Carl Maronich (Host): This is Expert Insights with the Carle Foundation Hospital. I'm Carl Maronich. And joining me today is Dr. Bryan McConomy, an internist and a clinical informatics specialist from the Carle Foundation Hospital. And we're going to be talking about wearable digital health technology. Doctor, welcome to the podcast.

Dr. Bryan McConomy: Hey, thanks. I appreciate you having me, and really looking forward to our talk today.

Host: Absolutely. And maybe we should start by kind of defining and sharing what exactly are digital health technologies, the wearable digital health technologies, and what does that incorporate.

Dr. Bryan McConomy: So, wearable technology has been around really for a long time. If we think about some of our early, Holter monitors, things that patients went home with, especially to look at the heart rhythm. And over the past couple of decades, it has really accelerated. But if you think about the early calculator watch, that was a wearable piece of technology. With our advances in technology though, you know, now we have opened it up to a whole new area, including health. And now, we are able to get more data really about ourselves than ever.

And so, most people, I think colloquially will think of the smartwatch as that piece of wearable technology. But now, you know, they have rings, and there's also more advanced devices, that are looking at heart rhythms, and being used specifically in heart failure patients. So, it's a really broad term. but like I said, going back to some of our first wearable technology is that early Casio calculator watch.

Host: Yeah. And so, with all this technology, is that kind of the advent of the clinical informatics area? That seems like a new title, a new area of medical expertise. And has that been developed because of all the wearables or what's the connection there?

Dr. Bryan McConomy: Yeah. The connection with clinical informatics really came out of that ability for computing. And so, you may be surprised to know that actually clinical informatics started in the 1950s and '60s, and there were labs at Massachusetts General Hospital that were looking at how to bring in computers into the healthcare arena.

Regenstrief Institute in Indianapolis had one of the first electronic medical record systems. So, clinical informatics really came out of how do we bring this computation, the computer, how do we improve healthcare delivery. And then, it really started to expand to all these different types of technologies.

So in clinical informatics, we're used to bringing in new technology. And so, things like wearables and, of course, now with artificial intelligence, the clinical informatician is really at that cutting-edge of how do we introduce these technologies and use it appropriately in the healthcare space.

Host: Yeah. And to that exact point, maybe you could talk a little bit about what the key measurement capabilities are of the wearable technologies.

Dr. Bryan McConomy: So, I'll take the smartwatch, this is probably one of those—you know, whether it be an Apple Watch or Samsung or whichever company is making it. But you'll notice that they're able to measure pulse, oxygen saturation. We have movement, activity, distance, all those things. So, the pulse in oxygen saturation actually is using what's called photoplethysmography. You may also see it being PPG. But being able to also get movement and activity uses an accelerometer as well as a gyroscope. So, those two pieces of technology, the accelerometer and the gyroscope, and then adding it with this photoplethysmography, really allows you to get a lot of physiologic data about how much you're moving, how quickly, and then what is the pulse doing with that. That photoplethysmography is how these watches are sensing your pulse and giving you that information.

Host: So, having information is one aspect of it, but then how is that information usable and in what context is it usable to really make it beneficial for the patient?

Dr. Bryan McConomy: And so, taking that a step further with the photoplethysmography, how it's really looking at it is it's detecting your pulse by using a light source. It's aimed at the skin. On the watch, there's also a photodetector. So as that light is reflected back, it is actually looking within that artery. And it's able to see when is that peak of like systole or the top of the blood pressure, and then what's that lower pressure, the diastole. And that's where you're getting this pulse.

Then, as you get that pulse data, now these companies have developed, proprietary kind of software to be able to interpret that data and to say, is that pulse regular? Is it irregular? And that is how these watches are going to tell you you might have atrial fibrillation. And that is important information because atrial fibrillation itself can lead to strokes. and depending on a person's comorbidities or health status, they may be at a much higher risk of developing a stroke.

