Remote Health Monitoring Is Already Here

(Sylvia Engdahl's background information for her novel Stewards of the Flame)

When I wrote Stewards of the Flame I had no idea of the extent to which remote health monitoring was already being developed, or that monitors now merely wearable will be implantable very soon. They are by no means limited to heart monitoring -- among the many experimental skin and under-skin devices that by now exist are sensors for glucose, blood pressure, stomach and lung performance, and the presence of cancer. There's even research underway on a tooth patch that can track what you eat. Probably the least credible premise in the novel is that in a time when we have starships, such monitors won't be used just as much on Earth as in a colony that carries medical control to excess.

Since my original posting of this page in 2007, remote monitoring has become big business -- most of the many websites now devoted to it are produced by suppliers of equipment and software. They discuss advantages and disadvantages from the standpoint of medical providers, emphasizing their needs and and what they feel patients want, or should want. If you look at these sites, bear in mind that their aim is commercial.

There are many legitimate uses for remote health monitoring. In addition to its value in providing continuous data about chronic medical conditions, it's invaluable for people who live in remote locations, or are too ill to visit medical offices easily, or lack transportation -- in fact, it may eventually be less costly than office visits even for people physically able to make them. It's certainly less time-consuming. And enabling the elderly to stay in their own homes instead of nursing homes is an indisputably desirable goal.

So the increasing availability of this technology raises troubling questions. People with chronic illnesses will welcome it. But once a person chooses to be monitored for a specific medical problem, where does it end? I don't want well-meaning healthcare professionals checking up on my body's status and how I live my life; I'd want monitoring only for conditions I had personally decided to have treated. Most of the discussion about privacy in connection with medical technology centers on whether the data can be made secure against unauthorized dissemination. But I want privacy from medical providers, too, except with respect to problems for which I've intentionally sought help. The right to keep one's own body private is recognized in all other contexts. If one's ongoing bodily functions and even the content of one's toilet become subject to surveillance, the very concept of personal privacy will inevitably be weakened.

This issue is particularly serious in the case of very old, or very ill, people who prefer to die naturally rather than on life support in a hospital. In the novel Jesse remarks that such people often refrain from doing anything about terminal illness: "That's how my great-granddad went, and nobody questioned it, and what he didn't tell the doctors was left unsaid." But if such people are monitored earlier when they do want treatment, will there be any way to stop? Or will the ambulance automatically come for them, just as in the story? We are a lot closer to that situation right now than even I used to think.

Furthermore, it's likely that once remote monitoring of illness becomes common, people who are healthy will want to be monitored just in case some illness should develop later. And that trend will be fueled by the suppliers of monitoring equipment, who like the pharmaceutical companies will do their best to convince medical providers, employers, and the general public that health depends on the use of their products. Even now some employers and insurance companies are urging workers to wear fitness monitors in exchange for rewards; at least one has tried, so far unsuccessfully, to make it compulsory. If this idea catches on, insurance might someday be denied to people who refuse to submit to monitoring, And that would be a large step toward the kind of society portrayed in my novel. It's all too easy to imagine the voters deciding that everyone ought to be monitored "for their own good," just as they've passed laws forcing everyone to wear seatbelts.

Surprisingly little concern about these issues can be found on the Web. The mere implantation of identifying microchips has been viewed with alarm for many years (see my page about it) but the prospect of other types of body sensors, even implanted ones, seems not to have aroused much worry. Perhaps no one has noticed the scary implications. On the other hand, perhaps the magic word "health" has blinded people to the possibility that the price of pursuing it to extremes might turn out to the the loss of their autonomy. Stewards of the Flame was intended as a warning, not a prophecy; but I've begun to wonder whether it's less far-fetched than I realized while writing it.

Some videos and links to articles about remote health monitoring.

The ‘Internet of Bodies’ Is Setting Dangerous Precedents by Mary Lee. Washington Post, October 15, 2018. "Bluetooth-equipped electronic pills are being developed to monitor the inner workings of your body, but they could eventually broadcast what you’ve eaten or whether you’ve taken drugs."

What Are Best Practices for Ethical Use of Nanosensors for Worker Surveillance? by Gary E. Marchant. AMA Journal of Ethics, April 2019. "These products can consist of wearable wristbands such as Fitbit or Apple Watch, sensors built into clothing or equipment, tattoo sensors applied to a person’s skin that can monitor physiological and chemical parameters in real time, and even some radio-frequency identification or memory chips that are placed under a person’s skin and provide a permanent built-in identification and communication device."

