Tuesday, June 3, 2014

Apple Enters the Healthcare Software Ecosystem

Here's a guest post by Dr. Henry Feldman from BIDMC's Division of Clinical Informatics:

I am writing this from the Apple Worldwide Developer Conference (WWDC) today here in San Francisco, where I got to substitute for John Halamka at the Keynote (now I keep having urges to raise Alpacas); John missed the most amazing seats [front row center!]. There were many, many, many (I can not recall a set of software announcements of this scale from Apple) new technologies that were announced, demoed and discussed, but I will limit this entry to a few technologies that have implications for healthcare.

If you remember the state of digital music, prior to the introduction of the iPod and iTunes music store, that is where I feel the current state of the healthcare app industry is at; there is no common infrastructure between any of the offerings, and consumers have been somewhat ambivalent towards them as everything is a data island; switching apps causes data loss and is not a pleasant experience for patients. Amazingly there are 40,000+ apps on the App store at Apple alone, showing huge demand from users, but probably a handful can talk to each other in a meaningful way; this is both on the consumer and professional side of healthcare.

Individual vendors such as Withings have made impressive strides towards data consolidation on the platform, but these are not baked into the OS, so will always have a lower adoption rate. If we take the music industry example further, Apple entering a market with a full push of an ecosystem at their scale, legitimizes the technology in ways that other vendors simply can’t match. In their introduction, Apple introduced 2 healthcare specific items, the Health App and HealthKit Framework.

The Health app is a central data repository on your phone that any HealthKit enabled app can deposit data into or read data from, under user control; it also serves as a display dashboard for the user of this data repository if they don’t want to use the source app. This will allow patients to aggregate their fitness and health data from a myriad of sensors (e.g. FitBit) and sources (say a PHR app) into a single place.

They showed using this as a gateway to broker between health goals, such as blood pressure control, set up by a physician on the Mayo Clinic’s EHR and then tying that back to the patient via the PHR app/Health App linkage. Since the patient can push data back once they grant permission to an app, you can imagine as a physician who is titrating blood pressure medications in the home, getting objective data from the patient electronically (the last mile problem). Engaging our patients is both our sworn duty as physicians and over time as we learn to use these tools effectively, will help us help our patients to be more self sufficient; as our mentor Warner Slack always says “the least utilized resource in the healthcare system is the patient!”

HealthKit is to me in some ways more significant, as it allows a common platform internally for health apps allowing for common data formats, data exchange, storage and presentation to the patient; Apple again is establishing an ecosystem here. Having centralized support for healthcare data, makes applications more interoperable and useful. Several of the healthcare vendors, such as Epic (I was seated near their CTO who was pumped), who were near me were very excited about integrating this framework into their apps. This will raise all the healthcare apps to a new level, and greatly increase utility and innovation around these apps.

There is some very legitimate concern for providers, that this will enable an avalanche of data (on top of the tsunami we already are being washed by) from patients, and we will have to figure out how to cope with this. With easier access to sensor data, patients will have to be educated, that not all changes are pathologic. A million years of evolution has allowed your body to control things like heart rate robustly, so we will need to be very specific in our education to patients about what they should and should not get concerned about. For patients undergoing fitness programs, this is a superb way to track fitness and can report objective improvement metrics to their healthcare provider or trainer.

Now for some non-healthcare specific technologies, that are very useful in healthcare.

TouchId, the technology behind the fingerprint login on the iPhone, is now open to 3rd party applications. This means that instead of relentlessly typing a password (which of course gets longer/more complicated with each policy change) you could for instance sign orders or login to your EHR; I type my password well over 100 times per day into the EHRs that I use, which gets frustrating, and can probably be quantified in lost productivity over all the docs multiplied by all the time spent reentering passwords as a serious sum of money.

A tiny change is that you can now respond to text messages and accept/decline appointments without leaving your current application. Why is this significant? While for many users this is a convenience, in healthcare this may prevent medical errors. John has previously cited a case of distracted computing occurring in the middle of creating orders for a patient, and leaving the task without signing orders, etc. Staying in context makes this error much harder to do.

Finally I will talk about Swift. Apple has created a new object oriented language, called Swift, which as they phrased it “took the C out of Objective-C”. This excited me as it reduces many common programming errors that are easy to create in C (for non-programmers, C is a language where you can do anything you gosh-darned please; and with great power comes great responsibility). They seemed to have stuck in some of the automagic of a language like Python with some of the strictness of Java, and then added modern power features, all in a very fast compiled language (under the awesome LLVM compiler).

In summary, I think we will look back on the WWDC 2014 as a day when Apple really brought the healthcare app industry to a whole new level, especially on the consumer side, and also putting in a robust infrastructure for professional and consumer applications to exchange data. This is a 1.0 release, and undoubtedly it will grow over time, and we will see creative uses, which will inspire all of us to grow with it. Similar to digital music, we are at the beginning of a major shift, and we will have to see what develops out of this, but getting consumers excited about healthcare data, and getting vendors excited about sharing data with each other via the patient, has got to be a good thing.


Ricky said...

I was at the keynote as well, and from a Duke Medicine perspective (who recently went live on Epic), equally excited. In my opinion, this helps solve the patient-data-access issue, but not the physician-EHR-data-access-from-mobile issue. We're working to solve that latter issue here at Duke.

Anonymous said...

As long as this is opened up as a cross platform item, it will be good. Studies have shown that the most in need of health tracking are on the lower end of the financial spectrum. Apple tries to place itself as a premium brand. If Apple opens up it's walled garden where all could benefit, great. My fear would be that since Apple enters the market it will intimidate all the other potential companies that would be better placed to help ALL patients.

Medical Quack said...

Thanks for the explanation of the new language, interesting. Good points too on the cost and with economic conditions that will determine who some of the participants will be.

The Mayo app is interesting in the fact that the patient can push back but they don't get their data and and I'm sure that might be related to Mayo giving all their medical records to Optum labs these days to crunch and sell analytic services, Boston Scientific just signed up as a paying member to search so the more data, the more money can go back to Mayo as a partial owner and they are out there getting other Hospitals to sign up too. I know they are looking at lesser reimbursements other wise Mayo would do this in house but they need the money after making $67 million on $9 billion of revenue.

The Optum Shared Clarity division too enters in here somewhere as well so with the connections to an insurer subsidiary people may feel a little worried about privacy too if this patient data goes into the "sale" hopper too.

The Epic connection is still kind of vague but right now it looks like a way that they can get more consumers excited about being affiliated with hospitals and doctors using an Epic EHR so they can see their data. Hooking up apps and devices too, it's the same data selling there too that's been around for a long time, so it will be interesting to see where it goes.

I did a post the other day too on "people don't work like that" which addressed some of the methodologies used with data as when the novelty wears off as you have make a commitment here to interact with the data, Fitbits and the other stuff just get put on shelves.