Digital Health: Going Deeper

Get ready because consumer digital health is about to go deeper than your Fitbit. We’re talking DNA deep. In fact, it’s already happening.

By Susan Nowell, PT, DPT

As technology and health care have become increasingly intertwined for physical therapists in the last decade, we’ve gotten better at implementing evaluation, treatment, and education apps into our practice. WebPT recently published a succinct article outlining the “top 10 iPad apps for physical therapists,” which range from digital goniometry to 3D anatomy display tools. See www.webpt.com/blog/post/top-10-ipad-apps-physical-therapists for the complete list. It’s safe to say that we’ve all stepped up to incorporate more real-time technology into practice. But what about our customers?

Digital health care consumers
In the past 10 years, we’ve seen an explosion of digital tools marketed directly to the customer in the fitness industry. For portable digital fitness tracking tools, such as Fitbit, the alleged mission is “to encourage users to become healthier and more active through the use of its devices, software or services.” Fitbit CEO James Park recently announced a transition in the company’s mission, “from a consumer electronics company to a digital healthcare company.” The accessibility, portability, and convenience of Fitbit and other fitness tracking tools have made their use more widespread. But despite the increasing popularity of these fitness tracking tools, questions still remain. Are people who wear fitness trackers really healthier than people who don’t? How accurate are fitness trackers?

For data-driven consumers interested in how much they actually move throughout the day or how much they are sleeping, using a fitness tracker may promote greater health awareness and exercise accountability. To Fitbit’s credit, there have been stories published about users seeking further medical care after noticing abnormal patterns in their heart rate data. However, while the devices do provide data about an individual user’s heart rate, number of steps, and sleep patterns, it does not offer clear interpretations of those data. The jury is still out as to whether the use of portable digital fitness tracking tools actually leads to lasting, measurable changes in fitness and health outcomes for the majority of users. Well-designed longitudinal studies are needed to infer clinical relevance. Fitbit recently announced new partnerships with other digital health care companies, so it appears that the company may be seeking to move into the realm of data interpretation.

The growth of digital health tools
“Over-the-counter” digital health tools are wonderful for consumers to have access to, but the science of measuring physiology and interpreting data is undoubtedly more exact when applied by an experienced user with the right set of tools and/or in a more controlled environment. Consider heart rate monitors, for instance. Measuring heart rate via heart rate monitor is a great way to look at the physiologic response to exercise, but it is considered more of a guide than an exact science when used in isolation. Additional factors such as fatigue, dehydration, illness, stress, and even caffeine intake can affect both resting and effort-induced heart rate. There is a big difference between “tracking” fitness using personal digital health tools and “measuring” fitness outcomes such as VO2max, lactate threshold, or metabolic efficiency in a credentialed testing facility. Many consumers purchasing digital health tools likely don’t truly understand the difference between tracking fitness and accurately measuring or interpreting fitness outcome data. The ability to show clinical relevance lies in the ability of the customer to interpret data. As movement specialists, we should be able to educate our clients on these distinctions and, when appropriate, make recommendations as to how and where more accurate fitness testing can be performed. Furthermore, we want to make sure we are considering specific functional movement outcomes related to fitness measures and that we are honoring client-specific goals, such as, “I want to be able to complete a 3-hour hike with my children,” or “I want to be able to swim a mile without needing to stop.”

The current digital health boom continues to expand beyond personal fitness tracking tools. The 2017 Consumer Electronics Show in Vegas showcased a robust number of new digital health tools, some of which promote more digital interaction between clients and health care professionals. A few tools of particular interest to physical therapists include:

• Healthimation’s Why WAIT, which is focused on digital diabetes prevention programs.
• The DIABNEXT AI platform, which uses the J.A.R.V.I.S. interface to connect doctors and patients with Clipsulin, a smart connected insulin dose recorder that captures and saves injection data to the Diabnext AI system via smartphone or computer.
• GYENNO Technologies Co.’s Smart Spoon and Fork, which is designed to offset hand tremors from Parkinson’s disease and other unsteadiness-causing conditions. The device collects data about tremors that can be sent to doctors and researchers.
• PillDrill’s new medication adherence and companion app, the PillDrill Hub, which sends audiovisual alerts to notify family or caregivers upon the absence of a medication scan.
• Polar’s new smart clothing item called the Polar Team Pro Shirt, which uses a motion-tracking sensor “pod” underneath the collar to track speed, distance, and acceleration.

