CW: Mental health, eating disorders, exercise
Health trackers have a huge presence in our lives, whether it’s the health app in iPhones or wearable devices such as Fitbits. They quietly record our steps, heart rate, sleep patterns and symptoms, as well as store personal information, all with the aim of helping us monitor and improve our overall health, or, in some cases, specific conditions. But do they really help, or are they a privacy risk? The Edinburgh Science Festival addressed the issue on Saturday, 13th of April. The panellists were Beverly Bryant, former director of digital technology for NHS England, Dr Paul Patras, a lecturer on cybersecurity at the University of Edinburgh, and Nick Harris-Fry, a fitness journalist who lead the event. They each sat comfortably on the sofas on the Quaker studio stage, keen to address the topic in hand – Do health trackers improve health or are they a privacy and security risk?
Nick Harris-Fry initiated the beginning of the event with an obligatory anecdotal joke, noting that his health tracker was picking up unusually high levels of stress. Laughter rippled through the audience in response.
Beverly Bryant began the presentations. Bryant now works for System C and founded One HealthTech, which advocates for the inclusion of women and other under-represented groups in leading health innovation.
Bryant’s view on health trackers came from an NHS and health perspective and sees their great potential. Health trackers provide a long term health strategy for the NHS and introduce the idea of the ‘empowered patient’. Trackers allow patients to take responsibility for their own health, which is becoming more significant due to our ageing population, reduced workforce and their burden on the NHS. The trackers ‘’put patients in the driving seat,’’ changing the relationship between general practitioner and patient, ultimately reducing paternalism. This doesn’t, however, take into account that health trackers could make optimal health care inaccessible to under-represented groups or individuals who may not have the time and luxury to buy trackers or document their symptoms.
Health trackers, both apps and devices alike, link communities and allow health care individuals to monitor how a patient is doing, which is significant in patients with conditions such as epilepsy and dementia. This allows health data to be collected between doctor appointments by health trackers, enabling GPs to gain a more contextualised view of a patient. An example described by Bryant was an epilepsy app, which launched in 2015. The app allows the patient, family members, doctors and the local community to assess a patient’s state and monitor their seizures, which can reduce preventable hospitalisations as patients and those caring for them can react appropriately to specific health data. This also results in reductions in the patient’s stress as they know clinicians are close by. Another major example provided was the apps used to monitor and prepare individuals for transplant surgery. The lack of pre-habilitation is one of the major reasons for cancellations, a strain on NHS resources.
Health trackers provide a long term health strategy for the NHS and introduce the idea of the ‘empowered patient’
There are many different health apps out there, many of which are accredited by the NHS with the aim of encouraging individuals to trust and use them. The apps, however, stand alone and have no link to medical records. According to Bryant, linking the data would result in ‘’[GPs] consumed by an avalanche of data.’’ Beyond the individual, however, the trackers provide insights into optimising supply chain processes and drug administration compliance.
Health trackers are, however, not perfect and come with liabilities – mostly legal. Data ownership is a major factor. Individuals using health trackers own the data, but once it enters the GP’s office it becomes part of your medical record. Consent is another issue. What is the NHS doing with our data? She laughed and reassured us that it is nothing sinister. She also brought up liability. Who is liable if a GP doesn’t act on collected data? Despite all the obstacles, she is still optimistic and finished her presentation highlighting that individuals engaged with health data are in turn engaged with their own health, which benefits them in the end.
Dr Paul Patras followed keenly in Bryant’s enthusiasm and optimism, stating that health trackers will provide “great benefits ahead.” The apps provide self-management and contribute to diagnoses. He then changed his tune and dropped the phrase ‘privacy risk.’ We were left in suspense as he asked for a show of hands, who had a health tracking device? The majority of those in the audience raised their hands. Paul then laughed and explained that the room showed a higher level than the national average, which is one in five households.
Individuals using health trackers own the data, but once it enters the GP’s office, it becomes part of your medical record
There are three main things to consider with health tracking apps and devices. Firstly, is the information confidential? Can someone intercept it? Secondly, can someone tamper with the data? This includes faking data, such as increasing your step count or spooking users with unusual measurements. And thirdly, could health providers enforce tight control of data?
