An Apple for my Teacher

As promised yesterday, here is my update on HealthKit.  This was a homework assignment for my Informatics class at OHSU.

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Is tracking consumer health data the next big niche for Apple?  

His iPhone alarm goes off at 7:30.  He hits his alarm, stumbles into the Kitchen to make coffee.  After downing his morning medications, he opens up an application on his iPhone and records that he remembered to take his blood pressure medication.  Slipping a blood pressure cuff over his wrist, he takes his daily reading.  He then sips his coffee, and realizes he forgot the cream.  On his way to the refrigerator to get the cream, he stops by the nearby scale and weighs himself.  Opening another app, he records that data.  Finally, he adds the cream to his coffee and begins reading his e-mails.  He wishes that he could have just one app for all these details, or that he could at least have a single app to show the impact of his weight on his blood pressure, and what happens when he forgets his medications.  

The story above is very nearly real life.  While I do not have an application to record whether or not I took my medications (I just look at my pill box), I might use one .  However, it is already too frustrating having to use two applications to track my health data.  There are presently more than 30,000 Health and Fitness Apps and 24,000 Medical Apps in the App Store(4) for Apple’s IOS based products.  Almost all of these applications do not work together in any way to share information.   However, Apple’s newest operating system feature for its iPhone devices could soon change that.

Recently Apple announced Health Kit(6), a new feature found in the IOS 8 Operating system to be released later this year, and a new Health App co-developed with Mayo Clinic.  Apple also announced a partnership with Epic, in which Health Kit may be used to share information with Epic’s MyChart portal application  for patients(7).  Other Apps by health and fitness recording device manufacturers Nike, FitBit, and iHealth were also hinted at during the Apple announcement.

From a software developer’s perspective(8), Health Kit is a framework of components that come with the IOS Developer tools used by programmers to develop applications on the IOS Platform.  These tools provide developers with basic components supporting the recording of user characteristics such as birth date and gender, and data samples, such as activity, caloric intake, weight, blood pressure, et cetera.  It also includes tools to create this information, and to access it through queries and aggregate statistic functions like sum, min, max and average.

Founded in 1976, Apple designs, builds and sells cell phones (i.e., iPhone), tablet computers (i.e., iPad and iPad Mini), personal computers (i.e., Mac), media devices (e.g., iPod and Apple TV) and software, services (e.g., iCloud and iLive) and content (e.g., iTunes and iBooks) that are supported on those devices.  Products are sold directly through retail outlets and online stores, and through third parties such as cellular network carriers (e.g., AT&T), retailers (e.g., Best Buy) and value added resellers(1).  With a market capitalization of $587B, worldwide distribution and manufacturing channels, and over $160B in cash, Apple could be a very strong competitor in any market it chose to enter.

Apple rarely competes on price, their products are typically targeted at the premium market, rather than the bottom(3).  Apple has also focused on key niche markets: The Apple II concentrated on the K-12 education market.  The MacIntosh focused on media creation; specifically graphic design, image manipulation, and music and video editing.  In the iPhone and iPad markets, Apple has again targeted the high end, prestige seeking user.  In the Healthcare sector, the iPad remains the tablet of choice according to a recent summary of two tablet market reports(5) and physicians also seem to favor the iPhone over other smart phones.
Historically, Apple has been noted for its attention to user experience with its products.  In 6 Reasons Apple Is So Successful, industry analyst Tim Barjarin enumerates why he feels Apple has succeeded(2).  The reasons include:

1. People creating the product must want it themselves
2. Products have to be easy to use
3. Things should be kept simple
4. Offer great customer service and in-store experiences
5. Only make products if Apple can do it better
6. Stay at least two years ahead of competitors

Every single one of these reasons speaks to various aspects of user experience.  The product needs to be desirable, easy to use, and simple to understand.  The customer should have a great experience, and the best and most technologically advanced product.  This focus on user experience may be the key to differentiating Health Kit form other offerings.

