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Potentially Disruptive


written by Ron Galloway

 

Potentially Disruptive looks at certain specific healthcare trends that may impact the healthcare system in unforeseen ways. Our research is focused around two core ideas:

  • Innovation in healthcare is going to be nonlinear, and the only way to understand such a complex system is to step back and think laterally.

  • Healthcare of the future will iterate/change constantly, because so many new factors are being introduced into it so quickly.

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Volume 1, Issue 2

Apple sets fhir to healthcare

In June 2018 Apple made an announcement that had a bigger effect on healthcare than many people realize.

At its annual worldwide developers' conference, Apple delivered a special tool for developers to help them write apps integrating electronic health record (EHR) data onto iPhone apps. Apple basically cemented the fact that if you wanted to write an application for its iPhone that involved electronic healthcare records, it had to conform to a new interoperability standard called FHIR – pronounced “fire” and standing for Fast Healthcare Interoperability Resource.

Apple laid the groundwork for this in January of 2018 with a press release announcing “an effortless solution to bringing health records to iPhone.”

Apple today introduced a significant update to the Health app with the iOS 11.3 beta, debuting a feature for customers to see their medical records right on their iPhone. The updated Health Records section within the Health app brings together hospitals, clinics and the existing Health app to make it easy for consumers to see their available medical data from multiple providers whenever they choose.”

And the chaser –

“Apple worked with the healthcare community to take a consumer-friendly approach, creating Health Records based on FHIR …, a standard for transferring electronic medical records.”

So what exactly is FHIR? It’s basically the follow-up to the earlier government-mandated HL7 interoperability standard, but up until this point no one had really forced the issue of making FHIR the “standard.” It took a company as big as Apple to promote a common standard for EHR interoperability. And that standard is FHIR.

Part of the growing consumerization of healthcare is the desire on the part of consumers to be able to view their electronic healthcare records on their phone. More and more hospitals and hospital systems are realizing this, and with Apple having the immense market share and mobile platform that they do, hospitals need to prepare for the fact that consumers are going to want their records on their iPhone.

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There are about 86 million iPhone users in the United States. If you own one of those iPhones, and pull up the Apple health app, you see a big shiny button there that says “Health Records.” If consumers don't have their health records on there now, pretty soon they’re going to want them.

When Apple made the announcement about the FHIR standard last June, they were only working with a handful of health systems to integrate EHRs into the Apple ecosystem. Just eight months later, they are working with 204 health systems and expanding the list quickly.

That 204 number is significant because it includes hospital systems with multiple facilities. So realistically, Apple already may be working with 5% to 7% of all U.S. hospitals.

There are roughly 5,200 community hospitals in the United States, and with the momentum that Apple now has, it’s a safe bet that at least 20% of them will be working on integrating their EHR data with Apple by the end of 2019.

Apple has also set its sight on the large market of government-provided healthcare. Just this week it was announced that:

“Apple Health Records is officially coming to US veterans courtesy of a Department of Veterans Affairs partnership announced by Apple this morning in a blog post. Soon, veterans receiving their care through the government organization will have access to a portable aggregated record of their allergies, immunizations, lab results, procedures and other health measures that they can view from the Health app of their iPhone.” [Accessed on 2/27/19:
https://www.mobihealthnews.com/content/apple-health-records-will-soon-be-deployed-us-vets ]

That is 9 million new users for Apple Health Records.

What is Apple’s ultimate motivation? Getting at the data.

Up until now, EHR data has been “siloed” in whatever EHR system a healthcare organization is using. For example, if a hospital is using Epic, then the data sits in Epic format in an Epic database that is currently difficult to share with other platforms.

Now, thanks to the government pushing its EHR focus to interoperability, Epic and all the other EHR vendors are slowly going to make EHR data compatible with whatever interoperability standard comes out the winner.

And right now that would appear to be FHIR.

This is fantastic for large tech companies such as Apple and Amazon because it gives them a unified data format to use once they get their hands on all this data.

And the data is where the money is.

The amount of data we're talking about here is immense. About a year ago a study funded by Google used machine learning to examine the EHR records of about 200,000 anonymized individuals. Those 200,000 patients generated 46 billion points of data. That's nearly 230,000 points of data per patient.

The ability for tech giants such as Apple to work with this data, and make inferences from it, is the next big wave in healthcare.

Up until the last few years patient data and hospitals might as well have been kept on 3-by-5 index cards. But hospitals and health systems have scaled up their data programs. We are entering an era where companies will be applying the most advanced predictive analytics and the most machine learning to this flood of data, which will gradually becoming available in the unified format under the FHIR standard.

And it’s one of the largest technology companies in the world, Apple, that finally tipped the scales towards FHIR – a company that is making healthcare a primary focus of its future business activities.

One of Apple's primary goals is to prevent people from switching out of its ecosystem. That is why iMessage, for example, is such an important part of Apple's business model. iMessage, and the advantages it offers over ordinary text messaging, keeps people locked in to Apple.

Becoming a de facto healthcare information platform is yet another way for Apple to keep people depending on its hardware and software.

And regarding hardware and software, one huge advantage that Apple has held for many years is the tight integration of its hardware and software. On the iPhone, Apple developed the operating system, but it also develops and manufactures the chip that runs the operating system.

What this means for healthcare is that Apple will not only be able to develop software to improve the user experience, but will also provide the hardware to speed up certain tasks as part of that experience. For example, Apple's facial recognition software to unlock the iPhone exists primarily as specialized hardware built right onto the phone.

Apple is developing hardware to handle certain healthcare-related tasks. The Apple Watch measures heart rate through its own hardware sensors, and now through clever use of two hardware sensors on the watch, it is able to provide an EKG. And this data flows across all Apple devices.

Throughout the day, when a consumer wants to look at her heart rate she has the option of looking at it on her Apple Watch, but she may also check it on her iPhone, where more sophisticated informatics can be applied to the data. There is even an app on the iPhone which compares a person’s heart rate to the heart rates of thousands of other people who were also using the combination of the Apple Watch and the iPhone.

Everything is all about the data.

Apple also has the luxury of time to develop these healthcare related products in the most sophisticated manner possible. The reason is money. Its huge cash pile is going to allow them to outspend other competitors in developing products, and also simply outlast others through attrition.

And in typical Apple fashion, it is trying to create all this with a minimum of effort on your part. You won't have to enter your own EHR data on the phone; it will automatically flow onto it through the FHIR standard and a connection to your healthcare provider. You won't have to enter your heart rate on your phone; your Apple Watch will do that for you. There is also other data that Apple may be able to gather from you in the future through a new version of its AirPods.

Apple is trying to make healthcare on its devices so invisible that you don't even know it's there, but you'll be glad it is.

The most fascinating thing is that none of this would be possible without a data interchange format that is able to decipher data from different electronic healthcare record systems. The importance of this interoperability standard cannot be overstated. FHIR is as important to healthcare records and analysis as the HTML standard was to the browser. Without HTML, the Internet might still be just a nerdy side hobby for scientists and geeks. FHIR has that same transformative potential with healthcare data.

Appendix:

Hospitals and hospital systems supporting Health Records on iPhone (as of 2.19.19)

Hospitals and hospital systems supporting Health Records on iPhone (as of 2.19.19)


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The Amazon Effect on Healthcare - February 13th, 2019

Apple Sets FHIR To Healthcare - February 19th, 2019