In June 2018 Apple made an announcement that had a bigger impact on healthcare than many people realize.
At their annual worldwide developers conference, Apple delivered an API for developers to help them write apps integrating EHR data onto iPhone apps. Apple basically cemented the fact that if you wanted to write an application for their iPhone that involved electronic healthcare records, it had to conform to the FHIR standard.
Apple had earlier said as much in January of 2018 with a press release stating “Apple announces effortless solution 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 (Fast Healthcare Interoperability Resources), a standard for transferring electronic medical records.”
FHIR is basically the follow-up to the HL7 interoperability standard, but up until this point no one had really forced the issue of making this the “standard.” It took a company as big as Apple to implicitly settle on a 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 that they do, hospitals need to prepare for the fact that consumers are going to want their records on their iPhone.
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 your “Health Records”. If they don't have it their health records on there now, pretty soon these consumers are going to want it there.
When Apple made the announcement about the FHIR standard they were only working with a handful of hospital systems, such as Johns Hopkins Medicine, Cedars-Sinai and Penn Medicine to integrate EHRs into the Apple ecosystem. As of today, February 19, 2019 it is 204. The list of hospital systems current as of this week that have decided to work with Apple in integrating their EHR data with Apple Health Records included at the end of this research note.
That 204 number is significant because that includes hospital systems with multiple facilities. So realistically Apple may be, after just one year, already working with 5% to 7% of all US hospitals.
There are roughly 5200 community hospitals in the United States, and with the momentum that Apple now has, I would bet that at least 20% the hospitals in the United States will be working on integrating their EHR data with Apple by the end of 2019.
Just this week this news was announced –
“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.”
That is 9 million new users for Apple Health Records. So the larger tech companies, such as Amazon, Google, Apple that are trying to shoehorn their data expertise in the healthcare, have all signed on to an agreement making FHIR the industry standard. As I stated, Apple forced the issue.
What is their motivation in doing this? Getting at the data.
Right now EHR data is “silo-ed” 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.
BTW, Apple has talked with EPIC about working together, but thus far EPIC is less than enthusiastic about opening up their HER wholesale to Apple. Cerner has a much closer relationship with Apple.
Well now, thanks to the government pushing its EHR focus from “meaningful use” 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. As I've mentioned before, the only reason Facebook has any value at all is because of the data it holds. Data that that people have voluntarily given it. Without this data it is worth nothing. With this data it's worth 478 billion dollars.
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 this data, is the next big wave in healthcare.
Up until the last few years patient data and hospitals might as well of being kept on 3 by 5 index cards. The technology was ancient. But now we are entering an era where companies will be applying the most advanced predictive analytics and the most advanced machine learning to this flood of data, which is gradually becoming available in a unified format under the FHIR standard.
And who finally tipped the scales towards FHIR? One of the largest technology companies in the world, Apple. A company that is making healthcare a primary focus of their future business activities.
One of Apple's primary goals is to prevent people from switching out of its ecosystem. For example that is why iMessage 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. People want to be a blue bubble on your phone, not the shameful green bubble.
Becoming a de facto healthcare information platform is yet another way for Apple to keep people buying 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 is also 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 your Apple devices.
Throughout the day, when I want to look at my heart rate I have the option of looking at it on the Apple Watch, but more often than not I find myself checking it on my iPhone, where more sophisticated informatics can be applied to the data. There is even an app on my phone which compares my 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. Their 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, they're trying to create all this with a minimum of effort on your part. You won't have to enter your own EHR our 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 their devices so invisible that you don't even know it's there, but you'll be glad it is.
The thing that fascinates me the most about all of this, 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. I think 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.
Then there is this from Healthdatamanagement.com -
The Office of the National Coordinator for Health IT, for the first time, said at HIMSS19 that it intends to make FHIR a requirement through a proposed rule. “While there are a variety of relevant healthcare standards for connecting labs, images, claims processing systems and other pieces of the provider world, when we look at the app economy and the clear trends in modern computing, one API approach seems to clearly emerge–Health Level Seven’s Fast Healthcare Interoperability Resources standards,” according to National Coordinator for HIT Don Rucker.
And Apple kicked off the FHIR era last June with a 500 word announcement.