Apple CareKit: Have They Done It Again?

If you’re thinking you’ve heard this story before, you’re not mistaken. Apple — arguably one of the most innovative and successful companies of our time — enters a new industry and completely flips it on its head through its blend of innovative design, intuitive user experience and groundbreaking technology. The outcome? A suite of products that’s so much better for consumers that it becomes the gold standard for everyone else in that industry to follow.

This happened with the personal computer industry, the mobile phone industry, and the music industry, among others. Apple even popularized a new market that no one thought would take off with the creation of the iPad and its dominance of the tablet industry. Now, with the introduction of the CareKit and Apple’s next foray into healthcare, is history about to repeat itself?
 
Not so fast…In healthcare, Apple may have met its toughest challenge yet. Although this notoriously complex and slow-moving industry is ripe for innovation and change (and there have been promising developments in the past few years), there are still key challenges that may stifle Apple’s usual speed of disruption.
 
To determine whether Apple’s transformation of healthcare will come to fruition, we’ll look at how their CareKit stacks up against three of the largest obstacles facing mobile health (or mHealth) apps today: interoperability, clinical viability, and adoption/retention.

What is the Apple CareKit?

Following the release of Apple ResearchKit in March 2015 — an open source framework which lets medical researches gather information for studies anonymously — Apple decided last month to focus on the audience where it shines the brightest: individual consumers.
 
The Apple CareKit is a new software framework designed to help developers build applications that enable people to actively manage their own medical conditions. iPhone apps using CareKit make it easier for individuals to keep track of treatment/care plans and monitor symptoms and medication adherence, with the goal of providing insights that help individuals better understand their own health. Coupled with the ability to share information with doctors, nurses or caregivers/family members, CareKit apps help people take a more proactive role in their health¹.

As Jeff Williams, Apple COO, states: “We believe that giving individuals the tools to understand what is happening with their health is incredibly powerful, and apps designed using CareKit make this a reality by empowering people to take a more active role in their care.”² 
 
A novel ambition, but how does it stack up against the biggest challenges facing mHealth today?

Interoperability

In healthcare, interoperability is “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.”³ The last part of that definition is key; Interoperability is not just about data exchange but how different technology systems can interpret data and leverage it to collectively advance the effective delivery of healthcare for individuals and communities.

Interoperability is one of the biggest challenges in healthcare right now, with communication gaps and the inability to seamlessly share data between different providers, hospitals and payers (and even departments within a health system!) currently the norm rather than the exception. The reasons for these obstacles range from a lack of standardization (or too general standards) and incompatible terminologies to the pervasive presence of outdated legacy systems⁴.
 
Because there is just so much data required from disparate sources (think electronic health records, claims data, drug data, activity data, etc.) to truly make a healthcare application viable, any new healthcare solution needs to prioritize and make interoperability a core feature. And this is especially true for mHealth apps. As James Hoffman from St. Jude Children’s Research Hospital asserts: “You could have a great app, but then if it doesn’t connect in with the electronic health records [or other software], then you’re missing a lot of crucial data.”⁵
 
Now when it comes to Apple, interoperability isn’t normally the first word that comes to mind. In fact, Apple has a reputation in the tech and developer community for being a predominantly proprietary company and having a closed system, often unable and/or unwilling to work with other technology systems. It’s only recently that they have been recognized for shifting to a broader open-source software platform (although Apple would claim otherwise)⁶.
 
Yet signs are pointing towards greater interoperability for the technology giant, with partnerships signed last year with Cisco and Google to collaborate on their respective products and solutions. It seems this move was made partly with healthcare in mind — Apple perhaps wanting to leverage 1) Cisco’s presence in hospital business communications systems and 2) Google’s Android Wear watch OS that is becoming popular with physicians⁷. Moreover, in a more overt play towards the health space, Apple has announced recent partnerships with IBM Watson, EHR powerhouse Epic, and the prestigious Mayo Clinic, amongst a multitude of other well-regarded hospital systems⁸.
 
Apple’s open-source framework for software development within the CareKit — allowing developers to build apps that share the same “innards” and smoothing the transfer of information between physicians and patients — along with its partnerships with some of the major players across the healthcare value chain, creates a potent combination to address interoperability. Though some of those in the tech community still have reservations about Apple’s proprietary reputation, remember, this is healthcare, where some of the leading software companies don’t even have open APIs! In this context, Apple has the potential to tackle interoperability with great success.

