If you're an engineer who wants to make the vision Steve paints into a reality--but for everybody, not just for Apple Watch owners--I'd love to talk with you.
I'm a co-founder at Cardiogram. In multiple N=14,011 studies with UCSF Cardiology, we've shown that heart rate sensors on consumer wearables can detect multiple major health conditions like sleep apnea, hypertension, diabetes, and atrial fibrillation (https://cardiogr.am/research). These conditions affect more than one billion people worldwide, and are frequently undiagnosed -- for example, more than 80% of people with sleep apnea don't know they have it.
We're live on iOS and Android, and we could use help in several areas: mobile and frontend engineering, senior machine learning engineers, and payer relations (the reimbursement from health insurers that Steve talks about). If that sounds like you, please email me at [email protected]!
> heart rate sensors on consumer wearables can detect multiple major health conditions
It sounds so logical and inevitable where this technology is heading for health care. Over 10 years ago, I paid $1200 to wear a Holter monitor[1] for 24 hours.
In contrast, a consumer wearable like Apple Watch is $399. Arguably, the Holter monitor fee also included the doctor's time to read the ECG recording. But it also seems like a lot of the rudimentary analysis of heart data from wearables will be done in the cloud with machine learning. Hence, the price of basic diagnosis goes way down.
With the increasing aging population in USA, Europe, and Japan that will want to stay on top of medical issues, it seems like a big business opportunity. A bunch of players are going to compete in this space. Good luck to you!
I need a list of seriously precise devices that are below 200$. By ~seriously I mean something I could rely medically and not a tiny wrist watch that will have too much noise / jitter to be useful. It's for family members (including me).
Is there any interest in developing software to help arrive at a diagnosis? As that would somewhat overlap with the ability to track users vitals.
I suffer from chronic pain, and doctors are seriously unreliable when it comes to diagnosing something relatively complex, even though the research is there and has been available for many years.
I would be interested in joining a project that would become a tool that helps diagnose complex conditions, or at least provide a path for diagnosis.
Medical device engineer / founder here. I'd love for the Apple Watch to fulfill Steve Blank's aims here, but there are very real clinical problems that don't automatically go away because Apple is great at industrial and UI design. The false positive risk with their a-fib detection will cause thousands of patients to ask their healthcare providers for further tests, only to find out they were fine. This isn't unlike the issue where iPhones have been inundating 911 call centers with unintentional "butt dials".
This doesn't mean that Apple won't be successful in healthcare. It's just that the main challenge isn't in creating a nicer product. The challenge is in showing a net positive impact on patient outcomes.
False positives are not really an issue. Last I heard 60% of chest pain cases ERs see are false positives (constipation or something like that doesn't require ER care). However it is sometimes the only symptom you get of real medical emergencies so you go to the ER anyway.
There are also a number of people who die of heart attacks with no symptoms. If Apple can get even 1% of them to the ER that would be a huge win. If the false positive rate is 80% that is still enough real positives that ERs will be get used to telling people "This time it is nothing, but it is good you came in anyway because sometimes this is all the warning you get".
The real worry is false negatives - someone who has chest pain and decides not to go because the watch says all is okay. These people will die when a hospital could save them.
Working in the industry you already know this but FP vs TP rates are a fundamental issue in nearly any system like this (i.e. non diagnostic). You typically can’t get rid of them, so the trick is to balance it in such a way for net positive benefit as you note. This may mean some unneeded visits, balanced by more needed interventions that would otherwise be missed.
Apple Watch isn’t really any different here, except potentially in scale. While that does mean potential impact is large, there is no a priori reason to assume apple has got it wrong; it’s not that difficult to find the right people for this sort of project.
It would be very interesting to see an ROC curve ...
> The question is are they are going to create millions of unnecessary doctors’ visits from unnecessarily concerned users or are they going to save thousands of lives? My bet is both – until traditional healthcare catches up with the fact that in the next decade screening devices will be in everyone’s hands (or wrists.)
>where iPhones have been inundating 911 call centers with unintentional "butt dials".
