Thursday, June 26, 2014

Unity Farm Journal - 4th week of June 2014

Last weekend, we had two days of clear, warm weather, perfect for harvesting vegetables, inoculating mushrooms, and caring for bees.

We received 40 pounds of mushroom spawn from our supplier, Field and Forest, and we created two new mushroom areas - 4 raised beds of compost with Agaricus (almond mushroom) and 12 new stacks of logs with Oysters.    The Golden Oysters are beginning to fruit in the warm humidity of summer afternoons.

Eating on the farm can be as simple as taking a basket to the hoop house and gathering a potpourri of delectable vegetables.    Sunday’s brunch was a bowl of fresh strawberries, handfuls of snap peas and tender zucchini pancakes.

We’re at the height of nectar production on the 15 acres of the farm and our 12 bee hives are storing away honey at a rapid clip.   At this point, we’ve done our best to gives the bees their best chance to build up brood and food stores for the winter ahead (yes, Christmas is 6 months from now).   When nectar flows stop in July, all the food reserves until next Spring will have been stored.    Here’s what the bee yard looks like as of this morning.    Plants like borage, chamomile, and clethra line the bee yard, while salt marsh hay keeps the weeds to a minimum.

This weekend includes many animal care tasks, updating immunizations, ensuring that our pregnant alpaca are healthy for their upcoming late July deliveries, and moving the keets (baby guinea fowl) that were hatched by the ducks to the coop.     On a farm, you never know what each day will bring, so I look forward to the 12 hours a day of joyful work that awaits.

Wednesday, June 25, 2014

Interoperability in Real Life

On Monday afternoon my wife was speaking with my 82 year old father-in-law, when he began speaking in word salad - not slurring his words, but clearly speaking words that made no sense.   He had no numbness or weakness, no confusion, and no change in consciousness.  After 5 minutes all symptoms resolved.

My wife called me and after hearing the history, I knew he was having a transient ischemic attack (TIA).   Given that he was stable, I recommended that we coordinate an immediate hospitalization at a site suggested by his primary care physician (PCP) rather than take an ambulance to a random nearby location.     My wife called his PCP and was given a choice of two hospitals - one with IT systems I control and one with IT systems I do not.   She drove him to the hospital that offered care coordination via interoperable IT systems.

My father-in-law has records at 3 locations - an academic medical center (home built EHR), a community hospital (Meditech), and a multi-speciality practice group affiliated with but not owned by BIDMC (Epic).

Upon arrival at the Emergency Department, he had a blood pressure of 180/90.   The physician asked - what is his baseline blood pressure and has it varied over the past 6 months?   The physician clicked on the external records link we’ve placed in Meditech and he immediately viewed my father-in-law’s blood pressures in his PCP's Epic system.  

He then asked about recently specialty care.  One click later, all this information appeared from the academic medical center.

His care was materially different because his continuous lifetime record - inpatient, outpatient and emergency department - was available without going to a separate portal or  adopting a new workflow.

Over 24 hours, he received an echocardiogram, EKG, carotid ultrasound, and MRI.   All were essentially normal and he was started on aspirin and will followup with a neurologist recommended by his PCP.  Upon discharge, he was given a meaningful use care summary and a transition of care document was sent electronically back to his PCP.

Interoperability becomes much more real when you watch your own family members experience it.    As I’ve said before, the end of paper records and data silos will happen in our lifetimes.  This will not be a problem we pass along to our children!

Thursday, June 19, 2014

Unity Farm Journal - Third Week of June 2014

With evenings lit by the amber hues of the June Honey Moon, we diligently worked on bees, hives, and honey over Father’s Day weekend.

At the beginning of the weekend, we had 11 hives, but with the transfer of queen cells to prevent swarming we ended the weekend with 12 hives.

