PubAnnotation

Id	Subject	Object	Predicate	Lexical cue
T1	0-74	Sentence	denotes	Wearable Technology and How This Can Be Implemented into Clinical Practice
T2	76-84	Sentence	denotes	Abstract
T3	85-102	Sentence	denotes	Purpose of Review
T4	103-186	Sentence	denotes	Our day-to-day life is saturated with health data that was previously out of reach.
T5	187-522	Sentence	denotes	Over the last decade, new devices and fitness technology companies are attempting to tap into this data, uncovering a treasure trove of useful information that, when applied correctly, has the potential to revolutionize the way we approach healthcare and chronic conditions like asthma, especially in the wake of the COVID-19 pandemic.
T6	524-539	Sentence	denotes	Recent Findings
T7	540-755	Sentence	denotes	By harnessing exciting developments in personalization, digitization, wellness, and patient engagement, care providers can improve health outcomes for our patients in a way we have never been able to do in the past.
T8	756-913	Sentence	denotes	While new technologies to capture individual health metrics are everywhere, how can we use this information to make a real difference in our patients’ lives?
T9	914-1077	Sentence	denotes	Navigating the complicated landscape of personal wearable devices, asthma inhaler sensors, and exercise apps can be daunting to even the most tech savvy physician.
T10	1079-1086	Sentence	denotes	Summary
T11	1087-1330	Sentence	denotes	This manuscript will give you the tools necessary to make lasting changes in your patients’ lives by exposing them to a world of usable, affordable, and relatable health technology that resonates with their personal fitness and wellness goals.
T12	1331-1528	Sentence	denotes	These tools will be even more important post-COVID-19, as the landscape of clinical outpatient care changes from mainly in-person visits to a greater reliance on telemedicine and remote monitoring.
T13	1530-1542	Sentence	denotes	Introduction
T14	1543-1696	Sentence	denotes	As our world has become upended with the arrival of COVID-19, the way in which healthcare will be provided in the future is likely to change drastically.
T15	1697-1879	Sentence	denotes	This pandemic is a big wake-up call for limiting in-person visits, especially during the flu season that put vulnerable patients at undo risk coming into the office for routine care.
T16	1880-2058	Sentence	denotes	We have had the technology to perform telemedicine visits for years, but patients’ hesitancy and poor insurance reimbursement have always been barriers for widespread acceptance.
T17	2059-2218	Sentence	denotes	In the wake of the COVID-19 pandemic, most primary care and specialty offices transitioned to a telemedicine-focused approach within a matter of days to weeks.
T18	2219-2382	Sentence	denotes	In response, the Centers for Medicare & Medicaid Services (CMS) relaxed many requirements for Medicare patients and the states followed suit for Medicaid patients.
T19	2383-2562	Sentence	denotes	Insurance companies also loosened restrictions giving healthcare providers increased flexibility to provide care for their patients from the comfort and safety of their own homes.
T20	2563-2787	Sentence	denotes	2020 will be the ultimate testing ground for various telehealth services and remote monitoring applications, and it is the hope of the authors that recent changes in access and reimbursement will remain in place permanently.
T21	2788-2970	Sentence	denotes	To meet the needs of this growing market, new technologies including wearable devices will play an important role in providing real-time data to objectively monitor patients at home.
T22	2971-3165	Sentence	denotes	These devices will be especially important for improving the health and control of chronically ill patients and for those with conditions like asthma, COPD, diabetes, and cardiovascular disease.
T23	3166-3280	Sentence	denotes	The focus of this paper revolves around wearable devices for asthma, but can be applied for any chronic condition.
T24	3281-3450	Sentence	denotes	If these home devices can provide usable data in a reliable, cheap, and easy-to-use format, then the need for in-person visits in the future will be drastically reduced.
T25	3452-3468	Sentence	denotes	Connected Health
T26	3469-3636	Sentence	denotes	Innovations in personalized health technology provide a unique opportunity to develop connected healthcare models that are built around the patients’ individual needs.
T27	3637-3969	Sentence	denotes	The term connected health describes the use of a variety of technologies to inform and aid healthcare delivery in a data-driven manner with the individual at the center.7 It covers a broad domain, including digital, mobile health, and telehealth, and ensures all stakeholders are connected with data that is accurate and timely [1].
T28	3970-4228	Sentence	denotes	An integrative connected health model can also offer social support through online forums or networks where users are able to interact with peers with similar healthcare conditions or goals helping to further enhance patient experience and improve adherence.
T29	4229-4451	Sentence	denotes	Commercial weight loss programs like WW (formerly Weight Watchers) was one of the first large-scale programs to take advantage of social support networks to motivate their clients and make them accountable to other people.
T30	4452-4768	Sentence	denotes	A 2005 systematic review of commercial and proprietary weight loss programs’ efficacy concluded that WW was the only program with demonstrated efficacy in achieving modest weight loss based on results from 3 randomized controlled trials (RCTs), and their unique social approach likely contributed to its success [2].
T31	4769-4962	Sentence	denotes	A recently published systematic review found relatively strong evidence that greater social support, self-efficacy, and self-motivation can predict higher adherence to home-based therapies [3].
T32	4963-5195	Sentence	denotes	There is enough data to suggest that social support networks improve adherence to fitness, weight loss, and home-based therapies that healthcare providers should be actively curating a wider support network for their patients [4–6].
T33	5196-5415	Sentence	denotes	Wearable devices and associated apps take social connectivity to the next level and provided unparalleled access to support networks that have the potential to further encourage adherence to fitness and health regimens.
T34	5416-5645	Sentence	denotes	Promising results have already been reported with the use of apps to improve adherence and outcomes in various healthcare scenarios including weight loss, smoking cessation, diabetic management, and home exercise programs [7–11].
T35	5647-5682	Sentence	denotes	The First Wave of Wearable Devices:
T36	5683-5700	Sentence	denotes	Activity Trackers
T37	5701-5904	Sentence	denotes	The concepts of wellness and mindfulness have become an increasing part of the public health discussion as there seems to be a growing appreciation for a more holistic approach to fitness and well-being.
T38	5905-6104	Sentence	denotes	With the advent of more advanced wearable technology like fitness trackers and smartwatches starting in 2014, consumers are no longer content with just tracking their weight loss goals or step count.
T39	6105-6378	Sentence	denotes	Personalized healthcare devices arm users with snapshots of their activity and recovery data and allow them to track advanced performance metrics including step tracking, heart rate, body fat percentage, sleep quality, stress levels, menstrual cycle, and fertility windows.
T40	6379-6575	Sentence	denotes	As this data becomes more accessible, consumers are discovering that overall health is the sum of all the small choices you make each day: what you eat, how much you move, how much you sleep, etc.
T41	6576-6751	Sentence	denotes	Having fitness and weight loss goals is an important first step, but converting that enthusiasm to actual gym time and change in habits has always been the rate limiting step.
T42	6752-7027	Sentence	denotes	That is where innovative fitness startups and fitness technology companies are focusing their attention: getting people excited about working out, offering unparalleled convenience, and keeping members engaged long-term by utilizing the latest in technology and social media.
T43	7028-7091	Sentence	denotes	Since 2014, the use of commercial wearable devices has doubled.
T44	7092-7259	Sentence	denotes	Currently, 19% of Americans use a wearable fitness tracker (e.g., Fitbit, Apple Watch) with sales projected to double by 2022, becoming a $27 billion+ market [12, 13].
T45	7261-7309	Sentence	denotes	Wearable Devices that Promote Health and Fitness
T46	7310-7467	Sentence	denotes	As more and more patients use wearable devices and smartphone apps to track their personal health data, how can this information be used in a meaningful way?
T47	7468-7711	Sentence	denotes	Fitness technology companies like Fitbit and Apple Health are leveraging insights from over 10 years of activity, exercise, and sleep data to better inform future applications and provide behavior change techniques and insights to their users.
T48	7712-7904	Sentence	denotes	Apple recently announced that customers in the USA can enroll in three landmark health studies: the Apple Women’s Health Study, the Apple Heart and Movement Study, and the Apple Hearing Study.
T49	7905-8222	Sentence	denotes	Conducted in partnership with leading academic and research institutions like the World Health Organization, these multi-year longitudinal studies are leveraging the ubiquity of Apple products to provide a treasure trove of user data to inform potential medical discoveries that could improve healthcare for all [14].
T50	8223-8383	Sentence	denotes	Wearable devices themselves can provide crude feedback like reminders to move or stand which prompts users to take more steps per hour or stand more frequently.
T51	8384-8569	Sentence	denotes	For additional charges, some devices can provide more detailed personal wellness reports, offering actionable guidance and coaching to help users achieve their health and fitness goals.
T52	8570-8833	Sentence	denotes	Some companies like Fitbit are taking it a step further and offering personal, one-on-one coaching services for weight loss and diabetes control providing users with a personalized plans and direct support from their team of certified health and wellness coaches.
T53	8834-8918	Sentence	denotes	A small sampling of highly rated fitness and nutrition apps are included in Table 1.
T54	8919-8963	Sentence	denotes	Table 1 Top rated fitness and nutrition apps
T55	8964-9009	Sentence	denotes	App Supporting devices Cost structure Details
T56	9010-9042	Sentence	denotes	For all-around healthy lifestyle
T57	9043-9275	Sentence	denotes	8fit iOS, Android Free; $59.99 per year; $44.99 per half-year; $19.99 per month for meal plans and more workouts On-demand workouts and meal planning for people who like a lot of guidance, suggestions, reminders, and instructions.
T58	9276-9376	Sentence	denotes	Provides realistic assessment of how hard or easy it will be to reach your health and fitness goals.
T59	9377-9381	Sentence	denotes	Yoga
T60	9382-9527	Sentence	denotes	Asana Rebel iOS, Android $39.99 for 3 months; $58.99 for 12 months Yoga-inspired fitness that has guided yoga flows alongside regular workouts.
T61	9528-9602	Sentence	denotes	Input goals, track progress, and choose classes based on experience level.
T62	9603-9762	Sentence	denotes	Yoga Wake Up iOS, Android $10 per month Offers different audio yoga and meditation sequences that are designed to start in bed and end with you on your feet.