For a more complete list of recently launched digital health tools: www.mobihealthnews.com/content/31-new-digital-health-tools-showcased-ces-2017 Beyond these digital assistive devices, ArthritisPower (www.ArthritisPower.org), created by the national, nonprofit, support group CreakyJoints and the University of Alabama at Birmingham, helps patients track their symptoms and treatment results while donating their data to researchers via informed consent. It also helps users share their data with their health care team, thereby encouraging data-driven health care decision making. Future iterations will further aggregate health outcomes data by connecting the app to activity trackers and commonly given lab tests, which will empower patients to better understand and interpret their overall health picture.

The depth of digital health tools
Over a decade ago, when we were using not-so-smart mobile phones, the human genome was sequenced. As the price of DNA sequencing for research and medical purposes continues to drop, a new wave of biotech startups known as consumer genomics companies are on a mission to create products and services designed specifically for your individual DNA. In health care, a fair number of partnerships between genomics companies and health systems have already been formed. One example is the partnership between Syapse and Intermountain Healthcare, which focuses on using genomic data to help develop personalized oncology treatment plans. The “genomics powerhouse” that is known for sequencing close to 90 percent of all the DNA data processed is called Illumina; it is the company that is most responsible for increasing access to DNA and the use of genomics as a tool for predicting drug responses and identifying genetic mutations that increase risk for illness.

Illumina has made it more affordable for companies such as Ancestry.com and 23andMe to market genealogy tests directly to consumers. 23andMe recently announced that its software integrates with Apple’s ResearchKit app, which will allow consumers to share genetic information with researchers. Helix, a San Francisco–based personal genomics company, aims to offer a digital hub for all things DNA testing related, from direct-to-consumer to doctor-ordered genetic testing and a platform for partners to develop DNA-powered applications. Helix’s test will offer exome sequencing, which provides a portrait of a person’s genetics by mapping the entire protein-coding region. Currently, the cheapest and most widely used sequencing technology available to consumers is genotyping. This technology looks at a predetermined set of sites in the genome to infer ancestry, genetic relationships, and some disease risks. Helix’s exome sequencing tools will provide consumers with a deeper level of DNA data. The company also proposes to store an individual’s data with the option to be used repeatedly as new digital health tools evolve. Other genomics companies are striving to move into the wellness sector. One such company is the Seattle-based company Arivale, which recently began marketing a saliva test kit and companion app to create individualized plans under their mission to offer a “scientific path to wellness.”

Meaningful use of digital health data
As the breadth and depth of digital health data evolves, so does the need for clinical interpretation. While the projected growth in consumer genomics is exciting, it is not without controversy. The FDA has required more clearance for tests offered by companies such as 23andMe. Some genetic researchers believe that the field is ripe for misuse or misinformation. As is the case with fitness tracking devices, it’s much easier to generate large numbers of data than it is to accurately interpret data for meaningful use. Many scientists and engineers agree that the ability to interpret a sequenced segment of DNA code or to find associations between genetic and phenotypic data is the rate-limiting step in the personal genomics industry. The genomics business relies heavily on aggregate consumer data for the development of applications and interpretation tools. Genetic data in the ecosystem will increase as more consumers buy into direct-to-consumer genomics products. The analysis of aggregate consumer health data now being generated from various personal fitness tracking sources is also needed to develop interpretation tools.

Susan Nowell, PT, DPT, is a PPS member and founder of Endurellect PT in San Francisco. She is licensed as a physical therapist in Italy and works as an onsite physical therapist for international endurance running events. She may be reached at sunowell@gmail.com or @Sturdy.