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A R O C K R E P O R T B Y
BIOSENSING WEARABLES
THE FUTURE OF
2014 JUN 09
A R O C K R E P O R T B Y
AUTHORED BY WITH HELP FROM
MALAY GANDHI
@mgxtro
TERESA WANG
@teresawang6
ROCK HEALTH is powering the future of the digital health ecosystem,
bringing together the brightest minds across disciplines to build
better solutions. Rock Health funds and supports startups building
the next generation of technologies transforming healthcare.
ROCK HEALTH partners include Deloitte, GE, Genentech, Harvard
Medical School, Kaiser Permanente, Kleiner Perkins Caufield &
Byers, Mayo Clinic, Mohr Davidow Ventures, Montreux Equity
Partners, Qualcomm Life and UCSF.
LEARN MORE AT rockhealth.com
SONIA HAVELE
@rock_health
HIS HAS BEEN A YEAR MARKED WITH PESSIMISM ABOUT THE
future of biosensing wearables. Put simply: we’re not
buying it. After spending over a year looking at the space—
including evaluating 100+ startups for investment, watching
venture trends, and working with giants from both in and
outside of healthcare—we know interest has never been greater.
However, excitement shouldn’t be mistaken for impact. We
expect biosensing wearables will need to leverage their
consumer learnings and evolve into highly functional and
accurate devices in order to gain adoption in the industry.
The opportunity here is not to be underestimated. A long tail of
evolved biosensing wearables, enabled through platforms, has
the potential to improve health outcomes and lower costs. Only
time will tell if the reality matches the promise—we’re optimistic.
T
PRESENTATION © 2014 ROCK HEALTH
Contents
4 Scope of report Definition of biosensing wearables
5 Landscape Companies by type of physiology measured
Venture funding of biosensing wearables
Market catalysts
18 Axes of innovation Evolution of biosensing wearables
Examples of progress
Potential for disruptive innovation
26 Platforms and business models Healthcare industry use cases
Examples of existing biosensing wearable platforms
Role of technology platforms
32 Acknowledgements Contact information
SECTION
PRESENTATION © 2014 ROCK HEALTH
Activity trackers Smart watches Smart clothing Patches and
tattoos
Ingestibles and
smart implants
Biosensing wearables allow continuous physiological monitoring
in a wide range of form factors
4
BIOSENSORS WEARABLES
Biosensors are devices
that convert a biological
recognition element into
a signal output
Wearables are on- or in-
body accessories that
enhance the user
experience
e.g. AliveCor,
Scanadu
e.g. Google Glass,
Oculus Rift
FOCUS OF REPORT: BIOSENSING WEARABLES
9:41
..........................................
Landscape
PRESENTATION © 2014 ROCK HEALTH
A wide range of products have emerged or are being developed in
the category, covering numerous aspects of human physiology
Source: Rock Health review of marketing for 75+ companies
Note: Companies are selected, not comprehensive 6
GROWING LONG TAIL
MOVEMENT HEART RATE SLEEP TEMPERATURE RESPIRATION SKIN
CONDUCTANCE
BRAIN
ACTIVITY
HYDRATION POSTURE GLUCOSE OXYGEN
LEVEL
HEART RATE
VARIABILITY
MUSCLE
ACTIVITY
BLOOD
PRESSURE
EYE-
TRACKING
INGESTION
COMMODITY
ZONE
PRESENTATION © 2014 ROCK HEALTH
Smartphones are out, wearables are
next
How wearable tech goes from geek fad
to mega-trend
2014 will be the year that wearables
become a key consumer technology
HOPE
Opinions on the future of the category are decidedly mixed, with
a tremendous amount of hype mixed with failure
Source: News stories, Twitter
As the health-gadget market swells, it’s lights
out for Zeo’s sleep tracker
Nike fires majority of FuelBand team, will stop
making wearable hardware
Are some fitness band trackers ‘digital snake
oil,’ with slick marketing but suspect results?
HYPE
7
“ “
” ”
PRESENTATION © 2014 ROCK HEALTH
Various estimates of wearable device sales through 2018
While the activity tracker segment has about 1-2% U.S.
