Apple Watch 4: Will it be suitable as a remote medical monitoring device? Part 1

When I first commented about the Apple Watch as being a possible platform for a remote medical monitoring system in 2015, I was initially excited about the possibilities. Sadly, the technology in 2015 was not quite ready as a platform for remote medical monitoring systems. However, Apple may be turning a corner with the Apple Watch 4 due to be released in Fall 2018. 

To be an effective remote medical monitoring and remote patient management device, the Apple Watch will need to reach acceptable levels of performance in the following seven areas of concern:

1. Bio-sensors
• Built in: are there enough bio sensors with enough resolution?
• Extended: the capability to have additional bio sensors that communicate wirelessly with the watch?
2. Communications over the Internet: Is there a reliable and secure means of communication back to the patient's monitoring system? And the means to communicate with the patient over that same communications channel(s)? 
3. Processing capability, hardware and software: Does the watch have the processing capability to host medical applications?
4. User interface: Visual, touch screen - will patients be able to interact with medical application using the touch screen? Will the watch have an effective audio user interface in order to hear instructions and make requests of the application running on the watch?
5. Reliability: Will the hardware and software reliable enough for a remote medical monitoring and patient management application to run on it?
6. Battery life: When running a remote medical monitoring and patient management application(s) on the watch, will the battery life before needing to recharge be acceptable?
7. Rugged: Is the Apple Watch 4 rugged enough to be a remote medical monitoring and patient management device?

I'm going to touch on each of the areas of concern regarding the performance of the Apple Watch 4.

1. Bio-sensors: I'm not going to address this issue until the Apple Watch 4 has been released. Once it has been released, I'll write an article specifically discussing this topic.
2. Communications over the Internet: A model of the Apple Watch 3 does have the capability of communicating over 4G so reliable communication over the commercial wireless provider networks is possible. We can assume that this capability will continue to the next release. So communications capabilities are likely to be adequate. 
3. Processing capability, hardware and software: Improvements in both are promised over the Apple Watch 3. We can probably assume that hardware and software capabilities will be adequate.
4. User interface:
• Visual, touch screen: The Apple Watch screen has been targeted to those with good visual acuity (with or without glasses) and fine finger control to be able to use the touch screen effectively. Current reports say that the screen will be larger than the Apple Watch 3. Nevertheless it's still a small screen. 
• Auditory: The Apple Watch 3 has Siri, meaning it does have an auditory user interface. More on this after the release of Watch 4.
5. Reliability: Apple has made positive strides in reliability with each release of the Apple Watch. We can assume that this will continue and that the Apple Watch 4 will be reliable enough to serve as a platform for remote medical monitoring and remote patient management applications.
6. Battery life: The Apple Watch 3 has a reported battery life of up to 18 hours. Again Apple has continued its improvements in this area. Patient medical monitoring should be continuous and without long breaks. Even with one or more days of battery life, the watch will still need to be changed and that could take hours. However, having said that, the price of an Apple Watch (because of the ruggedness requirement) that would serve as a remote medical monitoring and patient management device would be around $600. As medical devices go, that's inexpensive and inexpensive enough so that the patient could or should have at least two Apple Watches that would enable the patient to switch watches when necessary. That would place a burden on application software developers to manage when patients change watches, however, this should be manageable.
7. Rugged: The Apple Watch 3 has a version in a stainless steel case. This should be adequate for most situations. Also the issue of reasonably low price and the ability to have redundant watches should effectively address this issue.

Adhesives: Part of the Future for the Remote Monitoring Sensors?

I just ran across this article a few minutes ago. It's a serious article published in Machine Design. Here's the link: http://www.machinedesign.com/mechanical/adhesives-enabling-future-wearable-medical-devices?NL=MD-005&Issue=MD-005_20180724_MD-005_524&sfvc4enews=42&cl=article_1_b&utm_rid=CPG05000003255032&utm_campaign=18775&utm_medium=email&elq2=5b76b40ea8f44d76b2b883c5c09f23fe

It's an extremely readable article and what's being described has in my opinion real applicability in the future of medical sensors. Adhesive, "band-aid" or strip sensors development applies to both the fitness set as well as to remotely monitored patients.

Transmitting data to monitoring systems and people will likely require an intermediate device such as a smart phone. I suspect that the real issues and hurdles will likely revolve around digital communications issues and standardization. Having worked most of my life in the communications domain, communications issues can be successfully overcome.

Here are a few quotes from the article:

Device manufacturers are taking steps to create medical devices that are smaller, lighter, and less invasive. Whether they’re adhering device components together or sticking a device to skin, adhesives are uniquely bonded to a device’s success.

Both consumers and patients want wearable devices to be smaller, lighter and less cumbersome to use for seamless integration into their everyday lives. The design process can get challenging when devices must maintain accurate sensing capabilities, but also reduce friction to ensure precise data collection. Adhesives can help to keep friction to a minimum by being breathable and maintaining a low profile. In addition, options with flex electronics, as well as addressing battery implications and electromagnetic interference, provide opportunities for advancement.