T63	9763-9908	Sentence	denotes	Alo Moves iOS, Android $20 per month Has over 2000 videos organized into 200 plans and over 500 single classes taught by the top names in yoga.
T64	9909-10011	Sentence	denotes	YogaGlo iOS, Android $18 per month Offers more than 3800 yoga workouts and guided mediation classes.
T65	10012-10030	Sentence	denotes	On-demand workouts
T66	10031-10197	Sentence	denotes	Peloton Digital iOS, Android $20 per month Access live-streamed classes to use on any bike or treadmill or try one of their boot camp, strength, or outdoor classes.
T67	10198-10375	Sentence	denotes	Fitbit Coach iOS, Android Free; $9.99 per month or $79.99 per year for Premium Takes users daily Fitbit activity data to recommend exercises and personalized fitness feedback.
T68	10376-10447	Sentence	denotes	Large database of workout videos with step-by-step directions and tips.
T69	10448-10477	Sentence	denotes	Compatible with Fitbit Radio.
T70	10478-10661	Sentence	denotes	Nike Training Club iOS, Android Free; $14.99 per month or $119.99 per year for Premium Has classic short sessions but includes workout routines that are 30, 45, or even 60 min long.
T71	10662-10757	Sentence	denotes	A Premium account also comes with programs led by trainers and nutrition and wellness guidance.
T72	10758-10901	Sentence	denotes	Sworkit iOS, Android $10 per month Custom no-equipment training plans, complete with guided videos for each workout ranging from 5 to 60 min.
T73	10902-10987	Sentence	denotes	Users can also connect with personal trainers to ask questions and get expert advice.
T74	10988-11110	Sentence	denotes	Aaptiv iOS, Android $15 per month Audio classes taught by trainers guiding users through a fitness studio-style session.
T75	11111-11209	Sentence	denotes	Over 2500 workouts in cycling, yoga, strength training, stretching, elliptical workouts, and more.
T76	11210-11286	Sentence	denotes	Also comes with full marathon, half marathon, 10K, and 5K training programs.
T77	11287-11303	Sentence	denotes	Fitness tracking
T78	11304-11464	Sentence	denotes	Strava iOS, Android, Web Free; $7.99 per month or $59.99 per year Users can compete against themselves or others who have run, biked, or swam the same routes.
T79	11465-11587	Sentence	denotes	The app uses phone/watches GPS to track where users go and how fast then compares with other users creating a leaderboard.
T80	11588-11731	Sentence	denotes	Map My Fitness iOS, Android Free; $5.99 per month or $29.99 per year for MVP Recommended for those just getting started on a fitness journey.
T81	11732-11865	Sentence	denotes	Has hundreds of activities you can track, everything from vacuuming to rock climbing motivating user to keep a more active lifestyle.
T82	11866-11934	Sentence	denotes	Consolidates data from various fitness trackers or apps such Fitbit.
T83	11935-12051	Sentence	denotes	Charity Miles iOS, Android Free Motivates by donating money to charity for every mile users run, walk, or bicycle.
T84	12052-12225	Sentence	denotes	Supports a variety of nonprofit organizations, such as ASPCA, Habitat for Humanity, St. Jude Children’s Hospital, UNICEF, Save the Children, and the Wounded Warrior Project.
T85	12226-12244	Sentence	denotes	Nutrition-Tracking
T86	12245-12438	Sentence	denotes	MyFitnessPal iOS, Android Free; $9.99 per month or $49.99 per year for Premium Calorie counting app that also figures out how many calories users should eat to gain, lose, or maintain weight.
T87	12439-12565	Sentence	denotes	Consolidates everything users eat and drink, plus all their activities to calculate calories consumed against calories burned.
T88	12566-12637	Sentence	denotes	It also has tools for tracking weight and other body changes over time.
T89	12638-12722	Sentence	denotes	It has the largest database of foods and is the best food logging app on the market.
T90	12723-13004	Sentence	denotes	Noom iOS, Android $59 per month, $199 per year (additional pricing options available) Complete weight loss program with daily interactive content, a personal goal coach, and plenty of content to help users master the psychology involved with changing their relationships to food.
T91	13005-13197	Sentence	denotes	MyPlate iOS, Android, Web Free; $9.99 per month, $30 for six months, or $44.99 per year for Gold All-in-one fitness app, combining calorie counting, weight management, recipes, and workouts.
T92	13198-13356	Sentence	denotes	Users look up and record everything they eat and can see a nutritional analysis of macronutrient intake for free (requires paid subscription in MyFitnessPal).
T93	13357-13573	Sentence	denotes	WW Digital (formally WeightWatchers) iOS, Android, Web $23.99 per month or $219.99 per year Highly supportive community and app that focuses more on personalization and overall health rather than weight loss alone.
T94	13574-13682	Sentence	denotes	Users do not have to attend meetings or meet with a counselor (although this is an option for an added fee).
T95	13683-13758	Sentence	denotes	Monitors food intake with SmartPoints rather than counting calories or fat.
T96	13759-13785	Sentence	denotes	Mindfulness and meditation
T97	13786-14026	Sentence	denotes	Calm iOS, Android $14.99 per month or $69.99 per year Guided mindfulness meditation that initially offers a “7 Days of Calm” course which introduces users to mindfulness meditation, as well as some guided and unguided meditation sessions.
T98	14027-14139	Sentence	denotes	Paid users have access to more multi-day courses, a “Daily Calm” course, and many, many more guided meditations.
T99	14140-14277	Sentence	denotes	Headspace iOS, Android $12.99 per month or $69.99 per year Guided meditation for health issues, emotions, challenges, and productivity.
T100	14278-14353	Sentence	denotes	There are even “SOS” sessions for some of the more stressful times in life.
T101	14354-14470	Sentence	denotes	Recently added free content called Weathering the Storm for those struggling with the emotional effects of COVID-19.
T102	14471-14655	Sentence	denotes	The Mindfulness App iOS, Android $9.99 per month or $59.99 per year Starts with a 5-day introduction to mindfulness along with guided meditations to get you familiar with meditating.
T103	14656-14830	Sentence	denotes	With subscription choose guided or silent meditation sessions for challenges, travel, sleep, relationships, stress relief, emotions, body awareness, focus, and relationships.
T104	14831-15037	Sentence	denotes	*The authors are aware of the transient nature of fitness, nutrition, and lifestyle apps and understand that the recommendations provided at the time of this publication might not be available in the future
T105	15038-15299	Sentence	denotes	The ultimate goal with these devices and apps is to provide real-time feedback to patients so that they actually see data that illustrates how destructive behaviors impact them physically, providing additional motivation to more proactively manage their health.
T106	15300-15432	Sentence	denotes	The more the patient understands about their personal health, the more empowered they will be to make meaningful behavioral changes.
T107	15433-15570	Sentence	denotes	Healthcare providers need to be able to access and interpret personalized health data, as well as distill it into usable teaching points.
T108	15571-15730	Sentence	denotes	In the past, physicians often took an authoritarian approach to health and fitness education which did little to encourage active participation by the patient.
T109	15731-16011	Sentence	denotes	By employing a patient-centered approach utilizing data gleaned from wearable devices, healthcare providers have an opportunity to work in concert with patients to impart measurable skills and behaviors in a real and tangible way with the ability to track this progress over time.
T110	16012-16232	Sentence	denotes	When patients are included in a collaborative and patient-centered discussion about their health and well-being, compliance and satisfaction rates improve, leading to a more effective doctor-patient relationship [15–17].
T111	16233-16420	Sentence	denotes	It is important to note that these devices are still in their infancy, and the accuracy and validity of the data still need to be strengthened in order to provide the best medical advice.
T112	16422-16448	Sentence	denotes	Wearable Devices in Asthma
T113	16449-16627	Sentence	denotes	Most of the wearable fitness device research to date has focused in diseases associated with low levels of physical activity, namely cardiovascular disease, diabetes, and cancer.
T114	16628-16791	Sentence	denotes	Few have focused on asthma and of the studies conducted in asthma populations, all have honed in on the use of Fitbit-derived sleep measures (i.e., sleep quality).
T115	16792-16886	Sentence	denotes	Castner et al. used the Fitbit Charge™ to validate sleep measures in women with asthma [18••].
T116	16887-17036	Sentence	denotes	The sleep measures collected by the Fitbit were compared with Actigraph GT3X +, a well-known and validated device to collect sleep measures [19, 20].
T117	17037-17150	Sentence	denotes	The Fitbit device tended to overestimate sleep efficiency and underestimate wake counts compared with actigraphy.
T118	17151-17350	Sentence	denotes	Two additional studies were conducted in pediatric populations and focused on correlating Fitbit-derived sleep measures to patient-reported outcomes such as asthma control and asthma impact [21, 22].
T119	17351-17626	Sentence	denotes	Bian and colleagues assessed the association between self-reported asthma impact and Fitbit-derived sleep quality (the ratio of minutes asleep to minutes in bed) and physical activity measures (daily minutes of moderate and vigorous activity) in adolescents with asthma [21].
T120	17627-17920	Sentence	denotes	Fitbit-derived sleep quality was moderately correlated with Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance score (r = − 0.31, P = 0.01) and had a weak but significant correlation with the PROMIS pediatric asthma impact score (average r = − 0.18, P = 0.02).
T121	17921-18038	Sentence	denotes	Fitbit-derived physical activity levels were not associated with PROMIS pediatric asthma impact (r = 0.04, P = 0.62).
T122	18039-18228	Sentence	denotes	These findings suggest that measurement of sleep quality, using the Fitbit device, may help develop personalized asthma management strategies for children and their caregivers in real time.
T123	18229-18611	Sentence	denotes	The final study measured several mobile metrics of asthma including physical activity and sleep using Fitbits, forced expiratory volume in 1 s and peak expiratory flow, indoor air quality using Foobot (https://foobot.io/), and a mobile app that collected information on asthma control (symptoms, physical limitations due to asthma, nighttime awakenings, and medication intake) [22].
T124	18612-18859	Sentence	denotes	These metrics were used together to digitally phenotype children with asthma and provide a better measure of the patient’s asthma control to their clinician when compared with the Asthma Control Test scores taken infrequently during clinic visits.
T125	18860-19083	Sentence	denotes	Additional work using this ecological metric of asthma control is needed and may be used in the future to generate insights on the relationship between a patient’s asthma symptoms and triggers across different seasons [23].
T126	19084-19172	Sentence	denotes	Acoustic monitoring is another type of wearable devices that has been studied in asthma.
T127	19173-19358	Sentence	denotes	Breathing sound measured by microphones over human skin can detect breathing patterns (respiratory rate, flow rate, tidal volume) and symptoms that may be due to asthma (wheeze, cough).
T128	19359-19462	Sentence	denotes	Moreover, chest movement signals can be acquired using an accelerometer or belt-shaped device [24, 25].
