On Monday, Mark Gurman at 9to5Mac published a wealth of information about Apple's upcoming move into health and fitness. The report, focused on a new iOS app called Healthbook that is expected to ship as part of iOS 8, was based on information from "multiple sources working directly on the initiative’s development" and including several images described as "complete recreations of screenshots."
The report describes a card-based app like the iOS 7 versions of Apple's Passbook and Reminders apps that could be used to track a very large amount of information that goes beyond fitness and general wellness to record and track medical data -- including data related to common chronic conditions.
That data would be grouped into the following categories:
- Emergency Card -- Basic in case of emergency information like name, date of birth, current medication, weight, eye color, blood type, organ donor status, and emergency contacts -- essentially the information that every doctor's office, urgent care center, or hospital records in case of a health emergency. The report wasn't clear about whether this information would be available to medical staff of EMTs if a device was locked and the owner unconscious, though that is a distinct possibility given that the Passbook, Notification Center, and Control Center features of iOS can display data on the lock screen.
- Bloodwork -- The report didn't make clear what information would be stored on this card, though recent or important lab tests would be the most likely information
- Heart Rate -- Tracks a user's heart rate (and potentially heart rhythm).
- Hydration -- This would be a useful stat for athletes and it could have some implications for the general population since many wellness programs stress the importance of staying hydrated and some fitness tracking apps like Fitbit allow you to recording daily water intake.
- Blood Pressure -- Blood pressure plays a large role in the development and diagnosis of heart disease. Many adults with hypertension (or prehypertension), one of the most common chronic health issues, can benefit from ongoing monitoring to ensure medication and lifestyle choices are effectively managing the disease. Monitoring blood pressure over time also provides a more accurate picture of hypertension (as does monitoring outside the doctor's office).
- Activity -- This seems to be standard activity tracking data like that associated any number of standalone trackers as well as with the M7 chip in the iPhone 5s.
- Nutrition -- This is likely also standard tracking capabilities like those in many fitness and weight loss apps. It could, however, also offer advice on improving one's nutrition choices as well.
- Blood Sugar -- This appears to be focused on capturing blood glucose level, an important metric for individuals with diabetes (type one and type two).
- Sleep -- This would likely be another standard wellness tracking ability similar to what's available from other apps, activity trackers, or specialized sleep analyzing technologies.
- Respiratory Rate -- This goes beyond what most activity trackers offer and would likely help analyze a person's breathing.
- Oxygen Saturation -- This is a vital sign that indicates the amount of oxygen being carried from the lungs to all the cells in the body. Along with respiration rate and pattern, blood oxygen level can help deliver a picture about a person's ability to breath in and absorb oxygen.
- Weight -- This appears to include both weight, body mass index, and body fat tracking.
It's unlikely that every iOS user will want or need to track all of those data points. Some people might simply opt to fill out the emergency data in case of an accident or illness. Others might use just the activity, nutrition, and weight tracking features or just sleep tracking.
The remaining tracking options seem extremely tailored to specific common chronic conditions -- blood pressure and heart rate for those with hypertension or heart disease, blood sugar for those with diabetes or pre-diabetes, respiration and blood oxygen for those with COPD or asthma. With some of these conditions, supporting data from the more general Healthbook cards could also be helpful as well. Nutrition, for example, plays a big role in management of diabetes and it is also a factor related blood pressure and heart disease. Similarly, there's a growing body of evidence showing that sleep disruption can affect a range chronic conditions as well as overall physical and mental health.
There are a range of apps already on the market that offer the ability to track most of these metrics, but there are advantages to creating a single repository for this data, including accessibility and easy data entry, automatic backup and sync between devices, the ability to share data consistently with others like family members and doctors, the ability to analyze a broader data set, and integration with other devices like activity trackers.
Stopping just short of being a personal health record
Like the electronic health record systems (EHRs) used by hospitals and doctors offices, PHRs include a much broader range of medical data including vaccinations, healthcare diagnoses and treatments, surgeries, food and drug allergies, detailed medication histories, and information about family histories related to specific diseases or conditions.
