
The Apple Watch – Tipping Point Time for Healthcare - kulu2002
https://steveblank.com/2018/09/26/the-apple-watch-tipping-point-time-for-healthcare/
======
brandonb
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](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 brandon@cardiogr.am!

~~~
jasode
_> 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!

[1] link for those not familiar with the device:
[https://www.google.com/search?q=holter+monitor](https://www.google.com/search?q=holter+monitor)

~~~
JshWright
You're never going to diagnose something based on a watch (or other consumer
focused wearable). The watch is just telling you that you should go talk to
your doctor (so they can get you on a real cardiac monitor and get the level
of information needed to make a diagnosis). Consumer wearables aren't going to
be replacing Holter monitors.

EDIT: A lot of folks seem to be interpreting my comment as implying there is
no value in this technology. That is absolutely not the case. There is huge
value in widely deployed screening like this (especially since it looks like
the specificity is quite high). My point is that these devices will not be
replacing diagnostic equipment (in fact, it may very well increase its use as
more conditions that would otherwise have gone undetected will now be flagged
for further diagnostic testing).

~~~
coder543
The Apple Watch can perform an FDA-cleared diagnosis of certain forms of
Atrial Fibrillation, and if what they showed on stage is to be believed, it
can produce a really clear ECG that's also FDA-cleared. Just because you're
redirected to a doctor doesn't mean the watch did nothing, it just means the
watch can't provide a complete patient care cycle. The condition is
identified, now what? False-positives can happen even with current medical-
grade technology. It's just a question of how the false-positive rate
compares.

"Never" is just such a strong word, given how quickly technology has advanced,
and given how you don't seem to be aware of what exactly the new Apple Watch
is supposed to be able to do.

Do you work for a Holter-producing company or something?

~~~
JshWright
I am very aware of what the watch does. A doctor is not going to diagnose
atrial fibrillation based on a single ECG lead. They are going to do a more
complete ECG (either in-office, or with a Holter monitor style device at
home).

The watch absolutely plays an important role (it's a widely distributed, high
SNR screening tool; that's definitely valuable), but it's not replacing more
complete diagnostic tests.

As a meta comment... I think it's good to avoid using "you" too much when
replying to someone. Respond to what someone said, not assumptions about who
they are, what they know, or what their motivations are. For whatever it's
worth, I am a software developer and paramedic.

~~~
wrycoder
It sounds like there is an opportunity for a displayless device on the other
wrist.

~~~
JshWright
And a wire running between them...?

~~~
wrycoder
Bluetooth, I would think.

~~~
JshWright
They would need to be electrically connected (like the leads on a multimeter).

------
mikekij
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.

~~~
bluGill
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.

~~~
monkmartinez
The exploding ER / EMS system would like to have a word with you! Every niggle
or discomfort, it seems, can generate a 911 call and a visit to the ER.
Legally, EMS can not diagnose in the field so we send the bulk of people that
call 911 into the ER for further evaluation... whether they really need it or
not. I can tell you that most don't.

~~~
BRAlNlAC
counterpoint. The healthcare system pushes people into emergency medicine for
non-emergencies. About 10 years ago when I was in high school I got a cut on
my chin that required stitches, my mom got an urgent appointment with my PCP
later that day–who then told me to go the ER, saying, "we don't even have a
suture in this clinic" We were trying to save time, money and not burden the
system, and instead shot ourselves in the foot.

~~~
nradov
The healthcare system, or at least the insurance side of it, actively tries to
push patients to urgent care clinics instead of ERs for that type of problem.
Most health plans have a phone number where you can call a nurse to ask
whether you should go to the ER or not.

And the vast majority of primary care clinics do have sutures in stock.

------
chrisBob
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.

------
kendallpark
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.

~~~
gwbas1c
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.

~~~
breckuh
> The point will come when not regularly wearing one of these devices is
> considered hazardous to one's health

I 100% agree. I think we are on the cusp of the "cyborg" era, like it or not.
Humans will wear health tracking devices at all times. Already 10M+ do, from
basically 0 a decade ago.

Personally the sleep tracking and heart rate data from wearing my bands since
2014 led me to a diagnosis and fix for a number of health issues.

But the real promise lies ahead, as new and better sensors are engineered. In
addition to helping with traditional health issues, devices will increasingly
allow the conscious part of your mind to have real-time self-awareness of the
biological factors going on that influence your thoughts and decisions and
answer questions like these:

\- Did you say "no" to that thing because it was the right decision or because
your blood glucose level was so low? \- Was your high productivity level today
a fluke or influenced by the high caffeine level in your system? \- How
"tired" are you really?

Some people might not like it, but I don't know if they'll have a choice. Not
taking advantage of these technologies would put them at a disadvantage in
school, work, sports, and perhaps all other areas in life.

I think that moment is more like 10-20 years out, but otherwise agree with
you.