T129	19463-19568	Sentence	denotes	Boner et al. measured the nocturnal wheeze in children with asthma using an acoustic respiratory monitor.
T130	19569-19753	Sentence	denotes	They found that among children with apparently well-controlled asthma, 57% had considerable amounts of night wheezing that was unrelated to conventional measures of lung function [26].
T131	19754-19885	Sentence	denotes	The use of these continual wearable monitoring systems is still a developing field that needs further study on its clinical impact.
T132	19887-19933	Sentence	denotes	Use of Electronic Monitoring Devices in Asthma
T133	19934-20086	Sentence	denotes	Electronic monitoring devices (EMDs) in asthma are increasingly more common since they provide objective data and are not biased by patient self-report.
T134	20087-20254	Sentence	denotes	The majority of the currently available EMDs focus on addressing medication adherence, with a limited few focusing on sleep monitoring and identifying asthma triggers.
T135	20255-20435	Sentence	denotes	The devices measuring adherence use a variety of approaches from recording audio during inhaler use, using time and date to detect medication use and capturing spirometry measures.
T136	20436-20745	Sentence	denotes	These devices are paired with mobile applications (Apps) on smartphones which can provide the patient with audiovisual reminders for taking medications, correlate medication use with environmental exposures (i.e., weather, ozone, pollution) using smartphone GPS coordinates and feedback on proper inhaler use.
T137	20746-20848	Sentence	denotes	A summary of some of the current and emerging technologies in the asthma space is provided in Table 2.
T138	20849-20900	Sentence	denotes	Table 2 Current and emerging technologies in asthma
T139	20901-20956	Sentence	denotes	Technology Measures Outcomes in asthma studies Comments
T140	20957-20976	Sentence	denotes	Wearable technology
T141	20977-20986	Sentence	denotes	− Fitbit™
T142	20987-21167	Sentence	denotes	− Apple™ Watch Fitbit: heart rate (available on most but not all models), steps/day, physical activity (light, moderate and vigorous), sedentary time, sleep efficiency, wake counts
T143	21168-21372	Sentence	denotes	Apple Watch: heart rate, EKG, steps/day, physical activity (light, moderate and vigorous), sedentary time − Fitbit overestimated sleep efficiency and underestimated wake counts compared with actigraphy.18
T144	21373-21479	Sentence	denotes	− Fitbit-derived sleep quality correlated with PROMIS pediatric asthma impact score.21 Corresponding Apps:
T145	21480-21539	Sentence	denotes	Apple Watch App on iPhone, Fitbit App on iPhone and Android
T146	21540-21717	Sentence	denotes	Pros: portable; commercially available; may be useful when used with other measures such as air quality, lung function and asthma symptoms to digitally phenotype asthma patients
T147	21718-21723	Sentence	denotes	Cons:
T148	21724-21784	Sentence	denotes	No sleep data available on Apple Watch without 3rd party App
T149	21785-21798	Sentence	denotes	Data sharing:
T150	21799-21925	Sentence	denotes	Data does not sync to EMR directly but patient can access file and send to provider via mail, secure email, or patient portal.
T151	21926-22017	Sentence	denotes	Electronic monitoring devices (e.g., inhaler sensors ± digital health platform) Digihaler™:
T152	22018-22129	Sentence	denotes	− Inhaler time of inhaler use, peak inspiratory flow rate (PIFR), time to PIFR, inhalation volume and duration.
T153	22130-22154	Sentence	denotes	Propeller Health System:
T154	22155-22209	Sentence	denotes	− Inhaler sensor: date, time and number of doses taken
T155	22210-22239	Sentence	denotes	− Asthma Health Platform App:
T156	22240-22365	Sentence	denotes	Location of inhaler use using phone GPS, current weather/pollen counts/air pollution and self-report asthma symptoms/triggers
T157	22366-22383	Sentence	denotes	Hailie™ solution:
T158	22384-22459	Sentence	denotes	− Inhaler sensor: date, time, number of inhaler actuations and missed doses
T159	22460-22523	Sentence	denotes	− Hailie™ App: medication adherence, daily medication reminders
T160	22524-22561	Sentence	denotes	Inhaler compliance assessment device:
T161	22562-22657	Sentence	denotes	Time of dose, inhaler technique errors − Greater asthma control31,38–39 and symptom-free days33
T162	22658-22747	Sentence	denotes	− Reduction in daily symptoms31, rescue medication use29,32–33, and exacerbations34,38–39
T163	22748-22784	Sentence	denotes	− Improved medication adherence36–40
T164	22785-22857	Sentence	denotes	− High patient acceptability of device and digital health platform36–37.
T165	22858-22877	Sentence	denotes	Corresponding Apps:
T166	22878-22916	Sentence	denotes	Digihaler™, Propeller Health, Hailie™.
T167	22917-22990	Sentence	denotes	Web-based platform also available for Propeller Health, Hailie™ solution.
T168	22991-23156	Sentence	denotes	Pros: portable, high acceptability among patients, improvements in asthma control in those with a digital health platform (e.g., Propeller Health, Hailie™ solution).
T169	23157-23162	Sentence	denotes	Cons:
T170	23163-23283	Sentence	denotes	Additional efficacy studies of the devices are needed, cost of devices are not always covered by insurance reimbursement
T171	23284-23297	Sentence	denotes	Data sharing:
T172	23298-23458	Sentence	denotes	Provider platform available to share results (e.g. Digihaler™, Propeller Health, Hailie™ solution), patients may share data from Digihaler™ also via file share.
T173	23459-23504	Sentence	denotes	Mobile-based applications Self-monitoring of:
T174	23505-23522	Sentence	denotes	− Asthma symptoms
T175	23523-23533	Sentence	denotes	− Triggers
T176	23534-23612	Sentence	denotes	− Medication use -Improvements in asthma control though low-quality evidence45
T177	23613-23735	Sentence	denotes	-Improvements in asthma control in five studies, lung function in two studies and quality of life in three studies46 Pros:
T178	23736-23766	Sentence	denotes	Acceptable and feasible to use
T179	23767-23772	Sentence	denotes	Cons:
T180	23773-23894	Sentence	denotes	Vary in quality; data are self-reported, most apps have not been validated; risk of loss of privacy of health information
T181	23895-23908	Sentence	denotes	Data sharing:
T182	23909-23991	Sentence	denotes	Vary in ability to share with provider, most are up to user to share with provider
T183	23992-24179	Sentence	denotes	Teva’s Digihaler™ has been FDA approved for use with ProAir® (albuterol sulfate 117 mcg), AirDuo® (fluticasone propionate and salmeterol), and ArmonAir® (fluticasone propionate) inhalers.
T184	24180-24266	Sentence	denotes	The Digihaler™ contains built-in sensors that records inhalation data with timestamps.
T185	24267-24424	Sentence	denotes	The inhalation data includes parameters that are important for assessing inhaler technique including peak inspiratory flow rate and inhalation duration [27].
T186	24425-24550	Sentence	denotes	The device is connected via Bluetooth® technology to a companion App that provides information on inhaler use to the patient.
T187	24551-24685	Sentence	denotes	While to date, the efficacy of Digihalers has not been evaluated; one pilot study has shown its ability to predict exacerbations [28].
T188	24686-24775	Sentence	denotes	Adults with exacerbation-prone asthma (n = 360) used the ProAir® Digihaler™ for 12 weeks.
T189	24776-24946	Sentence	denotes	The Digihaler™ was able to predict asthma exacerbations (defined as need for oral corticosteroids) with an area under the receiver operating characteristic curve of 0.75.
T190	24947-25079	Sentence	denotes	The most predictive factor was the average number of albuterol inhalations per day during a period of 5 days before an exacerbation.
T191	25080-25216	Sentence	denotes	Further developments of the model in larger populations are needed to determine the efficacy of the Digihaler™ to predict exacerbations.
T192	25217-25371	Sentence	denotes	Propeller Health has developed a system which includes a sensor that can attach to both rescue and controller inhalers and an Asthma Health Platform [29].
T193	25372-25455	Sentence	denotes	The inhaler sensor collects date and time of inhaler use and number of puffs taken.
T194	25456-25628	Sentence	denotes	This data is transferred via Bluetooth® technology to the Asthma Health Platform on a mobile device and can be matched with GPS coordinates obtained from the mobile device.
T195	25629-25799	Sentence	denotes	The Asthma Health Platform can also be used to record asthma symptoms and triggers which integrates with other data streams such as weather, pollen counts, and pollution.
T196	25800-25863	Sentence	denotes	The Propeller Health System is one of the most studied to date.
T197	25864-26082	Sentence	denotes	A 4-month pilot study conducted in 30 individuals showed when the device and app were used along with weekly feedback, participants had an improvement in asthma control and a decline in day-to-day asthma symptoms [30].
T198	26083-26176	Sentence	denotes	The effectiveness of Propeller Health System on rescue inhaler has also been examined [31••].
T199	26177-26299	Sentence	denotes	In a study of 495 patients, all patients received the Propeller Health System but only 250 received sensor-based feedback.
T200	26300-26512	Sentence	denotes	The authors found a decrease in mean daily rescue medication use in those receiving sensor-based feedback (0.19 vs. 0.25 in control arm) which was more pronounced in patients with uncontrolled asthma at baseline.
T201	26513-26677	Sentence	denotes	These findings were confirmed in another study of 120 participants with a decrease in rescue medication use by 39% and an increase in symptom-free days by 12% [32].
T202	26678-26850	Sentence	denotes	Propeller Health has also developed a provider-facing web interface (portal) that allows providers and their staff to view patient medication use and asthma control status.
T203	26851-27032	Sentence	denotes	This is available to providers that enroll their patients with the Propeller Health System but can be integrated into existing EMR systems to allow for data sharing among providers.
T204	27033-27190	Sentence	denotes	Merchant et al. evaluated this enhanced Propeller Health System and found a decrease in asthma-related emergency department visits and hospitalizations [33].
T205	27191-27492	Sentence	denotes	The Hailie™ solution (previously known as SmartInhaler™ platform) is a system of medication sensors (e.g., SmartTrack™, SmartTouch™, SmartTouch AV™, SmartTurbo™; http://www.smartinhaler.com/devices/) that wrap around existing inhalers and automatically sends usage data to a patient’s smartphone [34].
T206	27493-27599	Sentence	denotes	The sensors record the date and time of actuations, the total number of actuations used, and missed doses.
T207	27600-27793	Sentence	denotes	The device pairs with the Hailie™ App and enables the patient and healthcare professionals to track medication adherence, set daily reminders, and discover insights into their medication usage.
T208	27794-27960	Sentence	denotes	The SmartInhaler™ sensors have been studied extensively and have demonstrated high user acceptability as well as efficacy in increasing medication adherence [35, 36].
T209	27961-28166	Sentence	denotes	Five randomized controlled trials using the SmartInhaler™ have been conducted in the UK, Australia, and New Zealand, including a total of 589 adults and children with asthma in a community setting [35–39].
T210	28167-28315	Sentence	denotes	The authors of these studies conclude that SmartInhaler™ devices were more effective than standard care in improving adherence to asthma medication.