How Health Kit may be different from Other Offerings

Neither Google Health nor Microsoft HealthVault seem to have been great successes for their respective owners.  Google dropped out the personal health record market three years ago, and Sean Nolan recently left his position as General Manager of HealthVault at Microsoft.  Using the cloud for personal health data seems to be on very shaky ground.  Is the consumer market really ready for yet another big vendor’s entre into (and potential early exit) from the consumer health space?

Apple’s foray into this space is a bit different than those of Google Health or Microsoft HealthVault.  Google Health and HealthVault were principally focused on storage of Health data in the cloud for consumers, and not on development for App makers.  However, Apple appears to be more focused on the App developer channel, rather than data in the cloud as being of interest to its consumers.  While Steve Jobs hinted at the future of medical data in the cloud(10), little information has been provided by Apple about where a Health Kit based Health Store lives, or how (or even if) it is synchronized between a user’s different mobile devices, and how iCloud services come into play.  A bit of research indicates that the Health Store object where all Health Kit data lives is not presently supported on iPad devices.  If the Health Store object were simply iCloud based, it would almost have to be supported on the iPad. Further investigation shows that the Health Kit data is presently limited to local storage on iPhone devices(11).

The developer base for IOS is a captive audience for Apple, similar to the MacIntosh before it and the Apple II before that.  Because developers have a great impact on the user experience of its customers, Apple strongly controls that channel.  One must be a Registered Apple Developer just to list an application in the company’s App Store.  As Apple’s App Store is the only method supported by the manufacturer to obtain apps for IOS devices, developers rely heavily on Apple for tools, SDKs, documentation and distribution.   Developers agree to Apple’s Program License Agreement, Human Interface Guidelines, and various other restrictions(9), including subjecting their application to review by Apple before inclusion into the App Store.

Both Microsoft and Google provided APIs and SDKs to access their services in web-based applications, but neither were developing APIs for a nearly captive audience like Apple has.  While Microsoft strongly controlled the Windows APIs, they did not have a lock on the Windows application distribution channel like Apple does.  Microsoft today supports the HealthVault .Net SDK and provides Open Source libraries for about a half-dozen other development platforms to use its HealthVault API.  Google Health had provided a library delivered over Google Code (Google’s own Open Source network) to support its API, but provided little else.  Developers consuming these APIs worked on diverse platforms, and were not readily controlled by either Microsoft or Google.  There was often no direct relationship between these developers and the companies hosting the health data in the cloud.

Apple’s developer channel has fewer development platform choices.  While the rest of the industry has focused on programming languages like C, C++, C#, Java and others for development, Apple has focused on Objective C as its programming language of choice. This stems from Apple’s acquisition of NeXT and the NeXTStep operating system from Steve Jobs, from which later Apple operating systems including IOS are eventually derived. The different development platform, and focus on customer experience makes Apple developers stand apart from the rest of the computing industry. It is essential to use Apple supplied development tools, APIs and selected programming environments and languages to develop for Apple products.  The focus on a single development platform makes it easier for Apple to develop for this market.  There are a few development platforms that support other languages in the IOS space, but these are principally targeted at companies developing Apps for multiple mobile platforms (e.g., Android, Windows Mobile and IOS) at the same time.

Competing Clouds

Fitness and Health Device vendors like FitBit and iHealth presently have their own consumer facing cloud storage offerings that work with their devices.  Several devices also have the capability to share data with Microsoft HealthVault.  Apple’s initial offering in Health Kit supporting local storage of health data appears non-threatening to these vendors because it does not propose to limit their ability to drive customers to their independent cloud solutions.  However, the tempting capabilities offered by Health Kit today could be driving more of cloud business to Apple tomorrow.  The only choice for some device developers may be to partner with Apple and use iCloud as their data provider to provide the same user experience for users of some of these devices.

