NSFW: Apple, iOS 8 Health, and the Gordian Knot of healthcare bureaucracy

NSFW: Apple, iOS 8 Health, and the Gordian Knot of healthcare bureaucracy

This year I've spent a lot of time in doctor's offices and I see what a giant mess the electronic health records (EHR) industry really is. And I don't think Apple's going to solve the problems facing the American healthcare industry. Apple's telling us that iOS 8's Health feature will give us a way of sharing important diagnostic information with our doctors. But it's predicated on a huge assumption: That our medical providers are affiliated with an institution that's willing to buy in to this particular data stream.

Because of my own health issues and those in my family, I deal with a lot of medical specialists. All of them use electronic health records (EHR) systems, because they're required to (especially if they expect reimbursement through Medicare and other social insurance programs). But getting these different medical providers to talk to each other is a byzantine process at best, thanks in part to a complete lack of interoperability between different EHR systems, federal and state restrictions, and pure administrative incompetence.

Case in point: My primary doctor wanted copies of lab tests that had been ordered by a specialist I'm seeing. Both of them required release forms signed by me in order to send and receive the paperwork. Even then, it would take days for it to happen.

I ended up just going to the specialist's office — fortunately I had to anyway, since I had another appointment scheduled — and asked for copies of my own lab tests. They were, of course, obliged to provide them, in hard copy form (they wouldn't or couldn't email them to me).

I just ended up faxing my doctor the results myself.

Faxing. Like a common 19th century fieldhand!

Because my primary provider recently switched over to a new EHR system that hasn't been fully implemented yet. They're either unwilling or unable to accept electronic records. So faxing the lab results was the only way they could have accepted the data, either from me or from the specialist I'm seeing.

They're promising at some point that I'll be able to do things like check their lab results or request medicine refills through their EHR system, but not today. They just launched it last month, replacing another system they'd used for a few years.

If my primary doctor and the specialist were part of the same network, they may have been able to just transfer the information between them. But that all depends on how recently both businesses had been integrated.

There's a lot of consolidation in health care these days, but healthcare IT moves at an entirely different pace than corporate mergers and acquisitions.

A couple of months ago I was seeing another specialist. When I checked in they asked me if I'd brought a medication list with me. I pulled out my phone and showed her the list.

"Do you think I can put that on the photocopier?" she said.

She was totally serious. She wanted to photocopy the screen of my phone.

Of course, I couldn't print out the list on their printer — closed network, as it should be. I offered to e-mail it, but they rebuffed the offer. So I wasted five minutes transcribing it by hand.

More wasted time, more wasted paper.

iOS 8's Health feature holds to promise to fundamentally change how many of us keep track of our health and fitness issues — it gives us a single location to store and review information on fitness, sleep patterns, nutrition — even set up a medical ID screen that's available from the lock screen of our phone, something to be used in an emergency.

I may be jaded by my experience, but I'm extremely skeptical that even Apple, with all its marketing acumen, its meetings with the FDA and even wins like the Mayo Clinic, is going to be able to make a dent here with iOS 8 Health.

What Apple is facing is nothing less than a Gordian Knot of EHR systems, healthcare IT, defensive corporate culture, administrative ambivalence and incompetence, and government bureaucracy.

And I don't think Apple, for all its graces, can do what Alexander the Great did with the Gordian Knot.

Peter Cohen

Managing Editor of iMore, Mac and gaming specialist and all-around technologist. Follow him on Twitter @flargh

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NSFW: Apple, iOS 8 Health, and the Gordian Knot of healthcare bureaucracy

44 Comments

Doctors will reject email because it is unsecured, even if SSL connections are used each endpoint in the route gets an unencrypted version. No way will doctors (or the majority of their patients) figure out PGP.

My primary doctor has a pretty nice iOS app that gives me access to lab results but it has no export option. And app for every specialist would be way annoying.

Peter - you're totally correct. Healthcare IT in general has been 15 or 20 years behind other industries. You left out the "back office" tangled nightmare of insurance billing and collections systems and software that often results in additional frustration and headache for the patient. No easy answers to this one...

I have Aetna and they provide lists of doctors and specialists that do accept my electronic records. They also have an app that syncs my data from my Jawbone UP24, which also gets sent to the doctor of my choice as well. It's just the beginning but I find that it has been working pretty well so far.

There is an easy answer--the first step toward an effective EHR system:

Single-payer, medicare for all. We could have the best system in the world, learning from all the other wealthy countries that have one and, contrary to those against anything smelling of--gasp!--socialism, which work much better than our current "system."

Of course, we already have other sectors that are socialistic, especially the vast corporate welfare system.

Exactly.

