Smart toilets may change healthcare: here’s why.

We all take the toilet for granted, but let’s explore the history of this essential device, the innovations that have made it what it is, and the future possibilities of how your toilet could become a key tool for monitoring your health.

A Messy Start to the History of the Toilet

Holes in the ground, chamber pots, and community outhouses describe the earliest history of the present-day toilet. By 315 AD, Rome had 144 public toilets, and going to the latrine was a ‘social event’.

Fast forward to the 11th-century castle-building boom, chamber pots were supplemented with toilets that were, for the first time, integrated into the architecture. These early bathrooms soon evolved into small rooms that protruded from castle walls as distinct bottomless bays.

The flush toilet, as we know it, was invented near the close of the 16th century, but didn’t become widespread until hundreds of years later, in the 1800s. Thomas Crapper is often attributed with designing the first flush toilet in the 1860s. His close relationship with King Edward VII meant his toilet seats were given the most attention and put in showrooms and several royal palaces. However, it seems the real credit for inventing the flush toilet goes to Sir John Harrington, godson of Elizabeth I, who invented a water closet, he called it the Ajax, with a raised cistern and a small downpipe through which water ran to flush the waste in 1592.

In 1775, Alexander Cumming, a watchmaker, invented the S-shaped pipe under the toilet basin, which was a huge innovation at the time (and still is) to keep out foul odors.

In the mid-1800s, following terrible outbreaks of cholera and the deaths of tens of thousands from water-borne diseases – due in a large part to the overcrowded cities, where up to 100 people might share a single toilet – the British government commissioned the building of the first system of sewers in London. This was an essential factor in making modern home plumbing possible.

The several toilet innovations that followed may have been less focused on life-saving health motivations, but are still important updates that we may take for granted: flushable valves, water tanks resting on the bowl, slow close hinges, and convenient toilet paper rolls (only first marketed in the early 1900s).

It wasn’t until as recently as 1992, with the passing of the US Energy Policy Act, which required flush toilets to use only 1.6 gallons of water, that drove companies all over the world to innovate on low-flush toilets that prevent clogging.

The Splash of the Smart Toilet

The latest splash in the bathroom these days is around “smart toilets.” Most simply put, a smart toilet is a toilet that has responsive technology integrated into it. In other words, smart toilets are toilets with the capability to interact and connect with the person using the toilet.

The most common “smart toilets” today have features built into them such as: seat warmers to fit one’s preferences, automatic lids for a touch-free experience, ambient lights to make night visits less perilous, water spray adjustments, drier features, or a built-in radio with music for entertainment… just to name a few. These features sound great but have innovated in a direction far beyond the initial mission of public health.

The Toto Neorest NX1 for example offers oscillating and pulsing comfort washing, auto-open / close lid and flush function for better hygiene, automatic air purification, and an adjustable heated seat for a personalized experience (the toilet costs a whopping $7,000). Kohler and others offer a ‘smart’ bidet attachment for hundreds of dollars where one can adjust the water temperature and pressure, seat temperature, and enjoy a night light and a self-cleaning wand using a UV light for automatic sanitizing.

Smart Toilet Innovation Wipes Around the Globe

Japan is known for its leadership in the smart toilet industry and has been offering ‘smart’ features since the 1980s. It is estimated that nearly 80% of households in Japan are equipped with a form of smart toilet or bidet – a number that has risen dramatically since the 1980s when only 14% of households were recorded to have a bidet when first introduced.

In Europe, the bidet has been adopted as a common household feature since the 1700s.

Most recently, smart toilet innovation in the US has accelerated, primarily in the form of bidet sales. Some attribute the growing interest to Covid as a way to thwart toilet paper consumption, and others attribute it to people spending more time in their home bathrooms and becoming more interested in exploring an upgrade. In 2020, the U.S. sales reports from bidet companies skyrocketed.

Waterless Toilet Bowls: Bringing the Conversation Back to Sitting on a Health Solution

Another, less publicized side of recent toilet innovation points to the work inspired by Bill Gates, Microsoft founder turned philanthropist, calling for the development of low-cost, high-efficiency toilets that would bring new levels of sanitation to the world’s most impoverished communities. In his speech at the Reinvented Toilet Expo in Beijing, Gates compared the change from traditional toilets to waterless models as similar to the development in computing around the time he founded Microsoft in the mid-1970s. Gates has inspired us to push the boundaries even further on how toilet innovation can move the needle on public health.

Will Our Smart Toilets Swirl A Renewed Story for Home Health?

The most interesting toilet innovation, to us at Casana, is around how the toilet can be an essential tool for unlocking home health monitoring (a tool that is ‘flush with data’ so to speak). There are two emerging categories of toilet home health monitoring: (1) the first is utilizing just the toilet seat to monitor vital signs, and (2) the second is using the whole toilet or some part of an extension of the bowl to monitor what comes out of the body (such as analyzing a urine sample).

Tracking Vitals: Inspired by the Ph.D. work that Nicholas Conn (Casana’s founder) completed at Rochester Institute of Technology, Casana believes that the toilet is the perfect form factor for collecting consistent and reliable health data in the home. The toilet seat is large enough to be self-contained with built-in skin contact while someone sits to do their business.

In addition, the seat is capable of housing batteries that last years, multiple sensors that are able to collect a range of health data, and a tiny computer to send one’s health data to a secure cloud in order to share with care teams and loved ones if they so choose. Interestingly, as humans are creatures of habit, we tend to use the bathroom around the same times each day, which provides a view into trends of the same physiological health state over time (e.g. post-coffee or pre-workout vitals).

But most importantly, almost everyone uses the toilet, meaning that there is no behavior change required to gather data from the toilet seat.

Tracking What Comes Out: Doctors have long used urine and fecal samples to diagnose and evaluate health, monitoring sugar or sodium levels in urine for example, or stool consistency and presence of blood in stool samples. There is also newer interest in gut or microbiome analysis. This approach to health monitoring with the toilet often requires replacing the whole toilet bowl and a complex system of preparing samples for analysis with test strips and reagents, refilling the chemicals needed to run the reaction.

A few early examples in development include Toto’s “Flowsky” toilet which looks like an ordinary toilet but was designed to check for abnormalities in urine flow that might signal bladder or prostate problems. Another example is from a Stanford research group that developed a research toilet which includes urine test strips as well as cameras to be able to perform a pictorial exam of the stool.

This is just the beginning of a new category of home health solutions that pay tribute to the original health advances with toilet innovation.

Casana’s Approach to Ensuring We’ve Got Your Back(side)

At Casana we believe the smart toilet seat is the key to unlocking a new wave of effortless home health monitoring. Casana’s first product, The Heart Seat’s goal is to solve the adherence challenge of monitoring vital signs at home. Adherence describes the phenomenon that many people don’t regularly use home monitoring devices, even if recommended by their doctor. Solving adherence is the foundation of successful health data collection in the home. Once we solve adherence, as a health monitoring industry, we can think about providing care teams and families with actionable data that can lead to better health outcomes. Without adherence, devices that are attempting to collect data in the home are a waste of time and effort.

We are often asked why a smart toilet capable of measuring vitals doesn’t already exist. The reason is that the signal processing (ie. complex math) required to turn the noise derived from our thighs into meaningful and clinically relevant health signals is extremely challenging and has taken our team years, and a handful of PhDs to investigate.

The Heart Seat is currently under development. What we hear from the market is that being able to passively measure clinical measures is a game-changer.