Apple’s Health Records App: A Ripple or a Roar?

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This blog post by Dr Joe Kvedar reflecting on Apple’s Health Record announcement makes for interesting reading (I’m very optimistic about what this means for Patients and Carers).

mHealth Insight

“To quote Yogi Berra, “It’s déjà vu all over again.” Or so it seems. Last week, Apple made a big announcement that headlines and excited many in our industry. They have enlisted two of the largest medical records companies, Epic Systems and Cerner, as well as Athenahealth, and a number of respected healthcare institutions, including Johns Hopkins Medicine, Cedars-Sinai, Penn Medicine and UC San Diego Health. And, according to their press release, they have built their newly updated Health Records app based on FHIR (Fast Healthcare Interoperability Resources), which is the interoperability standard for transferring electronic medical records”

I think it’s natural for those working in the US Healthcare system to think this is all nothing new because they have no real idea what to expect from a giant Mobile company that can afford to be focused on the needs of Patients and Carers (and not on reimbursement).

The Clinical Research industry thought ResearchKit was nothing significant until they saw it set new records eg. for Patient Recruitment (the biggest issue facing the industry eg. most trials in Europe fail to recruit enough Patients).

“This is all good very good news. I might add that Apple has build an undeniable reputation on their ability to create beautifully designed and highly intuitive software and highly integrated hardware. I dare say, no one does it better. But I can’t help but recall similar attempts to create health data repositories for patients on their mobile devices. In 2012, Google shut down Google Health after just three years due to “lack of widespread adoption.” Microsoft HealthVault has also seen its share of challenges since it launched in 2007”

I think a big difference is that none of these organisations have ever had their CEO state clearly that they weren’t going to be prioritising reimbursement. It’s actually all they were about but beyond that these were small scale projects that let Google and Microsoft look innovative while they continued to make billions from business as usual eg. Google continued selling billions of pharma and quack ads, Microsoft continued to sell £multibillion software licenses to Healthcare organisations, etc.

In stark contrast Apple’s senior executives are on record stating that the healthcare market that they seek to transform will dwarf the trillion$ smartphone market that they already dominate.

“Of course, Apple entered the health market in 2014 with its Apple HealthKit which, to date, has not been the game-changer it was originally expected to be. A few weeks after the HealthKit launch, I actually catalogued my wish list for Apple HealthKit, and several themes from that 2014 post are still very relevant”

To say HealthKit isn’t a game changer is classic Amara’s law (eg. We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run).

100 Million Patients and Carers have a native healthcare service on their mobiles (devices that they trust, carry and keep switched on 24×7 and look at 200+ times per day) and Apple is already getting to decide which brands win or lose in the global medical device market.

“While I applaud Apple and their partners for this latest attempt to put personal health data into the hands of consumers, we should keep a few important caveats in mind. Why haven’t these tech giants — and others — been successful? Why won’t this latest announcement from Apple revolutionize healthcare? I have a few theories”

I think the simple answer to that is that Apple has the trust of a hundred million plus people and has a system that lets them share with Apple what they’re doing with the most personal electronic device that they’ve ever used.

“First, access to medical records is just not that compelling for the average consumer. Think about it. How many times do you wake up in the morning and feel the urge to check your medical records? Don’t get me wrong. It should be an imperative to have easy access to important personal health data, that you can simply and securely share with your healthcare providers, or access in an emergency. I have long been a vocal proponent to giving individuals access to their personal health data”

I am lucky enough to work with Doctors who have been sharing medical records with Patients (the parents of some of the sickest children) for +30 years and my conclusion is  that the situation today that makes it difficult/impossible for Patients to access Health data exists because the sickcare industry is threatened by sharing and they’ve misled Doctors into thinking it’s value for Patients isn’t significant.

We have a classic chicken and egg situation because only once Patients get access to their data can services be built that add value.  In 2018 we have the Royal College of General Practitioners claiming that there’s no value to online access to Doctors but give 10 NHS Patients/Carers access to their NHS record and just watch how many mistakes and misunderstandings they’ll be able to point out, start counting the number of things that can now be talked about, look at how much more productive a relationship can become…

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No one would be at all surprised if an orchestra was terrible if it’s members were all signing off different music sheets and some hard no music sheets at all, so why is it any different when we’re talking about decisions and communications that are being made around personal information that isn’t being shared with Patients and Carers?

