September 21, 2018

Amazon's Alexa is Probably Not Ready for Healthcare Yet

Commentary
Chandana Fitzgerald

If Alexa can give information about the weather, the news, play music, tell jokes, etc, surely she can solve your health woes, right? Maybe not just yet.

Alexa won’t change healthcare delivery until she is HIPAA compliant. Until then, she will probably enable easier patient and HCP education, medication adherence, medication ordering, appointment scheduling. You are more likely to speak faster than you type/ write, you probably prefer to have a conversation with a virtual assistant than just a blunt ending transactional text. If you didn’t have to, you’d rather not have to use your hands to type - voice is hands free, vision free (think older people, poorer vision, difficulty in using phone based apps). Alexa also has the benefit of extensibility - new tools can be built on top of existing voice platforms for specific use cases.



Playing Devil’s Advocate: Accept Alexa with her flaws or not?

Although she is super helpful with basic questions (ref to weather, news, etc above), her knowledge of the complex medical world is limited, and Alexa generally only serves up one answer. If you were Googling your symptoms, like most people, you would have hundreds of  options to choose from. But Alexa won’t let you flick between a dozen browser tabs to determine whether your gurgling tummy is hunger, acute GE, IBS or a colonic stricture (probably not!). We also don’t want to hear a medical textbook long version of differential diagnosis to one question asked of Alexa - nobody likes a know-it-all who can’t answer to the point!

There are two ways to ask Alexa about your health issues. One, you can ask her built-in search tool, in which case she will cite one of Amazon’s verified, trusted sources (read Stats.com, IMDb, Accuweather, Yelp, Answers.com, Wikipedia, and WebMD). Although neither Alexa nor Amazon say where the artificial intelligence finds the most accurate answers to your health questions, we can reasonably assume she’s getting her health information from WebMD or Wikipedia. Two, you can install Amazon’s equivalent of a smartphone app - Skill. There are now over 1,000 health-related skills on Amazon available for free download although questions on quality and reliability remain. For context, a number of them come with a disclaimer ‘Not for medical advice’ and those that don’t may only be victims of poor regulation and verification.

Trust Test - Harvard Business Review conducted a survey of a group (numbers unknown) of pediatricians on how deep their trust of Alexa was: 55% of respondents were “somewhat” confident about the reliability of answers, but only 7% were very confident. 68% of the clinicians added that knowing the content came from a reliable hospital/ medical body would increase their confidence in the information provided.

But we can’t rubbish the facts: 40% of American adults already use voice search in their everyday lives, and studies estimate that 50% of all queries will be voice searches by 2020. An element of human interaction that typically gets lost with care automation can be given by voice tech. Voice enabled devices seamlessly integrate into daily routines as a companion in the home. These assistive support capabilities could reduce the administrative burden (nursing or admin time spent to answer routine queries) and lower the cost of care at hospitals and nursing homes. So, there is a silver lining, after all.

The Early Adopters

Boston Children’s Hospital were one of the first to speak up (voice pun alert) - they launched the KidsMD Alexa skill in early 2016. KidsMD answers worried parents’ queries about their child’s symptoms. They can also ask about weight- or age-specific dosing guidelines for over-the-counter drugs like acetaminophen.

They also brought Alexa into the hospital. In the ICU, Alexa provides nurses with basic  intelligence on medication dosing, specific protocols, staff contact info and other relevant data points (“Who is the charge nurse on 7 South?” “How many beds are available on 8 East?”). It also enables the user to pinpoint the location of a specific medical device or medication in a large stock room to save time. Lessons learned - (i) hospitals are noisy environments: To solve this, the team had to observe where the clinician would most likely be in the room when using the device so Alexa could clearly hear and be heard; (ii) key data point missing: Inability to access patient data through voice command due to HIPAA non-compliance.