T211	28316-28469	Sentence	denotes	Two of the studies showed significant improvement in clinical outcomes (e.g., asthma exacerbations, asthma control, and healthcare utilization) [37, 38].
T212	28470-28661	Sentence	denotes	The Inhaler Compliance Assessment (INCA) device uses time-stamped audio recordings of inhaler use to assess not only inhaler adherence but also inhaler technique (http://www.tueohealth.com/).
T213	28662-28806	Sentence	denotes	Specifically, it can assess proper inhaler technique by measuring a failure to prime the inhaler, inadequate inspiratory flow, and dose dumping.
T214	28807-28976	Sentence	denotes	This information can be used to determine if medication was not properly delivered due to inhaler technique errors (attempted adherence) or missed/late medication doses.
T215	28977-29117	Sentence	denotes	In one study of 184 people with chronic obstructive pulmonary disease, the INCA device was used to assess controller inhaler adherence [40].
T216	29118-29234	Sentence	denotes	The mean rate of attempted adherence was 58.7%, whereas actual adherence (proper timing and technique) was only 23%.
T217	29235-29358	Sentence	denotes	Only 7% of participants had actual adherence above 80%, underscoring the importance of addressing proper inhaler technique.
T218	29359-29472	Sentence	denotes	Currently, there is no mobile app for the INCA tool and the data must be downloaded onto a computer for analysis.
T219	29473-29589	Sentence	denotes	Additional studies are currently being conducted using an INCA App to assess its ability to improve asthma outcomes.
T220	29590-29726	Sentence	denotes	Tueo Health, which was acquired by Apple in 2019, developed a passive EMD to help parents monitor nighttime asthma symptoms in children.
T221	29727-29891	Sentence	denotes	Using commercial breathing sensors placed under the mattress, the device can passively measure key physiologic parameters during sleep (http://www.tueohealth.com/).
T222	29892-30020	Sentence	denotes	An asthma control score is then calculated from the physiologic data and available for the patient to view through a mobile app.
T223	30021-30189	Sentence	denotes	The score gives direct indication of their asthma control status based on their provider-issued asthma action plan and recommends evidence-based steps to manage asthma.
T224	30190-30323	Sentence	denotes	Such steps include reminders to avoid known triggers, refill a prescription, or make an appointment to see their healthcare provider.
T225	30325-30353	Sentence	denotes	Use of Mobile Apps in Asthma
T226	30354-30458	Sentence	denotes	As with wearable devices, the use of health apps on phones and tablets has rapidly been increasing [13].
T227	30459-30550	Sentence	denotes	There are a large number of asthma-related apps with well over 500 reported in 2019 [41••].
T228	30551-30671	Sentence	denotes	The mobile apps range from providing health education, symptom tracking, environmental alerts, and medication reminders.
T229	30672-30799	Sentence	denotes	A review conducted in 2015 selected 209 English asthma-related apps that were available in Google Play and/or Apple Store [42].
T230	30800-31202	Sentence	denotes	The majority (52%) of the apps evaluated were teaching and training information for patients, with 39% based on alternative treatments, such as yoga, acupressure, and breathing exercises; 22% helped users to monitor symptoms and medication adherence; 18% provided medical reference information for providers; 6% provided air quality information; and 2% served as social forums for patients with asthma.
T231	31203-31325	Sentence	denotes	Despite the great number of currently available mobile apps for asthma, few effectiveness evaluations have been conducted.
T232	31326-31428	Sentence	denotes	In 2013, Marcano and colleagues conducted a Cochrane review on mobile apps for asthma self-management.
T233	31429-31631	Sentence	denotes	Only two randomized controlled trials (RCTs) fit the review criteria and assessed efficacy of the apps on asthma outcomes such as asthma control, asthma quality of life, and healthcare utilization [43].
T234	31632-31820	Sentence	denotes	Both RCTs (n = 408) evaluated the effect of a mobile phone-based asthma self-management intervention on asthma control by comparing it with traditional, paper-based asthma self-management.
T235	31821-31958	Sentence	denotes	Overall, the results were inconclusive, as the evidence was low quality (GRADE) and attrition bias plus other sources of bias were found.
T236	31959-32050	Sentence	denotes	In 2017, another systematic review assessed asthma self-management using mHealth apps [44].
T237	32051-32195	Sentence	denotes	The authors found that mHealth apps improved asthma control in five studies, lung function in two studies, and quality of life in three studies.
T238	32196-32279	Sentence	denotes	There was no significant impact on economic outcomes such as hospitalization rates.
T239	32280-32459	Sentence	denotes	While there is preliminary evidence on the efficacy of asthma self-management mobile apps to improve asthma control and quality of life, the mechanisms have not been well studied.
T240	32460-32561	Sentence	denotes	Ramsey and colleagues reviewed the content and quality of mHealth asthma self-management apps [45••].
T241	32562-32751	Sentence	denotes	The mobile apps were identified through systematic searches of the Apple and Google Play stores and then coded to evaluate the inclusion of evidence-based behavior change techniques (BCTs).
T242	32752-32923	Sentence	denotes	Examples of BCTs include providing information about behavior-health link, identifying barriers to performing health behaviors, and prompting self-monitoring of behaviors.
T243	32924-33104	Sentence	denotes	The quality of the apps was also rated using the Mobile App Rating Scale (MARS) to determine app engagement, functionality, aesthetics, information quality, and subjective quality.
T244	33105-33185	Sentence	denotes	Of the twenty-three apps identified, a range of 1–11 BCTs were used by the apps.
T245	33186-33347	Sentence	denotes	The most commonly included BCTs were instruction, behavior-health link, self-monitoring, feedback, teach to use prompts/cues, consequences, and others’ approval.
T246	33348-33436	Sentence	denotes	Three apps used at least eight BCTs (i.e., AsthmaMD, Kiss myAsthma, and My Breathefree).
T247	33437-33541	Sentence	denotes	The overall quality of the apps, as measured by MARS, ranged from 2.45 to 4.50 (out of a possible 5.00).
T248	33542-33656	Sentence	denotes	Four apps had an overall MARS quality of > 4.0 (AsthmaMD, Asthma Health Storylines, Kiss myAsthma, and Wizdy Pets:
T249	33657-33676	Sentence	denotes	Kids’ Asthma Game).
T250	33677-33954	Sentence	denotes	As it is more common for patients to ask their healthcare providers to help them choose apps, it is important that providers are knowledgeable about which asthma management apps are high quality and include evidence-based components that will be successful for behavior change.
T251	33955-34111	Sentence	denotes	To date, Kiss myAsthma and AsthmaMD are the asthma management apps with the highest number of BCTs and quality scores, but this area is constantly evolving.
T252	34112-34195	Sentence	denotes	There are some limitations to consider regarding the use of mobile apps for asthma.
T253	34196-34284	Sentence	denotes	The majority of commercially available asthma apps lack validation in clinical settings.
T254	34285-34438	Sentence	denotes	Further, the apps are not regulated or approved as medical devices and may provide recommendations to patients that are not evidence-based or inaccurate.
T255	34439-34538	Sentence	denotes	Finally, there is a risk of loss of privacy of health information for patients that use these apps.
T256	34539-34635	Sentence	denotes	One study showed that only 30% of the most commonly used mHealth apps had privacy policies [46].
T257	34636-34791	Sentence	denotes	These policies often required a high-level of literacy for comprehension, were often not focused on the app itself, and were not informative for end users.
T258	34792-34961	Sentence	denotes	Therefore, clinicians should evaluate asthma management apps to ensure high quality and evidenced-based information prior to recommending them for their asthma patients.
T259	34963-35005	Sentence	denotes	Conclusion: a New Wave of Wearable Devices
T260	35006-35121	Sentence	denotes	The world and medicine as we know it are changing forever in the wake of the repercussions of the COVD-19 pandemic.
T261	35122-35323	Sentence	denotes	Limiting unnecessary in-person visits, especially for at-risk patients, and expanding the scope of what we can provide remotely using new technological advancements should be a priority moving forward.
T262	35324-35516	Sentence	denotes	The future of wearable devices seems to be headed towards continuous measurements of personal physiology to predict, prevent, or help to aid in the diagnosis of an underlying health condition.
T263	35517-35676	Sentence	denotes	This approach allows frequent and continuous measurements of body functions including heart rate, skin temperature, blood oxygen levels, and physical activity.
T264	35677-35919	Sentence	denotes	Recent studies investigating the utility of wearable sensors indicate that the information provided by these devices is physiologically meaningful and actionable and will likely to play an important role in managing health in the future [47].
T265	35920-36060	Sentence	denotes	Healthcare providers and patients themselves can do a much better job of tracking their health outside of regularly scheduled office visits.
T266	36061-36247	Sentence	denotes	Currently, providers are relying on patients with chronic health conditions to consistently self-report progress and medication compliance which is inefficient and unpredictable at best.
T267	36248-36457	Sentence	denotes	Having access to reliable home data on a consistent basis that is relevant to the patient’s specific medical condition is key to improving health outcomes not only for asthma but also for all chronic diseases.
T268	36458-36612	Sentence	denotes	Increased utilization of health monitoring devices by patients will likely become an important aspect of self-care and preventive medicine moving forward.
T269	36613-36802	Sentence	denotes	The data provided by these devices will allow care providers to provide patients with personalized tools and tailored solutions to improve their health and encourage fitness and diet goals.
T270	36803-36953	Sentence	denotes	They may also help to enhance accurate symptom reports, improve accuracy of diagnosis, and streamline appropriate specialty referral when appropriate.
T271	36955-37032	Sentence	denotes	This article is part of the Topical Collection on Telemedicine and Technology
T272	37033-37049	Sentence	denotes	Publisher’s Note
T273	37050-37168	Sentence	denotes	Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
T274	37170-37203	Sentence	denotes	Compliance with Ethical Standards
T275	37205-37225	Sentence	denotes	Conflict of Interest
T276	37226-37542	Sentence	denotes	Dr. Greiwe is a consultant for AstraZeneca on social media and respiratory biologics scientific expert on the virtual advisory board; Sanofi Grenzyme Dupixent scientific expert on the virtual advisory board; honoraria from AstraZeneca Fesenra Speakers Bureau, Regeneron, and Sanofi Grenzyme Dupixent Speakers Bureau.
T277	37543-37725	Sentence	denotes	Dr. Nyenhuis is a board member of Chicago Asthma Consortium; grant from National Institute of Health, honoraria from Sanofi, royalties from Springer Nature and Wolters Kluwer Health.
T278	37727-37771	Sentence	denotes	Human and Animal Rights and Informed Consent
T279	37772-37876	Sentence	denotes	This article does not contain any studies with human or animal subjects performed by any of the authors.