This happened to me just a few months ago. I'm sitting in the passenger's seat of a car and, out of the blue, I get a call from a weird Caller ID which, of course, I hang up on. I get another call, this time from a regular looking number in the local area code. I reluctantly answer it (in spite of my friend driving telling me to hang up) and it's nearby emergency services. I'm of course totally confused and ended up hanging up on them when they start asking my name etc.
It turns out there's a setting you can change to make this harder to do by accident but I had no idea until I looked it up.
Has anyone actually had a chance to try this feature on the Apple Watch 4? All the demo videos so far keep saying the feature is coming but no one actually has used it yet. I'm curious in how frequent it produces false positive results and in what types of situations or activities.
Having said that, I love the direction Apple is taking with this product. Smart watches have been on the market for quite a number of years now but they're pretty much restricted to being gimmicky devices only as most people don't find it very useful or have a real need for it. If Apple could achieve the breakthrough in blood glucose monitoring feature then I strongly believe we will see mass adoption in very near future.
Not to mention the health angle requires Apple lock down the device even further to stay HIPPA compliant; to keep from prying eyes. Apple has pit the FDA against the FBI.
I have signed up for, but not yet started a study at University of Michigan that is giving out apple watches and blood pressure monitors as part of a health study. Apple Inc is listed as a sponsor that will have access to all of the data. Among other things they are collecting blood samples and survey data. It has a concentrated period of 45 days of data collection, but goes on for 3 years. I am slightly concerned about the privacy issues, but I decided its worth it to see what they can come up with.
The study that I am joining "MIPACT" is not well publicized, and I only heard about it through a friend at work. I wonder how many similar projects they are supporting around the country.
Pardon my cynicism, but it strikes me either as naivety or fanboy-ism to label the Apple Watch as the "tipping point" for healthcare tech. Wearables for consumer health that touch on actual healthcare in a few areas are a pretty low hanging, low yield fruit if you want to talk about 'disrupting' the industry. Maybe I'll eat my words in a few years when wearables somehow force EHR systems to be interoperable or tackle some of the other massive issues in healthcare tech. I doubt it, though.
This is nothing against the Watch tech itself. There's probably a lot of cool applications for that tech. I just don't think Apple's advancement of wearables is monumental to the healthcare industry, or potentially disruptive.
> The FDA – Running Hard to Keep Up With Disruption
Honestly, I don't really know what he's talking about with this 'disruption.' Just because the FDA is trying to keep pace with all the tech being built by health tech startups, it doesn't mean anything is getting disrupted. I have yet to see what I would consider a disruptive technology sweeping over the healthcare industry.
The point will come when not regularly wearing one of these devices is considered hazardous to one's health... And this point will probably come before self-driving cars.
Some examples:
I always wondered why I had a lot of trouble sleeping. Doctors laughed at me, until an orthodontist told me I should get checked for sleep apnea. Turns out I had very severe sleep apnea. I would have like this diagnosed much sooner in my life.
My Dad had afib, had it been diagnosed sooner, his surgery wouldn't have been a "get it done now" situation.
Once the true positives outweigh the false positives, everyone's going to consider these essential for health. That moment will probably be in 2-5 years.
Speaking as someone who owns a company that makes electronic health records, interoperability between systems is not the bottleneck that people in technology think it is. The time it takes to request and receive records on a patient is measured in days not minutes. Often the larger EMRs aren't even interoperable with themselves, each deployment is an island unto itself. (Why would I expect EPIC to be able to talk with Cerner if it can't even talk with itself)
I think most doctors and patients would agree that getting information in a timely manner is more important than the mechanism by which it is transferred. While interoperability is something to strive for it's not the thing holding the system back.
Today the primary driver for clinical systems interoperability is federal government regulations (Meaningful Use, HITECH Act, MACRA, etc) plus requirements from payers (insurers). Apple's support for HL7 FHIR has also been a positive influence in convincing more provider organizations to open up public APIs, but that's really for iPhone / iPad devices and not directly related to wearables.
EHR vendors are actively working to enhance their applications to cope with new data streams coming in from consumer wearables as well as connected home healthcare devices such as smart scales and blood pressure monitors.
I have to wonder if the subsidizing of the Apple watch is a huge push for healthcare on it. For instance I was able to get the Series 3 for $120 through my provider. Which is a hefty drop from $400. I can't get the same discount on the Samsung watch, or any other smart watch, which is ironic since my Samsung watch works on both Android and iOS and does health tracking as well.