penetration, wearables overall are expected to grow significantly
Note: IDC reported smartphone market size as of 2013
Source: Respective company sites
PICK A NUMBER, ANY NUMBER
8
DATE OF ESTIMATE
Jan ’13 May ’13 Aug ’13 Sep ’13 Oct ’13 Apr ’14 May ’14 Present
$
50.0B
Credit Suisse
Market estimate in 2018
Market estimate in 2013
$5.8B
Transparency Market
Research
$8.0B
ReportsnReports
$8.4B
MarketsAndMarkets
$19.0B
Juniper
$12.6B
BI Intelligence
$6.0B
ABI Research
$20.6B
Institute for
Information
Industry (Taiwan)
$30.2B
BCC Research
$337B
Smartphone
market size
PRESENTATION © 2014 ROCK HEALTH
Venture capitalists are also betting on the space, with venture
funding up over 5X since 2011
Source: Rock Health funding database
Note: Does not include Jawbone financing events 9
$0M
$75M
$150M
$225M
$300M
2011 2012 2013
Biosensing Wearables
Biosensors
$20M
$29M
$58M
$54M
$229M
$53M
NOTABLE
DEALS
• Norwest Venture Partners
• Founders Fund
• Khosla Ventures
• Qualcomm Ventures
• Felicis Ventures
MOST ACTIVE INVESTORS
Total venture funding for biosensing wearables (2011-2013)
WEAR IT’S AT
PRESENTATION © 2014 ROCK HEALTH
The scale and utility of smartphones, in addition to a dramatic
shift in healthcare, has catalyzed the space
Sources: Smartphone penetration from Comscore as of March 2014; MEMS
accelerometer pricing from supply chain sources; ACO penetration from Leavitt Partners
OFFLOADING COMMODITIZATION VALUE-BASED HEALTHCARE
10
• Wearables can offload the display (through
software apps), the computing, and internet
connectivity to a smartphone
• Bluetooth Low Energy (BLE) has enabled
energy efficient data transfer between devices
and smartphones
2008 2013
$0.50
$2.00
MEMS accelerometer price per unit
• Due to inclusion in smartphones, many
popular sensors are now fully commoditized
• Prices for most sensors are dropping at >3%
per quarter
• Commoditization forces vendors to develop
novel sensors, creating a virtuous cycle of
innovation
• Following the ACA, healthcare has an increased
focus on value-based delivery and preventive care
• Health plans and employers are experimenting
with wearables as “source of truth” for incentives
• B2B has become one of the fastest growing
components of Fitbit’s business
69%
U.S. SMARTPHONE
PENETRATION
0M
5M
10M
15M
20M
2011 2012 2013 2014
Accountable care lives
“The ground has to be fertile for the seeds to
grow—innovative technology in wearables and
biosensors can be both economically- and
functionally-sound because it leverages the
trillions of dollars that have already gone into
that space.
Once the technology lines up, utility will come
from people knowing how to use the devices.
Healthcare is the biggest and most persistent
opportunity and will ultimately define the
market.”
AMAR KENDALE
VP of Marketing
MC10‘s technology
platform is a unique
combination of
conventional electronics
and novel mechanics
that enable a new
generation of thin,
conformal electronic
systems.
PRESENTATION © 2014 ROCK HEALTH
Biosensing wearable products being created today could not
have existed even three years ago
Source: Product and app rendering courtesy of Spire, Inc.
Note: Spire product is launching June 17th, 2014 12
Bluetooth Low Energy radio
First device to implement BLE
was the iPhone 4S in 2011
MEMS accelerometer
Price has fallen 4X in the last
five years
Wireless charging coil
Qi standards-based products
first hit market in 2013
Offloaded computation
Signal processing from sensors
is handled in cloud via iPhone
PRESENTATION © 2014 ROCK HEALTH
Rate of sustained activity tracker use over months of ownership
Despite such advancement, wearable products today fail to
engage users over meaningful periods of time
ENDEAVOUR PARTNERS SURVEY
(n = “thousands of internet-
connected Americans”)
THE TRUTH ABOUT WEARABLES
13
0%
25%
50%
75%
100%
0 3 6 9 12 15 18 21 24
Rate of decline is steepest
during the first 6 months
of ownership Rate of engagement
drops below 50%
before 18 months
PROPORTION OF
INDIVIDUALS
CONTINUING TO
USE AN ACTIVITY
TRACKER
MONTHS
ROCK HEALTH “SURVEY”
(n = 10 Rock Health staff)
Note: We sincerely appreciate and respect the Endeavour Partners work;
however we would be surprised if the survey could be replicated
PRESENTATION © 2014 ROCK HEALTH
The generic marketing language of most devices leaves use cases
to the purchaser's imagination
Source: Market share from NPD point-of-sale data (January 2013-January 2014);
marketing copy from company websites (May 2014) 14
97%
THE TOP 3 WEARABLE
ACTIVITY TRACKERS
REPRESENT
OF THE MARKET
“It’s the motivation you
need to get out and be
more active.”
“It celebrates milestones
and challenges you to
make each day better.”
“The smart, simple, and
fun way to get more
active.”
PRESENTATION © 2014 ROCK HEALTH
Trade-offs between mass market and personalized products
All companies face product marketing challenges when making
the trade-off between mass and niche markets
PARADOXICAL PRODUCTS
15
ADDRESSABLE
MARKET
(NUMBER OF
INDIVIDUALS)
UTILITY PER USER
SPECIAL PURPOSE DEVICESGENERAL PURPOSE DEVICES
Products in this area are
marketed towards large
audiences but fail to gain
widespread adoption due
to a lack of usefulness
Products in this area
are highly valued by
niche segments,
giving a feeling of
personalization
Products in this area are the ideal,
balancing the marketing of mass
market core utility with some level of
specialization for narrower segments
PRESENTATION © 2014 ROCK HEALTH
The pathway to reaching large markets for companies today
For most activity trackers, the lack of utility and failure of product
marketing have made it difficult to scale and meaningfully engage
Source: Reviews from Amazon.com and Reebok website
PARADOXICAL WEARABLES
16
ADDRESSABLE
MARKET
(NUMBER OF
INDIVIDUALS)
UTILITY PER USER
SPECIAL PURPOSE DEVICESGENERAL PURPOSE DEVICES
Activity
trackers
Single
purpose
wearables
“Piece of mind protection for a parent!”
“Great product. It works as
advertised and helps correct bad
habits.”