Adhesive wear time is a crucial consideration when designing a wearable device, impacting overall resilience and durability, as well as how often the user will need to change their device. 

______________

I should mention that by the looks of things, it appears to me that 3M maybe behind the article. Nevertheless, I think that considering adhesives in the research, design and development process of a bio-sensor is worth your time. 

15 Game-Changing Wireless Devices to Improve Patient Care

I happened across this slide show today and decided to share it.

https://www.medscape.com/features/slideshow/wireless-devices#17

Remote monitoring has by implication another side to it: remote patient management. The remote monitoring side of these devices seem to be on a strong, positive path of development, but I'm not seeing the same level of development on the remote patient management side. That piece of seems to be lagging and probably for good reason: it's the more difficult. And I can say that from experience working in the area. In addition, it will likely require further development of supporting automation, that is, artificial intelligence or expert systems.

Article: Remote Monitoring of Heart Failure Patients

Although this article was published in 2013, it's findings are still applicable today. Moreover, there is applicability of this system remote monitoring and remote patient management to patients with other chronic conditions other than heart failure. 

I have experience with engineering methods to support remote monitoring and treatment of heart failure patients and this article is an extensive review many of the systems that were and would be coming available in 2013 and later.

Here is the link: Remote Monitoring of Heart Failure Patients by Arvind Bhimaraj, M.D., M.P.H. I recommend this article if you have an interest in many of the details of remote monitoring and remote patient management.

Heart Failure

Heart failure is a chronic disorder and requires continual monitoring and management. The management of heart failure patients remotely can serve as a model for managing patients with other chronic disorders such as diabetes or COPD.

Article Abstract (from the article)

Heart failure continues to be a major burden on our health care system. As the number of patients with heart failure increases, the cost of hospitalization alone is contributing significantly to the overall cost of this disease. Readmission rate and hospital length of stay are emerging as quality markers of heart failure care along with reimbursement policies that force hospitals to optimize these outcomes. Apart from maintaining quality assurance, the disease process of heart failure per-se requires demanding and close attention to vitals, diet, and medication compliance to prevent acute decompensation episodes. Remote patient monitoring is morphing into a key disease management strategy to optimize care for heart failure. Innovative implantable technologies to monitor intracardiac hemodynamics also are evolving, which potentially could offer better and substantial parameters to monitor.

My Analysis

With the advent of smartphones and increasingly sophisticated, smaller and lower power bio-sensors, remote monitoring and remote patient management of all types of chronic conditions should be on the rise. Furthermore, the rise and acceptance of computerize expert medical systems (artificial intelligence), should make remote monitoring and remote patient management a first choice. Not only will this lower costs, but as we have seen it: increases patient satisfaction and mobility, enabling a patient to spend time traveling and enjoying the life that remains.

One more thing ... and I have to add this as a point of pride, a quote from the article:

Also, advancements in implantable wireless technology seen with the pulmonary capillary pressure monitoring device CardioMEMS® (CardioMEMS, Inc., Atlanta, GA) and the left atrial pressure monitor HeartPOD™ System (St. Jude Medical, Inc., St. Paul, MN) or Promote® LAP System (St. Jude Medical, Inc., St. Paul, MN) bring us closer to finding the holy grail of home monitoring systems. (my emphasis)

I had a part in SJM's LAP project. I was working at SJM when this project was in the state of early patient trial. The project manager needed assistance with issues related to and testing of operation of the user interface including the how the computerize system would interact with patients to collect necessary data and provide the patient with directions on what to do to manage their current condition -- mostly, taking medication and performing certain activities. I provided that assistance, design direction and usability testing for this early stage product. Although I haven't seen this system in it's commercial form, I suspect that a lot of what I did was included in the commercial product. The "holy grail" comment is personally gratifying. And I should mention that my experience with the LAP system was one of this things that lead me to starting and continuing with this blog.

The Low-Power Mantra Rings Louder with Next-Gen Medical Wearables

My interest in remote monitoring and the focus of this blog is primarily on wearable or implanted devices that support chronically ill or elderly patients. I link remote monitoring with remote patient management. I sometimes drift into the realm of wearable fitness devices because of the similarity in technology. However I think what really differentiates wearable fitness devices and medical remote monitoring devices is reliability, particularly when it comes to insuring that medical remote monitoring devices have a reliable source of power -- constant and steady.

Reliable and constant power is a major concern to any engineer who's designing a medical monitoring device. So this article should be of interest to those involved with the design, development and testing of medical remote monitoring devices. 

Here is the link to the article: http://www.electronicdesign.com/power/low-power-mantra-rings-louder-next-gen-medical-wearables

Here's a quote from the conclusion of the article: 

"Wearable devices represent the current and future wave in medical care. They hold promise in multiple areas from real-time patient monitoring to drug delivery, but the small space available for a battery imposes strict constraints on the designer, particularly in the area of power consumption."

Harvesting Power

When I was the principal investigator and Chief Technologist of a company focused on research and development of mobile and wearable devices, we were extremely concerned with power and reliable and constant sources for power for mobile devices. One of the ideas we began to pioneer was the ability to harvest power from the environment, from bioelectric sources such as people. I mention this because the article discusses this issue and some of the promising technologies and those interested in  this area should find this section interesting.