It's surprising that the Apple Watch still doesn't include an ANT+ radio receiver to gather data from dedicated heart rate monitors and other devices. Of course it's possible to use Bluetooth (BLE), but it's less efficient, less reliable, and not as well supported by third-party devices. I wonder why Apple left that feature out considering that most of their competitors have it and it doesn't cost much or really impact battery life?
It's surprising that the Apple Watch still doesn't include an ANT+ radio receiver
Most of their competitors? Garmin's latest watches won't even talk to an ANT scale anymore (well, there's $300 kinda wasted). Garmin still has their line of ANT+ accessories, though.
Moreso, I view ANT+ as the protocol for the athlete that isn't going to be using an Apple Watch during their workouts. "Oh, your $600 Garmin power meter pedals don't work over BLE with your Apple Watch?", asks no one ever. There are BLE heart monitors, foot pods, and power meters if you absolutely must use your sensors with something Apple. No, it's probably the optimal solution, but it's the solution Apple's market will be happy with.
I have a question about the Apple Watch's EKG/ECG feature, maybe someone can answer:
I had a routine EKG last week for a pilot medical certificate. Before the EKG, the nurse rubbed a cold gel on my skin, at the places where she then placed the EKG contacts. I'm assuming this gel was to ensure good contact. If doctors have to rub this gel before an EKG, why doesn't the Apple Watch need this, to ensure good contact?
Can Apple Watch be used without iCloud, with sensor data sent only to a local iOS device (iPad without LTE baseband radio, only WiFi) for local analysis?
If so, there could be open-source iOS apps that enable privacy-oriented health data collection on the watch, e.g. with E2E encrypted messaging initiated by the device owner, when data review is wanted.
Yes, you can use an Apple Watch without using iCloud. You cannot pair an Apple Watch to an iPad.
iCloud Syncing for your HealthKit data encrypts and stores your data in iCloud, similar to iCloud Keychain. If this is enabled, HealthKit information is stripped from iCloud backups, if you use them. You can also do local encrypted backups through iTunes. If you don’t use any of the above options, HealthKit data stays on the device.
On device, HealthKit has lots of permissions for apps to access health data, including per app reading and writing permissions for each data category.
I cringe thinking about people using an Apple Watch for healthcare. I had to give my Apple Watch 3 away because:
1) its heart rate monitoring while running was terrible. I run in a HR range and AW3 wasn't accurate enough for that. It would show a rate too low and then impossibly high within a couple minutes... couldn't use it to pace myself.
2) battery life. If you run for 2 hours, you likely can't get through the day. I had to charge it every night. In the case of a medical monitoring device, I guess you'll have to settle for being monitored for only part of the day???
I ended up buying a Garmin Forerunner 935 and its HR is more accurate and battery life is much better. (But not saying Garmin is OK for health care either)
Also a runner -- I had slightly different problems to you:
- The GPS on the watch was terrible, often dropping out for me, and leaving out a mile here and there. Is this an Apple thing? My Garmin is way more accurate.
- I need an always-on mode. I realize it drains the battery, but I own the battery and that is my choice. I need to be able to glance down and see my pace immediately, not fiddle with my wrist flicking until it comes on.
- I'm also bummed that there's no Spotify support yet, and that it's not a true standalone LTE device. I want to ditch my phone and have a watch only.
This shouldn't be down voted, you are exactly correct. Optical heart rate monitors can do fairly well for casual use as long as the watch band is fairly snug. But all of them whether from Apple, Garmin, or another vendor lose accuracy when they're bouncing around on a sweaty wrist. This is just a fundamental limit of the technology.
> Sooner than people think, virtually all home and outpatient diagnostics will be performed by consumer devices such as the Apple Watch, mobile phones, fitness trackers, etc.
Well I do think 'not very soon' - because I only know a handful of people (all doing computery things) with an Apple Watch or FitBit/Android thingy, and even of those fond of tech it's only a minority.
I cannot even fathom how long it would take to have this data even be acknowledged or just being able to be interchanged with German doctors and hospitals.
