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”[1]. 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[2]. 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[3]. 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[4].

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)[5]. Moreover, 78% of healthcare consumers across the globe wear or are willing to wear gadgets to track their lifestyle habits and/or vital signs[6]. 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[7].

Other findings suggest that the number of wearables produced for the healthcare segment will be growing steadily over the next five years[8]. 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[9].

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[10].

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[11]. 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.[12]

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.[13]

In Asia, a new Singapore-based startup ‘A Life of Active’ [14](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[15]. Studies show that regular but short periods of physical activity can help reduce the risk of such health issues[16]. 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.[17]

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.[18]

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.[19] Other factors that pose a significant challenge when it comes to the use and adoption of wearables by health consumers are:

1. Safety
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.[20] 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[21]. 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.

5. Over-engineering
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.[22]

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.[23]

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[24], 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.[25]

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;[26]

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.[27] 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.[28]

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.

References:
[1] https://en.wikipedia.org/wiki/Wearable_technology
[2]Tabitha Tonsaker, Gillian Bartlett and Cvetan Trpkov (2014) “Health information on the Internet: Gold mine or minefield?”, Canadian Family Physician; 60(5): 407-408.
[3] Carmen Wong, Christopher Harrison, Helena Britt and Joan Henderson (2014) “Patient use of the internet for health information”, Australian Family Physician; 43(12): 875-877.
[4] https://www.accenture.com/us-en/insight-predictable-disruption-digital-health
[5] https://www.accenture.com/us-en/insight-research-shows-patients-united-states-want-heavy
[6] https://www.accenture.com/us-en/insight-research-shows-patients-united-states-want-heavy
[7] http://www.juniperresearch.com/press/press-releases/smart-wearables-market-to-generate-$53bn-hardware
[8] https://www.strategyanalytics.com/strategy-analytics/news/strategy-analytics-press-releases/strategy-analytics-press-release/2016/06/22/strategy-analytics-wearables-revenues-projected-to-grow-31-percent-in-2016-as-smartwatches-lead-value-share
[9] https://www.accenture.com/us-en/insight-predictable-disruption-digital-health
[10] Mitesh S. Patel; David A. Asch and Kevin G. Volpp (2015) “Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change”, JAMA; 313 (5): 459-460
[11] Research.technologyadvice.com/wearable-technology-study
[12] Garvin, David A., and Michael A. Roberto. “Change Through Persuasion.” Harvard Business Review 83, no. 2 (February 2005): 104–112.
[13] Mitesh S. Patel; David A. Asch and Kevin G. Volpp (2015) “Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change”, JAMA ;313(5):459-460.
[14] http://alifeofactive.com/
[15] http://health.asiaone.com/health/body-mind/3-ways-busy-singaporeans-can-reduce-their-chances-getting-diabetes
[16] Tikkanen O, Haakana P, Pesola AJ, et al. Muscle Activity and Inactivity Periods during Normal Daily Life. Johannsen D, ed. PLoS ONE. 2013;8(1):e52228. doi:10.1371/journal.pone.0052228.
[17] Ryan, Richard M., and Edward L. Deci (2000) “Intrinsic and extrinsic motivations: Classic definitions and new directions.” Contemporary educational psychology 25.1: 54-67.
[18] Gneezy, U., Meier, S., & Ray-Biel, P. (2011). When and Why Incentives (Don’t) Work to Modify Behavior. Journal of Economic Perspectives, 25(4), 191-210.)
[19] http://www.forbes.com/sites/reenitadas/2016/01/07/the-future-of-wearables-can-companies-avoid-the-pitfalls-threatening-healthcare-wearables
[20] http://www.nytimes.com/2015/03/19/style/could-wearable-computers-be-as-harmful-as-cigarettes.html
[21] http://searchhealthit.techtarget.com/essentialguide/Wearable-health-technology-in-medical-and-consumer-arenas
[22] http://mobihealthnews.com/39382/global-survey-finds-8-percent-adoption-of-fitness-wearables
[23] http://forbes.com/sites/reenitadas/2016/01/07/the-future-of-wearables-can-companies-avoid-the-pitfalls-threatening-healthcare-wearables
[24] http://www.juniperresearch.com/press/press-releases/smart-wearables-market-to-generate-$53bn-hardware
[25] http://www.asiainsurancereview.com/Magazine/ReadMagazineArticle?aid=35855
[26] http://internetofthingsagenda.techtarget.com/feature/Wearable-device-heart-rate-monitoring-entering-the-consumer-mainstream
[27] http://searchhealthit.techtarget.com/essentialguide/Wearable-health-technology-in-medical-and-consumer-arenas
[28] http://hitconsultant.net/2016/01/19/future-wearables-healthcare/