Strategic approach:
• Improve software/insights
• Add more sensors/features
Strategic approach:
• Create family of segment-
specific devices
REEBOK
CHECKLIGHT
LUMOBACK
“Innovation for use case is important. Right now,
everyone is just using off-the-shelf technology
so they can only go after things that are
obvious, like counting steps and heart beats.
In order to provide something more meaningful,
it’s important to design a product that has a
specific utility. Then you can stand behind it
and say to somebody, ‘This is how I’m going to
help you.’”
DAVID O’REILLY
Chief Product Officer
Proteus’s vision is to
integrate medicines that
treat chronic conditions
with mobile technology –
via our ingestible
sensor– to make
healthcare more
accessible, manageable
and innovative.
Axes of innovation
PRESENTATION © 2014 ROCK HEALTH
FUNCTIONALITY RELIABILITY CONVENIENCE
• Collecting physiological factors with the
potential to be of value to individuals or
healthcare professionals
• Building software that makes physiology
meaningful and can close the loop with
actions (answering the question “So what?”)
• Measuring physiology with accuracy and
validity (or using software and algorithms to
correct for validity)
• Achieving accepted clinical standards and
receiving FDA (or other regulatory) clearance
or approval
• Packaging sensors in form factors that are
passive, comfortable, and provide positive
reinforcement to the user
• Managing battery life and various charging
issues
• Synchronizing data between wearable device,
smartphone, and cloud
In order to scale beyond early adopters, biosensing wearables
will need to innovate along three axes
19
High value segments will emerge at narrow use case intersections along these three axes
PRESENTATION © 2014 ROCK HEALTH
Functionality determines a biosensing wearable’s potential utility
to an end user, whether a consumer or healthcare professional
Source: Company website
• Novel measurement—monitors
your posture and coaches you to
improve throughout the day
20
• Provides consistent reminders to
maintain healthy posture
• Track progress over time as well
as daily activities (walking,
running, sitting, standing, and
sleeping)
FUNCTIONALITY
WHY IT MATTERS Without core
functionality, utility to the user
is highly limited.
WHAT IT REQUIRES Measuring
meaningful physiology and
closing the loop with users by
delivering insights.
WHY IT’S HARD Need to be
exceptional at hardware and
software.
EXAMPLE: LUMOBACK
PRESENTATION © 2014 ROCK HEALTH
Reliability influences the addressable segments due to the unique
constraints of operating in a healthcare environment
Source: Company website, fda.gov 21
• Single use patch
• 510(k) clearance—proven to
capture arrhythmias for earlier
diagnosis
• Interpretation designated for
healthcare professionals
• Report summarizes findings
based on FDA-cleared proprietary
algorithm to incorporate final
diagnosis
EXAMPLE: ZIO PATCHRELIABILITY
WHY IT MATTERS Healthcare
customers demand valid data
to inform clinical decisions.
WHAT IT REQUIRES For clinical
markets, a regulatory (e.g., FDA)
clearance or approval.
WHY IT’S HARD Signal processing
to overcome accuracy issues;
Few in the category have a FDA
clearance or approval.
PRESENTATION © 2014 ROCK HEALTH
CONVENIENCE
Finally, convenience plays a significant role in engagement with
biosensing wearables, particularly at the onset of use
Source: Company website 22
• Eschews charging with watch battery
that lasts up to a single year
• Background syncing handled through
Bluetooth Low Energy
• Waterproof and can be used while
swimming or showering
• Form factor is jewelry-like with
multiple ways to wear or display
EXAMPLE: SHINE
WHY IT MATTERS Without
convenience, user engagement
falls off a cliff.
WHAT IT REQUIRES Limiting the
number of actions required by
the user, covering everything
from unboxing through syncing.
WHY IT’S HARD Requires expertise
in packaging, industrial design
and user experience.
PRESENTATION © 2014 ROCK HEALTH23
FUNCTIONALITY RELIABILITY CONVENIENCE USE CASES
• Directly measures ingestion
event along with activity
and heart rate
• Provides information to
healthcare professional or
caregiver
• Binary state of reliability for
ingestion event
• Received FDA approval
(ingestible event monitor)
and clearance (patch)
• User wears disposable
patch and takes medicine as
usual
• No charging
• No additional tracking
required
• Medication adherence in
key therapeutic areas
including heart failure, CNS,
and transplant
• Measures respiration and
activity
• Software allows user to be
informed about state of
mind (e.g., focus) and take
clear action
• Respiration sensor is
comparable to clinical
standard spirometer
• Developed into a compact
form factor that can be
worn in multiple places
• Supports wireless charging
• Customized styles for users
• Health and performance of
knowledge workers
• Respiratory condition
monitoring
First products from Proteus and Spire demonstrate how
innovating along all three axes leads to high utility
PROTEUS HELIUS
SPIRE
Source: Proteus website; Spire product rendering courtesy of Spire, Inc.
PRESENTATION © 2014 ROCK HEALTH
Disruptive potential of biosensing wearables over time
Biosensing wearables that evolve along the three key axes have
the potential to disrupt large healthcare markets
A LITTLE MORE DISRUPTION, PLEASE
24
Note: We strongly object to the overuse of the phrase “disruptive innovation”; however, we feel
that it describes both the market dynamics as well as popular backlash against the category
PRODUCT
PERFORMANCE
TIME
as defined by
FUNCTIONALITY
RELIABILITY
CONVENIENCE
Performance
demanded by
healthcare markets
Driven primarily by
functionality and
reliability
Performance demanded
by consumer markets
Driven primarily by
convenience and price
SUSTAINING TECHNOLOGY
BIOSENSING
W
EARABLES
MEDICAL
DEVICES
REMOTE
PATIENT
MONITORING
CLINICAL
DATA
CAPTURE
EMPLOYER
WELLNESS
$100-125B $10B $6B $6B
Our arch competitor will not be
Boston Scientific, or St. Jude
Medical or Covidien or
HeartWare. It will be Google.