Washington Post: These Louisiana physicians can monitor your blood pressure — and you don’t even have to leave your living room

Interesting article from the Washington Post. What's interesting is that they focus on high blood pressure. Yes, high blood pressure is a concern, but with heart patients of even greater concern is low blood pressure. Nevertheless, it does discuss in detail and in a readable manner, the real benefits of remote monitoring and remote patient management.

Here's the link to the article:  https://www.washingtonpost.com/business/economy/these-louisiana-physicians-can-monitor-your-blood-pressure--and-you-dont-even-have-to-leave-your-living-room/2018/07/11/6d57f198-7beb-11e8-93cc-6d3beccdd7a3_story.html?utm_term=.383dd5c9dfb0

It's worth your time to read.

Remote Patient Monitoring System Market Expected to Grow USD 31 Bn by 2023

https://sectorhealthcare.com/remote-patient-monitoring-system-market-expected-to-grow-usd-31-bn-by-2023/

An article pointing to a research report regarding the growth in the market for remote monitoring and by implication, remote patient management.

From the article:

The global remote patient monitoring market was valued at around USD16 billion in 2017 and is expected to cross USD31 billion by 2023, increasing at an annual growth rate of 12% between 2017 and 2023. The increase in the geriatric population and individual spending on the medical treatments have supported the need for remote patient monitoring technology.

... 
There is a "however" in this article. As expected with the medical establishment, there are some concerns, slow-downs and possible blockers.

Also from the article:

However, hospitals in few countries are not showing any willingness to adopt these remote monitoring technologies owing to the huge expenditure involved in the setup of infrastructure and equipment, and the shortage of skilled human resources. Patients are advised by few healthcare professionals to implement the technology by themselves to avoid hospital expenses and repeated clinical visits. Strict government regulations and lack of proper reimbursement mechanism are also impeding the growth of global remote patient monitoring market.

Like it or not, governments ... most likely national and regional/state ... will need to be the ones pressing the medical establishments to make changes because governments in so many countries ... and believe or not, including the US because so much health care is paid out of Medicare and Medicaid funds ... are the ones ultimately footing the bill. 

Here's a link to the report. https://www.researchcosmos.com/reports/global-remote-patient-monitoring-system-market-professional-survey-report-2018/19032600

I warn you that it's an expensive report. You may work for a company that either can pay for this report or has access to the reporting service.

Also the article (and the report) discuss an area of remote monitoring and remote patient management that I have extensive experience in and that I've discussed in this blog:

Cardiac monitors are the most preferred remote monitoring systems due to the rise in heart-related diseases causing more than 31% of deaths world. Cardiac monitors include heart rate monitor, fetal heart rate monitors, ECG monitor, and blood pressure monitors that are having a huge demand in the global markets. To capitalize on the growing cardiovascular disease conditions, product developers across the world are implementing portable and wireless ECG monitors that easily carried around to anyplace.

Remote Monitoring Keeps Patients with Chronic Conditions out of the Hospital

https://www.prnewswire.com/news-releases/remote-monitoring-keeps-patients-with-chronic-conditions-out-of-the-hospital-300683952.html

From previous studies we know the economic value and cost reductions of remote monitoring and remote patient management. Here is an article about a study by Mercy Virtual regarding the value to patients of being remotely monitored and remotely managed. The results of this study although not surprising show without a doubt the use of remote monitoring and remote patient management have profoundly positive results not only for patients but for wider medical system. And that remote monitoring and remote patient management should be employed not only for patients who live long distances from medical facilities, but for all patients who require frequent monitoring and attention.

Overview and results of the study:

Mercy Virtual piloted vEngagement in Washington, Missouri, beginning in September 2015. The program is now available at Mercy hospitals and clinics in Arkansas, Kansas, Missouri and Oklahoma.

Results of the vEngagement program have been impressive among nearly 1,000 patients:

• 50 percent reduction in hospital readmissions 

• 50 percent reduction in emergency department visits and hospitalizations 

• 98 percent of patients who are extremely satisfied or satisfied

The article includes a case study of the experiences of one of the patients in the study:

After several hospitalizations for breathing problems over two years, Dolorse Murray agreed last September to try a home-based health management program her primary care physician believed would improve her health.

Murray, 71, of Neosho, Missouri, has chronic heart and lung conditions that make breathing difficult and sometimes lead to swelling in her legs and feet. Through the program, called vEngagement, a Mercy Virtual care team monitors Murray and makes suggestions about changes at home to better manage her symptoms.

After just a few months in the program, Murray said she feels better and is able to breathe easier. She has returned to her favorite hobbies, like gardening and painting, which she was too sick to do last year. 

"This is the most wonderful program, and I tell a lot of people about it," said Murray. "I feel like it's saved my life."

Murray meets by phone with her care team several times per month to discuss how she is feeling and determine any changes to her treatment plan. She can also hit a button to let Mercy Virtual co-workers know she doesn't feel well.