One by one we opened each hive, checked for signs of health issues, looked for queens, checked eggs/larva, inventoried food stores, and documented wax building progress.   Frame by frame we reviewed the status of 100,000 bees.    Here’s our report

Hive 1
First honey super (extra food stores) is full and some is capped
Starting to build out second honey super comb
Went into second deep (core of the hive) and found two frames with queen cells that are not yet capped
Gave one frame to hive 5 since it is queenless
Started hive 12 with one frame with 5 queen cells and also took two more frames of brood and nurse bees
Gave hive 1 four new frames of comb to work on

Hive 2
Building out some of the comb in the honey super
Looks healthy with plenty of brood
Did not go into bottom deep since second deep was good

Hive 3
Weak hive
Spotty laying of eggs and have not drawn out more than 60% of the comb in the first deep
Watch queen for poor mating
Added syrup to feeder
May be able to add a second deep at next inspection

Hive 4
Filled most of second deep with comb and brood
Took off feeder and gave them a honey super

Hive 5
No queen or eggs
Removed four frames and gave 3 to hive 11 and 1 to hive 9
Found a frame with eggs in hive 7 and gave it to hive 5
Added a queen obtained from another beekeeper

Hive 6
70% comb built out so may be able to add second super next week
Added syrup
Watch for egg laying in next two weeks if queen successfully mates

Hive 7
Saw queen laying in upper box
Built out 45% of frames
Beetle larvae in feeder cleaned out
Added syrup

Hive 8
Top brood chamber 60% built out in comb and already has brood of all ages
Added syrup

Hive 9
Added syrup
Left hive alone since a saw queen piping after hatching yesterday

Hive 10
Added syrup

Hive 11
Queen hatched today
Need to add a frame of brood
Added syrup

Hive 12
Started with three frames of brood and five queen cells uncapped from hive 1
Also nurse bees in abundance

While we were doing our work, a purple swallowtail decided to join us, looking for any traces of nectar on the burr comb we removed (extra comb built between frames).

At the end of the day, we had a large collection of wax fragments from our cleanup of every hive component.    My father in law and I built a solar wax melter (cypress with a lexan cover) on Father’s Day morning - it was a dad thing.   Wax melts at 144F and the greenhouse effect works very well to heat a box that hot.   We placed the raw wax pieces (which contain many contaminants from tree resin to bee parts) in women’s stockings which serve as a perfect filter.   Below are photographs of the raw wax/stockings, the melter, and the finished product.   We processed 3 pounds of wax over the weekend and we’ll be making votive candles and lip balm from it.

The rest of the weekend was filled with the usual Unity Farm visits

Egg laying snapping turtles

Wild turkeys in a meadow

The deer and groundhogs were very active but too fast to get a good picture.

We harvested Shitake (4 different subtypes) and Golden Oyster (has a citrus-like taste).   There’s nothing better than a fresh Shitake stir fry.

Next weekend will be more mushroom inoculation, and vegetable harvesting.   It’s definitely the peak of our vegetable season.

Tuesday, June 17, 2014

The June HIT Standards Committee

The June HIT Standards Committee focused on an update and evaluation of the standards and interoperability framework initiatives, consistent with the overall theme of ONC’s recent reorganization and strategic plan to focus on fewer goals with a greater depth.   Steve Posnack, who now leads the ONC Office of Standards and Technology, introduced the topic.   Mera Choi and John Feikema provided an overall update.    Evelyn Gallego, Jonathan Coleman, and Marc Hadley described their projects.

It was truly an amazing discussion.    The energy in the room was palpable.

Common themes included
*Embrace FHIR, JSON, REST and OAuth
*Avoid a different standard for every use case - research, clinical care, and population health should use the same standards if the standards are suitable for purpose
*Limit scope as needed to get real transactions in production
*Use emerging technologies whenever possible - use "early automobiles" not faster horses or fancier buggy whips
*Keep it simple (as simple as possible but no simpler)
*Support modularity and an innovative ecosystem of third party apps with Application Programming Interfaces (read/write) in EHRs
*Data provenance (who generated the data) and data integrity/quality are important
*Integration of transactions into sender and receiver workflow must be considered
*Market forces are even more powerful incentives than certification/regulation
*A trust fabric with appropriate security to respect patient privacy preferences is foundational

With these themes in mind, every member of the committee was asked to name the most important standards and interoperability framework priority.

