As somebody who teaches innovation, I am naturally interested in the response to new products, and the launch of the Apple Watch 4 and its heart monitoring functions provides a good case study on predicting and modeling reactions among specialists, as well as their value in the medium to long term. In short, how working intensively on a subject for a long time distorts views as to what is positive or negative about an innovation, as well as innovation in a particular context or subjected to processes of social adoption.
How might we classify such responses? To start with, doubts can be raised in an open format, as did Ethan Weiss, which I mentioned in my previous article on the subject, who during the Apple Watch presentation commented on Twitter: “I can’t work out whether this is the best day in the history of cardiology or the worst.” His doubts are laid out clearly and in neutral terms, foreseeing the kind of scenarios one might expect from an experienced cardiologist: non-intrusive monitoring able to identify problems before they become critical and its potential to ultimately save lives offset against cardiologists’ waiting rooms filled with people overreacting to data they don’t understand.
The Washington Post raised similar concerns the next day, after talking to several cardiologists, in an article called “What cardiologists think about the Apple Watch’s heart-tracking feature”: making these types of measurements in such a high popular product could generate unjustified anxiety and unnecessary visits to the GP. Interpreting an electrocardiogram requires a certain degree of familiarity with the technique and the metrics used, which could lead the untrained, in the face of natural variations in their heart rate, to become alarmed or feed their hypochondria. Undoubtedly, this is a minor problem in the context of the potential benefits of a technology that could alert people to possible heart problems early on. The possibility of people without the adequate level of preparation routinely accessing a diagnostic tool such as an electrocardiogram routinely may be cause for some alarm for professionals responsible for making decisions with those same tools, but the question we might usefully ask is whether it’s better to have some unnecessary visits to the cardiologist or for people to be uninformed about their health.
A different question all together is the reliability of the device used to capture and process the data. An article in Quartz, “The new heart-monitoring capabilities on the Apple Watch are not all that impressive”, points out that the electrocardiogram obtained by Apple Watch provides a much more imperfect and rudimentary result than a hospital would, where twelve electrodes are attached to different areas of the chest, arms and legs. The clinical device offers much higher precision, but in exchange for a much lower level of convenience. Even if it were possible for the Apple Watch to be hooked up in this way, the idea that a large number of people would use it routinely or daily is ridiculous. The clinical device provides very reliable and rigorous measures in a hospital environment, while the Apple Watch provides fewer indicators s and with a much lower level of accuracy, but at any time and under any circumstances. Could this contribute something to the health of patients with, for example, conditions that don’t manifest themselves when they are in their doctor’s office? I am sure we will see cardiologists looking at the records obtained by the Apple Watch of some of their patients. Which does not mean, of course, that this is necessary or justified in all cases, or that we should try to pressure doctors to do so.
These questions have been raised by the manufacturers of other consumer devices, such as WIWE, which I also mentioned in my previous article about the Apple Watch 4. The company has worked for years to produce a device the size of a credit card which works by holding both thumbs on, making sure your hands do not touch, that gives an electrocardiogram with complete data and graphs recording arrhythmia, atrial fibrillation, ventricular heterogeneity and oxygen saturation in the blood stream, and then Apple comes along with a device that provides similar data using… a watch. No wonder WIWE is skeptical:
While we haven’t tested it thoroughly yet, there are already a few concerns just by looking at the hardware setup of the watch which can significantly affect signal quality when recording ECG. While it is a common design element in one lead ECGs to allow for users to place their fingers on the sensors to achieve full contact and a strong signal, the watch obviously doesn’t provide such setup.
A very common problem could arise from a simple thing: the user’s hairy wrist can get in the way for the sensor that is supposed to pick up signals from that channel and so it becomes limited in its capacity the gather reliable information for assessment. Let’s see the other channel. The user’s right pointing finger needs to be hold in position for long enough to risk that it’s going to tremble, feel tension etc in other words moves so the steady and peaceful contact is hard to achieve. If you compare, You can place WIWE on a flat surface and rest your fingers steadily on the sensors for the duration of the measurement.
As for AF detection: we haven’t seen information about the accuracy of it (WIWE achieved 98.7% accuracy when tested against 10000 clinical samples — our certificate is available on request) and whether they examine atrial activation (by examining the “P” wave as WIWE does), or they do the assessment based on heart rate alone (RR distance?) As far as it can be seen from the published information, they don’t perform wave analysis so they can’t provide ECG specific information such as QRS, QTc, PQ, while WIWE offers all these to clinicians. If they only rely on heart rate, the assessment result can be confusing when detecting AF and that’s confirmed by their statement quoted from FDA: ‘the ECG app isn’t meant to be used in people younger than 22, nor is it recommended for people with other known heart conditions that can disturb your heart rhythm.’
Having said all that, it is a great achievement that they got the support of the AHA and was given FDA clearance so we obviously don’t say that the watch is not capable of AF detection, but there are concerns at this point.”
Once again: it seems clear that, within the category of consumer products, the accuracy of a device designed specifically for obtaining an electrocardiogram, with two sensors and a reasonably ergonomic configuration that allows you to keep your thumbs on them for a minute without problems will get more reliable results than a watch designed for a wide variety of functions, including telling the time. But the counterpart, again, is obvious: with the WIWE device I monitor my heart rate when I remember and, usually, not even on a daily basis. With the watch, I monitor myself at all times and under all kinds of circumstances.
Are the responses to innovation by physicians and designers of competing products justified? There are certainly within reasonable grounds. However, they ignore another issue in their analysis: the measurements, although less rigorous, can be taken at any time of the day. At the same time, we still don’t know what Apple or other developers will be able to do with the right algorithms when they have measurements obtained regularly or in various contexts — we should remember that the Apple Watch is also used, for example, for regular monitoring of physical activity.
Could the development of such devices represent a tangible improvement in the medium term for research or for the practice of cardiology and for Medicine in general? All things considered, I have to say that I am convinced they will.