T1

0-74

Sentence

denotes

Wearable Technology and How This Can Be Implemented into Clinical Practice

T2

76-84

Sentence

denotes

Abstract

T3

85-102

Sentence

denotes

Purpose of Review

T4

103-186

Sentence

denotes

Our day-to-day life is saturated with health data that was previously out of reach.

T5

187-522

Sentence

denotes

Over the last decade, new devices and fitness technology companies are attempting to tap into this data, uncovering a treasure trove of useful information that, when applied correctly, has the potential to revolutionize the way we approach healthcare and chronic conditions like asthma, especially in the wake of the COVID-19 pandemic.

T6

524-539

Sentence

denotes

Recent Findings

T7

540-755

Sentence

denotes

By harnessing exciting developments in personalization, digitization, wellness, and patient engagement, care providers can improve health outcomes for our patients in a way we have never been able to do in the past.

T8

756-913

Sentence

denotes

While new technologies to capture individual health metrics are everywhere, how can we use this information to make a real difference in our patients’ lives?

T9

914-1077

Sentence

denotes

Navigating the complicated landscape of personal wearable devices, asthma inhaler sensors, and exercise apps can be daunting to even the most tech savvy physician.

T10

1079-1086

Sentence

denotes

Summary

T11

1087-1330

Sentence

denotes

This manuscript will give you the tools necessary to make lasting changes in your patients’ lives by exposing them to a world of usable, affordable, and relatable health technology that resonates with their personal fitness and wellness goals.

T12

1331-1528

Sentence

denotes

These tools will be even more important post-COVID-19, as the landscape of clinical outpatient care changes from mainly in-person visits to a greater reliance on telemedicine and remote monitoring.

T13

1530-1542

Sentence

denotes

Introduction

T14

1543-1696

Sentence

denotes

As our world has become upended with the arrival of COVID-19, the way in which healthcare will be provided in the future is likely to change drastically.

T15

1697-1879

Sentence

denotes

This pandemic is a big wake-up call for limiting in-person visits, especially during the flu season that put vulnerable patients at undo risk coming into the office for routine care.

T16

1880-2058

Sentence

denotes

We have had the technology to perform telemedicine visits for years, but patients’ hesitancy and poor insurance reimbursement have always been barriers for widespread acceptance.

T17

2059-2218

Sentence

denotes

In the wake of the COVID-19 pandemic, most primary care and specialty offices transitioned to a telemedicine-focused approach within a matter of days to weeks.

T18

2219-2382

Sentence

denotes

In response, the Centers for Medicare & Medicaid Services (CMS) relaxed many requirements for Medicare patients and the states followed suit for Medicaid patients.

T19

2383-2562

Sentence

denotes

Insurance companies also loosened restrictions giving healthcare providers increased flexibility to provide care for their patients from the comfort and safety of their own homes.

T20

2563-2787

Sentence

denotes

2020 will be the ultimate testing ground for various telehealth services and remote monitoring applications, and it is the hope of the authors that recent changes in access and reimbursement will remain in place permanently.

T21

2788-2970

Sentence

denotes

To meet the needs of this growing market, new technologies including wearable devices will play an important role in providing real-time data to objectively monitor patients at home.

T22

2971-3165

Sentence

denotes

These devices will be especially important for improving the health and control of chronically ill patients and for those with conditions like asthma, COPD, diabetes, and cardiovascular disease.

T23

3166-3280

Sentence

denotes

The focus of this paper revolves around wearable devices for asthma, but can be applied for any chronic condition.

T24

3281-3450

Sentence

denotes

If these home devices can provide usable data in a reliable, cheap, and easy-to-use format, then the need for in-person visits in the future will be drastically reduced.

T25

3452-3468

Sentence

denotes

Connected Health

T26

3469-3636

Sentence

denotes

Innovations in personalized health technology provide a unique opportunity to develop connected healthcare models that are built around the patients’ individual needs.

T27

3637-3969

Sentence

denotes

The term connected health describes the use of a variety of technologies to inform and aid healthcare delivery in a data-driven manner with the individual at the center.7 It covers a broad domain, including digital, mobile health, and telehealth, and ensures all stakeholders are connected with data that is accurate and timely [1].

T28

3970-4228

Sentence

denotes

An integrative connected health model can also offer social support through online forums or networks where users are able to interact with peers with similar healthcare conditions or goals helping to further enhance patient experience and improve adherence.

T29

4229-4451

Sentence

denotes

Commercial weight loss programs like WW (formerly Weight Watchers) was one of the first large-scale programs to take advantage of social support networks to motivate their clients and make them accountable to other people.

T30

4452-4768

Sentence

denotes

A 2005 systematic review of commercial and proprietary weight loss programs’ efficacy concluded that WW was the only program with demonstrated efficacy in achieving modest weight loss based on results from 3 randomized controlled trials (RCTs), and their unique social approach likely contributed to its success [2].

T31

4769-4962

Sentence

denotes

A recently published systematic review found relatively strong evidence that greater social support, self-efficacy, and self-motivation can predict higher adherence to home-based therapies [3].

T32

4963-5195

Sentence

denotes

There is enough data to suggest that social support networks improve adherence to fitness, weight loss, and home-based therapies that healthcare providers should be actively curating a wider support network for their patients [4–6].

T33

5196-5415

Sentence

denotes

Wearable devices and associated apps take social connectivity to the next level and provided unparalleled access to support networks that have the potential to further encourage adherence to fitness and health regimens.

T34

5416-5645

Sentence

denotes

Promising results have already been reported with the use of apps to improve adherence and outcomes in various healthcare scenarios including weight loss, smoking cessation, diabetic management, and home exercise programs [7–11].

T35

5647-5682

Sentence

denotes

The First Wave of Wearable Devices:

T36

5683-5700

Sentence

denotes

Activity Trackers

T37

5701-5904

Sentence

denotes

The concepts of wellness and mindfulness have become an increasing part of the public health discussion as there seems to be a growing appreciation for a more holistic approach to fitness and well-being.

T38

5905-6104

Sentence

denotes

With the advent of more advanced wearable technology like fitness trackers and smartwatches starting in 2014, consumers are no longer content with just tracking their weight loss goals or step count.

T39

6105-6378

Sentence

denotes

Personalized healthcare devices arm users with snapshots of their activity and recovery data and allow them to track advanced performance metrics including step tracking, heart rate, body fat percentage, sleep quality, stress levels, menstrual cycle, and fertility windows.

T40

6379-6575

Sentence

denotes

As this data becomes more accessible, consumers are discovering that overall health is the sum of all the small choices you make each day: what you eat, how much you move, how much you sleep, etc.

T41

6576-6751

Sentence

denotes

Having fitness and weight loss goals is an important first step, but converting that enthusiasm to actual gym time and change in habits has always been the rate limiting step.

T42

6752-7027

Sentence

denotes

That is where innovative fitness startups and fitness technology companies are focusing their attention: getting people excited about working out, offering unparalleled convenience, and keeping members engaged long-term by utilizing the latest in technology and social media.

T43

7028-7091

Sentence

denotes

Since 2014, the use of commercial wearable devices has doubled.

T44

7092-7259

Sentence

denotes

Currently, 19% of Americans use a wearable fitness tracker (e.g., Fitbit, Apple Watch) with sales projected to double by 2022, becoming a $27 billion+ market [12, 13].

T45

7261-7309

Sentence

denotes

Wearable Devices that Promote Health and Fitness

T46

7310-7467

Sentence

denotes

As more and more patients use wearable devices and smartphone apps to track their personal health data, how can this information be used in a meaningful way?

T47

7468-7711

Sentence

denotes

Fitness technology companies like Fitbit and Apple Health are leveraging insights from over 10 years of activity, exercise, and sleep data to better inform future applications and provide behavior change techniques and insights to their users.

T48

7712-7904

Sentence

denotes

Apple recently announced that customers in the USA can enroll in three landmark health studies: the Apple Women’s Health Study, the Apple Heart and Movement Study, and the Apple Hearing Study.

T49

7905-8222

Sentence

denotes

Conducted in partnership with leading academic and research institutions like the World Health Organization, these multi-year longitudinal studies are leveraging the ubiquity of Apple products to provide a treasure trove of user data to inform potential medical discoveries that could improve healthcare for all [14].

T50

8223-8383

Sentence

denotes

Wearable devices themselves can provide crude feedback like reminders to move or stand which prompts users to take more steps per hour or stand more frequently.

T51

8384-8569

Sentence

denotes

For additional charges, some devices can provide more detailed personal wellness reports, offering actionable guidance and coaching to help users achieve their health and fitness goals.

T52

8570-8833

Sentence

denotes

Some companies like Fitbit are taking it a step further and offering personal, one-on-one coaching services for weight loss and diabetes control providing users with a personalized plans and direct support from their team of certified health and wellness coaches.

T53

8834-8918

Sentence

denotes

A small sampling of highly rated fitness and nutrition apps are included in Table 1.

T54

8919-8963

Sentence

denotes

Table 1 Top rated fitness and nutrition apps

T55

8964-9009

Sentence

denotes

App Supporting devices Cost structure Details

T56

9010-9042

Sentence

denotes

For all-around healthy lifestyle

T57

9043-9275

Sentence

denotes

8fit iOS, Android Free; $59.99 per year; $44.99 per half-year; $19.99 per month for meal plans and more workouts On-demand workouts and meal planning for people who like a lot of guidance, suggestions, reminders, and instructions.

T58

9276-9376

Sentence

denotes

Provides realistic assessment of how hard or easy it will be to reach your health and fitness goals.

T59

9377-9381

Sentence

denotes

Yoga

T60

9382-9527

Sentence

denotes

Asana Rebel iOS, Android $39.99 for 3 months; $58.99 for 12 months Yoga-inspired fitness that has guided yoga flows alongside regular workouts.

T61

9528-9602

Sentence

denotes

Input goals, track progress, and choose classes based on experience level.