Everyone agreed that data provenance/integrity and support for query-based exchange via APIs were the topics we should work on.

The entire committee came to a conclusion, representing independent opinions from a multi-stakeholder perspective, that aligned perfectly with ONC’s 10 year vision.   Per the recent ONC whitepaper, the goals of the next 3 years should be

*provider and patient ability to send, receive, query, and use data
*data provenance/quality and patient matching
*privacy and trust

At our next meeting we’ll drill deeper into a refinement of the standards and interoperability framework by asking what we are missing in the existing initiatives that is foundational to the ONC 10 year vision.   Although Meaningful Use is important, we need to think about standards beyond the confines of the next stage of Meaningful Use.

After the framework discussion, Dixie Baker and Lisa Gallagher provided an update on the Privacy and Security Workgroup’s evaluation of the 2015 Certification Notice of Proposed Rulemaking.   They recommended edits to 5 areas, which were approved by consensus:

Two-Factor Authentication - ONC should use a risk based framework aligned with DEA controlled substance e-prescribing without generally requiring two-factor authentication capability.

Accounting of Disclosures - given that the concept of a "Complete EHR" has been replaced with a series of selectable criteria, there no longer needs to be a statement that accounting of disclosures is optional.

Audit clarification within the context of ASTM E2147 -  The PSWG believes it is feasible to certify EHR compliance with the  ASTM E2147 audit log standard, and does not recommend ONC specify other actions in an updated standard for the 2017 Edition, or that ONC consider any additional standards.

Server authentication - A mechanism should exist for computer to computer data transfers as part of a trust fabric.

Automatic time-outs -  A timeout should restrict access to protected health information and ONC does not need to be prescriptive about how this happens.

A great meeting!

Thursday, June 12, 2014

Unity Farm Journal - Second Week of June 2014

My wife and I did not think it was possible for a duck to hatch guinea fowl, but this week it happened.

Guinea fowl are horrible parents.

They lay their eggs in piles throughout the forest and then abandon them.   Even if a “designated layer” sits on the communal egg pile, the young often get wet and chilled after hatching and do not make it back to the coop.

A few weeks ago, the guineas decided to lay a few eggs in the duck house.    Five of the ducks instantly began sitting on the eggs in shifts, keep them warm and protected.

Our sense was that dry guineas offer a very different humidity environment than constantly wet ducks.

Imagine Kathy’s surprise when she went into the duck house and found baby guineas running around.

In the end, it was nature over nurture - the guineas had no interest in swimming and the duck parents thought their new offspring were defective - a different kind of ugly duckling.   We brought four baby guineas into the warmth of our brooder and today they are happy and healthy.   In a few weeks, when they’re older and stronger, we’ll introduce the babies to the community of guineas so they can integrate into the family.

Speaking of ducks, one of our harlequins, Belle, had a traumatic eye injury, likely from her interactions with wild ducks which frequently visit the duck pond.   As the farm medical care professional, I know that Pseudomonas infection of the eye is a real barnyard risk.    Kathy and I did minor surgery to clean remove debris and loose tissue from the eye.   We washed the eye with saline and have been using Tobramycin ophthalmic twice a day.    They eye is now open and healing.   Here's a comparison of the injured eye to the good eye.   In a few weeks, we hope Belle will be good as new.

I’m 52 and too old for a mid-life crisis.   Some older men seek a red car that brings back memories of their youth.    Now that we are producing hundreds of pounds of vegetables, honey, mushrooms, and fiber, we needed something other than a Prius to haul farm goods to our customers.      We purchased a 2013 Ford Transit, the last of the “european style” delivery vans available from Ford.   Here’s my post mid-life crisis red car.

The weekend ahead will be a “honey do” list - spin honey, maintain hives, build new hives,  create new honey frames, etc.   I look forward to less trail building and more bee work.

Wednesday, June 11, 2014

The ONC 10 Year Vision

On June 5th 2014, ONC released  “Connecting Health and Care for the Nation: a 10-Year Vision to Achieve an Interoperable Health IT Infrastructure"

The plan is divided in 3 year goals, 6 year goals, and 10 year goals.  Five specific tactics support the strategies.

