Apple Enters the Healthcare Software Ecosystem

Apple Senior Vice President of Software Engineering Craig Federighi

I am writing this from the Apple Worldwide Developer Conference (WWDC) 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 two 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.

Henry Feldman, MD is an Assistant Professor of Medicine at Harvard Medical School and chief information architect in the division of clinical informatics at the Beth Israel Deaconess Medical Center.  This post originally appeared in Life as a Healthcare CIO.

7 replies »

  1. Where’s the beef?

    Where is the clinical concept parser with a codeable vocabulary customizable by the clinician?

    Where is the clinical concept processor with a customizable rules engine that can handle multivalued variables, e.g., problem list, medication list, intervention list…….etc?

    Where is the clinical note making environment that is NOT point and click but is focused on the chronology of the patient’s illness, free form and can be input via handwriting recognition, dictation and typing with intelligent support but without mandated input by menu prescription?

    Where is the support for the creation of an after visit summary in layman’s language that assists the patient in self care and home care?

    Where is the support for continuity of care with intelligent connectivity to the notes of ALL the doctors seeing the patient

  2. This is one of the points that my article specifically addresses. These new technologies will only be effective and useful when they are used to support the strong, trusted relationship with the clinician.

  3. The big thing that Apple did was to build a platform for developers instead of thinking they had to build it all themselves. Mobile tech is enormous in that it combines the two most important things in health care, information and communication, and put it in the hands of the people who matter. The paradigm where care is limited to the exam room is quickly being marginalized. Now let’s see if the advances of technology will be suffocating power of our payment system (as it has for computerized records).

  4. “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.”

    One hopes. But, Opacity = Margin in the conventional “free market.”

    I have a post on my KHIT Blog entitled

    “We should not prescribe specific functionality for the EHR other than interoperability and security.”
- John Halamka

    (THCB blocks my URL links, just Google it.)



    “One. That’s what the word “Standard” means — er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

    :One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable…”

  5. This is indeed exciting. Was any attention given to standards for the data in the Health App, or will we have (like in every other platform) a cacophony of different data formats, ontologies, etc.?