T62

9603-9762

Sentence

denotes

Yoga Wake Up iOS, Android $10 per month Offers different audio yoga and meditation sequences that are designed to start in bed and end with you on your feet.

T63

9763-9908

Sentence

denotes

Alo Moves iOS, Android $20 per month Has over 2000 videos organized into 200 plans and over 500 single classes taught by the top names in yoga.

T64

9909-10011

Sentence

denotes

YogaGlo iOS, Android $18 per month Offers more than 3800 yoga workouts and guided mediation classes.

T65

10012-10030

Sentence

denotes

On-demand workouts

T66

10031-10197

Sentence

denotes

Peloton Digital iOS, Android $20 per month Access live-streamed classes to use on any bike or treadmill or try one of their boot camp, strength, or outdoor classes.

T67

10198-10375

Sentence

denotes

Fitbit Coach iOS, Android Free; $9.99 per month or $79.99 per year for Premium Takes users daily Fitbit activity data to recommend exercises and personalized fitness feedback.

T68

10376-10447

Sentence

denotes

Large database of workout videos with step-by-step directions and tips.

T69

10448-10477

Sentence

denotes

Compatible with Fitbit Radio.

T70

10478-10661

Sentence

denotes

Nike Training Club iOS, Android Free; $14.99 per month or $119.99 per year for Premium Has classic short sessions but includes workout routines that are 30, 45, or even 60 min long.

T71

10662-10757

Sentence

denotes

A Premium account also comes with programs led by trainers and nutrition and wellness guidance.

T72

10758-10901

Sentence

denotes

Sworkit iOS, Android $10 per month Custom no-equipment training plans, complete with guided videos for each workout ranging from 5 to 60 min.

T73

10902-10987

Sentence

denotes

Users can also connect with personal trainers to ask questions and get expert advice.

T74

10988-11110

Sentence

denotes

Aaptiv iOS, Android $15 per month Audio classes taught by trainers guiding users through a fitness studio-style session.

T75

11111-11209

Sentence

denotes

Over 2500 workouts in cycling, yoga, strength training, stretching, elliptical workouts, and more.

T76

11210-11286

Sentence

denotes

Also comes with full marathon, half marathon, 10K, and 5K training programs.

T77

11287-11303

Sentence

denotes

Fitness tracking

T78

11304-11464

Sentence

denotes

Strava iOS, Android, Web Free; $7.99 per month or $59.99 per year Users can compete against themselves or others who have run, biked, or swam the same routes.

T79

11465-11587

Sentence

denotes

The app uses phone/watches GPS to track where users go and how fast then compares with other users creating a leaderboard.

T80

11588-11731

Sentence

denotes

Map My Fitness iOS, Android Free; $5.99 per month or $29.99 per year for MVP Recommended for those just getting started on a fitness journey.

T81

11732-11865

Sentence

denotes

Has hundreds of activities you can track, everything from vacuuming to rock climbing motivating user to keep a more active lifestyle.

T82

11866-11934

Sentence

denotes

Consolidates data from various fitness trackers or apps such Fitbit.

T83

11935-12051

Sentence

denotes

Charity Miles iOS, Android Free Motivates by donating money to charity for every mile users run, walk, or bicycle.

T84

12052-12225

Sentence

denotes

Supports a variety of nonprofit organizations, such as ASPCA, Habitat for Humanity, St. Jude Children’s Hospital, UNICEF, Save the Children, and the Wounded Warrior Project.

T85

12226-12244

Sentence

denotes

Nutrition-Tracking

T86

12245-12438

Sentence

denotes

MyFitnessPal iOS, Android Free; $9.99 per month or $49.99 per year for Premium Calorie counting app that also figures out how many calories users should eat to gain, lose, or maintain weight.

T87

12439-12565

Sentence

denotes

Consolidates everything users eat and drink, plus all their activities to calculate calories consumed against calories burned.

T88

12566-12637

Sentence

denotes

It also has tools for tracking weight and other body changes over time.

T89

12638-12722

Sentence

denotes

It has the largest database of foods and is the best food logging app on the market.

T90

12723-13004

Sentence

denotes

Noom iOS, Android $59 per month, $199 per year (additional pricing options available) Complete weight loss program with daily interactive content, a personal goal coach, and plenty of content to help users master the psychology involved with changing their relationships to food.

T91

13005-13197

Sentence

denotes

MyPlate iOS, Android, Web Free; $9.99 per month, $30 for six months, or $44.99 per year for Gold All-in-one fitness app, combining calorie counting, weight management, recipes, and workouts.

T92

13198-13356

Sentence

denotes

Users look up and record everything they eat and can see a nutritional analysis of macronutrient intake for free (requires paid subscription in MyFitnessPal).

T93

13357-13573

Sentence

denotes

WW Digital (formally WeightWatchers) iOS, Android, Web $23.99 per month or $219.99 per year Highly supportive community and app that focuses more on personalization and overall health rather than weight loss alone.

T94

13574-13682

Sentence

denotes

Users do not have to attend meetings or meet with a counselor (although this is an option for an added fee).

T95

13683-13758

Sentence

denotes

Monitors food intake with SmartPoints rather than counting calories or fat.

T96

13759-13785

Sentence

denotes

Mindfulness and meditation

T97

13786-14026

Sentence

denotes

Calm iOS, Android $14.99 per month or $69.99 per year Guided mindfulness meditation that initially offers a “7 Days of Calm” course which introduces users to mindfulness meditation, as well as some guided and unguided meditation sessions.

T98

14027-14139

Sentence

denotes

Paid users have access to more multi-day courses, a “Daily Calm” course, and many, many more guided meditations.

T99

14140-14277

Sentence

denotes

Headspace iOS, Android $12.99 per month or $69.99 per year Guided meditation for health issues, emotions, challenges, and productivity.

T100

14278-14353

Sentence

denotes

There are even “SOS” sessions for some of the more stressful times in life.

T101

14354-14470

Sentence

denotes

Recently added free content called Weathering the Storm for those struggling with the emotional effects of COVID-19.

T102

14471-14655

Sentence

denotes

The Mindfulness App iOS, Android $9.99 per month or $59.99 per year Starts with a 5-day introduction to mindfulness along with guided meditations to get you familiar with meditating.

T103

14656-14830

Sentence

denotes

With subscription choose guided or silent meditation sessions for challenges, travel, sleep, relationships, stress relief, emotions, body awareness, focus, and relationships.

T104

14831-15037

Sentence

denotes

*The authors are aware of the transient nature of fitness, nutrition, and lifestyle apps and understand that the recommendations provided at the time of this publication might not be available in the future

T105

15038-15299

Sentence

denotes

The ultimate goal with these devices and apps is to provide real-time feedback to patients so that they actually see data that illustrates how destructive behaviors impact them physically, providing additional motivation to more proactively manage their health.

T106

15300-15432

Sentence

denotes

The more the patient understands about their personal health, the more empowered they will be to make meaningful behavioral changes.

T107

15433-15570

Sentence

denotes

Healthcare providers need to be able to access and interpret personalized health data, as well as distill it into usable teaching points.

T108

15571-15730

Sentence

denotes

In the past, physicians often took an authoritarian approach to health and fitness education which did little to encourage active participation by the patient.

T109

15731-16011

Sentence

denotes

By employing a patient-centered approach utilizing data gleaned from wearable devices, healthcare providers have an opportunity to work in concert with patients to impart measurable skills and behaviors in a real and tangible way with the ability to track this progress over time.

T110

16012-16232

Sentence

denotes

When patients are included in a collaborative and patient-centered discussion about their health and well-being, compliance and satisfaction rates improve, leading to a more effective doctor-patient relationship [15–17].

T111

16233-16420

Sentence

denotes

It is important to note that these devices are still in their infancy, and the accuracy and validity of the data still need to be strengthened in order to provide the best medical advice.

T112

16422-16448

Sentence

denotes

Wearable Devices in Asthma

T113

16449-16627

Sentence

denotes

Most of the wearable fitness device research to date has focused in diseases associated with low levels of physical activity, namely cardiovascular disease, diabetes, and cancer.

T114

16628-16791

Sentence

denotes

Few have focused on asthma and of the studies conducted in asthma populations, all have honed in on the use of Fitbit-derived sleep measures (i.e., sleep quality).

T115

16792-16886

Sentence

denotes

Castner et al. used the Fitbit Charge™ to validate sleep measures in women with asthma [18••].

T116

16887-17036

Sentence

denotes

The sleep measures collected by the Fitbit were compared with Actigraph GT3X +, a well-known and validated device to collect sleep measures [19, 20].

T117

17037-17150

Sentence

denotes

The Fitbit device tended to overestimate sleep efficiency and underestimate wake counts compared with actigraphy.

T118

17151-17350

Sentence

denotes

Two additional studies were conducted in pediatric populations and focused on correlating Fitbit-derived sleep measures to patient-reported outcomes such as asthma control and asthma impact [21, 22].

T119

17351-17626

Sentence

denotes

Bian and colleagues assessed the association between self-reported asthma impact and Fitbit-derived sleep quality (the ratio of minutes asleep to minutes in bed) and physical activity measures (daily minutes of moderate and vigorous activity) in adolescents with asthma [21].

T120

17627-17920

Sentence

denotes

Fitbit-derived sleep quality was moderately correlated with Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance score (r = − 0.31, P = 0.01) and had a weak but significant correlation with the PROMIS pediatric asthma impact score (average r = − 0.18, P = 0.02).

T121

17921-18038

Sentence

denotes

Fitbit-derived physical activity levels were not associated with PROMIS pediatric asthma impact (r = 0.04, P = 0.62).

T122

18039-18228

Sentence

denotes

These findings suggest that measurement of sleep quality, using the Fitbit device, may help develop personalized asthma management strategies for children and their caregivers in real time.

T123

18229-18611

Sentence

denotes

The final study measured several mobile metrics of asthma including physical activity and sleep using Fitbits, forced expiratory volume in 1 s and peak expiratory flow, indoor air quality using Foobot (https://foobot.io/), and a mobile app that collected information on asthma control (symptoms, physical limitations due to asthma, nighttime awakenings, and medication intake) [22].

T124

18612-18859

Sentence

denotes

These metrics were used together to digitally phenotype children with asthma and provide a better measure of the patient’s asthma control to their clinician when compared with the Asthma Control Test scores taken infrequently during clinic visits.

T125

18860-19083

Sentence

denotes

Additional work using this ecological metric of asthma control is needed and may be used in the future to generate insights on the relationship between a patient’s asthma symptoms and triggers across different seasons [23].