Below is a summary of the report and a few comments from my Massachusetts experience that support the reasonableness of the ONC goals.   Based on the trajectory of current technology and policy, I’m confident we can achieve these milestones.   One caveat - since Meaningful Use Stage 3 takes effect in 2017, three years from now, we will need to adjust the scope and focus of Stage 3 to align with the ONC three year goals.   I’ve written in previous posts that we should simplify future stages of Meaningful Use to less than 10 policy goals, highlighting interoperability, without being overly prescriptive.   The ONC Vision gives us the opportunity to do that.

Three-Year Agenda: Send,  Receive,  Find, and Use Health Information to Improve Health Care Quality

1.  Ensure that individuals and care providers can send, receive, find, and use a basic set of essential health information.  This requires the ability to appropriately search for and retrieve health information, in addition to point-to-point information sharing.

Massachusetts has already built statewide Direct gateways for transport of payloads from one location to another.   The Commonwealth is also live with a master citizen index, relationship locator service, consent repository, and the necessary web services/standards to support query/retrieve workflows.   We stand ready to share 100% of our implementation guides with the HIT Standards Committee and ONC.    I know that the send, receive, find, and use goal is achievable in three years, because Massachusetts is in production with the functionality today.

2.  Address critical issues such as data provenance, data quality/reliability, and patient matching.

As with the first goal, the state government of Massachusetts has already implemented statewide patient data matching and a team to support demographic data cleanup.   BIDMC has worked with the Massachusetts eHealth collaborative to build a community-wide Quality Data Center that successful merges CCDAs from the state HIE, taking into account data provenance,  patient matching and data quality issues. We’ve experienced the operational realities of maintaining a public utility for patient identity management and data normalization, so we know it is possible to achieve at scale.

3.  Enhance trust by addressing key privacy, security, and business policy and practice challenges to advance secure, authorized health information exchange across existing networks.

Massachusetts has established a set of HISP to HISP connections using a combination of whitelists and blacklists.   Our approach has become simpler over time, shaped by the experience of day to day operations.   I am confident that a trust fabric of federated networks is possible without overcomplicating the technology and policy.

Six-Year Agenda: Use Information to Improve Health Care Quality and Lower Cost

1.  Enable individuals to be active participants in managing their care as an important contributor of information to the health record (e.g., patient experience, self-rated health, and self-generated data).

Since 1999, Beth Israel Deaconess has been gathering patient generated data in its PHR and EHR.   Massachusetts  has already connected sources of patient generated data to the health information exchange, delivering data from cloud-hosted consumer applications to the BIDMC EHR.  I’ve reviewed the Apple Healthkit technology and am confident it can serve as healthcare device middleware in the home.   I look forward to working with Apple on the terminology standards for HealthKit that will enable semantic interoperability between patients and providers.

2.  Multi-payer claims databases, clinical data registries, and other data aggregators will incrementally become more integrated as part of an interoperable technology ecosystem.

As mentioned above, BIDMC has aggregated clinical and financial transactions for its ACO in a community wide quality data center connected to the health information exchange.   We’ve sent over 2 million transactions from EHRs through the HIE to the data center and are confident that the all payer claims database, registries, and quality reporting goals in ONC’s Vision are achievable.

3.  As value-based payment gains traction across Medicare, Medicaid, and commercial payers and purchasers, there will be new methods of measuring clinical quality that represent the most important aspects of care delivery and health outcomes.

Massachusetts stakeholders agree that current quality measurement methods are insufficient.  BIDMC’s approach has been to send clinical observations, in the millions, to a third party cloud hosted solution which has the agility to compute all measures for ACO reporting, PQRS reporting, and pay for performance reporting.    We do not need hardcoded quality measures in our EHRs and the cloud hosted approach provides low cost and high value.   ONC’s vision is the right one.

10-Year Agenda: The Learning Health System

1.  More standardized data collection, sharing, and aggregation for patient-centered outcomes research.

All the hospitals associated with Harvard have implemented I2B2 for federated query of clinical data in support of outcomes research.  The ONC QueryHealth project in the Standards and Interoperability framework leverages the I2B2 experience.   Hundreds of studies and thousands of queries have already been enabled by I2B2, so this is achievable.