Host: With regard to stroke, it seems also that these technologies set up well to diagnose—if that's the right term— for cardiac disease and, arrhythmias.

Dr. Bryan McConomy: So, I would say we have to be careful about that word diagnose. If we're looking at it in the diagnose official kind of medical terminology, these watches are what the FDA considers prediagnostic. So, they are a signal. However—and this is what's important for healthcare providers—you know, somebody comes in and they have their wearable, "The smartwatch is saying I'm having an irregular rate. It thinks I might have atrial fibrillation." Okay, that is helpful information, but it is incumbent on us to then take it a step further. You've got to get that EKG or ECG, the electrocardiogram, that is how you are going to truly diagnose.

Host: What is the evidence that supports the effectiveness of the wearable technologies?

Dr. Bryan McConomy: So, there have been a couple of studies, and one specifically using the Apple Series watches, that it is able to use what we call a beat-to-beat pulsegram. And through its probabilistic approach of these pulse checks, if there are five out of six consecutive pulsegrams that meet an Irregularity criteria, then that algorithm notifies the user of an irregular rhythm. And so, it's good to know that when this watch has alerted the user, the person that owns the watch, it's going through a lot of processing. And it has to meet a certain threshold to do that. So, these watches are shown, and that's how the FDA has prediagnostic clearance for these.

But when we look at some of the other data to say has there been a lower mortality, that's really been a little harder to really prove, and then if you even look at quality of life. So, there was one randomized control trial called the IDEA study. And it actually showed that there was less weight loss at 24 months with the use of wearable devices compared to the actual standard behavioral weight loss. Now, that's one trial, so you can't say that wearables don't help at all. But I will say that the evidence, it's difficult to have a clear winner to say, "Oh yes, these wearables are definitely decreasing mortality, or they're definitely improving that quality of life."

Host: Is there any patient safety issue when it comes to the wearable devices?

Dr. Bryan McConomy: So generally, with patient safety, there is that concern of you get an irregular notification. And there could be some concern and worry about that. Am I having atrial fibrillation? Am I high-risk of a stroke? And then, presenting to your clinician. And so, there is that potential for higher worry and anxiety related to health.

So, that's really what we mostly see as far as that is concerned. We haven't seen other, patient harm come from that. But certainly, people can get very concerned about their health, understandably. And so, if you're somebody that is always very worried or gets kind of preoccupied, then using that wearable may not be for you.

Host: Are the wearable devices able to integrate with an electronic medical record?

Dr. Bryan McConomy: So, that is one area where we have a lot of difficulty with. Ideally, we would be able to have a good stream of information that is going into the electronic health record so that your primary care provider or cardiologist or endocrinologist, whoever it might be, is able to see this and get an idea of how much activity are you having, are you having any irregular heart rates, things like that.

And what we see though, unfortunately, is there is poor interoperability. And then, not only do you have that poor interoperability, meaning Apple or Samsung has trouble talking to, say, Epic, our electronic health record here at Carle—so it has trouble talking to each other—and then there's also different data formats.

So, just if you remember working on an Apple laptop and using their software to write a paper, it would save it in one file format. And if you tried to open it on a Windows computer or try to open it in Word, you would just see a bunch of symbols, it's because they're different data formats. And then, the electronic health record is not able to read that data format. So, we really see not only that poor interoperability, and then there's the proprietary data formats that make integration really difficult.

And then, another piece of it is that it is a lot of data. And if you have several hundred patients in your panel, or maybe over a thousand or 2000 patients, however many patients you have, if you're generating a lot of that data—it's continuous, high-frequency data—this can really lead to data overload. And so, there are definitely clinicians that are concerned about trying to be responsible for reviewing. And so, whose responsibility is it to review it? How do we respond back to the patient? So as far as integration into the electronic health record, that's where we see our biggest barriers.

Host: Are there any privacy concerns when it comes to wearables?