Digital Health Tracking: Preventive Care or Privacy Invasion? Harvard Health Letter, March 2018. "Will insurers or employers be able to pressure you to be monitored, if you have a health condition that might benefit from monitoring? There are also risks that hackers could illegally access your information and steal your identity, or worse, render an implanted device inoperable."

For Telehealth To Succeed, Privacy And Security Risks Must Be Identified And Addressed by Joseph L. Hall and Deven McGraw. Health Affairs, February 2014. "Sensors that are located in a patient’s home or that interface with the patient’s body to detect safety issues or medical emergencies may inadvertently collect sensitive information about household activities. For instance, home sensors intended to detect falls may also transmit information such as interactions with a spouse or religious activity, or indicate when no one is home."

Telemedicine Needs Ethical Guidelines by Bonnie Kaplan. Hastings Center, October 26, 2016. "Policies should be developed to ensure that patients’ decisions are freely made so that, for example, patients are not pushed into unwanted monitoring or other forms of remote care by their well-meaning children, clinicians, or caregivers."

Can your boss make you wear a Fitbit? by Eoin O'Carroll. Christian Science Monitor, March 15, 2018. "A proposed change to West Virginia’s public worker health plan would have asked teachers to download a mobile fitness app called Go365 and earn points on it by using a Fitbit or other fitness tracker designed to monitor the users's steps taken, heart rate, or other metrics. Those who declined, or who complied but failed to earn enough points, would face a penalty of $500 each year."

Fitbit-based Life Insurance is a Potential Privacy and Security Nightmare by Matthew Hughes. TheNextWeb.com, September 20, 2018. "When these insurance products eventually become standard across the market, consumers will have to decide between their privacy and their premiums."

Don’t Bet Your Life On Wearable Fitness Trackers by Jessica Baron. HuffPost, October 15, 2018. "The implications of anyone else knowing your fitness level, heart rate, nutrition choices and step count range from humiliation to outright discrimination. Is that loss of privacy worth an Amazon gift card?"


Sprinkling of Neural Dust Opens Door to Electroceuticals by Robert Sanders. Berkeley News, August 3, 2016. "UC Berkeley engineers have built the first dust-sized, wireless sensors that can be implanted in the body, bringing closer the day when a Fitbit-like device could monitor internal nerves, muscles or organs in real time."

Alarms Raised Over DARPA-Funded ‘Neural Dust’ -- Wireless Sensors Implanted in the Body: “Hacking Could Unleash Global Havoc. Daily Galaxy, September 20, 2016. "Dark forces could be unleashed in a world where millions have hundreds of tiny neural dust sensors gathering and transmitting the most personal of information into external computer networks."

Comcast Plans In-Home Health Surveillance and Medical Tracking Device by Nicholas West. Activist Post, May 23, 2019. "Medicine has pitted the powerful desire of human liberation from suffering and the pursuit of a longer life up against the powerful desire to create centralized systems of management, both for profit and control. . . . People want to feel better, for cheaper, and might be more willing than normal to trade a bit of liberty in order to make this a reality."

Privacy and Security Concerns in Telehealth by Timothy M. Hale and Joseph C. Kvedar. AMA Journal of Ethics, December 2014. "There are significant privacy and security risks in telehealth systems that can adversely affect patients’ and clinicians’ level of trust and willingness to adopt and use the system."

Clever Toilet Checks on Your Health, CNN.com, June 28, 2005. "The 'Intelligence Toilet' System, created by Japan's largest toilet company, Toto, can measure sugar levels in urine, blood pressure, body fat and weight." It is now on the market.

Japanese Masters Get Closer to the Toilet Nirvana, New York Times, October 8, 2002. '''You may think a toilet is just a toilet, but we would like to make a toilet a home health measuring center....We are going to install in a toilet devices to measure weight, fat, blood pressure, heart beat, urine sugar, albumin and blood in urine.' The results would be sent from the toilet to a doctor by an Internet-capable cellular phone built into the toilet."

Bathroom Innovation, Trends in Japan, July 26, 2005. "The aim of putting all this technology into the Intelligent Toilet is to improve quality of life by keeping a continuous check on symptoms indicative of 'lifestyle' diseases, such as diabetes."

Technology as a Solution -- and a Policy Problem?, Nursing Homes, May 2004. "One policy problem with these technologies is that they potentially violate the privacy of elderly individuals. It is clear that users must be willing to trade some degree of privacy for an added sense of security."