2.  Clinical decision support that is widely available to all stakeholders

BIDMC has implemented cloud hosted, centrally curated, decision support in several contexts including radiology ordering (with lab ordering currently in progress).  As suggested by ONC HealtheDecisions project in the Standards and Interoperability framework, we send questions to the cloud and receive knowledge as a response.    This works today and is definitely achievable in commercial EHR within 10 years.

3.  Clinical trials, public health surveillance, and evidence available at the point of care

Massachusetts has connected all of its public health data gathering and reporting functionality to the state HIE. The Meaningful Use transactions (immunizations, syndromic surveillance, reportable lab) are already in live production.    We are beginning work on query/retrieve of public health data (prescription drug monitoring program, immunization history), so I know this will be ready in 10 years.

The tactics listed by ONC include
1.  Core technical standards and functions - although Meaningful Use includes most of the content, vocabulary and transport standards needed to support the ONC vision, there are a few gaps to fill.   Massachusetts has already filled some of the gaps, so I’m confident the standards can be ready.

2.   Certification to support adoption and optimization of health IT products and services - the concept of certification is good. Now that ONC has reorganized and those writing the regulation will be responsible for certification and testing, I’m confident that the certification challenges of the past can be overcome.

3.  Privacy and security protections for health information - with increased Office of Civil Rights enforcement of the HIPAA Omnibus Rule, healthcare organizations throughout the country are building privacy educational programs and enhancing information security staffing, so the industry will be ready for new requirements.

4.  Support business, clinical, cultural, and regulatory environment - To me, the one great challenge of Meaningful Use Stage 2 has been the readiness of the cultural environment for such requirements as community wide transition of care summary exchange.   ONC’s focus on the ecosystem as well as policy/technology is welcome.

5.  Rules of engagement and governance of health information exchange - Each state has implemented its own rules of the road.  Massachusetts has solved its consent policy issues, but those solutions are different than other New England states.   I do not expect ONC to establish a single set of policies for the country, but a framework for policy development and governance would be very helpful.

ONC has done a good job with this vision statement, outlining a series of stepwise goals, reducing the scope of its projects so that existing staff/budgets can be applied at greater depth to fewer initiatives.    I look forward to being a part of the process.

Thursday, June 5, 2014

Unity Farm Journal - First Week of June 2014

As Spring begins to transform into Summer, everything on the farm is a sea of green.

As Paul Simon wrote in 1973 

They give us those nice bright colors
They give us the greens of summers
Makes you think all the world's
a sunny day

All of the guinea fowl are in crazed Summer mating mode, with males chasing females all over the property and communal nests appearing in the forest, with clusters of 30-40 eggs.   On some nights a “designated layer” sits on the nest and sometimes does not survive the prowling foxes, coyotes and fisher cats.    We lost one guinea this week, so we’re down to 27.

I’ve lined all our trails and pastures with bird houses.   Since we cleared 2 acres for the orchard, large numbers of tree swallows and barn swallows have arrived.   As I walk the dogs in the large meadow, tree swallows peek out of their nesting boxes at me.   A mated pair of barn swallows  has created a nest in the rafters of barn.

Every day we’re harvesting vegetables from the hoop house and dinner includes fresh Unity Farm kale, spinach,lettuces, peas, and garlic, pictured below.

With all the growth of late spring, we've had to mow the orchard and meadows.  Now that I'm mowing 5 acres, I've had to retire the push mower and use an exMark commercial mower.   The orchard is a 20 degree hill so mowing takes a lot of upper body strength.   I use a brush cutter around the blueberries and apple trees then use the mower to trim the 2 feet of clover to 4 inches high.   I've tried to save as much clover as possible since the bees are beginning to harvest clover nectar for our  light, fragrant spring honey.

