Q&A: Christiana Care Health CIO talks up Apple's Health Record app

in December, Christiana Care went live with Apple's Health Record app, enabling patients to get an aggregated view of their electronic health record information on their mobile devices.

Apple Health Records
Apple / Darko Stojanovic

On Dec. 12, Delaware-based Christiana Care Health System went live with Apple's Health Record platform, enabling its patients to use the mobile app and gain real-time access on their iOS devices to information contained in their electronic health records (EHRs).

The non-profit healthcare system is home to more than 260 doctors, has more than 11,800 workers and includes a network of outpatient services, home health care, medical aid units, and two hospitals with a total of 1,227 beds, among other services. Last year, there were more than 52,000 patient admissions.

Christiana Care is one of about 200 health systems in the United States that have deployed Apple Health Record – something fewer than 5% of healthcare facilities have done. As of last month, about 700 of Christiana Care's patients were using the Health Record app on their devices to access EHR information.

Previously, medical records were held in multiple locations, requiring patients to log into each care provider’s website and piece together their information manually.

While not granular, the information in Apple's Health Record does include a patient's allergies, medical conditions, immunizations, lab results, medications, procedures and vital signs; patients also can receive automatic notifications when their health data is updated.

Apple's Health Record platform uses the Health Level Seven (HL7) application programming interface (API) and the Fast Healthcare Interoperability Resources (FHIR) industry standard; the two specifications enable all EHR platforms to upload basic patient data from a standard continuity of care document (CCDA) into a single Apple format, once a patient opts in.

Over the past several years, the FHIR interface has been made available to every major EMR vendor, enabling the aggregation of patient information from different  treatment facilities into a single view. There's still a long way to go before that information can be easily transmitted between health systems, however, including the Veterans Administration (VA).

That's an issue Christiana Care had to confront.

In addition, Google has yet to announce whether it will create an app that builds on FHIR-capabilities to enable EHR access through its Android platform. A spokesman for Google's healthcare efforts said this week there are no updates to share.

The following are excerpts from an interview with Randy Gaboriault, CIO and senior vice president for Innovation and Strategic Development at Christiana Care.

Randy Gaboriault, CIO Christina Care Christiana Care

Randy Gaboriault, CIO and senior vice president for Innovation and Strategic Development at Christiana Care.

What's your opinion of Apple's Health Record interface? "It's really thoughtfully designed through the lens of Apple creative people in such a way that in terms of the way it lays things out it presents information thoughtfully from a consumer perspective, which you naturally don't necessarily get from the electronic health records vendors themselves. They sort of engineer a solution, but it's technically architected versus consumer architected."

A common complaint is EHRs are not user friendly and they're all proprietary. What's been your experience? "I'd agree. When you look at the rollout of [EHRs] over the last 9 to 10 years in healthcare, the way the incentive structure was put in place by the federal government was through the program called "Meaningful Use," and the concept was that every provider had to meet it to qualify for this subsidy in order to help underwrite the implementation of electronic medical records.

"You could see this slow-motion train coming in ... as everybody had to implement them and you had to actually sign up a particular percentage of your patients [to be reimbursed]. That meant if I'm a diabetic and really engaged in my active management of my diabetes and have a great clinical team around me, I have a primary care physician with a [an EHR web] portal, I have an endocrinologist with a portal, I have an ophthalmologist with a portal, and I likely at some point would have a vascular surgeon with a portal. Really, what we've done with that model is it effectively structurally architected fragmentation of information – albeit digital, but still fragmented.

"So we went from fragmented [records] on paper that were inaccessible to fragmented digital information that, while at least accessible, was still fragmented. We forced patients through this for years.

Apple now becomes the iTunes if you will... to bring all that information into one place; a thousand songs in your pocket, now 1,000 health records in your pocket."

Apple - iOS 12 - Health Records Apple

What do you think is most user friendly about Apple's Health Record? "Take a lab result. Typically, a lab result is positive or negative, but you can also show those results in a range. Health Record shows you where you are in a horizontal graph depicting if you're in a normal range or not. Broadly, it helps you understand where you fall and it doesn't take any cognitive processing or research on behalf of the patient to know a normal.

"For the patient, that immediately queues up questions for their physician because they're now informed. Patients, and myself, really find this inspiring.

"If you look at the standard way information is presented in an [EHR], the result is clinically interpreted by a domain expert, and for them it makes sense. But they don't think twice about a non-clinician translating it. We all have a one-in-one chance of intersecting with the healthcare system. So, it's going to become important for us at some point, either as a patient, a parent of a child, an advocate of an aging parent, to understand that information."

What was the problem prior to rolling out Apple Health Record? "Let's talk about a very real-world scenario. As health systems began to grow through more and more practices and these [Meaningful Use] rules in the marketplace changed, a lot of practices wanted to affiliate with [specific EHR] systems.

"One example is we've got about 70 unique EHRs in use in the state of Delaware. There's EPIC, and Cerner, and there's Athena, and NextGen and eClinical Works and there's Greenway; there's all of these EHRs. When we would bring on a new cardiology practice or a new pulmonary practice, they'd all gone through that journey of implementing their own [EHR]; now you've got patients who may be receiving care from the same system, but their data may reside in different systems, just because of the way healthcare systems have come together.

"What we did first was defragmentation, which was moving everybody onto a standard platform. So strategy one for us was to build a completely integrated record so that at least patients had one place to go. Over the past couple of years, that went from website accessible to being packaged as a mobile friendly interface, but it still lacked that consumer design DNA that you'd experience with Apple. It still published results for a clinical audience rather than a patient audience."

Apple Health Record mobile Apple

Applle's Health Record enables a view of high-level patient care data from different healthcare providers through standard industry interfaces."

How did you create a mobile front? "It was a combination of two things. So most of the [EHRs] provide some sort of mobile friendly front and we also skimmed our own front on top of that allowing lab patients to do a couple of things. You could log on and choose to go with your clinical record or choose to do certain things like find a provider, which wouldn't necessarily be integrated into your electronic health record. We also built into it the capability to access clinical notes – what we call "Open Notes." So, patients have 100% access to the stuff your doctors types.

"What's interesting about that is it forces clinicians, rather than writing for a peer audience, to actually rethink and rearchitect what they write in a way that the patient is not only the subject but also a community member in the conversation.

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