How the heart became the centre of the Apple Watch

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Earlier this year, Apple’s CEO Tim Cook commented on the importance of health to the company. In a statement that has been widely quoted, he said, “I believe, if you zoom out into the future, and you look back, and you ask the question, 'What was Apple's greatest contribution to mankind?', it will be about health.”

Although he only said it some months ago, it’s been a direction the company has been taking for years.

I’m meeting Jeff Williams, Apple’s Chief Operating Officer, along with Kevin Lynch, Vice President of Technology and Sumbul Desai, the company’s Vice President of Health.

The Apple Heart Study, conducted recently in conjunction with Stanford, was the largest study of its type. It examined atrial fibrillation in order to provide validation for the irregular rhythm notification, a feature available on most models of Apple Watch.

Apple has also announced three new health studies, which will appear in a new Research app, to become available later this year so users can participate in studies. The first study is the Apple Women’s Health Study focused on menstrual cycles and gynaecological conditions. Then there’s the Apple Heart and Movement Study, looking at how heart rate and mobility signals like walking pace relate to falls, heart health and more. And the Apple Hearing Study examines factors that affect hearing health.

I meet the Apple executives, appropriately enough, at the Wellness Centre in the company’s Cupertino headquarters, Apple Park, and ask exactly where the focus for health and fitness came from, especially for the Apple Watch.

Jeff Williams explains, “It was very organic. Most people think we had this major health initiative, well, we had some notions in the beginning but no idea where it would lead. And honestly, it's a situation where we started pulling on threads and the more we pulled, the more we realised there's such a huge opportunity for us to impact people with the information that's on their wrist.”

The first Apple Watch had a heart rate monitor built in, not because the company wanted heart health to be the primary focus but simply because it would give much more accurate step counting than rival fitness monitors which worked it out from the user’s height, for instance. But then, things changed.

“The first letter that we got about it saving somebody's life with just the heart rate monitor, we were surprised, because anybody can go watch the clock and get their heart rate. But then we started getting more and more and we realised we had a huge chance and maybe even an obligation to do more. That led us down the path to do everything including medically regulated apps. Health is such an important dimension. But it's just one dimension of the Watch. It does so much more, from telling the time to sending messages or making calls and so on. If you tried to sell a heart rate monitor to alert you to problems, you know, 12 people would buy it.”

There are so many capabilities to the Apple Watch, by contrast, that it’s gone on to become a best-seller. “So, the people who are wearing it, we get the chance to in some ways ambush them with information about their health, which is what's allowed us to have such a big impact,” Williams says.

Desai adds, “That's really important. Because I think part of the challenge with health is people don't want to think about their health all the time but here it’s just woven into the overall experience.”

But Apple is a phone maker, not a healthcare company, so was there pushback from the medical community? Desai says not. “Yeah, I think the medical community are actually really excited that we're doing this with them. The medical industry, and particularly the research community, see this is an interesting opportunity to really learn more about an individual. People may be sensing things earlier, so they are able to be more proactive and preventative with their health. And so that's something that they're welcoming with open arms. They’ve appreciated that we're not just throwing technology over the wall, we're actually trying to do the science together with them.”

Williams goes on, “It really dates back to when we launched ResearchKit, very early on. It's basically some frameworks that allow people to build apps that can conduct studies with everybody who has a phone or watch. It took so much friction out of the research process that it was well-accepted early on. Today, Apple is saying, gosh, we want to use the power of the Watch to really see if we can make some advances just like we did with AFib.”

Last year, the Apple Watch started monitoring wearers’ heart rates if the users wanted it, so it could alert them if it spotted what looked like atrial fibrillation. This has led to dramatic results.

One Watch wearer, Stefan Youngs, a 74-year-old researcher with the aviation history site, Air Crew Remembered had a striking experience. He lives in Norwich, and one day had a notification on his Apple Watch which led to him taking an ECG reading on his Watch – a feature on Apple Watch Series 4 and Series 5.