Trail maintenance continues and I completed the mulching of the Orchard Trail and portion of the Marsh trail.    My work was very timely since Kathy walked the trails with a local historian this week, pointing out the Revolutionary War era hand dug well, the Sherborn Powder House, and the grave of James Bullard, the powder house keeper, all of which are part of Unity Farm.

We pulled another ton of fallen poplar out of the forest and are busy inoculating logs with mushroom spawn.   We have a few visitors from California at the farm this weekend and I'll recruit them into mushroom permaculture.

Finally, we’re continuing our honey extraction.  This weekend we will spin the honey from an additional 22 frames - likely getting another 10-11 quarts of late season honey from last Fall.

Every night the sounds of Unity Farm become more Summer-like with crickets, bull frogs, and the gobble of wild turkeys climbing to their roosts in the tall pine trees.   Next week, I’ll post the sounds of approaching Summer from Unity Farm.

Wednesday, June 4, 2014

The ONC Reorganization

Many people have asked me to explain the recent reorganization at ONC, reducing 17 different offices to 10:

Office of Care Transformation:  Kelly Cronin
Office of the Chief Privacy Officer:   Joy Pritts
Office of the Chief Operating Officer:   Lisa Lewis
Office of the Chief Scientist:  Doug Fridsma, MD, PhD
Office of Clinical Quality and Safety:  Judy Murphy, RN
Office of Planning, Evaluation, and Analysis:  Seth Pazinski
Office of Policy:  Jodi Daniel
Office of Programs:  Kim Lynch
Office of Public Affairs and Communications:  Nora Super
Office of Standards and Technology:  Steve Posnack

In case you are looking for the Office of Consumer eHealth, it’s still there - in the Office of Programs.

Simply, the era of stimulus has ended and ONC no longer has the operating budget to do as many projects as fast as during the era of ARRA.

I believe that ONC will need to reduce the number of Standards and Interoperability framework (S&I) initiatives from 18 to a more manageable number - maybe 5.   This will be very challenging because many of the projects are priorities of other federal agencies.

Just as Apple has created an ecosystem for healthcare with HealthKit, I’m hopeful that a few good standards can accelerate the ecosystem.   For example, if content moves from CCDA to FHIR/JSON, transport moves from SMTP/SOAP to REST, and application program interfaces are available for home care devices/iPhone apps, then many S&I use cases currently requiring specialized standards become doable with the more generalizable approaches.   Remember, the web itself is basically HTML and HTTP.    If ONC focuses on fewer projects with greater depth, we’ll have the HTML (FHIR) and HTTP (REST) for healthcare.

Similarly, I’m hopeful that ONC will simplify Meaningful Use.  When you read articles like “Hitting the Wall on Meaningful Use”, you realize that Stage 2 tried to do too much, too fast, before the ecosystem was ready to support the change.    Stage 3 proposals should focus on outcomes and give providers/vendors the opportunity to achieve those outcomes without being overly prescriptive.    A more streamlined ONC, with better internal coordination can achieve that.   For example, in the new structure, the person responsible for regulation writing is now the person responsible for testing and certification - a perfect alignment of accountability.

I look forward to working on the HIT Standards Committee advising the new ONC.  I’m optimistic that the process will be more agile and responsive.

Tuesday, June 3, 2014

Apple Enters the Healthcare Software Ecosystem

Here's a guest post by Dr. Henry Feldman from BIDMC's Division of Clinical Informatics:

I am writing this from the Apple Worldwide Developer Conference (WWDC) today here in San Francisco, where I got to substitute for John Halamka at the Keynote (now I keep having urges to raise Alpacas); John missed the most amazing seats [front row center!]. There were many, many, many (I can not recall a set of software announcements of this scale from Apple) new technologies that were announced, demoed and discussed, but I will limit this entry to a few technologies that have implications for healthcare.

If you remember the state of digital music, prior to the introduction of the iPod and iTunes music store, that is where I feel the current state of the healthcare app industry is at; there is no common infrastructure between any of the offerings, and consumers have been somewhat ambivalent towards them as everything is a data island; switching apps causes data loss and is not a pleasant experience for patients. Amazingly there are 40,000+ apps on the App store at Apple alone, showing huge demand from users, but probably a handful can talk to each other in a meaningful way; this is both on the consumer and professional side of healthcare.