Apple seems to have gone very close to creating a true PHR and stopped just before crossing that threshold. One reason may be to avoid the much tighter regulation required by state and federal laws and agencies.
As I noted in discussing the medical implications of Apple's rumored iWatch, several federal agencies have jurisdiction over medical devices and, to a somewhat lesser degree, apps that function as or in conjunction with medical devices. The regulatory challenges also extend beyond the U.S. market as many countries or international bodies like the E.U. have differing and sometimes great regulatory requirements than U.S. agencies. Limiting Healthbook to just tracking information could very well allow Apple to avoid some regulatory or certification processes.
It's also possible that Apple has plans to integrate additional capabilities in a later version of Healthbook. If so, releasing the app in this form could get it into the market while Apple secures any approvals required for a more thorough and healthcare focused future version.
Beyond regulatory requirements, Apple could be holding off on full PHR functionality because until it feels the PHR market has fully matured. In an ideal world, PHRs would be able to exchange health data with EHR systems used by doctors and hospitals. The advantage there is to ensure all data in the PHR is accurate and help reduce the burden of entering manually entering health data as well as to provide easy access to a full health history to a new provider or hospital. That ideal world remains a way off for a couple of reasons.
Many EHR systems don't yet offer a consistent way to exchange information with each other let along with consumer or patient-facing solutions. Your primary care doctor, cardiologist, and an urgent care center may all have electronic records for you, but if they use different EHR platforms, they likely don't yet not have the ability to share the data in those records. Although EHR vendors and health IT leaders acknowledge this is a needed capability, work on creating standards for reliable data transfer is still in the early stages.
Another challenge is that there isn't yet a consensus that consumer-focused apps like PHRs and other tracking apps should even be able to deliver content into an EHR. While the argument for access is that user data could be very helpful to diagnosis and management of injuries or chronic conditions, there is a concern that having too much information might overwhelm physicians rather than help them. There are also concerns about potential security issues both in terms of the actual data involved and in terms of opening access to a system that contains a great deal of personal and confidential information.
Healthbook aligns with team-based care and wellness programs
Regardless of whether Healthbook ever becomes a true PHR or not, the app has a lot of potential for sharing key vital signs and health metrics with healthcare professionals. Having a set of daily blood pressure readings that your doctor can review on your device in the exam room is still incredibly useful because it illustrates how well you're managing your blood pressure, allows you and your doctor to spot and discuss patterns, and allows you to correlate blood pressure readings with other metrics like activity and nutrition. That layer of information and context can greatly aid in developing a treatment regimen that includes lifestyle changes as well as medication.
Being able to track related information like this lends itself to team-based medicine, where your doctor and a team of other health professionals like physician assistants, nutritionists, physical therapists, and health coaches coordinate care and encourage wellness. Team-based care is becoming more common as it offers a way to reduce healthcare costs while providing stronger and broader preventative care to patients.
In the same way, Healthbook also lends itself to wellness programs as a whole, such as those offered by medical groups and hospitals, insurers, and employers that track specific health metrics over time and employ gamifaction or competition among members to encourage healthier life choices.
How will Healthbook collect all this data?
One of the big questions about Healthbook that remains unanswered is how it will collect all of this information. There's a limited amount of data that an iPhone is likely to be able to record on its own -- activity data, sleep, and potentially heart rate and rhythm. A sensor-laden iWatch might could conceivably track a range of additional metrics like blood pressure, hydration, sleep, and blood oxygen, but that still falls short of some other data listed in 9to5Mac's report.
Apple could include an API in iOS 8 that allows third-party companies to build in support for transmitting data from devices like blood glucose meters, scales, or blood pressure cuffs using either Bluetooth or Wi-Fi. It's also possible that users may need to manually enter some items depending on the external devices required.
One thing that seems clear based on this report, the expected capabilities of an iWatch, and a number of Apple's high-profile hires over the past couple year, is that Apple has set its sites on health and wellness as the next industry that it wants to disrupt. If successful, this could be a very big and very lucrative market for Apple.