A recent Cochrane review found that telemonitoring was an effective way to lower levels of glycated hemo-globin and low-density lipoprotein.22 Although several studies on heart fail-ure have produced conflicting results regarding the overall benefits of home monitoring,23-26 systematic reviews have suggested that home telemoni-toring reduces all-cause mortality and hospitalizations, and improves quality of life compared with usual care.22,27 In addition, features such as automat-ed and mobile telemonitoring appear to be more effective compared with other forms of home telemonitoring.27

Further studies are needed to de-termine how home health monitoring can improve patient safety during the transition from acute care to com-munity care, and to examine the im-pact of home monitoring on health care costs. TEC4Home (Telehealth for Emergency-Community Conti-nuity 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 de-signed 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 settingEven though mobile apps, wearables, and sensor technologies are prom-ising, further research is needed to validate their use and long-term im-pact.29 This research will require the

505bc medical journal vol. 59 no. 10, december 2017 bcmj.org

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

collaboration of clinicians, health researchers, engineers, and com-puter scientists.30 Understanding the possible risks of using these tech-nologies, from physiological harm to breaching of privacy and confidenti-ality with insecure devices, and how to mitigate any risks is also important. Other important issues to consider in-clude 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 treat-ment and prevention of health condi-tions and disease and should not be used in isolation by patients who self- diagnose and self-manage without consulting a health professional.

Examples of three apps that physi-cians may wish to recommend to their patients follow:• Instant Heart Rate by Azumio.31

A free app downloadable to both Apple and Android operating sys-tems 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 quanti-fying the amount of true sleep they need and not just how long they should stay in bed.

• BellyBio Interactive Breathing by RelaxLine.33 A free app that helps users pace their breathing to achieve calmness. Placing the mobile phone against the abdomen, users can fol-low the sounds emitted to practise

deep, abdominal breathing using this simple yet surprisingly effec-tive tool.

Before recommending these and other apps to patients, physicians should experiment with the technolo-gies themselves so they understand the functions and limitations.

Clearly, it is increasingly impor-tant for physicians to have knowledge of the devices and platforms now available so that they can prescribe them to their patients in the appro-priate contexts, and provide ongoing support on appropriate and safe use. Patients look to their physicians for discernment, expertise and experi-ence, partnership, trials, and humility (DEPTH): • 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 technol-ogy 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

ConclusionsBased on today’s rapid pace of de-velopment 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 main-stream health care.

Competing interests

Dr Ho receives no personal financial com-

pensation 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 addi-

tional 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 inter-

ests to declare.

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