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Author shares his views on how techno-management innovation could help in dealing with the challenges in Emergency Medical Services in India

Emergency Medical Services (EMS), across the globe, play a crucial role in saving lives of the patients who require urgent medical assistance[1,2]. The concept of Star of Life[3] conceptualized by National Highway Traffic Safety Administration, United States of America (1995) drives the operations of EMS which include the out-of-hospital care to the emergency patients and transport the patients to the definitive care at hospitals within predefined time standards[4]. The Star of Life was adapted from the personal Medical Identification Symbol of the American Medical Association.

Each bar on the “Star of Life” represents one of six EMS functions. The functions include:

1. Detection
2. Reporting
3. Response
4. On-Scene Care5. Care in Transit
6. Transfer to Definitive Care

The story of Indian EMS started with the inception of Emergency Management and Research Institute in April 2005 that provided services across the state of Andhra Pradesh (currently Andhra Pradesh and Telangana). Earlier, people were mostly dependent on the ad-hoc emergency provider networks in which hospitals and taxis provided the services to meet the emergency needs. Later in 2005, the concept was conceived by National Health Mission (NHM) (then National Rural Health Mission) and initiated Emergency Response Services (ERS), popularly known as “108 Ambulance Service Project” to ensure emergency care for rural India along with urban India[6]. The number ‘108’ corresponds to the toll free number which allows the patients to report the emergency cases to emergency response Centres in each state. ERS is a part of National Ambulance Service (NAS) in which NHM guides and supports the states of India to operate various ambulance services directly or in Public Private Partnership (PPP). In most of the states of India, the 108 Ambulance Services are being run in PPP mode with various private service providers such as GVK EMRI[7], Ziqitza Health Care Limited (ZHL)[8] and BVG India Ltd[9]. Apart from the 108 ambulance services, there are various other services such as 102, 1298, 1033, Centralized Accident and Trauma Service (CATS) and different localized ambulance services run by private bodies[5]. Figure 2 shows the distribution of various types of emergency ambulance services such as 108, 102, 1033, 1298 and CATS in India.

102 Service, a government supported service, essentially consists of basic patient transport and primarily focuses on maternal and neonatal care. It provides free transfer from home to facility, inter facility transfer in case of referral and drop back for mothers and babies. 1298 and 1033 services are privately owned services which cater to various states of India. The Centralized Accident and Trauma Service (CATS) is one of the early ambulance services in India which was conceptualized and initiated well before EMRI. It focuses on accident and trauma and extends its services only in Delhi. There are various ambulance services run by private bodies which are controlled locally and serve the local people. For example, Accident Care and Transport Services in central Kerala which uses toll free number 1099. As the Figure 2 shows some of the state yet to have an EMS while other states have more than one type of EMS services which follow different implementation models [7,8,9,10].

Challenges in EMS in India

Although the implementation of NAS guidelines is mandatory for all the ambulances which are financially supported under NHM, the guidelines for training and operation of EMS are not well defined. Due to the state level PPP and private ownership models, the national level perception is lacking and people of some states do not have access to the services. The recommendation for a single number at national level for all emergency cases is yet to be implemented and there is a high variability in the emergency numbers which create confusion among the people. The lack of standardization in EMS education creates problematic situation as EMS requires highly skilled labor.

