What Is Next for Wearables?
Dr Kate Lazarenko is a founder and director of Health Industry Matters Pte. Ltd., a boutique consulting firm focused on creating customised solutions that address unique needs of clients across the health industry ecosystem. Kate holds a PhD in health information systems from Monash University, Australia and was as an adjunct Research Fellow post her doctorate. Apart from academia, Kate worked for the government-funded authority supporting a national vision for digital health for Australia (National E-Health Transition Authority), management consulting (PricewaterhouseCoopers, Singapore) and health IT industry. Kate is passionate about exploring ways in which companies can foster innovation in order to create better services and products.
Aaron Kong is a co-author and managing director of A Life of Active.
Wearable technology, also referred to as ‘wearables’, ‘fashionable technology’, ‘wearable devices’, ‘tech togs’ or ‘fashion electronics’, is defined by Wikipedia as “clothing and accessories incorporating computer and advanced electronic technologies”. We would argue that health technology wearables, with their increasing popularity and growing demand, are the better-known members of the Internet of Things family. In this paper we will touch upon the history of wearables, discuss their evolution and adoption, outline five main categories of wearables with a particular emphasis on wristwear as the most popular health technology wearable today, and the potential of such wearables for tracking health measurements. We will also touch upon certain challenges and opportunities associated with wearable devices and discuss what is to come.
Health Consumers circa 2016
There is a lot of research dedicated to the new generation of health consumers. The common agreement is that the new generation of consumers extensively uses the Internet to obtain health related information. Such consumers feel empowered due to the fact that they are not only able to consult their family doctors, but also get extensive Internet information about their topics of interest, get in touch with the communities and groups of consumers that are interested in the same issues, and even get recommended the best specialists in the area or country to get a second opinion. However, a number of health consumers these days do not stop there – they take health matters in their own hands and use various digital tools, also known as health technology wearables, to track and monitor health measurements, such as heart rate, number of steps, sleep patterns, calories burnt, food consumed, and more. These wearable devices are highly popular amongst the modern connected generation who are impatient, information and data hungry, value convenience above all and expect personalised, on-demand services that enable them to take control over their health.
The existing usage statistics and forecasts demonstrate that the use of health technology wearables has doubled over the last two years (21% in 2016 vs. 9% in 2014). Moreover, 78% of healthcare consumers across the globe wear or are willing to wear gadgets to track their lifestyle habits and/or vital signs. Juniper Research forecasts the wearable market to grow extensively in the next few years with the anticipated global revenue from smart wearable devices reaching $53.2 billion by 2019.
Other findings suggest that the number of wearables produced for the healthcare segment will be growing steadily over the next five years. Such predictions are easy to believe given the amount of non-traditional players that are stepping into the healthcare field with their original and competitive offerings, e.g. multiple startups that offer various wearables and devices that capture health measurements, analyse and share them in real time and on demand.
Health Technology Wearables
It is well known that we cannot effectively track something that we do not measure. The fact that health technology wearables allow users to effectively track health measurements in real time is one of the key factors that make them popular with the new generation of health consumers. As a proud owner of a fitness band for the last four years, I can unequivocally state that the ability to get instant access to my data (e.g. heart rate, amount of calories burnt, etc.) when I need it and with minimal effort from my part is the most useful feature of my fitness band. Moreover, there are a number of other attractions that help health technology wearables gain popularity:
– Availability and variety of wearables (different colours, shapes, interfaces, etc.);
– Effortless wireless connectivity and integration with smartphones;
– The convenience of getting real-time data at any given moment, at a glance and from anywhere;
– Different types of information and health measurements that are getting tracked, stored, analysed and presented in a user-friendly manner, and often in a manner conducive for decision-making;
– Relatively inexpensive price;
– Some of the wearables are highly customisable (e.g. classy designer cases made especially for Fitbit fitness bands);
– Plethora of applications that can be easily installed on and removed from smartphones and other smart devices, e.g. tablets, phablets, ipads, etc.;
– Provision of ‘extra’ functions, e.g. ability to see the caller or read a message using the wearable, that are similar to the functions of smartwatches that are often more expensive.
Moreover, there are a number of principles related to the design and performance of wearables that make empowered health consumers appreciate their wearable devices even more (see Figure 1).
When it comes to the wearable devices currently available on the market, there are various types of wearables that can literally cover us from head to toe. Whilst some of the wearables are very popular (e.g. fitness wristbands), others are not so well known (e.g. sensors that help adjust one’s posture in real time). Overall, all existing wearables can be divided into five distinctive categories as illustrated in Figure 2.