I have a watch with wrist HRM and I can say without a doubt that it is a complete gimmick. Sometimes I will be sitting calmly at my desk and I glance down and see it thinks my heart rate is 190. Or I will get back from a hard run and it thinks my heart rate hasn’t been above 70. A chest strap however gives plausible results.
Anyone basing serious health stuff on this is crazy.
An EKG is done via a 12-point lead at specific areas of the body. At the moment, there is only one ECG sensor on the watch. When I told my SO who is currently in medical residency, the look on her face was of pure horror. I think to physicians and medical professionals, all this feature will do is to create more false positives and needlessly clog up already stressed clinics with wasteful checkups and add to the number of hypochondriacs.
Maybe through ML Apple could enhance the accuracy and precision of the measurements but given Apple's history with iterating on intelligent features(Siri), it won't happen for a while. If Apple wants to have a meaningful impact on the health of their users, then maybe they ought to use the ECG sharing feature as a means of getting their foot in the door of the medical records industry where their product approach and design rigour is much needed. Moreover, Apple could leverage the ECG feature as part of the product experience to motivate people to engage in activities that get them moving which, at the end of the day, is where most users derive the most value from.
[+] [-] brandonb|7 years ago|reply
I'm a co-founder at Cardiogram. In multiple N=14,011 studies with UCSF Cardiology, we've shown that heart rate sensors on consumer wearables can detect multiple major health conditions like sleep apnea, hypertension, diabetes, and atrial fibrillation (https://cardiogr.am/research). These conditions affect more than one billion people worldwide, and are frequently undiagnosed -- for example, more than 80% of people with sleep apnea don't know they have it.
We're live on iOS and Android, and we could use help in several areas: mobile and frontend engineering, senior machine learning engineers, and payer relations (the reimbursement from health insurers that Steve talks about). If that sounds like you, please email me at [email protected]!
[+] [-] jasode|7 years ago|reply
It sounds so logical and inevitable where this technology is heading for health care. Over 10 years ago, I paid $1200 to wear a Holter monitor[1] for 24 hours.
In contrast, a consumer wearable like Apple Watch is $399. Arguably, the Holter monitor fee also included the doctor's time to read the ECG recording. But it also seems like a lot of the rudimentary analysis of heart data from wearables will be done in the cloud with machine learning. Hence, the price of basic diagnosis goes way down.
With the increasing aging population in USA, Europe, and Japan that will want to stay on top of medical issues, it seems like a big business opportunity. A bunch of players are going to compete in this space. Good luck to you!
[1] link for those not familiar with the device: https://www.google.com/search?q=holter+monitor
[+] [-] rootusrootus|7 years ago|reply
I don't have any real desire to move to SF but I do miss the fact that a lot of the cool jobs only happen down there. Ah well.
[+] [-] agumonkey|7 years ago|reply
thanks
[+] [-] avgDev|7 years ago|reply
I suffer from chronic pain, and doctors are seriously unreliable when it comes to diagnosing something relatively complex, even though the research is there and has been available for many years.
I would be interested in joining a project that would become a tool that helps diagnose complex conditions, or at least provide a path for diagnosis.
[+] [-] monkmartinez|7 years ago|reply
[+] [-] unknown|7 years ago|reply
[deleted]
[+] [-] toomuchtodo|7 years ago|reply
[+] [-] DenisM|7 years ago|reply
[+] [-] dmead|7 years ago|reply
[+] [-] mikekij|7 years ago|reply
This doesn't mean that Apple won't be successful in healthcare. It's just that the main challenge isn't in creating a nicer product. The challenge is in showing a net positive impact on patient outcomes.
[+] [-] bluGill|7 years ago|reply
There are also a number of people who die of heart attacks with no symptoms. If Apple can get even 1% of them to the ER that would be a huge win. If the false positive rate is 80% that is still enough real positives that ERs will be get used to telling people "This time it is nothing, but it is good you came in anyway because sometimes this is all the warning you get".
The real worry is false negatives - someone who has chest pain and decides not to go because the watch says all is okay. These people will die when a hospital could save them.