STEPHEN N. OESTERLE, M.D.
SVP, Medicine and Technology
Medtronic
“AgaMatrix was medical, medical, medical for 7-8
years. What we realized was that we had so
much difficulty trying to rapidly update our
apps. With Misfit, we thought we would go to
the consumer first, test, learn a lot, iterate over
and over again, and then hit the healthcare
market.”
SRIDHAR IYENGAR
Co-founder and CTO
Misfit invents and
manufactures great
wearable computing
products.
Platforms and business models
PRESENTATION © 2014 ROCK HEALTH
Critical use cases for the industry and biosensing wearables
Evolved biosensing wearables will solve significant problems for
the healthcare industry
AND THE QUEST FOR THE HOLY GRAIL
27
PAYERS PROVIDERS BIOPHARMA
IDEALIZED USE
CASES
• Consumer behavior change
• Early diagnosis and intervention
• Source of truth for biometric-based
incentive programs
• Remote patient monitoring
• Support for telemedicine services
• Clinical data capture for executing
adaptive clinical trials
• Collection of post-market and real world
effectiveness data
• Combination device and drug products
PERFORMANCE
REQUIREMENTS
• Functionality has to focus on making
physiological data highly meaningful and
actionable to the end user
• Convenience is paramount as consumers
are highly likely to abandon devices that
cause any type of engagement friction
• Functionality has to focus on data
transport and integration into clinical
workflow
• Requires high reliability (e.g. regulatory
clearance) if healthcare professionals are
dependent on data for healthcare delivery
• Functionality must focus on the clinical
endpoints tied to specific therapeutic
areas
• Reliability has to pass compliance with
existing regulation—data collection as
part of a clinical trial must be 21 CFR Part
11 compliant (U.S.)
PRESENTATION © 2014 ROCK HEALTH
INDIVIDUAL
WELLNESS
CORPORATE
WELLNESS
REMOTE PATIENT
MANAGEMENT
CONSUMER ENGAGEMENT
AND ANALYTICS
DATA NORMALIZATION
AND TRANSPORT
Consumers Payers Providers Payers, biopharma Agnostic (API)
Attempts at consumer/industry platforms for integrating biosensing wearables
Multiple companies have emerged in an attempt to enable these
use cases, although none are close to becoming scaled platforms
Note: Devices and platforms are selected, not comprehensive
COMPLETELY FRAGGED
28
EXAMPLE
PLATFORMS
USE CASE
TARGET
CUSTOMER
BIOSENSING
WEARABLES
PRESENTATION © 2014 ROCK HEALTH
CORE SOFTWARE
S Health Health
PLATFORM
Samsung Architecture
Multimodal Interactions
(S.A.M.I.)
HealthKit
ENABLING DEVICES
Galaxy S-series
Simband
(reference platform)
iPhone
?
Activity
trackers and
watches
Smart
clothing
Patches and
tattoos
Ingestibles
and smart
implants
Non-wearable
biosensors
Wearable makers and end customers are both heavily platform
shopping, limiting scale and leaving an opening for tech giants
Note: Yes, we expect Apple to release an enabling biosensing wearable device.
We do not know what the release date, form factor, or underlying product story will be. 29
..........................................
............................
9:41
HARDWARE ECOSYSTEM SOFTWARE ECOSYSTEM
Mobile apps
Data transport
and liquidity to/
from the
industry
PRESENTATION © 2014 ROCK HEALTH
VIRTUOUS CYCLE
Starting from a scaled platform could catalyze a virtuous cycle,
enabling new business models for wearable companies
PLATFORM SOLVES
30
HARDWARE
ECOSYSTEM
SOFTWARE
ECOSYSTEM
PLATFORM
ENABLING
DEVICES
CORE
SOFTWARE
1
2
3
1 Scale for everyone
A massively scaled consumer platform
attracts industry and developers, seeding an
ecosystem within the healthcare industry.
2
3
Software: challenges of fragmentation
Pure software players, including the industry,
can define valuable use cases and no longer
worry about choosing a specific type of
biosensing wearable—maximizing flexibility
and consumer choice.
Hardware: missing integration
Device companies can build once (for defined
use cases) and connect to multiple endpoints
(inclusive of both consumers and the industry)
through a scaled platform, eliminating the
current challenge of having to be a “full stack”
company (hardware, software, integration).
SUBSCRIPTION SOFTWARE
ADD ON SERVICES
(E.G., COACHING)
DISPOSABLES
HIGH GROSS MARGIN
(VALUE-BASED PRICING)
NEW BUSINESS MODELS
Characteristics of disruptive
businesses, at least in their initial
stages, can include: lower gross
margins, smaller target markets, and
simpler products and services that
may not appear as attractive as
existing solutions when compared
against traditional performance
metrics. 
“
”PROF. CLAYTON CHRISTENSEN
We’re at the beginning of a long journey
with biosensing wearables
ACKNOWLEDGEMENTS
We are indebted to our industry partners who not only
support our work every day but provided invaluable
feedback on an early draft of this report.