It is clear that consumers have plenty of choices when it comes to wearable devices, and each one of the five categories listed above, has a lot of potential when it comes to
tracking health measurements. However, from our perspective the most interesting and promising wearables from the world of health technology today are the wristwear, namely various fitness bands or activity trackers, along with smartwatches that often offer more extensive functionality. Further in this paper we will discuss the evolution of wristwear, elaborate on how this technology facilitates taking health measurements globally and talk about ‘A Life of Active’ – a case study from Singapore that demonstrates how wearables are currently being used in the Asian context.
It is clear that consumers have plenty of choices when it comes to wearable devices, and each one of the five categories listed above, has a lot of potential when it comes to tracking health measurements. However, from our perspective the most interesting and promising wearables from the world of health technology today are the wristwear, namely various fitness bands or activity trackers, along with smartwatches that often offer more extensive functionality. Further in this paper we will discuss the evolution of wristwear, elaborate on how this technology facilitates taking health measurements globally and talk about
‘A Life of Active’ – a case study from Singapore that demonstrates how wearables are currently being used in the Asian context.
Evolution and Adoption of Wristwear
According to Forbes, the wearables industry has been blooming with its market worth $5.1 billion in 2015, and is expected to grow by 25% more by 2020 . Wristwear is the most popular category of wearables as it currently accounts for 9 in 10 wearables bought worldwide . The wristwear has gone a long way before becoming the world’s most popular wearable (see Figure 3).
While Jawbone Up was the first wristwear of its kind with the ability to track and store health measurements on the go, some might argue that it was not always connected to the smartphones or laptops, which is partially true. Jawbone did not have a screen and could only display health measurements (such as the number of steps, hours of sleep, calories burnt, etc.) when plugged into a smartphone or connected to a laptop. However, the invention of this wristwear device was revolutionary, and was followed by a number of fitness trackers and smart watches that had displays and could be wirelessly connected to smartphones.
Inspired by a resounding success of Jawbone Up, Nike designed and manufactured Nike Fuelband released in 2012. The device had a small graphical display that notified the user of their daily activities, proximity to hitting their goals and provided other feedback. The fitness band came with its own Nike+ connect software that enabled calculation and customisation of personal statistics and achievements once the device was plugged into a laptop or a smartphone.
Pebble watch developed by Pebble Technology Corporation, USA in 2012-2013, was the first of its kind smartwatch that could wirelessly via Bluetooth connect to and display messages and notifications from iOS as well as Android smartphones. Pebble watch also had an online application store where users could download applications customised for Pebble watch that were developed by a myriad of third party sellers.
In the end of 2013, Nissan, a Japanese automobile manufacturer, created Nissan Nismo Smartwatch, the first smartwatch to communicate with a car and a smartphone via Bluetooth. The watch could connect with Nissan vehicles and monitor drivers’ biometrics, e.g. heart rate, in order to identify when the drivers were becoming tired. That information then would be matched to the car’s performance data, e.g. its current speed, and an appropriate action, e.g. to slow down or take a break, would be suggested to the driver.
Starting 2013 every big player in the smartphone market, such as Apple, Samsung, Sony, LG and many others have been working on their own smartwatches. In parallel, Fitbit, a consumer electronics company based in the USA, released Fitbit Flex in 2013, which was worn on a wrist as opposed to their other trackers that needed to be clipped onto the clothes. Since then, Fitbit released a large number of wristwear devices, and while they do not offer the extensive functionality of smartwatches, they meticulously track health measurements, easily and wirelessly connect to various smartphones and are offered at competitive prices.
The wristwear market keeps growing and offering more and more devices of various colours, sizes and functionalities. Nevertheless, it is important to understand whether the variety and availability of wearables drive their adoption, or are there other factors in play when it comes to choosing health technology wearables that empower users to measure progress towards their goals and trigger subsequent behavioural change.
According to Dr Mitesh Patel and his colleagues from the Philadelphia VA Medical Center, there are four major challenges pertaining to the use of wearables, including wristwear devices that need to be addressed in order to enable behavioural change:
1. Health consumers should be motivated and interested enough to be willing to invest in the wearable device;
2. Once acquired, the user needs to remember to wear the device and to recharge it;
3. The device has to be customisable enough to enable the user to regularly and accurately track their targeted behaviour;
4. Tracked information has to be presented back to the user in a way that can be easily understood, supports decision-making and motivates the user to take action.
