Apple May Transform Health Care in the Future

Avolonte Health, a startup established in 2011, chose a modest office park in Palo Alto, California as its headquarters. The unremarkable two-story building, equipped with numerous security cameras, served as the company’s base of operations. Prospective engineers applying for positions at Avolonte Health were kept in the dark about the nature of their potential work. However, upon joining the team, they discovered their mission was to innovate and transform the field of diabetes care.

Avolonte was not just any healthcare company. It was a project of Apple Inc., and its task came directly from Steve Jobs. Apple’s co-founder and then-CEO, who was stricken with pancreatic cancer that would take his life later that year, had commissioned a group of his key executives to develop a non-invasive blood glucose meter. It would potentially be a life-changing technology for diabetics who would no longer need to inject themselves to monitor their blood sugar. Medical device manufacturers had been trying for years to develop something like that. Even Alphabet Inc. unsuccessfully tried using special contact lenses to measure glucose in tears.

Four years after Avolonte’s quiet arrival, Tim Cook stood in the same packed auditorium where his predecessor Jobs had unveiled the original Macintosh and introduced the Apple Watch. Cook called it “the next chapter in the Apple story.” The new device had health features: a heart rate monitor, a way to measure steps and calories burned, and a fitness app to track workouts. But the original vision had been grander. The company had imagined the watch as a small medical laboratory, with the Avolonte glucose meter as the centerpiece.

Today – both within Apple and in the wider world of public health – there is a feeling that the potential has not been realized. The company’s quest to combine health monitoring and disease prevention into best-selling devices has produced breakthroughs, but the strategy has also been cut short by philosophical disagreements, a culture of conservatism, and technological realities. Apple has stopped or slowed work on several promising projects, frustrating some of the doctors and engineers working on them. The details, much of which has not been previously reported, are based on interviews with several people involved in the company’s health initiatives, who asked not to be identified because they were not authorized to discuss the work.

Even setting aside the enormous technical challenges, healthcare is a different beast than consumer electronics and telecommunications, two industries that Apple has successfully disrupted but which only very rarely deal with death and disease. “The things they’re trying to do are not easy,” said Eric Topol, a cardiologist and director of the Scripps Research Translational Institute. An Apple spokesman declined to comment, but the company has said its work is still early.

Once just a bullet point, health and fitness are now key to selling Apple’s watch. The latest model includes a thermometer to measure body temperature for fertility planning, a sensor to measure blood oxygen, algorithms to track sleep and a system to take EKG scans. The company has also turned the iPhone into a fitness tracker and enabled it to utilize hospital data. Apple has promoted stories of its products saving lives by warning users of deadly heart disease and automatically calling emergency services for people injured in falls or car crashes.

Apple’s efforts have helped bring health monitoring into the mainstream. It has an enticing roadmap to 2024, including blood pressure and sleep apnea detection for the watch and hearing aid capabilities for AirPods. Its future Vision Pro headset is also intended to be made into a health and fitness device. And work continues on the paid, AI-powered health coach service.

“Health is an opportunity to help people,” said Bob Mansfield, the company’s former head of hardware engineering, who helped create the company’s health and smartwatch efforts. The Apple Watch’s “ability to play a key role in health was one of the things that excited us most about building it,” he told Bloomberg. “Compared to today, the earliest technologies built were not very good. I find it exciting to see how this idea evolves and continues to evolve.

In Apple’s ideal future, people will need fewer single-use medical devices like blood pressure monitors and thermometers, fewer blood draws and fewer doctor visits. Cook has said that improving health will be his company’s “greatest contribution to humanity.” This future could be very lucrative for the company: The market for health and fitness trackers is growing rapidly, with some predicting it will be close to $200 billion a year within a decade.

The late essayist Susan Sontag famously wrote, “Everyone born has dual citizenship in the kingdom of the well and the sick.” By focusing on prevention, Apple has wanted to stay in the realm of the well. Its core market is the “worried well” in industry parlance, those of us anxiously trying to interpret our body’s signals for evidence that something is wrong. This makes some sense for a consumer electronics company. A transition to curing or even treating diseases would get the company tangled in the web of regulatory systems in different countries and raise difficult questions about business models. But taking them can also mean more lives are saved. And it’s a recurring tension within the company.