A number of industry, startup and venture folks also
offered their expertise. Special thanks to Aaron Duran,
Ingo Elfering, Sridhar Iyengar, Amar Kendale, David
O’Reilly, Jonathan Palley, and Sundeep Peechu for
their time and insights.
Finally, we are fortunate to work with the most
talented (and fun) team in digital health. Thanks to
Halle Tecco and Mollie McDowell for reviewing our
final drafts and providing edits.
research@rockhealth.org
@rock_health
PRESENTATION © 2014 ROCK HEALTH

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The Future of Biosensing Wearables by @Rock_Health

  • 1. A R O C K R E P O R T B Y BIOSENSING WEARABLES THE FUTURE OF 2014 JUN 09
  • 2. A R O C K R E P O R T B Y AUTHORED BY WITH HELP FROM MALAY GANDHI @mgxtro TERESA WANG @teresawang6 ROCK HEALTH is powering the future of the digital health ecosystem, bringing together the brightest minds across disciplines to build better solutions. Rock Health funds and supports startups building the next generation of technologies transforming healthcare. ROCK HEALTH partners include Deloitte, GE, Genentech, Harvard Medical School, Kaiser Permanente, Kleiner Perkins Caufield & Byers, Mayo Clinic, Mohr Davidow Ventures, Montreux Equity Partners, Qualcomm Life and UCSF. LEARN MORE AT rockhealth.com SONIA HAVELE @rock_health HIS HAS BEEN A YEAR MARKED WITH PESSIMISM ABOUT THE future of biosensing wearables. Put simply: we’re not buying it. After spending over a year looking at the space— including evaluating 100+ startups for investment, watching venture trends, and working with giants from both in and outside of healthcare—we know interest has never been greater. However, excitement shouldn’t be mistaken for impact. We expect biosensing wearables will need to leverage their consumer learnings and evolve into highly functional and accurate devices in order to gain adoption in the industry. The opportunity here is not to be underestimated. A long tail of evolved biosensing wearables, enabled through platforms, has the potential to improve health outcomes and lower costs. Only time will tell if the reality matches the promise—we’re optimistic. T
  • 3. PRESENTATION © 2014 ROCK HEALTH Contents 4 Scope of report Definition of biosensing wearables 5 Landscape Companies by type of physiology measured Venture funding of biosensing wearables Market catalysts 18 Axes of innovation Evolution of biosensing wearables Examples of progress Potential for disruptive innovation 26 Platforms and business models Healthcare industry use cases Examples of existing biosensing wearable platforms Role of technology platforms 32 Acknowledgements Contact information SECTION
  • 4. PRESENTATION © 2014 ROCK HEALTH Activity trackers Smart watches Smart clothing Patches and tattoos Ingestibles and smart implants Biosensing wearables allow continuous physiological monitoring in a wide range of form factors 4 BIOSENSORS WEARABLES Biosensors are devices that convert a biological recognition element into a signal output Wearables are on- or in- body accessories that enhance the user experience e.g. AliveCor, Scanadu e.g. Google Glass, Oculus Rift FOCUS OF REPORT: BIOSENSING WEARABLES 9:41 ..........................................
  • 6. PRESENTATION © 2014 ROCK HEALTH A wide range of products have emerged or are being developed in the category, covering numerous aspects of human physiology Source: Rock Health review of marketing for 75+ companies Note: Companies are selected, not comprehensive 6 GROWING LONG TAIL MOVEMENT HEART RATE SLEEP TEMPERATURE RESPIRATION SKIN CONDUCTANCE BRAIN ACTIVITY HYDRATION POSTURE GLUCOSE OXYGEN LEVEL HEART RATE VARIABILITY MUSCLE ACTIVITY BLOOD PRESSURE EYE- TRACKING INGESTION COMMODITY ZONE
  • 7. PRESENTATION © 2014 ROCK HEALTH Smartphones are out, wearables are next How wearable tech goes from geek fad to mega-trend 2014 will be the year that wearables become a key consumer technology HOPE Opinions on the future of the category are decidedly mixed, with a tremendous amount of hype mixed with failure Source: News stories, Twitter As the health-gadget market swells, it’s lights out for Zeo’s sleep tracker Nike fires majority of FuelBand team, will stop making wearable hardware Are some fitness band trackers ‘digital snake oil,’ with slick marketing but suspect results? HYPE 7 “ “ ” ”
  • 8. PRESENTATION © 2014 ROCK HEALTH Various estimates of wearable device sales through 2018 While the activity tracker segment has about 1-2% U.S. penetration, wearables overall are expected to grow significantly Note: IDC reported smartphone market size as of 2013 Source: Respective company sites PICK A NUMBER, ANY NUMBER 8 DATE OF ESTIMATE Jan ’13 May ’13 Aug ’13 Sep ’13 Oct ’13 Apr ’14 May ’14 Present $ 50.0B Credit Suisse Market estimate in 2018 Market estimate in 2013 $5.8B Transparency Market Research $8.0B ReportsnReports $8.4B MarketsAndMarkets $19.0B Juniper $12.6B BI Intelligence $6.0B ABI Research $20.6B Institute for Information Industry (Taiwan) $30.2B BCC Research $337B Smartphone market size
  • 9. PRESENTATION © 2014 ROCK HEALTH Venture capitalists are also betting on the space, with venture funding up over 5X since 2011 Source: Rock Health funding database Note: Does not include Jawbone financing events 9 $0M $75M $150M $225M $300M 2011 2012 2013 Biosensing Wearables Biosensors $20M $29M $58M $54M $229M $53M NOTABLE DEALS • Norwest Venture Partners • Founders Fund • Khosla Ventures • Qualcomm Ventures • Felicis Ventures MOST ACTIVE INVESTORS Total venture funding for biosensing wearables (2011-2013) WEAR IT’S AT
