- Health Records section added to Apple’s Health App for iOS mobile devices
- Several major health systems on board at launch (Penn Medicine, Cerner, and more)
- Uses FHIR-based integration (Fast Healthcare Interoperability Resources)
Apple’s recent announcement to enter the electronic health record (EHR) marketplace is intriguing. Health IT pundits largely agree – it was a long shot for Apple to think they can design, develop and market to compete and surpass the major players at their own game – on-premise or cloud-hosted EHRs.
But with Apple’s strategy to leverage their sizable handheld device market penetration to enable data access with the legacy platform players and data aggregation across different sources of EHR data, it appears we are about to enter what may be the largest disruption in healthcare IT since the inception of electronic medical records. Envision a data access and aggregation layer above the consumer’s EHR(s) or patient portal offerings under the control of the patient!
Integration standards, interoperability workflows, privacy consent methods, etc., have all evolved significantly in the last several years.
Leveraging these capabilities to access raw EHR data, having enough clout with the major EHR players to develop and nurture interoperability partnerships, and combining traditional provider-generated data with patient-generated/collected data from individual smartphone apps, and enabling consumers with the ability to initiate sharing of their own health data (think health data portability) will vault Apple once more with a unique market offering.
According to Apple’s January 24, 2018 announcement, the new capabilities for the Health App will provide consumers with “medical information from various institutions organized into one view covering allergies, conditions, immunizations, lab results, medications, procedures and vitals, and will receive notifications when their data is updated. Health Records data is encrypted and protected with the user’s iPhone passcode.”
What key challenges will Apple need to overcome?
Let’s start with healthcare data characteristics. It is complex, time-valued, longitudinal and has greater value when structured. To compile healthcare data across multiple disparate sources, it needs to be normalized by leveraging reference data standards. With a plethora of standards to choose from (ICD, CPT, SNOMED, LOINC, RxNorm, UMLS), the challenge will be mapping individual EHR data and health information exchange data to an abstraction level and aligning the incumbent players to adopt common normalization standards for patient data sharing.
At this time Epic, Cerner and athenahealth have committed to transform data from their EHR platforms to participate in the new ecosystem, and Apple is “curating” the data from multiple sources for the Health app. While these are significant first moves, Apple has not yet stated capabilities for the participating EHR vendors to accept data from the Health App. This means that patients, at least in the early stages, must continue using their patient portal(s) to schedule appointments, request medication refills or conduct other communications with their provider.
Kudos to Apple for enrolling Epic, Cerner and athenahealth in a data normalization approach, but the next layer of functionality is interoperability. There are many standards (HL7, FHIR, CCD-A, etc.) and all have varying pros and cons depending on the use case and technical capability of the exchange participants. Apple’s recent announcement states they have worked with the healthcare community to take a consumer-friendly approach, using FHIR (Fast Healthcare Interoperability Resources), as the standard for transferring health data into the Health app. It is notable that, at this point, the integration is one-way, from providers to the Health App. It will be interesting, if Apple adopts a goal to enable the ability for patients to share data back to their provider’s EHR.
The challenges of directory data
Patient identification and user authentication is the most obvious directory challenge. Apple’s approach here is to leverage the authentication that a patient already has with their healthcare providers’ patient portal. This puts the patient in control at the hub of their healthcare information sources, negating the need for any type of patient-matching algorithms. This workflow cannot fail, even once, at the risk of breaching existing HIPAA law, but will be no less secure than a patient interacting natively with their patient portal. The second use case will involve provider identification. While the National Provider Index (NPI) represents a common standard for provider directory data, there are layers of complexity when considering the relationships of individual vs. group vs. billing provider that may need to be addressed when/if Apple tackles patients sharing their data with participants in their care. And then there is the use case of children and elderly patients which are often represented by other family or designated individuals in a proxy relationship.
Usability could be a big challenge, and one that Apple touts as a strength of their products. The aggregation use case is powerful and inherently valuable for patients who receive care from multiple provider groups. But what use cases might the owner of the Health App data consent to share if they had the option to do so? One use case is health record portability or the ability to acquire and share their healthcare record in machine-readable format when moving from provider to provider (as is often required when patient residence, preference, referrals or payer relationships change). To simplify sharing, the use case could be a binary decision to share or not share the entire record. But will patients be comfortable in sharing all aspects of their medical history or will they want to suppress portions of their history if there are behavioral medicine or sexually transmitted disease encounters?
Another use case would be sharing just those components relevant to establishing a provider relationship based on the specialty of the provider. But who decides what components of the record are relevant? The typical patient will not know what is relevant or may not yet have established the trust to permit the new provider to deem what is necessary. While it is commonly established that providers who generate patient data have inherent access to it, what laws govern providers who acquire patient data from other health systems? Another use case may be suspending access to shared patient data. What are the procedural, legal and technical requirements when a patient deems that sharing is no longer desired? There are a plethora of legal and technical usability requirements, with many state variants, to support the consent process.
Transitioning into the realm of privacy raises a number of questions. While the HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, healthcare clearinghouses, and those health care providers that conduct certain healthcare transactions electronically, what does that mean for Apple in this service offering? Since the Health App will contain PHI, do they need to support relevant aspects of HIPPA like minimum necessary, user authentication and encryption of data? Will users understand and agree to these common-sense measures to protect themselves? If the protected health information is aggregated and stored in Apple platforms, does that vault them into one of the most prevalent covered entities or business associates?
What are some of the potential benefits that could emerge?
At the consumer level, the Health Records section of Apple’s Health App will begin to enable anytime/anywhere patient access to their electronic health records (at least the sections within scope of the Health App). Aggregated data will catalyze health app development focused on interaction with the aggregated health data. Examples could be: medication reminders, medication refill reminders, enrollment in “communities of interest” support and research groups, integration of social determinants of health and collection of research data. As the platform matures, a number of questions will spawn, related to enabling “hands-on ownership” – who gets access, for how long, and for what purposes.
At the provider level, sharing patient EHR data could lead to greater patient satisfaction. If the bi-directional sharing capability is developed, what easier way to acquire (with consent, of course) historical patient data than to request it directly from the patient and their aggregated health data mart?
For managing population health, with the necessary and appropriate opt-in gateways, this approach could enable authorized entities access to existing patient health data and the means to easily acquire the elusive social determinants of health data that are generally recognized to play a major influence on health outcomes. Down the road, this potential model could enable Apple with an extraordinary opportunity to aggregate and sell health data for medical research, the marketing of health products, and create a completely new ecosystem for App store developers to more deeply engage patients in their health challenges.
Are the new capabilities of Apple’s Health App going to be a big deal? Hold on, the innovation is just beginning.
To learn more about the EHR marketplace and the benefits and challenges providers face with the growing push to share patient data, contact Chris McShanag.