But three of the most powerful lobbying groups (AMA, ABA, insurance) are more interested in high incomes for their members than efficient and readily-available patient care.

Actually, many doctors have been frustrated by the AMA's generally friendly attitude towards government regulation of health care. Your assumption is incorrect.

I am totally with you. Look at the models of efficiency and high-quality care provided by the government-run VA and Medicaid.

As someone who has been on Medicaid I can tell you it is the worst thing ever. I am TOTALLY for single payer just not medicaid. Medicare for all just not Medicaid. Medicare is well supported because it's old people and you can't screw old people so PLENTY of doctors support it. Medicaid is for the poor though so basically NOBODY takes it. The poor get screwed. I was on it, not only did it take 4 months of beuracracy for them to even enroll me but once on it the only doctor that took me within 5 miles was a doctor not educated in the U.S. but in a middle eastern country we aren't exactly friendly with. When I saw him the first time for an injured foot and chest pain he literally refused to do an exam on me. who goes in with chest pain and has a doctor that doesn't even listen to his chest. He never had me even remove my chest to listen or check to see if it was a muscle injury. He told me to take advil without actually doing an exam.

I'm not anti single payer just medicaid because normal doctors don't take it. ACA (Obamacare), you can get a regular medical plan and every doctor takes it but medicaid? good luck. ACA you'll be able to see a doc in 15 days not medicaid. It'll take you about six months. Oh also, medicaid, they need approval to even take an x-ray. I had a possible broken foot and they wanted 10 days to x-ray it. He's the rub they covered dental cleanings so i had one, they took xrays without a referall for that. Go figure.

RE: single payor system. Leaving aside political philosophies, this idea is so bad I cannot believe that adult humans subscribe to it. The very last organization I would turn something as important as my health care over to is the US government. I could cite the VA and then go on for hours about government-run disasters.

Yet you let for-profit insurance companies manage your health care? Not saying I'm for single payer but the only things I trust less than government are private sector money whores.

It shouldn't be Gov't or For-Profit.. It should be strictly non-profit insurance pay systems. Similar to Credit Unions, where the members are the owners; a Health Union if you will.. Where members are the voters on larger policy changes and costs covered. That would keep costs controlled and balanced to what people want covered relative to what they can bare to pay monthly or annually for insurance.

Some would say we tried that with BlueCross BlueCare network, but that network is a joke.. it's only partly non-profit.. and that part is taxed to hell to keep competition 'fair' with for-profit.. artificially raising it's costs/pricing..

Lobbyist.. again, are the reason.. I think all lobbyists should be shot on site.. much of the issues we see today is because business interests take priority based on who's hands are getting greased.

Solamar I agree with your ideas. I'm in favor keeping all options open so everyone can choose where they get their insurance. The only thing I strongly oppose is turning it over to the government. That is the worst of all possible outcomes.

What's worse than government incompetence? Having a company assign a dollar figure to your life.

mjs416 I don't let anyone but me manage my healthcare. If you let the government run healthcare, they will insist on managing YOUR healthcare. Game over.

Do you have health insurance through your work? Unless you pay for all your doctors visits and procedures out of pocket then yes - an insurance company manages your health care. And actually - prior to obamacare (not saying I agree with 100% of it) an insurance company could give you the middle finger for pre-existing conditions and lifetime caps.

No I don't have my insurance through work. I am a member of a private organization that self-insures. I pay out of pocket for everything and (thank God) haven't met a deductible in over 20 years. So, NO, no one manages my healthcare but me.

depends which system. Medicaid is horrible and it's run through private insurance companies. It's a government program administered by private insurers like Kaiser. ACA is very good and it's also run through private insurance companies. It's great and it's also a government program but administered by private insurers, again like kaiser, blue cross etc. The difference is ACA is efficient, computerized and modern, at least in California, and Medicaid (Medi-Cal in California) is ancient, on old computers and paper, dependent on manual labor and it's antiquated and slow. So i depends which program that is implemented not whether the Government is involved.

No matter how you feel about single-payer (pro or con), it will not help solve any of the problems concerning the rudimentary state of EHR infrastructure. Definitely not an "easy answer", and definitely not even the "first step". This is an IT issue, not a government policy or payer scheme one.

Actually, doublebullout, the government is the creator of the EHR system, and thus they are the source of the problem. In my opinion.

Actually, Scott, EHR systems predate government programs to incentivize them. So, no, the government can't get any credit (or blame) for creating EHR systems. However, if you must blame anything as the source of the push for a nationwide EHR network, blame Hurricane Katrina. The difficulty of treating many thousands of displaced Katrina refugees without access to their paper records was held up by EHR proponents as a main reason for encouraging adoption across the country.