Dr. Bryan McConomy: So, anytime you are exchanging health data, even if you're giving permission to send your own health data across, there is that cybersecurity concern that that information could be breached, especially in transit. And so, your sensitive health data could be leaked or intercepted. And so, that is another large concern with integration.

Host: Sure. Doctor, maybe you could give us an example, a story of a patient that you've worked with that has used the wearable devices and had a positive result because of it.

Dr. Bryan McConomy: Several years ago, somebody that I worked with, she had noticed, "I hadn't been feeling real well. I had been coughing quite a bit, and had a fever," but just kind of thought, "I think maybe this is just a viral illness." You know, it was around the February, March timeframe. But she had an Apple watch, had that smartwatch on, and noticed that her pulse was jumping significantly, much more than usual. Like, she could tell that her physiology was off. We crossed over into that pathophysiology, right? Something's wrong.

And that really pushed her to get checked out. And what ended up being was that she had pneumonia. And so what the watch was able to tell her was that you're deviating from your body's normal state with that. It was very minimal activity that was leading to really rapid heart rates. And that was really that cue to say, "I need to get checked out. I'm not myself."

Host: From just monitoring health aspects to prevention, how might the wearables serve someone in terms of preventing disease or preventing medical issues?

Dr. Bryan McConomy: Well, I would say the nice thing about the wearables is it gives you feedback And what we do know is that just increasing your activity, and it doesn't even have to be a large, large amount, but just increasing your activity, like your daily step count, a little bit higher physical activity, you can cut your risk of death by up to like 20% compared to others. And a gait speed improvement of even just 0.1 meters per second is associated with a 12% lower risk of mortality at a five-year followup.

So, that's where we see probably that help that where you get the most benefit, is to just be able to help give yourself that data and to say, "Oh, I haven't been as active today, right? I've only had about 3000 steps. I can make time today to get out and go do a walk."

Host: The future of the digital wearable technology, Doctor, where do you see that evolving based on what you've seen so far?

Dr. Bryan McConomy: So, what I think what we're going to see is wearable technology, these devices really trying to combat chronic illness. And, you know, in the area of like cardiology and heart failure, there are some wearables that are measuring even how much fluid is building up into that lung space, so trying to see what we call that pulmonary edema. But it's really trying to act on an issue that is going wrong. We know that that patient needs a diuretic faster. We're trying to prevent that hospitalization.

Similar with the continuous glucose monitors, which is also another type of wearable technology, we're really trying to lower that A1c or decrease the risk of low blood sugar, the hypoglycemia. So, I think where we're going to see most of your wearable technologies, and probably their impact is going to be on chronic disease management.

Host: What would you say to someone who's considering diving in, if you will, to the use of wearable devices?

Dr. Bryan McConomy: The question really is, is there something that I'm wanting to try to change or is there a problem I'm trying to solve? Sometimes just getting a new piece of technology just to have it doesn't always really solve a problem. But if you're saying, "I really want to try to improve my activity level," or "I want to be able to try to walk a little faster and I need to be able to have that data. I need to be able to see my progress over time that helps to motivate me," then you would be a candidate, I think, for a wearable and to make positive health changes.

Host: And is this something you talk with your primary care provider about?

Dr. Bryan McConomy: Yeah, your primary care provider is well-situated to give you some advice on the wearables, and also maybe even share experiences with other patients that they're interacting with. So definitely, they're a great resource on what might be the benefit for you or are there other considerations and maybe that isn't the right thing.

Host: Very good. Dr. Bryan McConomy, we appreciate all the great information.

Dr. Bryan McConomy: Yeah, I appreciate your time and being able to share some of this exciting developments that have been coming about in the world of informatics and wearables.

Host: Yeah, it's been an interesting conversation. And for more information and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers. And to view Carle-sponsored educational activities, visit our website at carleconnect.com. I am Carl Maronich. And this is Expert Insights. Thanks for listening.