  • 10. PRESENTATION © 2014 ROCK HEALTH The scale and utility of smartphones, in addition to a dramatic shift in healthcare, has catalyzed the space Sources: Smartphone penetration from Comscore as of March 2014; MEMS accelerometer pricing from supply chain sources; ACO penetration from Leavitt Partners OFFLOADING COMMODITIZATION VALUE-BASED HEALTHCARE 10 • Wearables can offload the display (through software apps), the computing, and internet connectivity to a smartphone • Bluetooth Low Energy (BLE) has enabled energy efficient data transfer between devices and smartphones 2008 2013 $0.50 $2.00 MEMS accelerometer price per unit • Due to inclusion in smartphones, many popular sensors are now fully commoditized • Prices for most sensors are dropping at >3% per quarter • Commoditization forces vendors to develop novel sensors, creating a virtuous cycle of innovation • Following the ACA, healthcare has an increased focus on value-based delivery and preventive care • Health plans and employers are experimenting with wearables as “source of truth” for incentives • B2B has become one of the fastest growing components of Fitbit’s business 69% U.S. SMARTPHONE PENETRATION 0M 5M 10M 15M 20M 2011 2012 2013 2014 Accountable care lives
  • 11. “The ground has to be fertile for the seeds to grow—innovative technology in wearables and biosensors can be both economically- and functionally-sound because it leverages the trillions of dollars that have already gone into that space. Once the technology lines up, utility will come from people knowing how to use the devices. Healthcare is the biggest and most persistent opportunity and will ultimately define the market.” AMAR KENDALE VP of Marketing MC10‘s technology platform is a unique combination of conventional electronics and novel mechanics that enable a new generation of thin, conformal electronic systems.
  • 12. PRESENTATION © 2014 ROCK HEALTH Biosensing wearable products being created today could not have existed even three years ago Source: Product and app rendering courtesy of Spire, Inc. Note: Spire product is launching June 17th, 2014 12 Bluetooth Low Energy radio First device to implement BLE was the iPhone 4S in 2011 MEMS accelerometer Price has fallen 4X in the last five years Wireless charging coil Qi standards-based products first hit market in 2013 Offloaded computation Signal processing from sensors is handled in cloud via iPhone
  • 13. PRESENTATION © 2014 ROCK HEALTH Rate of sustained activity tracker use over months of ownership Despite such advancement, wearable products today fail to engage users over meaningful periods of time ENDEAVOUR PARTNERS SURVEY (n = “thousands of internet- connected Americans”) THE TRUTH ABOUT WEARABLES 13 0% 25% 50% 75% 100% 0 3 6 9 12 15 18 21 24 Rate of decline is steepest during the first 6 months of ownership Rate of engagement drops below 50% before 18 months PROPORTION OF INDIVIDUALS CONTINUING TO USE AN ACTIVITY TRACKER MONTHS ROCK HEALTH “SURVEY” (n = 10 Rock Health staff) Note: We sincerely appreciate and respect the Endeavour Partners work; however we would be surprised if the survey could be replicated
  • 14. PRESENTATION © 2014 ROCK HEALTH The generic marketing language of most devices leaves use cases to the purchaser's imagination Source: Market share from NPD point-of-sale data (January 2013-January 2014); marketing copy from company websites (May 2014) 14 97% THE TOP 3 WEARABLE ACTIVITY TRACKERS REPRESENT OF THE MARKET “It’s the motivation you need to get out and be more active.” “It celebrates milestones and challenges you to make each day better.” “The smart, simple, and fun way to get more active.”
  • 15. PRESENTATION © 2014 ROCK HEALTH Trade-offs between mass market and personalized products All companies face product marketing challenges when making the trade-off between mass and niche markets PARADOXICAL PRODUCTS 15 ADDRESSABLE MARKET (NUMBER OF INDIVIDUALS) UTILITY PER USER SPECIAL PURPOSE DEVICESGENERAL PURPOSE DEVICES Products in this area are marketed towards large audiences but fail to gain widespread adoption due to a lack of usefulness Products in this area are highly valued by niche segments, giving a feeling of personalization Products in this area are the ideal, balancing the marketing of mass market core utility with some level of specialization for narrower segments
  • 16. PRESENTATION © 2014 ROCK HEALTH The pathway to reaching large markets for companies today For most activity trackers, the lack of utility and failure of product marketing have made it difficult to scale and meaningfully engage Source: Reviews from Amazon.com and Reebok website PARADOXICAL WEARABLES 16 ADDRESSABLE MARKET (NUMBER OF INDIVIDUALS) UTILITY PER USER SPECIAL PURPOSE DEVICESGENERAL PURPOSE DEVICES Activity trackers Single purpose wearables “Piece of mind protection for a parent!” “Great product. It works as advertised and helps correct bad habits.” Strategic approach: • Improve software/insights • Add more sensors/features Strategic approach: • Create family of segment- specific devices REEBOK CHECKLIGHT LUMOBACK
  • 17. “Innovation for use case is important. Right now, everyone is just using off-the-shelf technology so they can only go after things that are obvious, like counting steps and heart beats. In order to provide something more meaningful, it’s important to design a product that has a specific utility. Then you can stand behind it and say to somebody, ‘This is how I’m going to help you.’” DAVID O’REILLY Chief Product Officer Proteus’s vision is to integrate medicines that treat chronic conditions with mobile technology – via our ingestible sensor– to make healthcare more accessible, manageable and innovative.