Alexa is great for wellness. In the UK, Public Health England has launched a new service delivering approved breastfeeding advice via Alexa. Through “Breastfeeding Friend”, users can ask the platform questions and get answers tailored to the age of their baby. Breastfeeding is something that mothers learn as they do it and may have questions and setbacks as they go. Interestingly, the peak time for online searches related to breastfeeding support is between 2am to 6am when in-person help is unlikely to be available and this is the void that Alexa fills.

Libertana Home Health Care in Los Angeles is using Alexa powered by Orbita (these are the guys doing all the voice tech work in healthcare, straight up) to help residents do their day-to-day tasks like checking their daily schedule, connecting with caregivers, scheduling appointments, playing games or music.

In 2017, Amazon acknowledged the problem of HIPAA non-compliance at its "Alexa Diabetes Challenge" with Merck and Co. The competition invited a series of partners to promote uses for Alexa that would benefit patients with diabetes. Sugarpod by Wellpepper emerged a winner. Sugarpod includes a voice-powered scale and foot scanner that monitors for diabetic foot ulcers. It also takes pictures of the feet, which are classified for the provider, care team, and patient. The prototype was tested with 370 images on 100 patients. They are currently awaiting patent approval and further testing before market release. Do you have an update on them for us? Let us know.

The same Harvard Business Review survey of pediatricians mentioned above reported: 48% would be willing to deploy the technology in their clinical setting, 16% stated they would not try voice, another 36% were undecided, many of whom cited a lack of familiarity with how the technology could support patient care. Many physicians also added that they would use voice-assistant technology for clinical decision support in their office or home. They were much less inclined to do so in the presence of their patients.



Amazon’s Alexa Strategy

What might Amazon’s strategic approach with Alexa be? Disclaimer: We are assuming you know about Amazon’s PillPack acquisition, and about Amazon’s partnership with the digital health assets prescription platform, Xealth.

Amazon could bring Alexa as a health assistant into the patient’s home and recommend ancillary services under their umbrella to boost product sales. This would be key as Amazon gets hold of elective patient generated data shared via apps or other offerings (wearables, health records, medication records). The outcomes of this may be OTC product recommendations,  lifestyle product recommendations, digital asset recommendations (leveraging partnership with Xealth).

There is the potential to partner with medical facilities and start-ups to provide options for tele-consultation and virtual health coaches (and integrate this into a voice assistant paradigm), display educational videos highlighting health products and display ads for products to purchase via Amazon Online Store. Not to forget the potential for Alexa to do all the things the cool home bot Pillo does - speak to you, remind you of your meds, and dispense the right dose at the right time.

So, Amazon can become one big all inclusive platform for healthcare services delivery. Slick.

Back to reality. What's missing? Amazon does not have many ‘clinical’ services to offer as yet or similar partnerships to leverage at present.  While medications can be made available, associated clinical services are lacking.

The Challenges

HIPAA non-compliance, of course. Multi-user access- although Echo allows multi-user access, jumping off one account to another can involve a few steps. There will be a good bit of training of users until the NLP becomes accurate enough to tell apart different voices and accents. Accuracy of speech recognition to prevent impersonation is also key. Unlikely we will tolerate if our pharmacist mistook us for somebody else and dispensed the wrong meds! Along these lines, Lisa Suennen, a.k.a Venture Valkyrie has rightly said in her blog post on voice tech ‘’The Amazon Echo, while incredibly useful for summoning essential items like food and transport and designer shoes, can’t distinguish between different people’s voices yet. That is a problem where there is risk of abuse, particularly over-use of the purchasing feature by seniors easily taken advantage of by those without their best interests at heart. It’s also a problem for those whose memory isn’t what it used to be (like me!) who might accidentally order the same thing multiple times. Alexa developers will need to find a way to more easily decouple purchasing from the skills they create and to allow for the differentiation of speakers by the device.’’

What about software bugs (keeping it non-technical for convenience) that impact the health of individuals? Liability and responsibility remain unanswered areas - is the doctor responsible? The pharmacy/ pharmacist? Amazon? The patient?