Some device makers, like FitBit, are not wholly bound to Apple for their user experience.  The iPhone or iPad App simply provides transportation from the Bluetooth connected health or fitness device to the Internet and enables display of recent history.  Risks for these device makers in using Health Kit seem marginal.  However, Apple’s insistence that App developers follow Apple’s rules and use Apple’s APIs to support capabilities could hinder future health data exchange outside of iCloud.  For example, Apple’s Push Notifications API is the only way that Apps can receive push notifications, even though numerous other push technologies could be implemented in software under IOS.  Apps which are found to implement these other methods are not permitted in the App Store and can be removed from it should Apple discover later that they exist.  Similar restrictions on API use in the future could prevent device makers from utilizing something other than Apple’s APIs to push health data out to the web. This seems an unlikely strategy for Apple. Clearly the partnership with Epic and its MyChart product promises that data will flow from the Apple device to the physician chart, and perhaps even back again.

Industry experts have pointed out the complexity of multiple device access and security(11). Synchronization of health data across multiple devices is also challenging.  It is not surprising that Apple chose not to support that capability in its first release.  Apple’s documentation over the Health Kit API and developer guidelines shows a strong integration of security into not just the HealthKit framework, but also the Health Kit user experience.  With all of the attention being paid to security of Health data, Apple may well be waiting until it gets the fingerprint scanner (now integrated in new iPhone models) into the new models of the iPad and iPad mini before supporting Health Kit on those products.

Conclusion

Health Kit promises to solve real problems for consumers and their healthcare providers by enabling them to selectively share health data via various Health and Fitness Apps.  By focusing on the App developer channel, Apple can approach this problem in ways that neither HealthVault nor Google Health were able.  The Health Kit API seems to have been developed to support straightforward migration for existing Apps manipulating health data.  Apples engagement with key industry leaders, such as Mayo Clinic, Nike, and Epic in the recent announcement of HealthKit should also encourage other App and Health and Fitness device vendors to line up behind it.

Avoiding complex challenges like multiple device synchronization and cloud storage also makes the capability easier to understand.  It also becomes simpler for App developers and consumers who may have some concerns about security of their data in the cloud.  There are many obvious ways that Apple could advance Health Kit in the future; however, Apple appears to be proceeding with caution to see how well Health Kit takes hold.  The company has a long history of secretive strategy development which it unfolds over time.
I look forward to using my first Health Kit enabled apps on my personal device, where presently I keep track of various health data in different apps, none of which can share data with each other today.  I also look forward to a time when I can share some of that data with my physician, a capability already promised with some EHR systems in the recent announcement.  To summarize: I want it, it looks easy, it feels better than other solutions, and appears to have a strong future.  In short, Health Kit appears like another example of Apple following a time honored recipe for success.
 
References
1. Apple Inc (AAPL.O) Company Profile: Reuters; 2014 [cited 2014 July 30. Available from: http://www.reuters.com/finance/stocks/companyProfile?rpc=66&symbol=AAPL.O.
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3. Nair S. Apple’s premium pricing strategy and product differentiation: Yahoo! Finance; 2014 [cited 2014 July 30]. Available from: http://finance.yahoo.com/news/apple-premium-pricing-strategy-product-191247308.html.
4. App Store Metrics: Pocket Gamer.biz; 2014 [cited 2014 July 30]. Available from: http://www.pocketgamer.biz/metrics/app-store/categories/.
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6. Apple Inc. Apple - iOS 8 - Health: Apple; 2014 [cited 2014 July 30]. Available from: https://www.apple.com/ios/ios8/health/.
7. Moukheiber Z. Behind Epic Systems' Alliance With Apple: Forbes; 2014 [updated June 4, 2014; cited 2014 June 30]. Available from: http://www.forbes.com/sites/zinamoukheiber/2014/06/04/behind-epic-systems-alliance-with-apple/.
8. Apple Inc. Introducing HealthKit. WWDC 2014 Session Videos - Apple Developer: Apple; 2014.
9. Apple Inc. App Store Review Guidelines - App Store Resource Center: Apple; 2014 [cited 2014 July 30]. Available from: https://developer.apple.com/appstore/resources/approval/guidelines.html.
10. Isaacson W. Steve Jobs: Simon & Schuster; 2011.
11. Shaughnessy H. The Revolution Hidden In The Apple Health Kit: Forbes; 2014 [cited 2014 July 30]. Available from: http://www.forbes.com/sites/haydnshaughnessy/2014/06/17/the-revolution-hidden-in-the-apple-health-kit/.