“The key takeaway from their whole strategy is that they’re eschewing actual care,” said Adrian Aoun, Forward’s founder and CEO. The Forward company maintains a chain of high-tech in-person and remote clinics. Apple is building “great technologies,” but they’re “skating around the problem,” he said. “Health care is messy, and you have to get your hands dirty,” he said. “At some point you have to be willing to draw blood.”

In the early 2010s, Apple began hiring health consultants, medical device specialists, and sleep researchers. It hired sensor guys from places like Medtronic Plc with expertise in all the metrics Apple wanted its smartwatch to handle. Avolonte was the most insidious initiative. The group was ostensibly separate from its parent company, allowing it to acquire components and conduct human trials without publicity, people with knowledge of the effort said.

Only Apple’s top executives knew what was going on in an office 15 minutes away from headquarters. Avolonte was not listed in any official Apple system, and employees were prevented from bringing Apple clothing into the vicinity. Employees wore the Avolonte logo (an A with an infinity symbol, a nod to the address of Apple’s old headquarters on a private road called the Infinite Loop). And when Cook visited the office for a status update, he arrived wearing a baseball cap pulled low to avoid detection.

A few years and hundreds of millions of dollars into the project, Avolonte researchers arrived at the technology of short-wave infrared absorption spectroscopy. This technique involves shining lasers through the skin into the interstitial fluid between blood vessels and the cells they serve. Researchers have found that the intensity of light back-reflection can be used to calculate the glucose concentration in the interstitial fluid and thus in the bloodstream – and the only thing that has had to enter the body is light.

However, Apple had a ways to go before producing a market-ready sensor. The non-invasive system must see through a wide range of skin colors and analyze different blood types. It should also last indefinitely, unlike sensor patches like the FreeStyle Libre on the shelves now, which poke the skin and need to be replaced frequently. And the system designed by Apple requires the use of artificial intelligence to sift through the raw data and create a prediction of when a person might become diabetic.

As Apple prepared to introduce the Watch in 2014, it became clear that the glucose sensor wasn’t going to make it. Neither are the blood pressure, blood oxygen, and EKG features the company was trying to develop. There were component sourcing issues, battery and reliability issues, and the real issue of cramming them into the tight spaces of a less than 2 inch x 2 inch device.

Because of these limitations, Apple felt it didn’t make sense to market the watch primarily as a healthcare device. Instead, it was positioned as a bling-y technology accessory for managing incoming calls and texts, tracking health and, of course, telling the time. Then-design chief Jony Ive, legendary for helping Jobs hone Apple’s austerely luxurious aesthetic, pushed the company to offer $17,000 watch variants made of rose gold. Apple somewhat downplayed the heart rate monitor in the first version of the device due to the sensor’s initially limited performance.

Since then, Apple has been working to add health features to the watch, believing the fitness device could be a significant new business that doesn’t cannibalize the iPhone. The glucose monitor project has continued in secret, costing tens of millions of dollars a year. When Apple reassessed its operations when the Covid-19 pandemic hit, it decided to bring the project to its own campus. It is now led by Apple’s Exploratory Design Group, or XDG, a secretive team in the chip design division. The job was recently taken over by one of Apple’s top Mac and iPhone chip executives, but it remains unlikely to appear in a product for at least a few years, according to people familiar with the effort.

Other key projects were excluded during development. Apple explored building a nutrition tracker into its Health app and considered selling Apple Watch peripherals, including a bathroom scale and an Ive-designed blood pressure cuff that didn’t need to be inflated. The company created prototype watch straps with sensors that collect data from below the wrist, and explored both a bed-mounted sleep tracker and a bedside device whose sensors monitor users overnight before pushing the technology into the watch itself.

For a while, Apple engineers were also deeply committed to making the watch and the Health app compatible with the billions of Android devices in circulation. The move, codenamed Project Fennel, would have brought the company’s health-related features — and the health benefits that Apple has repeatedly touted — to more people, especially in countries where Apple has little market share. But other business considerations won out: the job was almost done when Project Fennel was canceled, in part because the Apple Watch is a driver of iPhone sales. “If you give the watch to Android, you would dilute the value of the watch to the iPhone,” said someone with knowledge of the decision.