“But that leads me to my second point. Access to personal health records will not magically improve clinical outcomes, or even motivate individuals to better manage their health and wellness. As we now know from our work at Partners Connected Health, it takes a sustained, highly personalized experience, seamlessly imbedded into our daily lives, in order to change behavior that can lead to better outcomes. Knowing my blood pressure results from my last doctor’s appointment six months ago will not motivate me to take a walk after dinner.  We must not think that access to health records will automatically lead  to improved health outcomes”

This is classic group think. Because I can’t imagine the future of healthcare in our hospital means no one else can build it.

“My third caveat is that, while this is a very worthwhile advance for Apple users, but what about those committed to devices that run on an Android operating system? According to data from Gartner, in QI 2017, 86% of smartphones sold worldwide ran on Android. If we are going to make personal health records available to consumers, we must make it device agnostic in order to create real change.”

I think this is interesting but aren’t we all aware that every single unique mobile phone design and application has been copied exhaustively?

We know that nearly all those Androids have a touchscreen and app store that works like the one that Apple launched on the incredibly expensive iPhone 10 years ago. So why if Apple Health Record is a huge success wouldn’t Google and device makers copy it and offer it on the Android operating system? Why wouldn’t Apple give it away or make it available on Google Play (eg. just like they make Apple Music available to Android users)?

Then again perhaps Apple Health Record won’t work on Android operating systems because so many of them have been forked by the device manufacturers and mobile operators and Apple will get the Healthcare partners to subsidise/gift Apple devices to their Patients/Carers? Have we already forgotten that this is what they got the Mobile Operators to do to the tune of +$100 Billion?

“I suggest that we more closely examine how Apple’s new Health Records feature is actually different from past attempts.  It will likely be much easier to set up than Google Health or HealthVault and anything on a mobile platform is immediately more accessible. Apple also has their wonderful consumer design capabilities to bring to the party.  Undoubtedly, they will talk about those instances where an individual whose home is in Massachusetts breaks a leg skiing in the Rockies and is able to present her health record to folks in the Denver emergency room.  This is progress”

I think analysts are underestimating the opportunity Apple have because they have full end to end control of the system (unlike Google have with Android that might run on a device manufactured by Samsung and sold/subsidised by Verizon). If they can controversially put a U2 track on customers phones why would they need to make customers have to jump through set up processes. Next time you update your iPhone I expect Apple Health Records will just be a native part of an iPhone (fulfilling a prediction of mine that Health will soon just be another thing we do with our mobiles).

“There are just so many other problems that providing access to medical records don’t solve.  Medical record data is not that compelling from a consumer perspective.   If they bring something to the table that inspires consumers to care (and Apple knows how to do this), that could be transformational”

I’ve found lots of Doctors mistakenly think statements like “Medical record data is not that compelling from a consumer perspective” are valid. It’s consistent with thinking that the medical record access breakthrough is when “an individual whose home is in Massachusetts breaks a leg skiing in the Rockies and is able to present her health record to folks in the Denver emergency room” (>80% of Healthcare resources go on chronic disease care).

Firstly Apple is talking about ‘Patients’ and not ‘Consumers’ and it’s important we all appreciate the difference.

The lines are blurred so I really hope that Apple is going to put some effort into helping educate Patients and Carers on the difference between being treated as Patient and as a Consumer. If you consider “Consumers” as “persons who purchase goods and services for personal use” medical record data is clearly financially very compelling (and profitable). Look at the “free” helpline industry that has sprung up as Google shares medical information with referral agents and you’ll quickly realise there are $billions of short term profits to be made by corporations who treat Patients as Consumers eg. in terms of a ‘compelling offer’ a corporation like Google could probably give these ‘consumers’ free* mobiles in exchange for all the kick backs that they would make by selling on their personal information to others.

Medical record data from a Patient perspective is invaluable.  Of course it’s presence on your always carried mobile won’t make you lose 50lbs of fat overnight or help you with a mental health concern but the services that it’s availability will enable Apple to support will help motivate a Patient who is overweight to start sharing their concerns (they won’t for example fear the judgement many obese people feel they face when presenting overweight to a clinic) or mental health concerns (eg. you’re not going to have to pay to endure a conversation with a stranger who has no idea why you’re sat in front of them).

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