Statistics demonstrates that 27.2% of US adults do not intend to use wristwear or other wearable devices to track their fitness or health measurements. Therefore, it’s safe to assume that whilst some, more technologically savvy, health consumers are comfortable to use various wristwear and other wearable devices, others might find such devices not particularly useful, interesting or needed. However, half of these same respondents state that they would be prepared to reconsider if:
1. The tracking device is provided by their physician, or;
2. Wearing such a device would result in better healthcare advice from their physician, or;
3. There would be a possibility of lowering their health insurance premiums.
To conclude, the respondents indicate that they would be willing to use wristwear and other wearables to track and store their health measurements, if that would result in certain tangible benefits for them, whether it’s monetary incentives or better health advice. However, we would argue that simply tracking and storing health measurements using wristwear and other wearable devices might not be enough to trigger behavioural change. Therefore, the increasingly growing popularity of wristwear does not always suggest that just because the health consumers are enabled to track their health measurements, they will readily change their behaviour or adjust their lifestyle habits.
Wristwear to Support Behavioural Change
There are a number of books and articles written about behavioural change. Most authors agree that it is a complex phenomenon that does not happen overnight.
While it is difficult to persuade people to perform their tasks in a different way to trigger behavioural change, it is even more challenging to maintain such behaviour change in the long run. Therefore, the importance of persuasion and the right motivation in enabling and promoting behavioural change cannot be overstated and emphasised enough.
Researchers from the Philadelphia VA Medical Centre suggest that whilst wristwear and other wearable devices have the potential to trigger behavioural change in health consumers, the devices alone cannot trigger such a change. In fact, there is little evidence to suggest that the gap between recording information and changing user behaviour is being effectively bridged by wearable devices. The authors suggest that a combination of various behavioural economics concepts and engagement strategies, such as individual encouragement, social competition and collaboration, effective feedback loops, gamification, could help initiate and achieve behavioural change.
In Asia, a new Singapore-based startup ‘A Life of Active’ (ALOA) has created an online wellness portal that rewards its members for walking. According to a 2012 survey, seven out of ten Singaporeans do not get enough daily exercise, which contributes to health conditions such as heart disease and diabetes. Studies show that regular but short periods of physical activity can help reduce the risk of such health issues. ALOA was created to encourage Singaporeans to engage in and maintain a healthy lifestyle. Each consumer subscribed to the ALOA portal, has a wearable device – a wristband – that collects data about the number of steps taken and distance walked. The data is then synced from the wristband to the portal and displayed back to the users. Members are encouraged to take part in various challenges of different intensity to win cash, vouchers or to participate in lucky draws.
The ALOA founders wanted to determine whether implementation of various engagement strategies could, in fact, lead to and promote behavioural change, and how such strategies would influence consumers’ motivation. A number of studies talk about the power of intrinsic motivation that can be defined as a desire to act in a specific manner because of the sense of fulfilment gained, and how it can supersede external rewards.
However, the ALOA founders have found that the intrinsic motivation often encourages the creation of a variety of motivational techniques but not the behaviour change per se. In the meantime, there are cases where external motivators, such as cash rewards, positively influence behaviour changes. Such cases demonstrate that successful behaviour change initiatives, such as quitting smoking, changing diets and increasing exercise frequency, have been encouraged and facilitated by cash rewards.
The ALOA founders wanted to determine whether health consumers would increase their level of physical activity if they were rewarded for walking more, and set out to become the external motivational trigger for members to become more active. The level of physical activity was measured by an increase in either the frequency of the consumers’ sessions or the number of steps taken. The consumers were invited to participate in weekly challenges, where they were asked to walk between 4,000 to 15,000 steps either in one go, daily or over five to seven consecutive days.
The ALOA founders found that the monetary incentives proved to be a substantial motivator for the consumers to take part in physical activities. In fact, out of the 15 challenges ran from June until September 2016, those with monetary rewards were the most popular and had the highest number of members completing them. Interestingly, lucky draws (for big-ticket items) that represented the element of chance were not as popular as challenges with guaranteed monetary rewards. Based on the three months trial run of the portal, the ALOA founders conclude that the external motivation can serve as a framework or even a backbone of their programme to drive behaviour change. They identify three important lessons learnt:
1. Engage consumers in early stages of their adopting a new behaviour
Giving health consumers realistic and achievable targets with the means to monitor their achievements is most effective when done in early stages of adopting new behaviour, i.e. when the consumers are starting to establish new habits.