[+] [-] ascagnel_|7 years ago|reply
https://twitter.com/benbajarin/status/1040018930637520896
[+] [-] ska|7 years ago|reply
Apple Watch isn’t really any different here, except potentially in scale. While that does mean potential impact is large, there is no a priori reason to assume apple has got it wrong; it’s not that difficult to find the right people for this sort of project.
It would be very interesting to see an ROC curve ...
[+] [-] _lbaq|7 years ago|reply
http://www.drjohnm.org/2018/09/thoughts-on-the-apple-watch/
[+] [-] oflannabhra|7 years ago|reply
[+] [-] ghaff|7 years ago|reply
This happened to me just a few months ago. I'm sitting in the passenger's seat of a car and, out of the blue, I get a call from a weird Caller ID which, of course, I hang up on. I get another call, this time from a regular looking number in the local area code. I reluctantly answer it (in spite of my friend driving telling me to hang up) and it's nearby emergency services. I'm of course totally confused and ended up hanging up on them when they start asking my name etc.
It turns out there's a setting you can change to make this harder to do by accident but I had no idea until I looked it up.
[+] [-] netwanderer2|7 years ago|reply
Having said that, I love the direction Apple is taking with this product. Smart watches have been on the market for quite a number of years now but they're pretty much restricted to being gimmicky devices only as most people don't find it very useful or have a real need for it. If Apple could achieve the breakthrough in blood glucose monitoring feature then I strongly believe we will see mass adoption in very near future.
[+] [-] unknown|7 years ago|reply
[deleted]
[+] [-] debt|7 years ago|reply
[+] [-] visarga|7 years ago|reply
Because they fill that lock screen with junk making it a butt dial magnet.
[+] [-] killjoywashere|7 years ago|reply
[+] [-] soperj|7 years ago|reply
This is no longer the case.
[+] [-] chrisBob|7 years ago|reply
The study that I am joining "MIPACT" is not well publicized, and I only heard about it through a friend at work. I wonder how many similar projects they are supporting around the country.
[+] [-] kendallpark|7 years ago|reply
This is nothing against the Watch tech itself. There's probably a lot of cool applications for that tech. I just don't think Apple's advancement of wearables is monumental to the healthcare industry, or potentially disruptive.
> The FDA – Running Hard to Keep Up With Disruption
Honestly, I don't really know what he's talking about with this 'disruption.' Just because the FDA is trying to keep pace with all the tech being built by health tech startups, it doesn't mean anything is getting disrupted. I have yet to see what I would consider a disruptive technology sweeping over the healthcare industry.
[+] [-] gwbas1c|7 years ago|reply
Some examples:
I always wondered why I had a lot of trouble sleeping. Doctors laughed at me, until an orthodontist told me I should get checked for sleep apnea. Turns out I had very severe sleep apnea. I would have like this diagnosed much sooner in my life.
My Dad had afib, had it been diagnosed sooner, his surgery wouldn't have been a "get it done now" situation.
Once the true positives outweigh the false positives, everyone's going to consider these essential for health. That moment will probably be in 2-5 years.
[+] [-] pg_bot|7 years ago|reply
I think most doctors and patients would agree that getting information in a timely manner is more important than the mechanism by which it is transferred. While interoperability is something to strive for it's not the thing holding the system back.
[+] [-] nradov|7 years ago|reply
EHR vendors are actively working to enhance their applications to cope with new data streams coming in from consumer wearables as well as connected home healthcare devices such as smart scales and blood pressure monitors.
[+] [-] post_break|7 years ago|reply
[+] [-] nradov|7 years ago|reply
[+] [-] mikestew|7 years ago|reply
Most of their competitors? Garmin's latest watches won't even talk to an ANT scale anymore (well, there's $300 kinda wasted). Garmin still has their line of ANT+ accessories, though.
Moreso, I view ANT+ as the protocol for the athlete that isn't going to be using an Apple Watch during their workouts. "Oh, your $600 Garmin power meter pedals don't work over BLE with your Apple Watch?", asks no one ever. There are BLE heart monitors, foot pods, and power meters if you absolutely must use your sensors with something Apple. No, it's probably the optimal solution, but it's the solution Apple's market will be happy with.