  • 19. PRESENTATION © 2014 ROCK HEALTH FUNCTIONALITY RELIABILITY CONVENIENCE • Collecting physiological factors with the potential to be of value to individuals or healthcare professionals • Building software that makes physiology meaningful and can close the loop with actions (answering the question “So what?”) • Measuring physiology with accuracy and validity (or using software and algorithms to correct for validity) • Achieving accepted clinical standards and receiving FDA (or other regulatory) clearance or approval • Packaging sensors in form factors that are passive, comfortable, and provide positive reinforcement to the user • Managing battery life and various charging issues • Synchronizing data between wearable device, smartphone, and cloud In order to scale beyond early adopters, biosensing wearables will need to innovate along three axes 19 High value segments will emerge at narrow use case intersections along these three axes
  • 20. PRESENTATION © 2014 ROCK HEALTH Functionality determines a biosensing wearable’s potential utility to an end user, whether a consumer or healthcare professional Source: Company website • Novel measurement—monitors your posture and coaches you to improve throughout the day 20 • Provides consistent reminders to maintain healthy posture • Track progress over time as well as daily activities (walking, running, sitting, standing, and sleeping) FUNCTIONALITY WHY IT MATTERS Without core functionality, utility to the user is highly limited. WHAT IT REQUIRES Measuring meaningful physiology and closing the loop with users by delivering insights. WHY IT’S HARD Need to be exceptional at hardware and software. EXAMPLE: LUMOBACK
  • 21. PRESENTATION © 2014 ROCK HEALTH Reliability influences the addressable segments due to the unique constraints of operating in a healthcare environment Source: Company website, fda.gov 21 • Single use patch • 510(k) clearance—proven to capture arrhythmias for earlier diagnosis • Interpretation designated for healthcare professionals • Report summarizes findings based on FDA-cleared proprietary algorithm to incorporate final diagnosis EXAMPLE: ZIO PATCHRELIABILITY WHY IT MATTERS Healthcare customers demand valid data to inform clinical decisions. WHAT IT REQUIRES For clinical markets, a regulatory (e.g., FDA) clearance or approval. WHY IT’S HARD Signal processing to overcome accuracy issues; Few in the category have a FDA clearance or approval.
  • 22. PRESENTATION © 2014 ROCK HEALTH CONVENIENCE Finally, convenience plays a significant role in engagement with biosensing wearables, particularly at the onset of use Source: Company website 22 • Eschews charging with watch battery that lasts up to a single year • Background syncing handled through Bluetooth Low Energy • Waterproof and can be used while swimming or showering • Form factor is jewelry-like with multiple ways to wear or display EXAMPLE: SHINE WHY IT MATTERS Without convenience, user engagement falls off a cliff. WHAT IT REQUIRES Limiting the number of actions required by the user, covering everything from unboxing through syncing. WHY IT’S HARD Requires expertise in packaging, industrial design and user experience.
  • 23. PRESENTATION © 2014 ROCK HEALTH23 FUNCTIONALITY RELIABILITY CONVENIENCE USE CASES • Directly measures ingestion event along with activity and heart rate • Provides information to healthcare professional or caregiver • Binary state of reliability for ingestion event • Received FDA approval (ingestible event monitor) and clearance (patch) • User wears disposable patch and takes medicine as usual • No charging • No additional tracking required • Medication adherence in key therapeutic areas including heart failure, CNS, and transplant • Measures respiration and activity • Software allows user to be informed about state of mind (e.g., focus) and take clear action • Respiration sensor is comparable to clinical standard spirometer • Developed into a compact form factor that can be worn in multiple places • Supports wireless charging • Customized styles for users • Health and performance of knowledge workers • Respiratory condition monitoring First products from Proteus and Spire demonstrate how innovating along all three axes leads to high utility PROTEUS HELIUS SPIRE Source: Proteus website; Spire product rendering courtesy of Spire, Inc.
  • 24. PRESENTATION © 2014 ROCK HEALTH Disruptive potential of biosensing wearables over time Biosensing wearables that evolve along the three key axes have the potential to disrupt large healthcare markets A LITTLE MORE DISRUPTION, PLEASE 24 Note: We strongly object to the overuse of the phrase “disruptive innovation”; however, we feel that it describes both the market dynamics as well as popular backlash against the category PRODUCT PERFORMANCE TIME as defined by FUNCTIONALITY RELIABILITY CONVENIENCE Performance demanded by healthcare markets Driven primarily by functionality and reliability Performance demanded by consumer markets Driven primarily by convenience and price SUSTAINING TECHNOLOGY BIOSENSING W EARABLES MEDICAL DEVICES REMOTE PATIENT MONITORING CLINICAL DATA CAPTURE EMPLOYER WELLNESS $100-125B $10B $6B $6B Our arch competitor will not be Boston Scientific, or St. Jude Medical or Covidien or HeartWare. It will be Google. STEPHEN N. OESTERLE, M.D. SVP, Medicine and Technology Medtronic
  • 25. “AgaMatrix was medical, medical, medical for 7-8 years. What we realized was that we had so much difficulty trying to rapidly update our apps. With Misfit, we thought we would go to the consumer first, test, learn a lot, iterate over and over again, and then hit the healthcare market.” SRIDHAR IYENGAR Co-founder and CTO Misfit invents and manufactures great wearable computing products.