Most apps and devices are encrypted, which prevents those without the key from reading the data. Patras highlighted this by showing the room a slide full of rows of numbers. He then explained that end to end encryption is ideal, preventing the app itself from looking at the data. There are, however, many devices that use plaintext instead of encryption, which allows the data to be read.
Patras then described the data’s journey from Tracker, which alone is not very capable, to the App, which collects the data from the device, through Bluetooth. The information is then sent to the server via HTTPS (Hypertext Transfer Protocol Secure). The ‘S’ means that the data is encrypted throughout this stretch. The information displayed on your phone is an activity summary, which is obtained from the server, and it is this stretch, between server and device, that can be easily attacked or have its security removed. This allows private information to be leaked or fake step counts to be injected. Luckily, Petras reassured us that vendors have fixed this.
Another vulnerability of the health tracker is Firmware update processes. Firmware (FW) is a ‘’small piece of software that runs on the fitness tracker,’ and occasionally notifications will pop up asking you to click for an update. Its vulnerabilities lie with flashing firmware without authorisation. Once an FW is understood, an attacker could overwrite official FW with custom code. An example Patras supplied was multiplying each ‘real’ step by 1000 to get gift cards and other incentives, win bets, or for insurance. Apps and devices are continually being developed and corrected by improving privacy and reduced vulnerabilities. Patras finished by telling us not to be afraid. Vendors patch most weaknesses, and the UK government also cares and encourages products to have security in their original design.
The event then opened to the floor, marking the beginning of Q&As. The first question brought up was how doctors have reacted to health trackers. Bryant replied by explaining that “doctors don’t represent each other,’’ each has their own opinion, but that the GP committee is positive. She also reminded us that it is still early days. Harris-Fry then added that the apps are ‘’pretty inaccurate most of the time,’’ highlighting that health tracker technology is not accurate enough for the data to be used alone for a diagnosis. The panellists laughed and explained that moving a frying pan could be interpreted by a tracker as running, and that heart rate measurements are usually inaccurate when running as the device slips and jumps along the arm. The tracker does, however, contextualise the patient’s symptoms and guides the GP’s questions that lead to diagnoses.
Credit card detail security was then mentioned. Patras replied by stating that most devices are not intelligent and don’t do much. Credit card transactions are mostly cellular, which is a very secure line and requires military-grade technology to hack. The benefit would be very small in comparison to the cost involved.
Harris-Fry then added that the apps are ‘’pretty inaccurate most of the time,’’ highlighting that health tracker technology is not accurate enough for the data to be used alone for a diagnosis
The idea of diet and mental health was then raised. Diet trackers are not sophisticated enough to track food and require the individual to enter in what they have eaten. This comes with many problems as people lie, forget to add meals, or have to convert measurements depending on the units the app works in. Mental health trackers are very similar in this way and require the individual to self-report. Bryant, however, explained that apps could be an advantage here, as in some cases individuals feel more comfortable interacting with technology than other people. There is, however, a limit. Obsessive health observation is a huge problem. Watching your physiological measurements can become addictive and we need to watch and talk about it. Excessive exercise, eating disorders and health related anxiety can be easily overlooked when talking about health trackers. The general panel consensus was that balance is important and constantly being in the presence of technology can negatively affect our mental health.
Bryant was asked whether she thought financial incentives would ever be used to encourage people to exercise. Her answer was simple: no. She explained that people want to be healthy. These apps could reduce NHS costs, preventing patients from getting into dangerous health situations, such as diabetic hypoglycemic comas and allow people to monitor their own conditions. ‘’Health trackers won’t be limited to financial benefit,’’ or at least she hopes not.
Obsessive health observation is a huge problem. Watching your physiological measurements can become addictive, and we need to watch and talk about it
The final question was then asked, ‘’is the way we look at physical activity changing due to its association with technology?’’ Their answer, in short, is yes. There has been a huge reduction in physical activity and increased levels of childhood obesity. These health trackers are almost an overreaction to the health crisis and the need to inspire people to become active.
The general view of health trackers, both apps and devices, is positive. Although they come with their dangers and uncertainty, we have to remember that it is still early days. They have many potential uses and, in the end, they benefit the individual in the way the individual uses it. Either way, they are not a fad. The apps are constantly improving in both accuracy and security, and clearly, have a significant role in the NHS’s long term goals.
This article was written by Tara Wagner-Gamble and edited by Karolina Zieba.