Recently, a NEJM perspective article titled No Small Change for the Health Information Economy advocates that a Health IT platform should be created in imitation of some of the successful technology platforms in other areas. Specifically the iphone was mentioned. The relevant paragraph:
The Apple iPhone, for example, uses a software platform with a published interface that allows software developers outside Apple to create applications; there are now nearly 10,000 applications that consumers can download and use with the common phone interface. The platform separates the system from the functionality provided by the applications. And the applications are substitutable: a consumer can download a calendar reminder system, reject it, and then download another one. The consumer is committed to the platform, but the applications compete on value and cost.
The whole article is worth a read, there are some pretty invaluable fundamental insights that are provided here that are right on. However, there are problems with the iphone app universe. Imitating that universe will require that those problems find new solutions. The NEJM article recognizes some of these implicit difficulties, and suggests that the solution is for the government to step in and evaluate individual applications.
Here is a quick list of things that are true about the iphone that really should not be true in a HIT platform:
- Apple plays favorites. Alot. Google was given special access to forbidden APIs for a voice application. Nike is another great example of company that created an application that has special privileges. It gets to have device integration that no one else gets. From Apples perspective these kind of things are acceptable because they create a user experience that is excellent. But it is not fair to developers. Developers who do not have the clout of Google or Nike know that they might be blown out of the water by a special deal that Apple might make with a bigger partner. It creates risk to developers and alot of resentment. Playing favorites gives Apple a short term advantage but ultimimately prevents a true meritocracy from developing. A Health IT plaform has to be truly open, and not play favorites.
- Apple protects its cash cows at the expense of innovation. Google Voice could have broken the back of the AT&T price for SMS messages, which can cost about $5000 per megabyte . It was rejected by Apple because it hit them in the cashflow. But Google Voice is probably one of the most fundamentally innovative technologies to appear in a long time. A Health IT platform will need to find a way for this kind of blatant incentive problem from occuring. Its harder then you might think.
- Apples approval process is inscrutable. Sometimes applications are rejected for content, even though that content is already available through Apple elsewhere. The approval process is slow, painful and does not make sense most importantly people hate it. The problem is that you have to have an approval process, and the reason that Apple is so closed about the process, probably has to do with the unpleasantness of watching sausage get made. It is not trivial to have an approval process that is fair and open, while also ensuring that developers do not abuse users. It takes time, which means money and it is not clear where that money will come from in a Health IT platform.
- Apple is a locked-in provider of software. This can easily be fixed by jail-breaking your iphone, so that you can easily download apps from other sources. Apple limits the source of downloads for a reason, you can download anything with an jail-broken iphone… even things that will make your iphone much less stable. How do you ensure that applications are trustworthy, without having an exclusive source? Tough one.
- Apple forbids creating applications that replicate core functionality. Which is exactly the opposite of what you want to do with a Health IT application. But no one will use the system unless you provide high-quality initial applications.
So is the iphone system, as an ideal, is fine to emulate. But you can see where your problems might be with such a platform by looking carefully at the problems that Apple is dealing with.
This is not really a criticism of the authors of the NEJM article… who, for instance, already see that the platform needs to be open source, addressing many of the problems that Apple is having by default… this is just to point out that all is not well in Apple land… analogies have their limits.
(update 9-01-09 I should talk about the iphone more often, this article has generated more comments, faster than anything I have written in years. One comment particularly stands out. Piyush Daiya over at androidmedapps.com has provided a very careful analysis that shows that Andriod is a better embodiment of the ten principles, that the NEJM authors endorsed. He is 100% right-on about that, and I wish I had thought to point that out myself. Thanks for reminding me, Piyush…)
-FT
I agree with your points, but just want to point out Apple is not the only platform that is guilty of these things. Regarding “playing favorites”, Facebook does the same by allowing Blackberry access to unpublished APIs for BB’s native Facebook app. And I would bet Microsoft will allow Amalga to access non-published areas of Healthvault, etc.
You find this pattern all over, and criticism always follows. Yet those businesses are still successful at promoting a substantial level of innovation with their platforms.
I’d like to know your opinion in more detail – what distinguishes Health IT in particular that in this case this model won’t work?