Prototypes and projects that don’t make it to market are commonplace in the tech world. However, some of those working on new technologies have chafed at Apple’s caution. They say the company’s engineers and doctors have long struggled with senior executives’ fears that a bad medical experience with Apple could tarnish the perception of the company. “Tim and Jeff are so terrified they’re doing something wrong and are focused on protecting the company’s image,” one person said, referring to Cook and Chief Operating Officer Jeff Williams, who oversees the company’s health efforts. Other people familiar with the health team blame caution on privacy requirements and the difficulty of gathering viable health data from the wrist.

This mix of excitement and ambition is shaping some of the new features the company is rolling out. The planned addition of a blood pressure sensor to the Apple Watch next year is groundbreaking technology. However, in its first iteration, the system was only designed to tell the user if their blood pressure was rising and to provide the user with a diary where the user could write down what happened when the hypertension occurred. To avoid possible misdiagnosis, the feature directs the user to talk to a doctor or check their blood pressure with a traditional cuff, which can provide accurate systolic and diastolic measurements. A future version of the system is being prepared that will be able to provide accurate numbers – and even diagnose related diseases. But these improvements are far from over.

The blood sugar system may work the same way at first. During development, it was designed to track a person’s blood sugar trend and warn users of pre-diabetes, rather than providing an actual blood sugar reading. “Apple is pursuing nanotechnology and software,” a person involved in the work said. “That’s what we’re very good at. What we’re not interested in is post-disease health care.”

The difference between health and healthcare will determine much of what Apple plans to do in the near future. Early considerations for the virtual health and fitness coach include the ability to create eating, sleeping and exercise recommendations from data collected from Apple devices, according to people familiar with its development. There are also concepts to tap into devices’ cameras to track and correct users’ form as they exercise. This is similar to Peloton Interactive Inc.’s TV-connected exercise device. If everything goes according to plan, next year AirPods will be able to function as an over-the-counter hearing aid and perform hearing tests that are typically performed in audiologists’ offices.

At the same time, Apple is laying the groundwork to turn the Vision Pro headphones into health devices. The company is developing new anti-anxiety and improved meditation features for the product, as well as a virtual reality system to strengthen positive thinking and improve mental health. Apple has also explored using the device’s sensors to scan cognitive health data from the user’s eyes. A headset version of Fitness, Apple’s workout video subscription, is still on the table, and the company is trying to develop a full-body tracking system that could use a headset to interpret a person’s leg movements during exercise. That would put the $3,500 product in competition with Meta Platforms Inc.’s Quest, which already allows people to exercise in a virtual environment.

The 2024 map also has a watch-based sleep apnea detection feature. It uses sleep and breathing patterns to assess whether someone has the disease. It then directs users to a doctor.

Still, there are some signs that the company is exploring capabilities that could be in the pipeline. Currently, its pulse oximeter sensor only shows a person their blood oxygen percentage, not what the data means. The current version of the app makes this clear, telling users: “Blood oxygen measurements are not intended for medical use.” The company is considering applying for approval from health authorities, which would allow it to interpret information for consumers. Apple also wants to expand the watch’s thermometer to detect fever, not just boost its fertility tracking feature. And last year it launched AFib History, a feature that lets sufferers track how long they’ve been in atrial fibrillation.

Apple has been exploring different business models for the watch, including one inspired by a practice that has worked for the company in the past. In the early days of the iPhone, Apple sold the devices to consumers at a discount, with wireless carriers covering the rest. Apple got full value, while carriers were able to lock consumers into long-term phone service contracts. Apple explored a similar arrangement with its Watch: health insurers would cover much or all of the cost of the Apple Watch, hooking consumers into their insurance plans and ultimately paying doctors less because Apple’s health features keep customers out of the hospital. . In recent years, Apple has struck deals with Aetna Inc. and UnitedHealthcare, but several other insurers rejected Apple’s proposals, believing it would take too long to see a return on their investment.

