Does Apple need to choose between consumer and B2B in health?

Helping individuals develop healthier habits may be easier than making the healthcare industry user friendly. Apple may have to choose between the two.

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On Linkedin recently, a doctor wrote an open letter to Apple asking for help with some of the bigger problems in healthcare:

"Taking a more aggressive approach to healthcare may make investors nervous, but what's the point of making bold statements about your contributions to the health of mankind if you aren't willing to take a risk? ...Your greatest ability to help humankind may lie beyond wearables, HealthKit, and FHIR."

The feedback on Linkedin was mostly positive — encouraging comments from people who see the need to redesign healthcare and the need to involve doctors in that process.

Meanwhile, on Twitter, Benjamin Schwartz, MD got thumped for thinking that Apple was a healthcare company.

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Tim Cook does want to have it both ways. He wants the cool factor of helping individuals live healthier lives as well as the business clout of "fixing" the healthcare system in America. Apple is making progress on both fronts, but he may have to pick one goal or the other. 

There's an argument that Apple is building compelling consumer apps that patients could use as leverage to get healthcare systems to evolve. And, there's no question that hospitals and physicians deal with data in more helpful and user friendly ways. There's also an argument that Apple will need to choose between the consumer side of health and the business side.

Here are three reasons why succeeding both on the B2B front and the consumer front may be incompatible goals for Apple.

How useful is patient-generated data—really?

For an individual who is trying to change her daily habits, personal health data is helpful and compelling. It's also valuable to marketers who have books and apps and supplements and personal trainers who can support that behavior change. The value proposition is completely different for doctors.

For all the buzz around the potential of patient-generated data — "See how many steps I've got today, doc!" — there is skepticism from the actual doctors who would need to review and evaluate this data. The biggest problem is fitting this data into the physician workflow. Doctors already have a limited amount of time with each patient. Uploading the data, looking at it, and then making treatment recommendations is not built into that time. Data quality is also an issue.

There are early adopters among physicians who will make time for patient-generated data. But there are many more physicians who are already burned out from the burden of technology in their daily work. The potential impact of patient-generated data fades significantly if doctors and nurses don't—or won't use it. 

Personal change vs. systems change

Behavior change is not easy, particularly when it comes to exercise. The results are mixed when it comes to fitness trackers: Some people definitely move more, but the dropoff rate is pretty high too. The idea of "closing your rings" is a much simpler concept than actually counting steps or standing time. On the consumer side, Apple is making progress.

Behavior change at an individual level is one thing— reforming an entire industry to be customer centric and user friendly is another challenge altogether. Apple may be good at building partnerships but that's not the case for healthcare systems. Patient data—whether its medical records or insurance claims—is considered a competitive tool. There is no incentive for big hospital systems to share data. Google "health information exchanges" to get a brief history of how data sharing has worked in the healthcare world. 

While compelling design can shift individual behavior, it requires policy, incentives, and will to shift an industry's behavior. Apple has made progress on this work also, but it remains to be seen if the health team will keep at it long enough to succeed.

EHRs are an ongoing design challenge

Healthcare systems are slowly getting better at technology adoption, although interoperability remains a challenge. Patient portals are mostly terrible, and only about 30% of patients use them.

The biggest challenge is shifting the mindset from building a service that works for the system vs. a service that works for the user. Apple started this evolution with Health Records, launching with big names like Stanford Medicine, Partners Health Care, Ochsner Health System in New Orleans, Vanderbilt University Medical Center, and Duke University Medical Center. As of August 2019, there were more than 300 doctors and healthcare providers that use the service. People who use the health records service can see allergies, medications, conditions, and immunization records. The data is encrypted and password protected. 

The first study of adoption rates for Health Records shows a fairly typical reaction from consumers when it comes to digital access to health records: Meh. A study of 425 patients who downloaded the app at UC San Diego Health showed that a few hundred users downloaded their records. In 2018, the health system had more than 830,000 patient visits.

It's worth mentioning other EHR efforts from big tech players: Microsoft just shut down HealthVault, but Google hasn't given up yet. A patent application filed in 2017 suggests that Google wants to build a system to store patient records and to analyze the data with machine learning to predict future health events. It's easier to imagine Google building a product to take on established EHR companies like Epic and Cerner than Apple taking on that challenge.

Who has the stamina and endurance to change healthcare?

There is no silver bullet that will improve public health across the board. It is encouraging that Apple is taking a long view and partnering with leaders in the industry to study solutions for hard problems like dementia. 

The question is how important is the cool factor. Does Apple want to become a service company instead of a maker of shiny gadgets? Maybe—Apple is working with insurers to expand the reach of the Watch and to make insurance claims available on the iPhone

If an Apple Watch can detect an irregular heartbeat, that is a priceless service to an individual who might not have any other early warning signs. Providing a similar service to the American healthcare system is a much heavier and less exciting lift.

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