It was the best of times. It was the worst of times.
We are awash in data. But we can’t access data when and where we need it.
We are awash in dollars. But untold billions are lost to waste, fraud and abuse.
Apple recently announced its foray into the personal health record market. Its initial offering is limited to a handful of health care systems, and the data collected and placed in the palms of our hands is PHR data, not full EHR data, as some outlets had reported, but the rollout has certainly engaged the commentariat in a deep dive into the pros and cons of Apple’s latest move in the healthcare sphere.
Amazon, together with Berkshire Hathaway and JP Morgan Chase, just announced the establishment of a new joint venture said to focus on technological solutions to lower healthcare costs for their employees. (They have, collectively, a lot of employees — over a million of them — and healthcare insurance company and other healthcare sector stocks dropped measurably following the announcement.) Presumably, this offering (whatever it is) will be made available to other employers in the future.
How do these announcements relate to each other and to other developments in the healthcare arena?
Apple’s PHR announcement is interesting despite the strikes against it. Let’s get some of those out of the way up front:
- The data is limited to PHR data (and there are plenty of apps and services that can show you your PHR data on your phone already, though maybe they can’t integrate data from multiple providers as seamlessly — but see point 3, below)
- iPhone users only amount to 15% of the smartphone market as a whole (though physicians are better represented among iPhone users — market share among physicians is at least 75% — so why is Apple focusing on patients rather than physicians?)
- The pilot institutions are small in number and not likely to have many patients in common (thus limiting the demonstration of one of the key selling points of the offering: integrating data from multiple provider organizations)
- Data flow is unidirectional (provider to patient only)
Some of these are short-term problems, though the truth is, we just don’t know whether Apple will be able to make the tool it’s rolling out ubiquitous. The road to hell is paved with good intentions, and the road to our digital health utopia of seamless data interoperability and transparency is littered with rusted hulks of other really great ideas.
The longer-term promise inherent in Apple’s announcement is that more people will be able to access more of their own health data more easily. If the pilot works out nicely, Apple will have other health care systems lining up to take part, and will eventually make it easy for health care providers of all shapes and sizes to hook up their EHR to the data pipes. Having the provenance of the data baked into the system will likely allow other health care providers to relax a little about getting information from patients — via their iPhones. (Imagine a telemedicine encounter via iPhone where the remote clinician can get a better picture of the patient’s health by being granted permission to access data in the Apple PHR on the phone. Imagine a diagnostic test where the results can be interpreted more accurately by accessing data in the Apple PHR.) Many consumer advocates prefer Apple’s approach to end user data (it stays on the phone and Apple doesn’t want to mine it) over the approaches taken by certain other tech titans (their services are free, which means you are the product). If this thing has legs, then expect a similar initiative on the Android side of the house (though it would likely not come with the Apple hands-off approach to personal data).
The Amazon-JP Morgan-Berkshire Hathaway effort may well be one expression of the future vision described by Dave Chase, for one. Dave is talking about change on a generational time scale to rationalize health benefits purchasing. (Check out his book and my recent chat with him.) The announcement of the titans may speed up the process.
The effort will never get off the ground without aggregating employee health data, and the sort of data standards and plumbing that enables the Apple project can also enable the Amazon project. These didn’t really exist in the days of Google Health, but the Argonaut Project and other initiatives have laid the table. (Perhaps Amazon etc. will key into the Apple PHR ecosystem, with patient consent, or perhaps they will build their own standards-based infrastructure — or perhaps both.) There have certainly been all sorts of employer-focused efforts to slay the healthcare beast before (workplace clinics, employer-sponsored health data networks, and more — valiant efforts, but not successful to date in moving us closer to the quadruple aim), and there are a whole variety of value-based care efforts that have been underway for years (and years) in the government payor and in the commercial payor universes, though they are either self-limiting, or haven’t quite ever gotten to the point of being really successful. There are many reasons why the PHR effort taken on by Apple and the employee health cost control effort by Amazon et al., which made sense before now but failed to reach escape velocity, might succeed at this point in time. One of the bright points that may give hope that the employee effort could succeed is, frankly, the proponents’ track record of success. Of particular interest is the Amazon experience in managing cost of products and the supply chain (which can translate nicely to pharmaceuticals and medical supplies) — not to mention its analytics superpowers (which could be retrained, though not overnight, from retail to healthcare), JP Morgan Chase’s experience in managing financial transactions and secure consumer access to confidential data (consumer banking seems to be at least ten years ahead of healthcare in terms of consumer-friendliness and interoperability), and Berkshire Hathaway’s experience in — well, in being Berkshire Hathaway. Ultimately, success in this effort is as much about controlling unit prices as it is about anything else. The real question is whether one million employees plus a couple million more family members, spread out across the country, equal sufficient critical mass to actually move the needle on unit prices.
The self-insured behemoth employers are doing well to initiate this project through a separate entity, and they will continue to do well if their employees can be confident that health information well beyond what is traditionally held by self-insured employee health plans will maintained in confidence, for the benefit of employee health and for no other reason. Questions about data privacy, and health data being used for employment-related decisions, would quickly torpedo this effort.
The internet is full of lists and examinations of potential future directions of the Apple PHR project and of the Amazon et al. employee health management project, and the ways in which they affect or are affected by other developments and combinations across the healthcare landscape. I won’t add to that carbon footprint today. (We’ll all think of more ways this could play out tomorrow — feel free to share your thoughts in the comments section.) Clearly, though, we have come to this pass because of intransigence of a number of entrenched interests (the “Mexican standoff” among health systems that don’t want to permit the liquidity of health data because they fear losing market share; the self-preservation instincts of sectors of the healthcare economy that stand to see the ground fall out from under their feet — one person’s waste is another person’s revenue, after all); in other words, we have a business and a political problem, not a technological problem, and it has now grown to gargantuan proportions.
Nevertheless, when the 800-pound gorillas in the business world decide to forge ahead despite the business challenges and clear a path forward, the technical solutions are more likely to be able to get a little sun and maybe even thrive.