Unlike healthcare executives at some other tech companies, Williams is a design and operations specialist, not a doctor. That’s why much of Apple’s health strategy is led by Sumbul Desai, a physician-turned-healthcare executive who Williams recruited to Apple in 2017 and manages its employee health clinics. Desai came from Stanford University, where he served as a medical assistant and led what is known as digital primary care at the school’s health system.

Apple had ambitions to build something similar. The concept, known at the company as Infinite Health, meant that Apple would invest in consumer healthcare by building clinics in major cities and even in its retail stores, according to people familiar with the discussions. The clinics would have the open spaces and clean lines of an Apple retail store, along with sleek equipment like a non-inflatable blood pressure cuff. There, doctors employed by Apple would review the data collected from the company’s devices and fill in the gaps with standardized devices.

Some people at Apple envisioned the clinics as a way for the company to reinvent healthcare the way it revolutionized music players and phones. Apple was even in acquisition talks with Crossover Health, which ran clinics where Apple employees received treatment at work, and One Medical, a chain that Amazon.com Inc. would buy for nearly $4 billion in 2023. “What Amazon is doing now,” said of the project person who worked, “this is something we really hoped we could do in an Apple-like way.”

Williams pitched the idea of a consumer clinic to Cook many years ago, but the two ultimately reached a compromise: taking over the infrastructure and technology of Apple’s existing employee clinics. The idea was to turn the company’s benefit into a kind of healthcare innovation laboratory and, in Silicon Valley vernacular, ask employees to eat the same dog food they were going to sell to their customers. “The thought process was that if we can’t deliver something good enough for our employees, no consumer will want this,” said a person involved in the work. “It was a bit of a dogfooding exercise.”

However, the dog food wasn’t great. The Silicon Valley clinics, which Desai eventually relaunched as AC Wellness, provide adequate care but are very expensive to maintain. “There’s no way a consumer or an employer would pay what Apple is asking to run the clinics,” said a person involved in their creation, given the high cost of equipment, salaries and back-end services needed to make the offering more efficient. “It’s probably great for young and healthy workers, but you don’t want to run a Medicare Advantage plan with it,” said another person familiar with the clinics. Still, the broader Infinite Health concept of consumer clinics has not been completely abandoned.

Another dogfooding exercise was the HealthHabit app, where users can chat with a care coordinator and, if necessary, refer them to a health professional. Doctors could answer simple questions like, “Should I take Advil with a knee injury?” but the service could not provide many new prescriptions or diagnoses. At the peak of its internal testing, HealthHabit had only about 3,500 users out of several tens of thousands in Apple’s Silicon Valley offices. “This was the first real experiment where you could get a doctor on board during Apple’s healthcare, and it was such a failure that it killed the eye,” said the person involved in its development. Apple canceled the extension for employees in Texas, and the app never made it to consumers. In the end, the company used some of the work for a new internal tool.

According to several people who have worked on this and other health projects, part of the problem has been the leadership of the health team. After leaving in late 2019, one of the group’s doctors sent Cook and Williams an explosive email that Bloomberg described as a workplace characterized by “authoritarian rule through intimidation and harsh retaliation for not marching in line.” In addition to such complaints, doctors have criticized managers for offering incorrect medical information in meetings and then berating colleagues who objected to it.

At the product event held in September, the company did not fuss about health as usual. It released a mental health feature for the iPhone and Apple Watch that allows the user to record how they feel throughout the day, and a mechanism to warn users against holding their devices too close to their eyes for long periods of time.

In a sense, the fate of the blood glucose sensor is a sign of how willing the company is to move over the worried well into the sick realm. Some people involved in Apple’s health efforts don’t believe the company will use its upcoming blood glucose meter in the Apple Watch as a medical device for people who already have diabetes — due to regulatory and technology limitations that could pose a risk to the patient. wrong result.

Still, the company’s top management and board members point out that preventing millions of people from getting diabetes is a huge achievement. “The goal is not just to fix the injection problem,” said someone briefed on the work by one of its leaders, “but to change the global problem of diabetes.” Apple, in other words, is still thinking big. – with Ike Swetlitz