Clinical Viability

Would you download a mHealth app that doesn’t actually make you healthier? As Murray Aitken, Executive Director of the IMS Institute for Healthcare Informatics explains, this question isn’t as straightforward as we think: “For all the enthusiasm…there are still legitimate concerns by physicians about the evidence for which apps are good.”⁹ Most of the recent research on mHealth has focused on app usage rather than analyzing their clinical effectiveness. And although some apps claim to lower costs and improve outcomes when helping to manage diabetes or other chronic conditions, there are few peer-reviewed studies, the usual standard-bearer for demonstrating clinical efficacy in the healthcare industry.h

Truly robust evidence of clinical viability and positive healthcare outcomes takes time to generate and is processed against very rigorous standards, which you would hope for in healthcare. Just as pharmaceutical drugs need to go through rigorous clinical trials to get FDA approval, many mobile apps are undergoing scientific scrutiny to be taken seriously as a potential therapeutic solution. The level of efficacy required will differ based on the utility of the mHealth app, but scientific evidence will undoubtedly be necessary to increase provider confidence in leveraging and prescribing these products and solutions¹⁰. Whether this involves clinical trials or peer-review studies, this is going to be a key area to watch moving forward. And although we are already seeing traction in this space — for instance, the number of clinical trials using mobile apps having doubled in the past two years from 135 to 300¹¹ — there is still a long way to go before mHealth apps are fully integrated into standards of care and workflow processes.

While it is far too early to speculate on the clinical viability of apps coming out of the CareKit, we can look to its older sibling in the ResearchKit for some preliminary guidance. Some of the research studies launched with ResearchKit have been tremendously successful, in particular the launch of the original mPower research app, built using the ResearchKit by the University of Rochester in conjunction with Sage BioNetworks. This app has enrolled over 10,000 patients, making it the largest Parkinson’s study in history, with 93% of participants never having taken part in any kind of research before¹².
 
As Ray Dorsey, Professor of Neurology at the University of Rochester Medical Center, states “with ResearchKit, we quickly realized the power of mobile apps for running inexpensive, high-quality clinical studies with unprecedented reach.”¹³ Researchers have gained insights into key factors that make symptoms better or worse and are looking to extend the benefit of the research using CareKit modules.

In addition, thanks to ResearchKit-enabled apps, asthma triggers are now known across the entire US and neurologists are gaining a better understanding of the nature of epileptic attacks, among other conditions. Although this doesn’t directly showcase the clinical viability of apps coming out of CareKit, it does show promising signs of what can be achieved by putting technology into the right medical hands.
 
It’s mind-blowing what the built-in features of the iPhone, from the gyroscope and accelerometer to the camera and microphone, can tell us about our health. Whether detecting early signs of stroke through monitoring heart rhythms or identifying preliminary signs of lung cancer through our breath, the technology already exists for us to better understand our health. Opening this up to developers through the CareKit can accelerate these developments even further. Now we just need to figure out whether these technologies can actually make us healthier…. But Apple is clearly off to a good start.

Adoption and Retention

True consumer adoption and retention has been one of the largest hurdles for mHealth apps to achieve their goal of mainstream success over the past few years. Even the most popular healthcare apps on the market have struggled to get real traction and surpass the million number mark for overall downloads. So why is adoption so low? There are multiple factors at play here:

  • Interoperability: There is little value if mHealth apps can’t operate with other healthcare technology systems.
  • Clinical Viability: There is little evidence so far that these technologies actually have positive clinical outcomes.
  • Privacy: Concerns over privacy and data security with such sensitive information create reluctance of use and barriers to adoption.
  • User Experience: Some mHealth apps lack a user-friendly, convenient, and intuitive experience for consumers.
  • Paradox of Choice: With so many mHealth apps available today, it is difficult for the average individual to effectively evaluate them all and know what will work for them.

We addressed interoperability and clinical viability in the above sections. Regarding privacy, an Economist Intelligence Unit survey about mobile health conducted in 2015 found that 49% of survey respondents thought that consumer wariness about privacy violations could be a stumbling block for adoption, and 51% say data privacy risks are their biggest concerns¹⁴. The issue of privacy and data security cannot be understated. After all, we are dealing with the information that is dearest to us all — our personal biology and health information. In fact, this medical information is worth ten times more than credit card information on the black market, further underscoring the paramount importance of keeping it safe and secure¹⁵. Apple has demonstrated, especially in recent times, the lengths it is willing to go to ensure the privacy of its customers’ data, and with CareKit this will be no exception.