2. Customise and diversify
Health consumers operate in a range of personal situations and no external trigger affects them in the same way. To that end, while the majority of members enjoyed receiving monetary rewards, the others looked to earn vouchers or lucky draw prizes that addressed practical matters. Therefore, diversifying and introducing a variety of engagement strategies and rewards, facilitates behavioural change.
3. Money talks
It is necessary to establish baseline levels of activity to gauge fitness improvements and to determine behaviour change. Incentives, especially monetary ones, can help overcome inertia and procrastination barriers towards starting and maintaining participation in a walking programme.
The ALOA founders state they are looking forward to the next stage of engaging with their members. Having built up an understanding of triggers and a walking programme baseline, they want to move into providing challenges on demand (‘Start a challenge just before the daily walk and earn!’) as well as stronger personalisation with thresholds, where the portal alerts the consumers when they fall under or go above their pre-selected milestones.
Challenges and Opportunities
The world of wearables has its own challenges and hurdles to overcome. Despite the growing popularity of wristwear and other health technology wearables, the research suggests that, depending on a wearable, anywhere between 33% to 50% of health customers will stop using a device within six months from the day of purchase. This can be attributed to a number of factors, including the fierce competition amongst manufacturers of wristwear and other health technology wearables. The reality is that for every one hundred of wearable devices, less than five per cent will be somewhat successful when they make it to the market. Other factors that pose a significant challenge when it comes to the use and adoption of wearables by health consumers are:
Most of the health technology wearables give users a unique and enticing opportunity to be constantly connected to the smartphones via the means of Wi-Fi, Bluetooth and NFC. However, would a prolonged use of such devices expose health consumers to unwanted health risks? Most scientists believe that wearable devices emit low levels of electromagnetic radiation (typically two orders of magnitude less than a mobile phone) and therefore, pose no health risk. However, there are some researchers who are more sceptical on the matter and believe that more work needs to be done in order to unequivocally state that wearables cause no harm to their users. Another safety related concern is about the fact that at times wearables can be rather distracting. Whilst it is impressive to have a smartwatch that monitors all your email accounts, phone calls and messages in real-time, and notifies you the moment there is new activity detected (including health-related notifications), such alerts can be distracting and potentially dangerous in certain situations, e.g. when driving a car.
2. Unreliable or inaccurate data
The drawback of most of the health technology wearables is that the data is not quite captured in the real-time. There is almost always a delay from the moment when the data is captured to the moment when it is displayed. This is not a critical issue in most cases, however, as more and more health consumers rely on the wearables to track their fitness activities, amount of calories burnt, etc. it is important to ensure that the information is tracked, analysed and presented accurately and the right way. Instead of taking collected data at face value without being concerned about how accurately it has been captured or whether it is correct, the manufacturers of the wearables should ensure that the health consumers can fully trust their devices. This issue can become paramount when such wearable devices are used for specific medical purposes (e.g. measuring blood glucose levels) and the collected data gets integrated into the hospitals’ electronic health records systems.
3. Privacy issues
There is no secret that some of the health consumers are rather reluctant to share their data with the rest of the world. Therefore, manufacturers of health technology wearables have to ensure that the data is protected at all times. Along with data accuracy, data privacy is of particular importance if such data gets transferred to and stored in the hospitals’ electronic health records systems.
4. Information overload
Wristwear devices that track health measurements on a daily basis, such as the number of steps taken, sleep patterns, heart rate, etc. generate a huge amount of data per user. Therefore, another challenge for the manufacturers of the health technology wearables is to make sure that the data is presented in a way that does not overwhelm with information, but instead allows the user to get an accurate synthesis of information that will enable them to make better decisions and lifestyle choices.
The manufacturers of wearable devices collecting data that has a potential to be used by the physicians, face a similar challenge. In fact, one of the cases against health technology wearables is that encouraging physicians to work with data derived from wearable devices could result in a technology overload and drive physicians away from face-to-face patient-physician interactions. Therefore, it is important to ensure that the data that could potentially be used by the physicians is accurate, reliable and presented in a way that is easily understood and digested by the medical professionals. Moreover, engaging the medical community in the design of such wearable devices as early as possible will ensure that doctors and other medical professionals will get the right data at the right time and in the preferred format.
While most of the manufacturers strive to make their wearables user friendly, unfortunately it does not always work. One of the studies suggests that 24% of consumers find the monitor of their health technology wearable to be too complicated. Various factors, such as the number of functions available, a lack of wristwear buttons, the size of displays contribute to the fact that the users sometimes find it hard to understand multifaceted applications of their wearables, or appreciate their sleek designs.