Oh, brother...

Well, it's not surprising the anti-government, "big government is evil" folks have dutifully chimed in--as if ignorance and black and white thinking will cure what ails us...

If you haven't made your mind up yet, please don't believe all the hype against a single-payer system. They're winning, yes, but the day will come when EVERYONE finally gets tired of the old system of private insurance companies running most of the show and we all demand free health care. And, of course, the poorly organized and run VA and Medicare sectors will be changed and improved.

And, no, that doesn't mean the "Affordable Care Act" is a step in the right direction: actually, it's just what the insurance companies wanted (they had a hand in creating it, after all). And, no, don't trust the Democrats or the Republicans to change the system; as I said, we need to have so many citizens get tired of what's going on that they throw the bums out and elect pro-human rights and real "pro-life" officials that see that the single-payer system is the only one that makes sense.

I've been in health care for 30 years and I can tell you that what's going on is criminal, not to mention inefficient and wasteful. The for-profit model is killing people everyday, among other crimes.

Again: just because Federal dollars pay for the health care system doesn't require an inefficient and/or ineffective bureaucracy to run it. In fact, we have a multitude of inefficient and ineffective bureaucracies running it right now. Duh.

Nope. Canada has a single-payer system, and our health care has just as much backward, bureaucratic nonsense as this article describes. Attempts to modernize have inevitably resulted in the massive, failed boondoggles and corruption - look up the eHealth Ontario scandal for a typical example.

Peter I absolutely agree. During the announcement of Health Kit at WWDC all I could think was "cool idea, but its success - and even just basic usage - depends on whether or not doctors have the functionality on their end as well." Clearly they do not. At least not yet. I'm sure there are a select few out there whose patients could benefit from this, but it is certainly not the norm.

It may be a mess now, but I think it's getting better. As it happens, I work the IT Help Desk at MaineHealth, a hospital system based in Portland, ME, that runs about half the hospitals and affiliated offices in the state. Right now, there are about a half dozen different EHR systems in use, as each individual hospital was using something different, but we are slowly standardizing on one system called Epic.

At least one of the major hospital systems based in Boston, MA, is in the process of converting over to Epic.

From an interchange point of view, Epic is, or should be, the future for everyone, as it has built-in functionality to securely share with health providers not in the same domains, called CareEverywhere. So, for example, once that Boston system is on Epic, an affiliated specialist there can send medical info to the patient's primary care doctor in Portland.

And it has a patient-facing functionality called MyChart where you can see your lab results, schedule appointments, and communicate with your doctor(s) securely online.

I work as a system analyst for Bon Secours Health System in the Home Care department and we've already implemented Epic in our Hospitals. Next up - Home Care and Hospice.

We have a fax at work and customers still insist on faxing to get their orders. It's ridiculous and unreliable. Just let the fax die! No one will miss it. I have told people in my office to just get rid of the damn thing. People will adapt.

ಠ益ಠ

Peter our Sharp copiers now have wifi and are also air print friendly.
So you can send or print to our copiers with your phone or tablet without getting on the server.

Just thought i would let you know.

Excellent and fair article, Peter. I've been an EHR development and implementation specialist for 8 years, and you're right on point.

There is some good news, though. The largest EHR vendors (like EPIC, NextGen, Greenway, eClinical Works, Allscripts, and several more) are putting more emphasis on cross-platform compatibility when it comes to sharing information. CMS Meaningful Use requirements, as well as a host of health care quality reporting initiatives from other payers like BCBS and Humana, are driving this. For example, NextGen just announced its 100% free "Share" product (based on open source Mirth) for NextGen clients. This will allow NextGen clients to send C-CDA documents (a standardized document format supported by multiple EHR vendors) with referrals to any other "Share" users. It's just a start, but a good one.

If Apple's iHealthKit allows users to export their data in C-CDA, that will be huge. Naturally the Holy Grail would be exporting discrete data values to specific fields in multiple EHR software products, but that may not ever be practical, or even possible.

I work for a company that builds Healthcare Information Exchanges (HIE) to act as a secure hub for transferring the data as well as a data mapping engine to translate to/from incompatible formats. So I have to state these are my own opinions, not theirs. But yes, the key will be to get secure, compatible formats for exchanging EHR. Of course there are many successes in HIE, but whenever you are dealing with hospitals, physicians, patients, insurance companies, local / state / federal government, its really difficult to get them all to agree and co-fund and co-manage these exchanges. Its going to take time.

I actually work more specifically with hospitals from a finance, supply chain, and HR perspective and those areas seem to be much further along in information exchange. Direct deposit (ACH), purchase orders (EDI 850), employee data (HR-XML), etc. all have standards, but usage is still nowhere near 100%.