Big Data Healthcare: The Pros and Cons of Remote Patient Monitoringby Daniela Hernandez. MedCity News, March 10, 2014. "The influx of data from internet-connected devices could be a valuable tool for health systems, helping them to maximize resources and target interventions toward patients who will benefit most. It’s also a huge potential boon for companies that manufacture these technologies."

Technology Transforms Senior Health Care, Privacy Concerns by Clay Aiena, IoTevolution, September 01, 2017. "The advances in IoT-based health monitoring, cloud computing, and in-team communications create a new risk for health care providers in the form of patient privacy. This risk must be addressed to protect the universal right for medical and health privacy, one of the requirements of the Hippocratic Oath."

Every Breath You Take by By Sarah Kellogg. Washington Lawyer, December 2015. "An individual's heart rate or blood glucose levels certainly seem to qualify as health data, but are they exempt from health privacy regulations because people create that data on their smartphones? It is a muddle."

Hard to Swallow? New Digital Pill Raises Personal Privacy Concerns by v Colin Poitras. UConn Today, December 27, 2017. "The U.S. Food and Drug Administration recently approved a new digital pill capable of monitoring whether individuals are taking a prescribed medication."

Hi-tech Skin Patch Might Someday Track Your Health by Alan Mozes. Medical Xpress, November 18, 2016. "The patch, which weighs less than one-hundredth of an ounce, can help doctors monitor heart health, stomach condition, vocal cord activity, lung performance and potentially many other bodily functions."

15 Biometric Sensors in the Work That Will Replace Medical Records and Diagnose the Most Common Disorders by Saoirse Kerrigan. Interesting Engineering, May 1, 2018. "Researchers from Tufts University developed sensors that can be worn on your tooth and can track your dietary information in real time. The tiny sensors can track everything from alcohol consumption to levels of sodium and glucose."

How to Mitigate the Risks of Remote Patient Monitoring by Susan Shepard. The Doctors Weigh In, December 7, 2018. "Three million patients worldwide are currently connected to a remote monitoring device that sends personal medical data to their healthcare provider."

The Future of Medicine: Remote Patient Monitoring by Ameya Kulkarni, M.D. MAPMG on Health Blog, Mid-Atlantic Permanente Medical Group, July 5, 2018. "Through remote patient monitoring, these devices allow data to be delivered on a continual basis straight to your medical team, who are automatically alerted if there is a change that requires intervention."

Remote patient monitoring: How mobiledevices will curb chronic conditions by John Morrissey. Medical Economics, July 08, 2014. "It’s only a matter of time before the exam-room-centered focus of patient care gives way to management of assigned populations to maintain or improve health."

Patient Monitoring, Big Data, and the Future of Healthcare by Stephen F. DeAngelis. Wired, August 2014. "Doctors are studying the use of wearable devices to determine whether monitoring patient activity can help make patients ealthier."

Medicare's (Small) Step to Encourage Remote Monitoring for Seniors Living at Home by Howard Gleckman. Forbes, July 13, 2018. "Wearable monitors are all the rage. But FierceHealthcare.com reports that one extensive literature review found little evidence that wearables improve patient outcomes."

These Companies Make Remote Monitoring for Seniors Less Intrusive by Satta Sarmah-Hightower. Care.com, March 12, 2018. "Like a regular insole, caregivers can insert the GPS-enabled insoles into their loved one’s shoes, hiding it from the wearer, if they so choose. The GPS SmartSole® uses a combination of GPS, cellular, Bluetooth, and Wi-Fi technology to capture data, log the location of the wearer, and wirelessly transmit the data to the cloud. . . . GTX Corp is next moving its focus to insoles that provide biometrics, like information on activity, mobility, weight and heart rate."

Personal Medical Monitoring Devices, iHealth, University of Maryland, Spring 2004. "While personal devices today are largely if not completely external, the next generation may be implanted under the skin. Such devices ... could include artificial retinas, glucose monitors, organ monitors, cancer detectors, and general health monitors."

What does the future of remote patient monitoring look like? by Brooke Murphy. Becker Hospital Review, April 5, 2018. "Once it's implanted -- just under the skin in the chest during a quick outpatient procedure—Confirm Rx continuously monitors heart rhythms. Data collected by the device is securely transmitted to the physician via the mobile app."

Internet Takes Heart as Pacemakers Move Online, EE Times, May 4, 2001. "Ultimately, engineers say they can foresee a day when an implanted heart monitor will detect a problem and call an ambulance, all while the patient lies sleeping.... 'We'd like to believe that someday a pacemaker could send a signal directly to a satellite.... When it comes to this kind of patient management, we'd like to believe the sky's the limit.'"