  • 27. PRESENTATION © 2014 ROCK HEALTH Critical use cases for the industry and biosensing wearables Evolved biosensing wearables will solve significant problems for the healthcare industry AND THE QUEST FOR THE HOLY GRAIL 27 PAYERS PROVIDERS BIOPHARMA IDEALIZED USE CASES • Consumer behavior change • Early diagnosis and intervention • Source of truth for biometric-based incentive programs • Remote patient monitoring • Support for telemedicine services • Clinical data capture for executing adaptive clinical trials • Collection of post-market and real world effectiveness data • Combination device and drug products PERFORMANCE REQUIREMENTS • Functionality has to focus on making physiological data highly meaningful and actionable to the end user • Convenience is paramount as consumers are highly likely to abandon devices that cause any type of engagement friction • Functionality has to focus on data transport and integration into clinical workflow • Requires high reliability (e.g. regulatory clearance) if healthcare professionals are dependent on data for healthcare delivery • Functionality must focus on the clinical endpoints tied to specific therapeutic areas • Reliability has to pass compliance with existing regulation—data collection as part of a clinical trial must be 21 CFR Part 11 compliant (U.S.)
  • 28. PRESENTATION © 2014 ROCK HEALTH INDIVIDUAL WELLNESS CORPORATE WELLNESS REMOTE PATIENT MANAGEMENT CONSUMER ENGAGEMENT AND ANALYTICS DATA NORMALIZATION AND TRANSPORT Consumers Payers Providers Payers, biopharma Agnostic (API) Attempts at consumer/industry platforms for integrating biosensing wearables Multiple companies have emerged in an attempt to enable these use cases, although none are close to becoming scaled platforms Note: Devices and platforms are selected, not comprehensive COMPLETELY FRAGGED 28 EXAMPLE PLATFORMS USE CASE TARGET CUSTOMER BIOSENSING WEARABLES
  • 29. PRESENTATION © 2014 ROCK HEALTH CORE SOFTWARE S Health Health PLATFORM Samsung Architecture Multimodal Interactions (S.A.M.I.) HealthKit ENABLING DEVICES Galaxy S-series Simband (reference platform) iPhone ? Activity trackers and watches Smart clothing Patches and tattoos Ingestibles and smart implants Non-wearable biosensors Wearable makers and end customers are both heavily platform shopping, limiting scale and leaving an opening for tech giants Note: Yes, we expect Apple to release an enabling biosensing wearable device. We do not know what the release date, form factor, or underlying product story will be. 29 .......................................... ............................ 9:41 HARDWARE ECOSYSTEM SOFTWARE ECOSYSTEM Mobile apps Data transport and liquidity to/ from the industry
  • 30. PRESENTATION © 2014 ROCK HEALTH VIRTUOUS CYCLE Starting from a scaled platform could catalyze a virtuous cycle, enabling new business models for wearable companies PLATFORM SOLVES 30 HARDWARE ECOSYSTEM SOFTWARE ECOSYSTEM PLATFORM ENABLING DEVICES CORE SOFTWARE 1 2 3 1 Scale for everyone A massively scaled consumer platform attracts industry and developers, seeding an ecosystem within the healthcare industry. 2 3 Software: challenges of fragmentation Pure software players, including the industry, can define valuable use cases and no longer worry about choosing a specific type of biosensing wearable—maximizing flexibility and consumer choice. Hardware: missing integration Device companies can build once (for defined use cases) and connect to multiple endpoints (inclusive of both consumers and the industry) through a scaled platform, eliminating the current challenge of having to be a “full stack” company (hardware, software, integration). SUBSCRIPTION SOFTWARE ADD ON SERVICES (E.G., COACHING) DISPOSABLES HIGH GROSS MARGIN (VALUE-BASED PRICING) NEW BUSINESS MODELS
  • 31. Characteristics of disruptive businesses, at least in their initial stages, can include: lower gross margins, smaller target markets, and simpler products and services that may not appear as attractive as existing solutions when compared against traditional performance metrics.  “ ”PROF. CLAYTON CHRISTENSEN We’re at the beginning of a long journey with biosensing wearables
  • 32. ACKNOWLEDGEMENTS We are indebted to our industry partners who not only support our work every day but provided invaluable feedback on an early draft of this report. A number of industry, startup and venture folks also offered their expertise. Special thanks to Aaron Duran, Ingo Elfering, Sridhar Iyengar, Amar Kendale, David O’Reilly, Jonathan Palley, and Sundeep Peechu for their time and insights. Finally, we are fortunate to work with the most talented (and fun) team in digital health. Thanks to Halle Tecco and Mollie McDowell for reviewing our final drafts and providing edits. research@rockhealth.org @rock_health PRESENTATION © 2014 ROCK HEALTH