Apple’s EHR: Why Health Records on Your iPhone is Just the Beginning

Americans on average will visit a care provider about 300 times over the course of their lives. That’s hundreds of blood pressure readings, numerous diagnoses, and hundreds of entries into a patient’s medical record—and that’s potentially with dozens of different doctors. So it’s understandable, inevitable even, that patients would struggle to keep every provider up-to-date on their medical history.

This issue is compounded by much of our healthcare information being fragmented among multiple, incompatible health systems’ electronic health records. The majority of these systems store and exchange health information in unique, often proprietary ways—and thus don’t effectively talk with one another.

Fortunately, recent news from Apple points to a reprieve for patients struggling to keep all of their providers up-to-date. Apple has teamed with roughly a dozen hospitals across the country, including the likes of Geisinger Health, Johns Hopkins Medicine, and Cedars-Sinai Medical Center, to make patient’s medical history available to them on their phone. Patients can bring their phone with them to participating health systems and provide caregivers with an up-to-date medical history.

Empowering patients with the ability to carry their health records on their phone is great, and will surely help them overcome the issue of fragmented healthcare records. Yet the underlying standardization of how healthcare data is exchanged that has made this possible is the real feat. In fact, this standardization may potentially pave the way for innovation and rapid expansion of the health information technology (HIT) industry.

Growing agreement upon a standard way to store and exchange electronic healthcare information is what made Apple’s foray into health records possible in the first place. Fast Healthcare Interoperability Resources (FHIR) emerged four years ago as an interoperability standard for electronic exchange of healthcare information. It is a standard framework for the sharing, integration, and retrieval of clinical health data and other electronic health information. Enough agreement upon such a standard for health information exchange has promoted modularity.

How modularity fast-tracks innovation

A system is modular when all its components fit together in a standardized way, whether physically, mechanically, chemically or in this case digitally. This standardization enables people to design one component without having to know how everything else in the system works. An everyday example of this is the USB port. It is a standard cable connection interface upon which any number of products can connect—whether it be a keyboard, a charger, external memory, or any other device that can meet the specification. This differs from interdependent systems, in which the design of parts are customized, nuanced, and how they work together is not widely-known. Thus, a designer has to know how the whole system works to be able to design any part of it.

In the case of the FHIR standard, the manner in which digital healthcare information is exchanged is modularized—the rules of the road are established and easy to follow. Adoption of this bit of digital standardization, by an influential group of healthcare providers, is what allowed the third-party giant, Apple, entry into the modular electronic health records game. Even though their experience in healthcare is limited, the standard lays out the rules well enough for them (and other third parties) to participate in the HIT market.

We’ve learned in the past that the creation of and agreement upon standards can expand industries by creating a new ecosystem in which third-party players can add value. In fact, the preeminent example of this type of ecosystem creation is Apple itself, and their AppStore.

Along with their AppStore, Apple created a set of standards that specified how third-parties (from companies to individual hobbyists) can more easily create applications that make use of the information on their phone and the Internet. These apps were made available to Apple’s network of users and developers were paid according to the amount of revenue the app generated Apple (based on usage). Over the span of 10 years Apple has paid AppStore developers $86.5 billion (paying out $26.5 billion in 2017). The rapid expansion of the market for creating substitutable apps in return gave everyday users the ability to harness information in any number of more convenient, simple, and potentially meaningful new ways.

What does this relatively recent and still unfolding story mean for HIT? It means that as opposed to merely viewing your health record, standardization may also allow for the creation of new tools that actually make use of your health record in new, meaningful ways. For example, developers may create an app that helps patients understand their risk of a cardiac event base pulling specific data points from the health record. In short, applications can be created by third party creators for use by the patient that make their healthcare data more accessible, easier to understand, and more actionable.

In this way, not only does modularity stand to make healthcare data more accessible to providers, researchers, and public health organizations (current consumers of health data), but to a new market—the patient. Standardization mediated by the adoption of FHIR opens up the market for innovators outside of the traditional health IT industry. These new players can then compete to reach everyday people (just as app creators did on Apple’s AppStore platform), with useful tools that empower them in their struggle for health.

Ryan Marling is a research associate at the Clayton Christensen Institute for Disruptive Innovation. 

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11 replies »

  1. It indeed is just the beginning. But then I am not sure about the extent to which it can go. Mainly because of the security of the data and the privacy of user data. The recent trends have been showing us that data privacy and security have become a bigger burden for the health IT companies and they are not able to provide the complete picture of their systems anywhere. https://blueehr.com

  2. I Read your Article which is packed with facts and data. Each point is very well explained.
    I have Written an article on Build vs. Buy: How to Know When You Should Build Custom Healthcare Payers Solutions Software.
    I would like your views on the same- http://bit.ly/2Bt7K9T

  3. Hi Steve2, it does actually work with EPIC. Cedars-Sinai among others of the group run EPIC, and EPIC was a major stakeholder with major hospitals and EHR vendors in Project Argonaut, which outlined the development of the FHIR-based API and Core Data Services specifications.
    I totally agree about the importance of solid data standards and health records. Modular records should allow for more freedom in customizing the process of data entry to physician workflows as opposed to physicians having to change their workflows to accommodate data entry.
    Should be an exciting space to keep an eye on. Thanks!