“I’m a former sportsman and keep myself in good nick so I was surprised one day when I got a tap on the wrist saying I displayed symptoms of atrial fibrillation. I had no visible symptoms, but I took an ECG on the Watch and it confirmed it. I went straight to A&E. They were sceptical but I showed them the ECG on my iPhone. They put me on a 12-lead ECG machine and the doctor asked to see the phone ECG readout again. He said it was every bit as accurate as their machine. He said the big advantage of coming in straight away is that intervention is much more likely to succeed. Normally, the only time someone presents with AFib is when they’re unconscious, they've had a stroke.”

Youngs was put on medication straight away and he no longer has atrial fibrillation. “So, I wrote to Tim Cook to tell him,” he said. “I said that I’d paid £400 for the Watch but I’d have paid a thousand times that for what it did for me.”

Williams confirms Desai’s experience and thinks values are what help the medical community appreciate Apple’s input. “We're not seeing any resistance. In fact, the opposite. We're seeing pull, whether it's from pharmaceutical companies, providers or universities, they're interested in the opportunities here. One of the things that has been so important is our approach to privacy and the data. There's nothing more sensitive than your health data. I think our approach to privacy is a real help.”

With studies like this, it’s the scale of the data that is an important ingredient. Before ResearchKit, studies would involve thousands of letters being mailed to patients and only tiny numbers of people would respond.

“We had over 400,000 people participate in a recent Heart Study. Our approach is, when you buy an Apple Watch, we don't see your data unless you want to contribute. But we found people really don't mind contributing to health research, if they know the information is going to be handled in a delicate way. It does take a lot of data sometimes to find to find the things that you want in terms of the advancements,” Williams says.

So, do more advances require more hardware upgrades to the Watch? Lynch says that’s only one part of the story. “There's already a tremendous amount we can learn from the current hardware. Heart studies are a good example. With the existing monitor in the Watch, we were able to get AFib readings from that. That didn't require a change in hardware, but it did require innovation in terms of software algorithms and machine learning on that data, and the clinical research behind that, and asking the right questions. There's already so much that we can work on. It’s really a matter of choosing our focus areas and asking really great questions that then lead to insightful answers. That's the journey we’re on. The latest studies around hearing health, for example, women's health, more heart studies, we think we can learn a ton from those areas with all the existing technology that we have, using them in this focused way. That may lead to inventing some other new things, but even with the current stuff, we’re at the beginning right now. There's so much to learn. There are so many areas that we could focus on. And so that's strategically the most important thing for us: asking where can we make a meaningful contribution?”

There have been rumours that the Apple Watch will have a glucose sensor built in one day. Williams is cautious. “Non-invasive sensing of the human body is incredibly challenge. You mention glucose, people have been talking about non-invasive glucose sensing for decades. I read every year that somebody has a non-invasive glucose sensing monitor ready. And what I'll tell you is, it's hard enough detect glucose when you can access the interstitial fluid, it's way harder to do it with photons. And so, of course, we will be interested in more sensors down the road. But as Kevin said, we think there's a lot of things we can do with the existing hardware.”

I ask Williams if there are areas which are off limits or if Apple wants to work on all health issues.

“We don't think in terms of all, we think in terms of where we see we can make an impact. Everything starts with the individual. It goes from there. When you have a problem with your health, everything else falls to the bottom of the list. So, we haven't ruled out anything. But it's more about opportunities. We're going to keep pulling on threads and see where this journey takes us.”

Williams talks passionately about health. What makes it such a pressing subject for him?

“Every day I come into Apple, I love the impact we've had on people with our products. But when I got the first couple letters saying, ‘this saved my life’, it's just a whole different feeling. That's my octane for the day. If somebody had suggested five years ago that I would be able to work with a team of people and together we would be making contributions in the health space, I would have thought they were crazy. And it's such an exciting area, and it's so full of opportunities. Everyone says the biggest challenge in health is actually behaviour-change and awareness. They talk about the last mile and connecting with the patient. And when we've got hundreds of millions of phones in people's pockets and tens of millions of devices on people's wrists, plus trust from customers, well, this is an opportunity we can't squander.”