Very interesting read! In particular much of the health industry discussions around iPhone talk about it in terms of the new paradigm for mHealth and mobile usability (http://tinyurl.com/mqbtqp), so considering that other aspect about the platform as an open marketplace is refreshing.
Just want to point out Apple is not the only platform that is guilty of these things. Regarding “playing favorites”, Facebook does the same by allowing Blackberry access to unpublished APIs for BB’s native Facebook app. You can bet Microsoft will allow Amalga to access non-published areas of Healthvault, etc, etc.
This is a recurring pattern, and criticism always follows. Yet those businesses are still successful at promoting a some substantial level of innovation with their platforms.
I’d like to know your opinion in more detail – what distinguishes Health IT from other industries to the point that a lack of true “openness” would result in failure?
Good points but i disagree.
As a niche (albeit rapidly growing) Smartphone OS, Apple would be wise to continue to play favorites as it enters the mHealth market, particularly as the media darling status of the platform will ensure it can take its pick of the major players (eg. JnJ Lifescan) and get their genuine commitment.
Playing favorites is an effective strategy when the biggest barrier is not technology (it’s easy to piece that together) but the user experience and the delivery of a coherent/comprehensive offering.
David and Didier,
Both of you have made the same error. You assume that the issue is whether the corporation is successful is the relevant question. I do not care whether a single company thrives or fails. I am quite sure that Apples business model would function just fine in the Healthcare space. The problem is that this is not what Healthcare needs. You both are focused on what the software does, whether it pleases the end user. But we need more from healthcare software than just happy users. We need to have an ethical way of handling health information. That means that putting one party in a position of absolute control is inappropriate. The position that Apple and Facebook enjoy over their users is probably morally wrong in their respective space… but it is clearly wrong to have that role in healthcare IT.
Consider, Apple is happy to lock customers to one cell network. Would you be happy to be locked in to one doctor? Would you be happy to locked in to one heart monitor for patients?
What is ethical in IT is not always ethical in Health IT. These kind of back room dealings result in a dominant monopolistic player. That is exactly what medicine does not need. We already suffer because we have essentially superfelious insurance companies involved in Health finance. We must avoid those kind of power dynamics moving forward with health information.
-FT
Fred,
Nice article. Surprised how this kind article didn’t come up earlier. I blogged about how Android platform was better fit for Healthcare than Apple. It is available on http://www.androidmedapps.com/index.php/2009/06/ten-principles-for-fostering-development-of-platform-for-healthcare-information-technology/, if you are interested.
Fred,
I’m not necessarily an Apple hater, I even bought an iTouch (iPhone without a ball & chain monthly contract) for my partner–who btw rarely uses it except for easy WiFi access)
I might add that one reason the iPhone is successful though flawed is the Apple brand advertising (the supposedly intuitive interface is only partially so, the rest comes from paid clever informative ads that demonstrated how to use it). Success (iPod) breeds success (iPhone & other Apple products) breeds monopoly like behavior breeds loss of freedom (need to jailbreak etc).
I own the Nokia N800 tablet and believe it (and its N815 big brother) are woefully underrated and under-advertised in the US. Sure it has a slightly ‘under development’ feel, but it is Linux based, wide open for development, and when used as a platform for voice Skype (video Skype not yet feasible – at least on my old 2007 OS) is indistinguishable from a regular computer. It has all the great optional features (except cell phone feature) but lacks market share. It is just waiting for Health IT app development.
With the Nokia model you can choose whether you want to open yourself to independently developed applications or stay with the ‘official’ repositories. I love freedom.
While I agree with everything you say, Fred (I hate my iPhone for all those reasons and more), I think you’re sucked into the same trap as the original authors – as an example the quote:
……uses a software platform with a published interface that allows software developers…..
Can be applied equally to Windows, GNOME, KDE, (+whatever the Mac thing is called) to name a few. Yes, they are orders of magnitude more complex, but for…..
….a consumer can download a calendar reminder system, reject it, and then download another one…
..read ‘apt-get’. Or Firefox.
Having said that, there is a (just as proprietary as iPhone) health-specific app platform in Oracle HTB.
I think what separates the iphone platform from the other proprietary ones you mention is the fact that it is approaching an Internet/cloud based operating system/platform…. But I agree that there are FOSS ways to achieve the same thing…
-FT