Even though the 108 ambulances are conceptualized to cater only emergency patients, in some states these ambulances play the role of 102 ambulances to provide maternal and neonatal care including the transfer from facility to home. The dual role play makes the situations complicated as the emergency resources are allocated for elective cases which would require the basic transportation facility only. Furthermore, the challenges become harder as there are budgetary constraints and the cost of operations are ever increasing along with the high capital investments. It is important to notice that the increase in the number of strikes by the emergency health care professionals in various states in the recent past. In addition to that, there are requirements for replacing existing ambulances with new ambulances as most of the ambulances have attained the mandatory cut-off retirement age of five years and covered more than 0.5 million kilometers[11]. There is a call for more ambulances as the existing number of ambulances is not enough to serve the high density population of India.

The services are dependent on technology like Global Positioning Satellites (GPS) / Geo-spatial Information Systems (GIS) and other information and communication technologies (ICT) including internet of things (IoT). The technology development in India needs to go a long way to reduce the preventable manual error in the system. Presently, the data entries in most of the states heavily depend up on the manual effort and there is a possibility of human error in entries which makes the collected data highly unreliable. Moreover, the GPS technology fails miserably in some rural part of India which forces the system to have manual intervention in locating the incidents.

The awareness among the general community regarding the emergency service is crucial for success of the service. The people who call to the emergency response centre for non-emergency cases are not only misusing the resources, but they also prevent the real emergency users from using it. As the service is free, the chances of misuse are very high due to the ignorance about the significance of these services.

Techno-management innovation as solution

As the services are constrained with budget, resources and skilled laborers, the innovation in the way it is managed is necessary. Technological innovation could help in reducing the cost and improve the management of system.

Technology Innovation:

Technology innovation is necessary to identify and forecast the requirements so that we could plan well and reduce the waste. It would help us to design and develop the ambulances with necessary equipment and remove unnecessary equipment so that cost of ambulances will be reduced, and we could place different types of ambulances depending up on the demand. The big data analytics could help us in processing the data and forecast the need so that we could be in a better position to act. Long term forecast may help us to decide up on the budget and strategic decisions. The reduction of manual intervention in data management and the streamlining of information flow in the system will help us to improve the quality of service and make action quicker. There is a need to develop an ambulance tracking system using indigenous GPS system developed by ISRO which will cover entire country and provide information more accurately.

In a nutshell, we need innovation in technology to capture and disseminate the information accurately and in a well-defined fashion, and the information captured should be processed to have better insights.

Management Innovation

Management innovation is inevitable as the cost of operations is ever increasing and 70% of the cost is attributed to the labor cost. Developing a national standard for operations and training may improve the services, and it will improve the transparency in the system. The innovation in operations management techniques is necessary as most of the existing techniques use assumptions from other countries which are not applicable to Indian context. The high population density and low level of health literacy makes Indian EMS context a difficult nut to crack. With the help of appropriate technology interventions, we need to develop new management methods to minimize the labor cost and to improve the service quality. The regionalization of EMS, standard training process, appropriate budgetary provisions, and improving awareness among the general community might improve the performance of EMS.