6. Limited plug-and-play features
Some of the manufacturers of wearable devices, in an effort to emulate Apple, create products that are only capable to operate on a restrictive proprietary platform.
Needless to say, this poses certain challenges for the health consumers as well as third party developers because it limits their application development options.
Despite some of the drawback and existing challenges, the number of heath technology wearables and their applications keeps growing. Therefore, another question to ask is whether these gadgets are merely a trend or do they have real staying power and the ability to disrupt healthcare and create a substantial impact?
Where to from Here?
We, the authors of this paper, firmly believe that the future of wearables lies in a firm understanding of their existing limitations and challenges, and uncovering ways to overcome them. One of the very first questions that the manufacturers of health technology wearables should ask themselves is whether they would like to position their device as a consumer device for health and wellness, or as a true medical-grade product validated for use in the clinical setting and approved for clinical decision-making.
If certain health technology wearables are created and marketed as a health and wellness device used to track the number of steps and calories burnt, the manufacturers should continue on working with the users to build better and more user-friendly interfaces and desirable functionality. Given that smartwatches will reportedly replace fitness bands as the most purchased wristwear by 2017, the current wearables’ manufacturers along with other industry players might want to reassess their strategy and rethink their offerings in the near future. Moreover, such manufacturers might want to consider engaging with the consumers by proactively supporting them in managing health and wellness through utilisation of both ‘push’ and ‘pull’ methods of information delivery. Accurateness of measurements, privacy and security have to be of high priority as well, as discussed earlier in this paper. There should be emphasis on value, i.e. identifying what functionality matters to the customers most, and high performance, e.g. there should be no noticeable delays in the device’s performance. The manufacturers might also consider a better adoption of outcome-based models and algorithms that will enable users to state their ultimate goals (e.g. their fitness goals) so that the device can work with the user towards achieving such goals, as well as remind the user to take necessary actions on a day-to-day basis. This functionality can be particularly appreciated by the users who share data collected by their wearables, with their insurance companies in order to get future discounts or better premiums.
However, if manufacturers decide to create a health technology wearable that can be used as a medical device in a clinical setting, the number of challenges to overcome grows exponentially. There is no doubt that there is a huge market for such devices, and they are much needed in this day and age. Most medical institutions and insurance providers might be willing to pay significant amounts of money for such wearables; various venture capitalist firms might consider investing large sums in such project, but most importantly, such devices have a real opportunity to make a huge difference in people’s lives. However, every one of such manufacturers will have a few hurdles to overcome before the devices can successfully reach their targeted patient base:
1. Specific health technology wearables developed specifically for the physicians and other medical professionals require an extensive collaboration between medical personnel and IT teams. Such devices will have to have the ability to deliver exactly what is expected of them, provide accurate data and be endorsed by the clinicians;
2. Safety is another serious matter that is taken to the whole new level once a wearable gets classified as a medical device, as it would have to undergo the Food and Drug Administration, USA (or similar organisations in other countries) regulatory scrutiny to ensure it is safe to use;
3. Privacy becomes a major challenge that has to be addressed. For instance, in the USA any data that comes from patient-bought wearables is not required to be protected under HIPAA, but hospital-assigned devices that contain protected health information must be HIPAA-compliant. Therefore, such device manufacturers have to make sure that their wearables are HIPAA compliant, or compliant with other Data Protection Acts (e.g. in Canada, UK, etc.).
Amongst the three challenges listed above, privacy is one of the most complex and crucial ones. Case in point – when the creators of GoogleGlass realised that their device could be recalibrated and used in a clinical setting, e.g. to audio or video tape clinicians’ conversations with their patients and transcribe them directly into the hospitals’ electronic health records systems, or to assist the surgeons with certain real-time time data during complicated procedures, they faced the HIPAA compliance issue that is yet to be resolved.
In conclusion, there is no doubt that health technology wearables have a potential to enrich lives of and help millions of people globally. In the technology enabled world where health consumers are getting empowered and willing to take responsibility for their lifestyle choices, the shift from intervention to prevention when it comes to healthcare is undeniable. There is little argument that increased interconnectedness and enhanced technological knowledge of the general population facilitates a slow transformation of patient care from episodic visits into continuous support of patient wellness and wellbeing, and health technology wearables certainly have a huge role to play in this powerful transition.
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