  4. Most stake-holders in the C-suite are chiefly connected to equity growth for their stockholders. Social responsibility for institutions should begin with a comprehensive definition of HEALTH and its origins along with a connection with a community-centric understanding of the Common Good. The current levels of cognitive dissonance within healthcare reform reflects a lack of commonality about the antecedents for its cost and quality problems. And, so it also goes for achieving meaningful progress.

    For a representative example, see http://www.nationalhealthusa.net/home/rationale/

  5. Does this work with EPIC? I would be surprised if it does. Anyway, really hope something like this works out. If we had a useable, universal record designed for physician use and understandable by patients, not one designed of administrators and billing, life would be so much better. So many of my patients don’t remember their meds, what surgeries they have had or test results. Absent a decent medical record it is a guessing game.


  6. Hi pjnelson, great questions. The FHIR standard itself was created by a not-for-profit called HL7. On their board sits MDs, PhDs, MHAs, and others. The standard is used to create a platform upon which substitutable applications can be created for physician use, patient use, or even researcher use. The platform is built on top of the standardized data.

    Apple’s “carry your health records with you” application was created to work on the platform, and I’m not sure about its ease of use and what research went into the app itself. A great question I will leave to the doctors and patients using it, but will definitely be keeping my ear to the ground for it.

  7. Great distinction Brian, between use and movement of data.
    We see standardization as an important step in helping data move more freely, and developing new use cases for it.
    In helping data move, standardizing how data flows to and from the patient, with authorization, will only make it easier for other relevant parties (think researchers, community health workers, etc.) develop protocol to receive data, safely use it, and potentially have a more comprehensive record.
    Use of data is the area I see as very exciting and will watch closely to see how things play out.. Its the meaningful use cases and streamlined / well designed patient/caregiver/etc interfaces that will ultimately drive further adoption of the platform, and make it an attractive option to more users and creators.

  8. Hey John, thanks for the response and great point about the distinction between Apple creating the software and third parties creating modular hirable/firable applications. In latter instance, the AppStore has been a huge revenue generator for Apple and the 3rd party creation of new apps only end up making their products more customizable, convenient to use, and applicable to more use cases—which drives further hardware sales and consumer loyalty.
    To take into consideration Steve Jobs’ opinion on the matter, he was initially against the idea of an AppStore, and definitely wanted to ensure that his product experience was designed flawlessly at each stage of use. This is tough to do when suddenly third-parties are creating applications people use each day. One thing that gets around this issue is the ease of hiring and firing apps–substituting one for another–until we find one that meets our liking. All the same, look for Apple to heavily vet any new apps third parties bring to the table in the early stages.

    Thanks again!

  9. This underscores the point that there are two key dimensions to health data – movement of data and use of data.

    Movement needs to be controlled by the “individual”. A transaction like approach that enables a clear value decision by the individual. (I want to go to a new doc…therefore, I authorize the sharing of my health data. I want a discount on my health insurance, therefore I authorize the sharing of very select health data to demonstrate my compliance with the terms of the discounted benefit plan. I want to use an Apple health management app and therefore I authorize relevant health data historic and as it is created to flow to the app.)

    Use of data – is the wild west. Let the innovators innovate and present their value propositions to the market. (And to pjnelson’s point – there should not be an “Apple” physician experience. The data should be delivered in the format of the physician’s platform. FHIR is a step in that direction.)

    We’ve got to get beyond the “have a problem, build a network” approach to data sharing in healthcare.

  10. Nice post, Ryan. There are many reasons to like this move, I guess

    I just don’t think Steve Jobs would have done it, not because there isn’t an argument for it but because he recognized what it would do his company’s focus …

    Click on the shiny icons that comes prepackaged on your Mac. How often do you use Mail.app? Calendar? Contacts? Maps? Ever have any problems with iTunes?

    The Apple approach translates to software that looks good and sells, but often leaves users hanging .. If the past decade in digital health teaches us anything, it is that it is far too easy to create ambitious software that doesn’t do very much, has no real reason for existing and ends up not being used ..

    On the other hand, if the goal is to create an app store like- ecosystem they may be on the right track. This is an idea people in Silicon Valley have been drooling about for years, along with hospitals that look like the Apple store and 21st century doctors levitating into patient rooms with iPads ..

  11. So, to what extent did Primary Physicians have an involvement in the design of this innovation? As in, is it intuitively usable for 15-25 direct encounters a day involving iterative sequences of brief deductive and inductive bursts of reasoning? And, has it been tested for a period of time (aka 5-7 years) to improve the cost and quality of healthcare including any associated medical TRIAGE?