T126

19084-19172

Sentence

denotes

Acoustic monitoring is another type of wearable devices that has been studied in asthma.

T127

19173-19358

Sentence

denotes

Breathing sound measured by microphones over human skin can detect breathing patterns (respiratory rate, flow rate, tidal volume) and symptoms that may be due to asthma (wheeze, cough).

T128

19359-19462

Sentence

denotes

Moreover, chest movement signals can be acquired using an accelerometer or belt-shaped device [24, 25].

T129

19463-19568

Sentence

denotes

Boner et al. measured the nocturnal wheeze in children with asthma using an acoustic respiratory monitor.

T130

19569-19753

Sentence

denotes

They found that among children with apparently well-controlled asthma, 57% had considerable amounts of night wheezing that was unrelated to conventional measures of lung function [26].

T131

19754-19885

Sentence

denotes

The use of these continual wearable monitoring systems is still a developing field that needs further study on its clinical impact.

T132

19887-19933

Sentence

denotes

Use of Electronic Monitoring Devices in Asthma

T133

19934-20086

Sentence

denotes

Electronic monitoring devices (EMDs) in asthma are increasingly more common since they provide objective data and are not biased by patient self-report.

T134

20087-20254

Sentence

denotes

The majority of the currently available EMDs focus on addressing medication adherence, with a limited few focusing on sleep monitoring and identifying asthma triggers.

T135

20255-20435

Sentence

denotes

The devices measuring adherence use a variety of approaches from recording audio during inhaler use, using time and date to detect medication use and capturing spirometry measures.

T136

20436-20745

Sentence

denotes

These devices are paired with mobile applications (Apps) on smartphones which can provide the patient with audiovisual reminders for taking medications, correlate medication use with environmental exposures (i.e., weather, ozone, pollution) using smartphone GPS coordinates and feedback on proper inhaler use.

T137

20746-20848

Sentence

denotes

A summary of some of the current and emerging technologies in the asthma space is provided in Table 2.

T138

20849-20900

Sentence

denotes

Table 2 Current and emerging technologies in asthma

T139

20901-20956

Sentence

denotes

Technology Measures Outcomes in asthma studies Comments

T140

20957-20976

Sentence

denotes

Wearable technology

T141

20977-20986

Sentence

denotes

− Fitbit™

T142

20987-21167

Sentence

denotes

− Apple™ Watch Fitbit: heart rate (available on most but not all models), steps/day, physical activity (light, moderate and vigorous), sedentary time, sleep efficiency, wake counts

T143

21168-21372

Sentence

denotes

Apple Watch: heart rate, EKG, steps/day, physical activity (light, moderate and vigorous), sedentary time − Fitbit overestimated sleep efficiency and underestimated wake counts compared with actigraphy.18

T144

21373-21479

Sentence

denotes

− Fitbit-derived sleep quality correlated with PROMIS pediatric asthma impact score.21 Corresponding Apps:

T145

21480-21539

Sentence

denotes

Apple Watch App on iPhone, Fitbit App on iPhone and Android

T146

21540-21717

Sentence

denotes

Pros: portable; commercially available; may be useful when used with other measures such as air quality, lung function and asthma symptoms to digitally phenotype asthma patients

T147

21718-21723

Sentence

denotes

Cons:

T148

21724-21784

Sentence

denotes

No sleep data available on Apple Watch without 3rd party App

T149

21785-21798

Sentence

denotes

Data sharing:

T150

21799-21925

Sentence

denotes

Data does not sync to EMR directly but patient can access file and send to provider via mail, secure email, or patient portal.

T151

21926-22017

Sentence

denotes

Electronic monitoring devices (e.g., inhaler sensors ± digital health platform) Digihaler™:

T152

22018-22129

Sentence

denotes

− Inhaler time of inhaler use, peak inspiratory flow rate (PIFR), time to PIFR, inhalation volume and duration.

T153

22130-22154

Sentence

denotes

Propeller Health System:

T154

22155-22209

Sentence

denotes

− Inhaler sensor: date, time and number of doses taken

T155

22210-22239

Sentence

denotes

− Asthma Health Platform App:

T156

22240-22365

Sentence

denotes

Location of inhaler use using phone GPS, current weather/pollen counts/air pollution and self-report asthma symptoms/triggers

T157

22366-22383

Sentence

denotes

Hailie™ solution:

T158

22384-22459

Sentence

denotes

− Inhaler sensor: date, time, number of inhaler actuations and missed doses

T159

22460-22523

Sentence

denotes

− Hailie™ App: medication adherence, daily medication reminders

T160

22524-22561

Sentence

denotes

Inhaler compliance assessment device:

T161

22562-22657

Sentence

denotes

Time of dose, inhaler technique errors − Greater asthma control31,38–39 and symptom-free days33

T162

22658-22747

Sentence

denotes

− Reduction in daily symptoms31, rescue medication use29,32–33, and exacerbations34,38–39

T163

22748-22784

Sentence

denotes

− Improved medication adherence36–40

T164

22785-22857

Sentence

denotes

− High patient acceptability of device and digital health platform36–37.

T165

22858-22877

Sentence

denotes

Corresponding Apps:

T166

22878-22916

Sentence

denotes

Digihaler™, Propeller Health, Hailie™.

T167

22917-22990

Sentence

denotes

Web-based platform also available for Propeller Health, Hailie™ solution.

T168

22991-23156

Sentence

denotes

Pros: portable, high acceptability among patients, improvements in asthma control in those with a digital health platform (e.g., Propeller Health, Hailie™ solution).

T169

23157-23162

Sentence

denotes

Cons:

T170

23163-23283

Sentence

denotes

Additional efficacy studies of the devices are needed, cost of devices are not always covered by insurance reimbursement

T171

23284-23297

Sentence

denotes

Data sharing:

T172

23298-23458

Sentence

denotes

Provider platform available to share results (e.g. Digihaler™, Propeller Health, Hailie™ solution), patients may share data from Digihaler™ also via file share.

T173

23459-23504

Sentence

denotes

Mobile-based applications Self-monitoring of:

T174

23505-23522

Sentence

denotes

− Asthma symptoms

T175

23523-23533

Sentence

denotes

− Triggers

T176

23534-23612

Sentence

denotes

− Medication use -Improvements in asthma control though low-quality evidence45

T177

23613-23735

Sentence

denotes

-Improvements in asthma control in five studies, lung function in two studies and quality of life in three studies46 Pros:

T178

23736-23766

Sentence

denotes

Acceptable and feasible to use

T179

23767-23772

Sentence

denotes

Cons:

T180

23773-23894

Sentence

denotes

Vary in quality; data are self-reported, most apps have not been validated; risk of loss of privacy of health information

T181

23895-23908

Sentence

denotes

Data sharing:

T182

23909-23991

Sentence

denotes

Vary in ability to share with provider, most are up to user to share with provider

T183

23992-24179

Sentence

denotes

Teva’s Digihaler™ has been FDA approved for use with ProAir® (albuterol sulfate 117 mcg), AirDuo® (fluticasone propionate and salmeterol), and ArmonAir® (fluticasone propionate) inhalers.

T184

24180-24266

Sentence

denotes

The Digihaler™ contains built-in sensors that records inhalation data with timestamps.

T185

24267-24424

Sentence

denotes

The inhalation data includes parameters that are important for assessing inhaler technique including peak inspiratory flow rate and inhalation duration [27].

T186

24425-24550

Sentence

denotes

The device is connected via Bluetooth® technology to a companion App that provides information on inhaler use to the patient.

T187

24551-24685

Sentence

denotes

While to date, the efficacy of Digihalers has not been evaluated; one pilot study has shown its ability to predict exacerbations [28].

T188

24686-24775

Sentence

denotes

Adults with exacerbation-prone asthma (n = 360) used the ProAir® Digihaler™ for 12 weeks.

T189

24776-24946

Sentence

denotes

The Digihaler™ was able to predict asthma exacerbations (defined as need for oral corticosteroids) with an area under the receiver operating characteristic curve of 0.75.

T190

24947-25079

Sentence

denotes

The most predictive factor was the average number of albuterol inhalations per day during a period of 5 days before an exacerbation.

T191

25080-25216

Sentence

denotes

Further developments of the model in larger populations are needed to determine the efficacy of the Digihaler™ to predict exacerbations.

T192

25217-25371

Sentence

denotes

Propeller Health has developed a system which includes a sensor that can attach to both rescue and controller inhalers and an Asthma Health Platform [29].

T193

25372-25455

Sentence

denotes

The inhaler sensor collects date and time of inhaler use and number of puffs taken.

T194

25456-25628

Sentence

denotes

This data is transferred via Bluetooth® technology to the Asthma Health Platform on a mobile device and can be matched with GPS coordinates obtained from the mobile device.

T195

25629-25799

Sentence

denotes

The Asthma Health Platform can also be used to record asthma symptoms and triggers which integrates with other data streams such as weather, pollen counts, and pollution.

T196

25800-25863

Sentence

denotes

The Propeller Health System is one of the most studied to date.

T197

25864-26082

Sentence

denotes

A 4-month pilot study conducted in 30 individuals showed when the device and app were used along with weekly feedback, participants had an improvement in asthma control and a decline in day-to-day asthma symptoms [30].

T198

26083-26176

Sentence

denotes

The effectiveness of Propeller Health System on rescue inhaler has also been examined [31••].

T199

26177-26299

Sentence

denotes

In a study of 495 patients, all patients received the Propeller Health System but only 250 received sensor-based feedback.

T200

26300-26512

Sentence

denotes

The authors found a decrease in mean daily rescue medication use in those receiving sensor-based feedback (0.19 vs. 0.25 in control arm) which was more pronounced in patients with uncontrolled asthma at baseline.

T201

26513-26677

Sentence

denotes

These findings were confirmed in another study of 120 participants with a decrease in rescue medication use by 39% and an increase in symptom-free days by 12% [32].

T202

26678-26850

Sentence

denotes

Propeller Health has also developed a provider-facing web interface (portal) that allows providers and their staff to view patient medication use and asthma control status.

T203

26851-27032

Sentence

denotes

This is available to providers that enroll their patients with the Propeller Health System but can be integrated into existing EMR systems to allow for data sharing among providers.

T204

27033-27190

Sentence

denotes

Merchant et al. evaluated this enhanced Propeller Health System and found a decrease in asthma-related emergency department visits and hospitalizations [33].