User experience is critical for adoption of any new technology (not to mention the retention of its users) and this is especially true for healthcare. Consumers want a seamless, integrated experience that is easy to use and doesn’t require them to constantly conduct tedious manual inputs of information. For example having to repeatedly submit data on their nutrition, medication, or other important biometric health information is a chore; this should all be automatically generated. There are few (if any) companies in the world that are better at tackling this than Apple. By combining its user-centric and intuitive design with a strong technology backbone through the CareKit, Apple is best positioned to transform this user experience.
 
Finally, the proliferation of apps makes it hard for both physicians and consumers to select the right one for them. There are currently over 165,000 mHealth apps available to consumers, yet just 36 apps account for nearly half of all downloads, while 40% of apps have fewer than 5,000 downloads¹⁶. While CareKit’s open platform for developers to build new mHealth apps might add yet more choices to the mix of apps in the short term, Apple’s brand cachet for both consumers and developers alike may become the signal in the noise of the universe of mHealth apps in the long term. If these apps can tackle some of the key challenges outlined here, then they can likely rise to the top and become the apps of choice for the medical community.

Conclusion

Apple isn’t the first player to build a platform for developers to create innovative healthcare apps that aim to help patients better manage their health. One of the most prominent examples of a large player entering this space was Aetna’s CarePass, an open API platform that connected and received data from a variety of health wearables and apps to build new healthcare tools. Unfortunately for Aetna, CarePass never really took off and folded in 2014 for a number of the reasons mentioned above: lack of integration with EHRs and other healthcare software, and lack of crossover of consumer health data to actionable clinical data leading to marginal adoption by Aetna’s customers¹⁷.
 
Apple must learn from Aetna’s mistakes in order to succeed. By solving for interoperability and clinical outcomes, it can slowly start to turn the dial on critical mass adoption. With more users, clinical outcomes will become more robust and the impetus for large players to create incentives for interoperability will increase. And the growing body of rich data from the iPhone’s huge user base can have enormous research benefits and speed up the development of medical treatments.

Oh… speaking of Apple’s user base. The latest statistics show that there are about 101 million iPhone users in the US alone, about a third of the overall population¹⁸. Even if they only get 1% adoption of apps created by CareKit, that still surpasses the most downloads currently by a mHealth app.

Maybe it’s in all of our interest to bet on Apple succeeding in healthcare. Besides…it’s Apple. From what we’ve seen in the past, is it really wise to bet against them?

Sources:

¹ Apple Press Release (2016) ‘Apple Advances Health Apps with CareKit’

² Apple Press Release (2016) ‘Apple Advances Health Apps with CareKit’

³ HIMSS (2013) ‘What is Interoperability?’

Healthcare IT News (2015) ‘EHRs and healthcare interoperability: The challenges, complexities, opportunities and reality’

IMS Institute for Healthcare Informatics (2015) ‘Patient Adoption of mHealth’

ZDNet (2015) ‘Was Apple the first major open-source company? Not even close’

‘Apple Gears Up with Interoperability Pacts, iPad Expansion’

InformationWeek Healthcare (2014) ‘Apple Partners with Epic, Mayo Clinic for HealthKit’

IMS Institute for Healthcare Informatics (2015) ‘Patient Adoption of mHealth’

¹⁰ IMS Institute for Healthcare Informatics (2015) ‘Patient Adoption of mHealth’

¹¹ IMS Institute for Healthcare Informatics (2015) ‘Patient Adoption of mHealth’

¹² Medical News Today (2016) ‘Apple’s new CareKit will help patients monitor medical conditions’

¹³ Medical News Today (2016) ‘Apple’s new CareKit will help patients monitor medical conditions’

¹⁴ The Economist Intelligence Unit (2015) ‘Power to the patient: How mobile technology is transforming healthcare’

¹⁵ Reuters (2014) ‘Your medical record is worth more to hackers than your credit card’

¹⁶ IMS Institute for Healthcare Informatics (2015) ‘Patient Adoption of mHealth’

¹⁷ Venture Beat (2014) ‘Failure of Aetna’s CarePass platform might be a bad omen for Apple HealthKit and others’

¹⁸ DMR Stats and Gadgets (2016) ‘iPhone Statistics’

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