How Wearables Can Enhance Cardiac Care, Boost Patient Engagement  

October 25, 2022 - The past decade has seen a massive spike in the development and use of wearable technology in healthcare. While the technology offers several benefits, including a wealth of data collected outside the doctor's office, implementing it effectively into clinical care can be challenging.

In a survey this year that polled more than 2,000 Americans, about 41 percent said they owned a smartwatch or fitness tracker. That figure is up 2 percentage points from 2021. A vast majority (90 percent) of those who own these devices use them to track fitness and monitor health, with heart health being the third most common health category tracked by wearable technology users.

Further, the survey shows that over half (55 percent) of wearable device owners share the data gathered by their wearable devices with their healthcare providers.

Once collected and analyzed, heart health data can help cardiologists detect cardiac issues early and enable them to develop and fine-tune treatment plans for patients, according to experts that spoke with mHealthIntelligence. But integrating wearables into cardiac care poses various challenges, ranging from patient education to data accuracy.

WHY CARDIOLOGISTS ARE TURNING TO WEARABLES FOR CARE

Cardiologists are increasingly leveraging wearables, both medical-grade and direct-to-consumer, to improve clinical care for their patients.

At Duke Health, the wearable devices used include CardioMEMS devices — which are implanted ICD devices that can be used to remotely monitor metrics — smartwatches and AliveCor devices.

Duke cardiologists gather the data from these devices in various ways, including through smartphone applications and the patient portal, said Marat Fudim, MD, a cardiologist and advanced heart failure specialist at Duke Health, in a phone interview.

This data is valuable for clinicians as it is comprehensive and objective. Without the use of wearables, patients can confuse measurements or misremember the time of measurement, leading to subjective metrics, according to Fudim.

"[With wearables] we usually get high resolution and timed data, which is important because timing matters," he said. "Is this happening during the night, or does it happen in the day? Also, [we get metrics] you cannot [manually] measure at night. Watches measure it for you all the time."

For similar reasons, Kaiser Permanente is using wearable technology to support its home-based cardiac rehabilitation program.

The eight-week program is intended for patients who have experienced a cardiac event such as a heart attack, heart failure, or heart surgery, said Edward Lee, MD, executive vice president of IT and chief information officer for The Permanente Federation at Kaiser Permanente, in an email.

The care plan, which is customized to patient needs, includes using a smartwatch that pairs with a smartphone via Bluetooth.

"The watch monitors the patient's heart rate and activity data, tracks their personalized treatment plan, and uses a digital calendar and checklist for prescribed, home-based care routines, and shares exercise reminders and other care routines with the patient," Lee said.

The data gathered by the watch is automatically uploaded into the patient's EHR through the smartphone, allowing clinicians and physical therapists to track patient progress. Patients meet with their care manager once a week virtually.

The health system has seen clinical outcomes improve among patients enrolled in the program.

"Our home-based cardiac rehabilitation program is proving to keep patients engaged and reduce hospital readmissions," Lee said. "Kaiser Permanente has demonstrated promising results in reducing secondary cardiac events and rehospitalizations."

Researchers from the health system published a study earlier this year in JAMA Network Open, showing that its home-based program lowered hospitalization rates compared to center-based cardiac rehabilitation services. Only 14.8 percent of those who received home-based cardiac rehabilitation were hospitalized in the 12 months following the program, compared with 18.1 percent of those who received center-based care.

At Texas Heart Institute, clinicians are also applying data from both direct-to-consumer wearables, like Apple Watches, and medical-grade devices, to patient care, said Emerson Perin, MD, PhD, medical director at the institute.

In some cases, the direct-to-consumer wearable becomes the starting point of a patient's care journey. An Apple Watch, which has an atrial fibrillation detection feature, may prompt the patient to visit the doctor's office. There, the physician can run tests, like an electrocardiogram (EKG), or provide the patient with a medical-grade device to monitor them for a few weeks, Perin explained. 

This points to one of the major advantages of integrating wearable technology into clinical care — patient engagement.

"[Wearables] really, for one, gets the patients more involved in their own care," Perin said in a phone interview. "It motivates them to do things and really helps them accurately assess how they're doing or how their disease is doing or if they're having some [issue]."

Wearables like Apple Watches have also made people more aware of their fitness levels and encouraged a culture around fitness improvement, which is, ultimately, better for heart health.

"I think that the application of wearables to different fitness things is really fantastic," said Perin. "If that [device] not only can monitor what you're doing, it motivates you to do better when you're doing it or even to keep it up because it's like, 'Oh, man, I didn't do this today.'"

CHALLENGES TO WEARABLES USE IN CARDIOLOGY

Implementing wearables in cardiac care comes with its own set of challenges.

According to Kaiser Permanente's Lee, as wearables have become more sophisticated, allowing for tracking metrics like heart rate and oxygen saturation, the challenges lie in determining what data to collect and for which patients.