------
post_break
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.

~~~
graeme
Interesting. Is the Samsung watch less effective at heart health tracking, or
does Apple just have better partnerships with insurers?

~~~
brandonb
For what it's worth, United Healthcare's Motion program supports Fitbit,
Garmin, Samsung, Apple Watch, and more:
[https://www.mobihealthnews.com/content/unitedhealthcare-
adds...](https://www.mobihealthnews.com/content/unitedhealthcare-adds-apple-
watch-motion-employee-wellness-program)

UHC is the U.S.'s largest insurer, and they claim to have validation data that
shows this program saves money.

~~~
awakeasleep
UHC's Motion program is an incentive program for higher value employees.

It's more of a perk for the c-suite or law partners than a serious attempt to
improve health.

------
nradov
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?

~~~
mikestew
_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.

~~~
nradov
You'd be surprised how many athletes are wearing Apple watches now, either
alone or along with other fitness trackers or bike computers. I see Apple
watches more and more at races and on Strava activities.

------
clamprecht
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?

~~~
mtw
In the same manner that in a conventional ECG, 10 electrodes are used while
this only requires you to put your finger on the crown. The data is less
accurate but apparently good enough to detect 98% of AFib cases.

~~~
GeekyBear
The 12 lead ECG is used for a different diagnostic purpose.

The Apple Watch is positioned as a cardiac event monitor. Those are intended
for extended wear and only need to take measurements between a single pair of
electrodes to function.

For instance, a Zio Patch is a modern version designed to be compact and
unobtrusive.

Here's a comparison between a Zio Patch and the old school tech of a Holter
Monitor.

[https://www.medgadget.com/2014/01/zio-wireless-patch-may-
be-...](https://www.medgadget.com/2014/01/zio-wireless-patch-may-be-better-
option-than-holter-monitors-for-cardiac-arrhythmia-diagnosis.html)

One of the tech journalists at Ziff Davis who took part in Apple's heart study
ended up being dignosed with Afib by his cardiologist. He wrote about the
process he went through.

TLDR: The watch flagged that there was a potential problem, he was given a
traditional tape on cardiac event monitor to wear for an extended period to
confirm the watch data, and was then diagnosed and treated.

[https://www.zdnet.com/article/how-apple-watch-saved-my-
life/](https://www.zdnet.com/article/how-apple-watch-saved-my-life/)

For me, this was the money quote: "I've had EKGs a number of times, and there
was never any indication anything was wrong."

------
walterbell
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.

~~~
oflannabhra
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.

------
appleiigs
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)

~~~
stcredzero
_I run in a HR range_

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
Endurance athletes commonly do workouts around heart rate ranges, sometimes
holding a steady rate or sometimes cycling up and down between zones. Heart
rates are typically divided into 5 zones based on the athlete's maximum rate.
Targeting specific zones for specific amounts of time can be an effective way
to boost aerobic or anaerobic capacity.

------
wink
> 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.

------
paul7986
What about the Apple toilet? No joke!

A toilet that analyzes specimen data and alerts you of potential issues.

~~~
breckuh
[https://www.youtube.com/watch?v=DJklHwoYgBQ](https://www.youtube.com/watch?v=DJklHwoYgBQ)

This is a parody but actually has some great product ideas :)

~~~
paul7986
That pipe sounds solid ... maybe you can’t get solid data by analyzing poo?
Though you sure can from urine.

Overall I guess I’m missing things... like why is this idea being parodied?

~~~
breckuh
It's more of a parody of the Valley than the idea itself. Most of the aspects
of the idea surround things like Tweeting, followers, et cetera.

I like the idea of a pipe! Perhaps makes more sense than a smart toilet.

------
IBM
Guess he's just going to ignore this post:

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...](https://steveblank.com/2016/10/24/why-tim-cook-is-steve-ballmer-and-
why-he-still-has-his-job-at-apple/)

------
gaius
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.

------
trophycase
Yes, the tipping point for human privacy.

------
chicob
Insurance companies are already salivating to the prospect of ever accessing
their customers' health monitor data.

Cross that data with customer loyalty card data regarding groceries purchases
for the next decades, and one can practically automate ineligibility.

------
unionjack22
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.

~~~
briandear
So the president of the American Heart Association as well as doctors at
Stanford are all masking the “horror” of your resident wife?

You know what’s worse than a false positive? A real positive and no way to
know about it.

~~~
bennyelv
On an individual basis, yes. Across a population, not necessarily.

If the false positives result in investigations that carry medical risk then
it's possible that on the whole, more harm than good is done.

There's also an interesting consideration around real positives that we've
never detected in the past and that never presented any symptoms or negative
outcomes. It's possible that we now start detecting cases which previously the
patient went their whole life without knowing about and would be totally
unaffected by, and introducing medical interventions that have downsides.

How it all stacks up in the end we can't possibly know, but this development
isn't automatically "good".