Individual vendors such as Withings have made impressive strides towards data consolidation on the platform, but these are not baked into the OS, so will always have a lower adoption rate. If we take the music industry example further, Apple entering a market with a full push of an ecosystem at their scale, legitimizes the technology in ways that other vendors simply can’t match. In their introduction, Apple introduced 2 healthcare specific items, the Health App and HealthKit Framework.

The Health app is a central data repository on your phone that any HealthKit enabled app can deposit data into or read data from, under user control; it also serves as a display dashboard for the user of this data repository if they don’t want to use the source app. This will allow patients to aggregate their fitness and health data from a myriad of sensors (e.g. FitBit) and sources (say a PHR app) into a single place.

They showed using this as a gateway to broker between health goals, such as blood pressure control, set up by a physician on the Mayo Clinic’s EHR and then tying that back to the patient via the PHR app/Health App linkage. Since the patient can push data back once they grant permission to an app, you can imagine as a physician who is titrating blood pressure medications in the home, getting objective data from the patient electronically (the last mile problem). Engaging our patients is both our sworn duty as physicians and over time as we learn to use these tools effectively, will help us help our patients to be more self sufficient; as our mentor Warner Slack always says “the least utilized resource in the healthcare system is the patient!”

HealthKit is to me in some ways more significant, as it allows a common platform internally for health apps allowing for common data formats, data exchange, storage and presentation to the patient; Apple again is establishing an ecosystem here. Having centralized support for healthcare data, makes applications more interoperable and useful. Several of the healthcare vendors, such as Epic (I was seated near their CTO who was pumped), who were near me were very excited about integrating this framework into their apps. This will raise all the healthcare apps to a new level, and greatly increase utility and innovation around these apps.

There is some very legitimate concern for providers, that this will enable an avalanche of data (on top of the tsunami we already are being washed by) from patients, and we will have to figure out how to cope with this. With easier access to sensor data, patients will have to be educated, that not all changes are pathologic. A million years of evolution has allowed your body to control things like heart rate robustly, so we will need to be very specific in our education to patients about what they should and should not get concerned about. For patients undergoing fitness programs, this is a superb way to track fitness and can report objective improvement metrics to their healthcare provider or trainer.

Now for some non-healthcare specific technologies, that are very useful in healthcare.

TouchId, the technology behind the fingerprint login on the iPhone, is now open to 3rd party applications. This means that instead of relentlessly typing a password (which of course gets longer/more complicated with each policy change) you could for instance sign orders or login to your EHR; I type my password well over 100 times per day into the EHRs that I use, which gets frustrating, and can probably be quantified in lost productivity over all the docs multiplied by all the time spent reentering passwords as a serious sum of money.

A tiny change is that you can now respond to text messages and accept/decline appointments without leaving your current application. Why is this significant? While for many users this is a convenience, in healthcare this may prevent medical errors. John has previously cited a case of distracted computing occurring in the middle of creating orders for a patient, and leaving the task without signing orders, etc. Staying in context makes this error much harder to do.

Finally I will talk about Swift. Apple has created a new object oriented language, called Swift, which as they phrased it “took the C out of Objective-C”. This excited me as it reduces many common programming errors that are easy to create in C (for non-programmers, C is a language where you can do anything you gosh-darned please; and with great power comes great responsibility). They seemed to have stuck in some of the automagic of a language like Python with some of the strictness of Java, and then added modern power features, all in a very fast compiled language (under the awesome LLVM compiler).

In summary, I think we will look back on the WWDC 2014 as a day when Apple really brought the healthcare app industry to a whole new level, especially on the consumer side, and also putting in a robust infrastructure for professional and consumer applications to exchange data. This is a 1.0 release, and undoubtedly it will grow over time, and we will see creative uses, which will inspire all of us to grow with it. Similar to digital music, we are at the beginning of a major shift, and we will have to see what develops out of this, but getting consumers excited about healthcare data, and getting vendors excited about sharing data with each other via the patient, has got to be a good thing.