"Some studies have shown that collecting this type of data in the general population may not be the right thing to do," he said. "We need to understand which patients would benefit from having this data available, what specific data elements should be collected, and which members of the care team are best suited to review this data."

There is also the added complication of collecting potentially inaccurate data. Wearable devices are not always accurate and can cause false alarms, Texas Heart Institute's Perin said. This could lead to added stress among patients, compounding clinical issues they already have.

"In the future, maybe the wearables will have a lot more AI [artificial intelligence] and be able to tell you things much more accurately, but now, we need to make sure that we're also not doing any harm," he said.

In addition to improving the accuracy of wearables, patient education is key to preventing false alarms and misinterpretation of data, Duke Health's Fudim said.

For example, patients who watch their blood pressure change as they perform various activities consecutively, like exercising, cooking, or writing, may start to worry if they have not been told that some fluctuations in blood pressure are normal. Fudim noted that patients might not know that in the clinic, physicians record blood pressure multiple times and try and make the surroundings as relaxing as possible to get accurate results.

"You can imagine how we're now getting data streams which are no longer curated or supervised," he said.

While access to objective data is one benefit of wearables, the sheer volume of data being created can be difficult to manage. Operational, staffing, and financial issues may prevent clinical teams from taking full advantage of this data, and instead, the data volume could overwhelm them, Fudim said.

Not only that, but the increasing number of wearable devices available can make it hard for patients and providers to decide which ones to use. Since wearable technology is a relatively new field, not all devices have undergone the same rigorous testing, according to Fudim.

"The problem becomes that we as clinicians or as a patient need to disentangle which one might be quote-unquote 'the best' and there might be several that are on par," he said.

Data privacy concerns are another hurdle to widespread wearables use in cardiac care. These concerns are primarily related to direct-to-consumer wearables rather than medical-grade devices, which provide more secure options for data-sharing, Fudim noted. But with the former, cybersecurity breaches may occur, even though developers are very vocal about the strategies they are implementing to protect data.

"Nobody would want to have that bad press associated with their name. So, they're taking [data security] very, very seriously," he said. "But it doesn't seem like anybody's safe these days."

NEW CAPABILITIES FOR THE FUTURE

The cardiac care wearables arena is growing fast, with new devices coming to market and researchers exploring new applications for existing devices.

For instance, Perin and his team at Texas Heart Institute plan to explore whether the use of the Apple Watch's EKG feature can be expanded.

Physicians perform EKGs, which are recordings of the heart's electrical activity, to determine heartbeat and heart rhythm. A 12-lead EKG, which is commonly used in clinical settings, involves looking at the electrical activity from 12 different angles, Perin explained.

"If [the 12-lead EKG is] done properly and technically well, then we have criteria that we can [use to] look at those squiggles, and we can say, 'Oh my god, this patient's having a heart attack,'" he added.

The Apple Watch's EKG feature can only record a single-lead EKG, but the Texas Heart Institute researchers are studying whether the device can be placed on different parts of the body to create an abbreviated, six-lead EKG that could provide information on whether the patient is suffering a heart attack.

"That's something that could be very helpful, especially to patients with known disease or patients who are having symptoms who might be in doubt about if they should come to the emergency room or not," Perin said. "So, it's something that could really aid in speeding up the diagnosis of a heart attack because when you're having a heart attack, you're on the clock."

The study will involve taking the abbreviated EKG readings from the Apple Watch and comparing them to 12-lead EKG readings and seeing if the information matches. It is currently undergoing committee approvals and, once started, will likely take a year to complete, Perin said.

As devices evolve and new features are created, the potential for wearables use in cardiology is vast.

For instance, Perin believes it would be possible to develop a wearable device worn on the skin that could provide information on lung pressure, which could be helpful in heart failure monitoring.

"That's just an example," he said. "There are dozens and dozens of these things in development right now. It's going to explode. It really will. It's an exponential rise. As technology gets better, it gets miniaturized, [and] algorithms get smarter."

Duke Health's Fudim also believes that future wearable devices will have capabilities to monitor metrics beyond heart rate and blood pressure, like congestion metrics.

"My personal feeling is that five, 10 years from now, people will be all hooked up to multiple sensors," he said.

But, as capabilities multiply, wearable device developers must ensure that they are integrated, and data can be shared easily across platforms so that providers can incorporate it into clinical care, Fudim added.

The future for cardiac care wearables appears bright. The experts that spoke with mHealthIntelligence agree that as clinicians, researchers and developers expand wearable device applicability and overcome challenges to use, they will continue to play a vital role in healthcare, particularly cardiology.

"I think that they can play a super important role," Perin said. "Like I said, [wearables] make the potential patient then partner with their doctor so they can become healthier, and we can prevent [cardiac issues] from ever happening."