Refernces:
[1] Aboueljinane, L., Sahin, E., &Jemai, Z. (2013). A review on simulation models applied to emergency medical service operations. Computers & Industrial Engineering, 66(4), 734–750. http://doi.org/10.1016/j.cie.2013.09.017
[2] Al-Shaqsi, S. Z. K. (2010). Response time as a sole performance indicator in EMS: Pitfalls and solutions. Open Access Emergency Medicine, 2, 1–6.
[3] National Highway Traffic Safety Administration. (1995). “Star of Life”, Emergency Medical Care Symbol: Background, Specifications, and Criteria. U.S. Department of Transportation, National Highway Traffic Safety Administration, Office of Enforcement and Emergency Services. Retrieved from http://www.ems.gov/vgn-ext-templating/ems/sol/index.htm
[4] Rajagopalan, H. K., Saydam, C., Setzler, H., & Sharer, E. (2011). Ambulance Deployment and Shift Scheduling: An Integrated Approach. Journal of Service Science and Management, 4(1), 66–78. http://doi.org/10.4236/jssm.2011.41010
[5] Sharma, M., &Brandler, E. S. (2014). Emergency Medical Services in India: The Present and Future. Prehospital and Disaster Medicine, 29(3), 307–zs310. http://doi.org/10.1017/S1049023X14000296
[6] Emergency Response Services /Patient Transport Service, National Ambulance Service(NAS), http://nrhm.gov.in/nrhm-components/health-systems-strengthening/emri-patient-transport-service.html
[7] Emergency Management and Research Institute (EMRI), http://www.emri.in Ziqitza Health Care Limited (ZHL), http://zhl.org.in/
[8] Bharat Vikas Group (BVG) India Ltd, http://bvgindia.com/emergency-medical-service Chandigarh Metro, Chandigarh now has 2 Ambulance Services (102 and 108), http://chandigarhmetro.com/chandigarh-emergency-ambulance-services-102-and-108
[9] The Hindu, 108 services in critical stage, http://www.thehindu.com/news/cities/Hyderabad/108-services-in-critical-stage/article7279007.ece

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This paper enumerates the structural and cultural challenges of Big Data implementation in Healthcare organizations in the hierarchy of numbers, juxtaposed along the binary of the developed and developing world, which depicts the inherent digital divide which reflects in the adoption of emerging technologies.

Introduction

Big Data is the currency of the digital era, as oil was for the twentieth century. This article maps two major concepts; Big Data and Healthcare. Defining these two terms will help in informing the reader to comprehend the epistemic origins of the application, which in turn will help in unpacking the technological black box. Big Data is defined as;

“An evolving term that describes any voluminous amount of structured, semi-structured and unstructured data that has the potential to be mined for information.”[1]

And, Healthcare is defined as;

“The act of taking preventative or necessary medical procedures to improve a person’s well-being. This may be done with surgery, the administering of medicine, or other alterations in a person’s lifestyle. These services are typically offered through a health care system made up of hospitals and physicians.”[2]

Healthcare is a public good, as it is a social justice issue inter twined with our fundamental human rights. Big Data is a byproduct of twin drivers, Information Communication Technology (ICT) revolution and globalization. Data in the healthcare space is generated furiously at every node of the value chain: Payer, Provider and Global Health. The Internet of Things paradigm generates multitude of data points per second as well with numerous tracking health indicators on their smart phones. Hence, from electronic Emergency Health Records to Insurance, Data in the Healthcare space is notionally ‘Big’.

The Opportunities

Medical Practitioners decide upon the course of treatment on the basis of data which is gathered from monitoring instruments to gauge various parameters and the outcomes of diagnostic tests. Doctors leverage data to extrapolate health trends to recommend treatments to their patients particularly while treating oncological ailment. Electronic Health Records are the basic unit of medical information which needs to be stored. There are hundreds of millions of such records in federal health system architectures in the developed world.

In contrast there is unstructured, fragmented data in the medical services market in the developing world due to the standard practice which is mostly handwritten prescriptions and hard copy filing of medical reports. These data points often get lost in the complex web of files and a comparative cannot be drawn at ease between two longitudinal data points which is the basis of medical decision making. Digitization brings benefits of on boarding this enormous data set on the mainstream decision making grid such as on the enterprise architecture or on the cloud.

This treasure trove of data is an incredible opportunity to mine consumer insights for healthcare service providers. According to a research study released by BIS Research in 20153, the growth rates are in double digits for the big data analytics market across its financial, clinical and operational segments. The clinical analytics pie of the healthcare analytics market is growing at 22.54% CAGR from 2015 to 2020 while the financial slice is more than half the overall market space as depicted in figure below.

Challenges

Big Data in Healthcare as argued in the previous section is a huge opportunity to improve decision making capabilities through enhanced data storage and enabling sophisticated enablers to make sense of the data. In this section, it is our endeavor to cut through the market rhetoric and ask some hard questions regarding the actual acceptance rate of Big Data as a critical lever to leverage value in the healthcare space.