It costs money to implement these things and today the average hospital only makes 2.3% margin and by 2021 its predicated they will make -16.7% margin... If they don't invest heavily in both clinical and back office systems, optimization, and integration. This is pretty much my opening words to all the healthcare organizations I speak to these days.

Apple already signed up with some of the biggest healthcare providers in the nation. I'm with one of them, Sutter Health, and I can see my lab results, make appointments (including specialists), pay bills, email doctors and probably a host of other things I am not aware of, all online via their web site. I see no issue integrating that with Healthkit. I can certainly see places not working with Apple having a difficult time with this though.

To me it seems like one complaining that Apple could never offer streaming movies because none of the ISPs offer high speed internet where they live.

p.s. it sucks that the author and his family have had so many health issues. Stay healthy brother!

Sadly, it's all too true of the general state of medicine. But Kaiser Permanente is way ahead of the curve. I can see my test results, read my emails from my doc and renew prescriptions. It's a very good start.

You are missing two additional huge assumptions - that the data stores HealthKit is associated with are secure and private up to all HIPAA regulations, and that the devices gathering information are of diagnostic grade, which may or may not require certification.

Without HIPAA compliance, no physician is going to touch it until her legal obligations are clear. If the gear is more akin to the drugstore blood pressure cuff than a holter monitor, most physicians are going to be leery of basing any treatment plan on it.

Health system IT and legal departments routinely demand proof of complete HIPAA HITECH security compliance before any IT product or service is purchased. A sales rep for a product that isn't HIPAA compliant won't get very far these days.

Welcome to the wonderful world of HIPPA. The most ridiculous government implementation of a good idea done horribly wrong. What was meant to keep any unscrupulous company or person from gaining access to your private medical info has turned into a nightmare for most medical professionals

I can report from the Ems side of the act and how it does not allow for common sense actions and huge potential for delay in care due to its need for signatures and forms and general duplication of information

Say for instance you fall at a ice rink and try to catch yourself but instead injury both wrists. Ems is called. We arrive and provide care. But first due to the HIPPA law, we have to remove all the people that inevitably crowd around you. They are forbidden to overhear your medical history. Than I have to get your written consent before technically I can treat you. Wait, you have injured wrists and cannot sign paperwork. There is no where on our forms for verbal consent. Now I have to wait for a legal adult in your family to arrive to sign the consent form and to give the acknowledgement of receipt of written HIPPA policy that you must be given. But you tell me your 17 year old son is here and you wish for him to sign the forms. nope. Law states he has to be 18 to enter into a legal agreement ( just like a 16 year old cannot refuse treatment after a car accident if they are not with there legal guardian). Next after I get your written consent and than removed all people from earshot. I can start getting your medical history for the Ems report. But you tell me that the er has all that info already. Sorry you have to tell me again. I don't have access to that info and the law says I have to have a complete Ems form competed on each transport. But than you tell me our Ems system transported you last month after you got good poisoning and you gave all that info than. Sorry our computers cannot access previous patients info. You have to give me that info again.

That is just a small part of the whole messed up musical system. Not just technology problems but policy problems are part of it too

I'm positive Apple can solve all the issues with health book. :( Good luck.

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Keith Buenzow, you are right in ascribing the ultimate blame for the EHR mess to the federal government. They created the mess with the HIPAA law in 1996 and have done nothing to improve it since. It's a disaster.

Funny thing is, you aren't making anything up. My brother fell of his roof cleaning his gutters a few years ago and it took them forever to transport him because of this same crap. Thank God his injuries weren't life threatening or he would have died before they left his driveway!

I get my test results before my doctor even sees them! I love that I can email my doctor about my health care within this App that my health system has signed on to. I am looking forward to improvements in healthbook and health care management.

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"Faxing. Like a common 19th century field hand!"

HA!!! This is great! I cringe every time someone says the word "fax." I use MyFax just so I don't have to invest in a hardline and equipment at work. All of my faxes show up in my email in PDF format. When I show it to people they marvel like I have shown them a portal into another universe. Anyone in the healthcare bureaucracy listening?

Yes. There are EHR vendors who offer similar features already. Our fax servers handle thousands of documents weekly. Moreover, Meaningful Use Phase 2 requires EHR vendors to be able to transfer data securely via interfaces. (e.g., lab orders and results, radiology orders and reports, immunization data, syndromic surveillance data, cancer registry, etc.) Easier said than done, though, and expensive to implement.

I don't really care about sending it to Medical people I care about me having Access to the info where I can get it. That's what the app will start out as. In time it my progress to the distributor of our electronic records. But for now it is for me.

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