[+] [-] clamprecht|7 years ago|reply
I had a routine EKG last week for a pilot medical certificate. Before the EKG, the nurse rubbed a cold gel on my skin, at the places where she then placed the EKG contacts. I'm assuming this gel was to ensure good contact. If doctors have to rub this gel before an EKG, why doesn't the Apple Watch need this, to ensure good contact?
[+] [-] walterbell|7 years ago|reply
If so, there could be open-source iOS apps that enable privacy-oriented health data collection on the watch, e.g. with E2E encrypted messaging initiated by the device owner, when data review is wanted.
[+] [-] oflannabhra|7 years ago|reply
iCloud Syncing for your HealthKit data encrypts and stores your data in iCloud, similar to iCloud Keychain. If this is enabled, HealthKit information is stripped from iCloud backups, if you use them. You can also do local encrypted backups through iTunes. If you don’t use any of the above options, HealthKit data stays on the device.
On device, HealthKit has lots of permissions for apps to access health data, including per app reading and writing permissions for each data category.
[+] [-] sirn|7 years ago|reply
Apple Watch can only be connected to iPhone, though (not iPod touch) so have it sync to a device without LTE baseband radio is not possible.
[+] [-] maxerickson|7 years ago|reply
https://developer.apple.com/documentation/healthkit/protecti...
[+] [-] appleiigs|7 years ago|reply
1) its heart rate monitoring while running was terrible. I run in a HR range and AW3 wasn't accurate enough for that. It would show a rate too low and then impossibly high within a couple minutes... couldn't use it to pace myself.
2) battery life. If you run for 2 hours, you likely can't get through the day. I had to charge it every night. In the case of a medical monitoring device, I guess you'll have to settle for being monitored for only part of the day???
I ended up buying a Garmin Forerunner 935 and its HR is more accurate and battery life is much better. (But not saying Garmin is OK for health care either)
[+] [-] joegahona|7 years ago|reply
- The GPS on the watch was terrible, often dropping out for me, and leaving out a mile here and there. Is this an Apple thing? My Garmin is way more accurate.
- I need an always-on mode. I realize it drains the battery, but I own the battery and that is my choice. I need to be able to glance down and see my pace immediately, not fiddle with my wrist flicking until it comes on.
- I'm also bummed that there's no Spotify support yet, and that it's not a true standalone LTE device. I want to ditch my phone and have a watch only.
[+] [-] stcredzero|7 years ago|reply
I'm not familiar with this term. I just had an image of our Human Resources officer shooting at people running on an indoor track with a nerf gun.
[+] [-] nradov|7 years ago|reply
[+] [-] wink|7 years ago|reply
Well I do think 'not very soon' - because I only know a handful of people (all doing computery things) with an Apple Watch or FitBit/Android thingy, and even of those fond of tech it's only a minority.
I cannot even fathom how long it would take to have this data even be acknowledged or just being able to be interchanged with German doctors and hospitals.
[+] [-] paul7986|7 years ago|reply
A toilet that analyzes specimen data and alerts you of potential issues.
[+] [-] breckuh|7 years ago|reply
This is a parody but actually has some great product ideas :)
[+] [-] unknown|7 years ago|reply
[deleted]
[+] [-] IBM|7 years ago|reply
Why Tim Cook is Steve Ballmer and Why He Still Has His Job at Apple (2016)
https://steveblank.com/2016/10/24/why-tim-cook-is-steve-ball...
[+] [-] SeanFerree|7 years ago|reply
[deleted]
[+] [-] gaius|7 years ago|reply
Anyone basing serious health stuff on this is crazy.
[+] [-] trophycase|7 years ago|reply
[+] [-] chicob|7 years ago|reply
Cross that data with customer loyalty card data regarding groceries purchases for the next decades, and one can practically automate ineligibility.
[+] [-] unionjack22|7 years ago|reply
Maybe through ML Apple could enhance the accuracy and precision of the measurements but given Apple's history with iterating on intelligent features(Siri), it won't happen for a while. If Apple wants to have a meaningful impact on the health of their users, then maybe they ought to use the ECG sharing feature as a means of getting their foot in the door of the medical records industry where their product approach and design rigour is much needed. Moreover, Apple could leverage the ECG feature as part of the product experience to motivate people to engage in activities that get them moving which, at the end of the day, is where most users derive the most value from.