The major structural barrier in the implementation of Big Data platforms in the developing world are the following three factors:

Capital: The initial deployment of capital in order to digitize paper records and have systems which can present the data in a format which is conversant with the end user; the medical practitioner is prohibitory for small players. The consumer in the global south is cost sensitive and the back end enablers to improving decision making is not a priority for the patient. If the infrastructure up gradation costs is passed on to the patient, then it is a discomforting factor.

Skills Barrier: Medical school education pedagogy has not evolved for decades in the global south and seems to have frozen in bureaucratic and intellectual stasis. The data analytics paradigm has not seeped in to the medical school curriculum in the developing world, and there is an evident skills chasm between the potential of the market as seen from the technology industry perspective and its adoption on the ground by the healthcare service actors.

Service Providers are ‘Tech Laggards’: Doctors consider additional data entry work into electronic database systems for medical records as a ‘burden’ on top of their existing medical duties.

The recent changes in the regulatory landscape in the Unites States compulsorily mandated electronic medical records as per The Health Information Technology for Economic and Clinical Health (HITECH) Act and Obamacare, the landmark legislation expanding medical coverage in the United States has made electronic medical records a part of the health services conversation. The quest for documentation from a cultural perspective is an effort to leave a paper trail in lieu of any legal action. The big data intervention here does not create greater efficiencies; rather it adds a new layer of bureaucracy, which has a negative externality.

Big Data in the Healthcare space is an opportunity from a techno-deterministic standpoint as it is a data rich environment, but in order for Big Data to become a tool for performance improvement; structural and cultural barriers need to be resolved.

The Market Scenario

There are numerous small, medium and large healthcare providers which are utilizing big data depending on the availability of skills and infrastructure. Pharmaceutical research organizations with well-equipped infrastructure and domain expertise are leveraging on big data in oncology and other clinical trials for the toxicity and safety analysis of the medicinal products [4,5]. Big data analytics is enabling value based future for the healthcare organizations which helps them prioritize healthcare outcomes for patients through precise data. Healthcare payers are implementing predictive analytics to detect fraudulent claims. Medium scale healthcare providers are not able to benefit from big data analytics despite of established infrastructure because of technical expertise scarcity and lack of cultural perspective as explained above. Small healthcare organizations still rely on decentralized data for decision making, making big data analytics implementation strenuous due to the paucity of spare capital.

The Big Data phenomenon is well underway in developed economies. Increasing healthcare expenses and focus on value based care are driving the demand of big data analytics in the healthcare domain. Healthcare providers are moving towards evidence based medicine for systematic clinical data analysis. Meanwhile from 2010, many new innovative health-care applications and smart devices have been developed with 40% of the lot rendering predictive capabilities.

In low and middle income countries, presence of advance IT systems is limited or non-existent which end up health data on paper records. The growing and ageing population is acting as a key driver for this market which demands value based metrics for enhanced healthcare outcomes. As the healthcare infrastructural spine gets digitized, the opportunities for big data in healthcare are manifold, but this will take time as the digital inequities are symmetrically mapped in the healthcare space as in the financial inclusion sphere.

Conclusions:

Healthcare operates at the intersection of socioeconomic variables, public service delivery, demography and technology. Big Data if the correct questions are asked, this paradigm has the potential to better create decision making tools for medical professionals across the board. The attempt of the authors in this paper has been to identify the gaps in the wide scale implementation of Big Data vis-à-vis the ticket size of the players in the healthcare arena which in turn is the intellectual anchor of the paper.

Refernces:
[1] http://searchcloudcomputing.techtarget.com/definition/big-data-Big-Data, 8th August 2016
[2] http://www.businessdictionary.com/definition/health-care.html, 8th August 2016
[3] BIS Research Industry Report on ‘Big Data in Healthcare’, August 2015
[4] Bertsimas D, O’Hair A, Reylia S, Silberholz J (2013) An Analytics Approach to Designing Clinical Trials for Cancer. MIT Working Paper.
[5] https://www.hpcwire.com/2016/05/18/machine-learning-fighting-cancer , 16th August 2016)

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