T205

27191-27492

Sentence

denotes

The Hailie™ solution (previously known as SmartInhaler™ platform) is a system of medication sensors (e.g., SmartTrack™, SmartTouch™, SmartTouch AV™, SmartTurbo™; http://www.smartinhaler.com/devices/) that wrap around existing inhalers and automatically sends usage data to a patient’s smartphone [34].

T206

27493-27599

Sentence

denotes

The sensors record the date and time of actuations, the total number of actuations used, and missed doses.

T207

27600-27793

Sentence

denotes

The device pairs with the Hailie™ App and enables the patient and healthcare professionals to track medication adherence, set daily reminders, and discover insights into their medication usage.

T208

27794-27960

Sentence

denotes

The SmartInhaler™ sensors have been studied extensively and have demonstrated high user acceptability as well as efficacy in increasing medication adherence [35, 36].

T209

27961-28166

Sentence

denotes

Five randomized controlled trials using the SmartInhaler™ have been conducted in the UK, Australia, and New Zealand, including a total of 589 adults and children with asthma in a community setting [35–39].

T210

28167-28315

Sentence

denotes

The authors of these studies conclude that SmartInhaler™ devices were more effective than standard care in improving adherence to asthma medication.

T211

28316-28469

Sentence

denotes

Two of the studies showed significant improvement in clinical outcomes (e.g., asthma exacerbations, asthma control, and healthcare utilization) [37, 38].

T212

28470-28661

Sentence

denotes

The Inhaler Compliance Assessment (INCA) device uses time-stamped audio recordings of inhaler use to assess not only inhaler adherence but also inhaler technique (http://www.tueohealth.com/).

T213

28662-28806

Sentence

denotes

Specifically, it can assess proper inhaler technique by measuring a failure to prime the inhaler, inadequate inspiratory flow, and dose dumping.

T214

28807-28976

Sentence

denotes

This information can be used to determine if medication was not properly delivered due to inhaler technique errors (attempted adherence) or missed/late medication doses.

T215

28977-29117

Sentence

denotes

In one study of 184 people with chronic obstructive pulmonary disease, the INCA device was used to assess controller inhaler adherence [40].

T216

29118-29234

Sentence

denotes

The mean rate of attempted adherence was 58.7%, whereas actual adherence (proper timing and technique) was only 23%.

T217

29235-29358

Sentence

denotes

Only 7% of participants had actual adherence above 80%, underscoring the importance of addressing proper inhaler technique.

T218

29359-29472

Sentence

denotes

Currently, there is no mobile app for the INCA tool and the data must be downloaded onto a computer for analysis.

T219

29473-29589

Sentence

denotes

Additional studies are currently being conducted using an INCA App to assess its ability to improve asthma outcomes.

T220

29590-29726

Sentence

denotes

Tueo Health, which was acquired by Apple in 2019, developed a passive EMD to help parents monitor nighttime asthma symptoms in children.

T221

29727-29891

Sentence

denotes

Using commercial breathing sensors placed under the mattress, the device can passively measure key physiologic parameters during sleep (http://www.tueohealth.com/).

T222

29892-30020

Sentence

denotes

An asthma control score is then calculated from the physiologic data and available for the patient to view through a mobile app.

T223

30021-30189

Sentence

denotes

The score gives direct indication of their asthma control status based on their provider-issued asthma action plan and recommends evidence-based steps to manage asthma.

T224

30190-30323

Sentence

denotes

Such steps include reminders to avoid known triggers, refill a prescription, or make an appointment to see their healthcare provider.

T225

30325-30353

Sentence

denotes

Use of Mobile Apps in Asthma

T226

30354-30458

Sentence

denotes

As with wearable devices, the use of health apps on phones and tablets has rapidly been increasing [13].

T227

30459-30550

Sentence

denotes

There are a large number of asthma-related apps with well over 500 reported in 2019 [41••].

T228

30551-30671

Sentence

denotes

The mobile apps range from providing health education, symptom tracking, environmental alerts, and medication reminders.

T229

30672-30799

Sentence

denotes

A review conducted in 2015 selected 209 English asthma-related apps that were available in Google Play and/or Apple Store [42].

T230

30800-31202

Sentence

denotes

The majority (52%) of the apps evaluated were teaching and training information for patients, with 39% based on alternative treatments, such as yoga, acupressure, and breathing exercises; 22% helped users to monitor symptoms and medication adherence; 18% provided medical reference information for providers; 6% provided air quality information; and 2% served as social forums for patients with asthma.

T231

31203-31325

Sentence

denotes

Despite the great number of currently available mobile apps for asthma, few effectiveness evaluations have been conducted.

T232

31326-31428

Sentence

denotes

In 2013, Marcano and colleagues conducted a Cochrane review on mobile apps for asthma self-management.

T233

31429-31631

Sentence

denotes

Only two randomized controlled trials (RCTs) fit the review criteria and assessed efficacy of the apps on asthma outcomes such as asthma control, asthma quality of life, and healthcare utilization [43].

T234

31632-31820

Sentence

denotes

Both RCTs (n = 408) evaluated the effect of a mobile phone-based asthma self-management intervention on asthma control by comparing it with traditional, paper-based asthma self-management.

T235

31821-31958

Sentence

denotes

Overall, the results were inconclusive, as the evidence was low quality (GRADE) and attrition bias plus other sources of bias were found.

T236

31959-32050

Sentence

denotes

In 2017, another systematic review assessed asthma self-management using mHealth apps [44].

T237

32051-32195

Sentence

denotes

The authors found that mHealth apps improved asthma control in five studies, lung function in two studies, and quality of life in three studies.

T238

32196-32279

Sentence

denotes

There was no significant impact on economic outcomes such as hospitalization rates.

T239

32280-32459

Sentence

denotes

While there is preliminary evidence on the efficacy of asthma self-management mobile apps to improve asthma control and quality of life, the mechanisms have not been well studied.

T240

32460-32561

Sentence

denotes

Ramsey and colleagues reviewed the content and quality of mHealth asthma self-management apps [45••].

T241

32562-32751

Sentence

denotes

The mobile apps were identified through systematic searches of the Apple and Google Play stores and then coded to evaluate the inclusion of evidence-based behavior change techniques (BCTs).

T242

32752-32923

Sentence

denotes

Examples of BCTs include providing information about behavior-health link, identifying barriers to performing health behaviors, and prompting self-monitoring of behaviors.

T243

32924-33104

Sentence

denotes

The quality of the apps was also rated using the Mobile App Rating Scale (MARS) to determine app engagement, functionality, aesthetics, information quality, and subjective quality.

T244

33105-33185

Sentence

denotes

Of the twenty-three apps identified, a range of 1–11 BCTs were used by the apps.

T245

33186-33347

Sentence

denotes

The most commonly included BCTs were instruction, behavior-health link, self-monitoring, feedback, teach to use prompts/cues, consequences, and others’ approval.

T246

33348-33436

Sentence

denotes

Three apps used at least eight BCTs (i.e., AsthmaMD, Kiss myAsthma, and My Breathefree).

T247

33437-33541

Sentence

denotes

The overall quality of the apps, as measured by MARS, ranged from 2.45 to 4.50 (out of a possible 5.00).

T248

33542-33656

Sentence

denotes

Four apps had an overall MARS quality of > 4.0 (AsthmaMD, Asthma Health Storylines, Kiss myAsthma, and Wizdy Pets:

T249

33657-33676

Sentence

denotes

Kids’ Asthma Game).

T250

33677-33954

Sentence

denotes

As it is more common for patients to ask their healthcare providers to help them choose apps, it is important that providers are knowledgeable about which asthma management apps are high quality and include evidence-based components that will be successful for behavior change.

T251

33955-34111

Sentence

denotes

To date, Kiss myAsthma and AsthmaMD are the asthma management apps with the highest number of BCTs and quality scores, but this area is constantly evolving.

T252

34112-34195

Sentence

denotes

There are some limitations to consider regarding the use of mobile apps for asthma.

T253

34196-34284

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The majority of commercially available asthma apps lack validation in clinical settings.

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Further, the apps are not regulated or approved as medical devices and may provide recommendations to patients that are not evidence-based or inaccurate.

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Finally, there is a risk of loss of privacy of health information for patients that use these apps.

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One study showed that only 30% of the most commonly used mHealth apps had privacy policies [46].

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These policies often required a high-level of literacy for comprehension, were often not focused on the app itself, and were not informative for end users.

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Therefore, clinicians should evaluate asthma management apps to ensure high quality and evidenced-based information prior to recommending them for their asthma patients.

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Conclusion: a New Wave of Wearable Devices

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The world and medicine as we know it are changing forever in the wake of the repercussions of the COVD-19 pandemic.

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Limiting unnecessary in-person visits, especially for at-risk patients, and expanding the scope of what we can provide remotely using new technological advancements should be a priority moving forward.

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The future of wearable devices seems to be headed towards continuous measurements of personal physiology to predict, prevent, or help to aid in the diagnosis of an underlying health condition.

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This approach allows frequent and continuous measurements of body functions including heart rate, skin temperature, blood oxygen levels, and physical activity.

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Recent studies investigating the utility of wearable sensors indicate that the information provided by these devices is physiologically meaningful and actionable and will likely to play an important role in managing health in the future [47].

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Healthcare providers and patients themselves can do a much better job of tracking their health outside of regularly scheduled office visits.

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Currently, providers are relying on patients with chronic health conditions to consistently self-report progress and medication compliance which is inefficient and unpredictable at best.

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Having access to reliable home data on a consistent basis that is relevant to the patient’s specific medical condition is key to improving health outcomes not only for asthma but also for all chronic diseases.

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Increased utilization of health monitoring devices by patients will likely become an important aspect of self-care and preventive medicine moving forward.

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The data provided by these devices will allow care providers to provide patients with personalized tools and tailored solutions to improve their health and encourage fitness and diet goals.

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They may also help to enhance accurate symptom reports, improve accuracy of diagnosis, and streamline appropriate specialty referral when appropriate.

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This article is part of the Topical Collection on Telemedicine and Technology

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Publisher’s Note

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Compliance with Ethical Standards

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Conflict of Interest

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Dr. Greiwe is a consultant for AstraZeneca on social media and respiratory biologics scientific expert on the virtual advisory board; Sanofi Grenzyme Dupixent scientific expert on the virtual advisory board; honoraria from AstraZeneca Fesenra Speakers Bureau, Regeneron, and Sanofi Grenzyme Dupixent Speakers Bureau.

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Dr. Nyenhuis is a board member of Chicago Asthma Consortium; grant from National Institute of Health, honoraria from Sanofi, royalties from Springer Nature and Wolters Kluwer Health.

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Human and Animal Rights and Informed Consent

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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