By Adriana Krasniansky
Over the past several days, technology players Google, Apple, and Facebook have each reported health-related business news. In this blog post, we examine their announcements and identify emerging ethical questions in the digital health space.
On Nov. 1, Google announced plans to acquire smartwatch maker Fitbit for $2.1 billion in 2020, subject to regulatory approval. The purchase is expected to jumpstart the production of Google’s own health wearables; the company has already invested at least $40 million in wearable research, absorbing watchmaker Fossil’s R&D technology in January 2019.
In another corner of the wearables market, Apple beat earnings expectations, largely driven by 54% year-over-year growth of its “Wearables, Home, and Accessories” group. The category now accounts for more revenue than Apple’s iPads, and there are indications that Apple is developing its wearables with health in mind. Since 2014, Apple has filed patents for in-ear technology to monitor heart activity, stress levels, and temperature.
Facebook is working with health organizations to develop its Preventive Health tool, which allows users to opt-in for checkup reminders, such as cholesterol tests or mammograms, based on their age and gender. In addition to receiving notifications, users can locate health centers and mark when tests are completed.
Together, these announcements unveil emergent ethical considerations in personal digital health.
Health as a newsfeed
Google and Apple’s announcements emphasize investment in continuous health monitoring, where individuals can track their health outside of the hospital—creating a personal health newsfeed that mimics our social platforms.
While continuous monitoring offers important benefits (e.g., simplifying disease management, encouraging healthy habits, or catching undiagnosed conditions), it also surfaces ethical concerns. These include a possible increase in health anxiety (exacerbated by social reminders on Facebook) that fuels overmedication or unnecessary treatment. Conversely, some of the population may experience alarm fatigue and ignore otherwise important indicators.
“There will be a day in the future that we look back and Apple’s greatest contribution will be to people’s health.”
– Apple CEO Tim Cook, Q4 2019 earnings call
Data sales & advertising
Google and Facebook have stated that health data will not be used for advertising. However, subsequent activities—such as purchasing a blood pressure monitor or joining a digital health support group—are fair game. As Facebook writes:
We don’t show ads based on the information you provide in Preventive Health…As always, other actions that you take on Facebook could inform the ads you see, for example, liking the Facebook page of a health organization or visiting an external website linked to from Preventive Health.
Increased health awareness suggests that our digital browsing and buying behaviors will be more indicative of our health states; thus, while not explicitly sharing data, our digital ecosystems are likely to result in more health-based advertising in the near future.
Health industry partnerships
While technology players won’t sell health data, there are other lucrative opportunities, particularly partnerships with insurance partners and employers. For example, Fitbit’s corporate wellness initiative has been one of the business’s most effective growth strategies, and the company even launched a separate device for corporate partners.
In health monitoring programs, individuals are incentivized to participate with reduced health premiums, copayment reimbursements, or cash. In exchange, participants’ health data is shared with their employers, wellness plan administrators, or health insurers to inform plan structure and pricing. According to the Kaiser Family Foundation, 21% of large employers who offered health insurance collected data from employee wearables in 2018.
Corporate-device relationships are increasingly common; Aetna and Apple and Fitbit and United Healthcare are just two examples. However, concern exists that these relationships could eventually favor healthy employees or act upon unhealthy employee behavior outside of the office. Subconsciously, these programs may also impose a dimension of health surveillance that amplifies the power dynamic between employer and employee.
A shadow health record
Largely in response to public concern, Facebook, Google, and Apple have taken precautions to guard user health data. Existing Fitbit and Apple device partnerships exhibit HIPAA compliance under business associate agreements (read more about BAAs and consumer technology in a previous Bill of Health post), and Facebook has gone to great lengths to emphasize its protection of Preventative Health behavior.
However, it’s unclear how well these initiatives will integrate with medical records. Many similar health applications—from fertility trackers to running apps—are not HIPAA compliant and do not integrate with medical records. The explosion of (good and bad) direct-to-consumer health technology stands to create shadow health records that are neither protected nor clinically considered. While digital health tools may lead individuals to feel empowered by data, current practices indicate that resulting health profiles are likely to be fragmented, under-protected, and, in some cases, beyond individuals’ control.