More information on CCDA and HealthKit

Last week I reported that Apple is bringing support for CCDA to HealthKit, enabling users to download their medical records from any Meaningful Use Stage 2-compliant electronic health record system. At the time there wasn't much additional information available. Since that time, Apple has publicly posted the WWDC session on the topic, which can be viewed here. The portion on Health Records starts at the 17:20 mark.

From the presentation it is clear that Apple allows users to download and view their documents:

One question I've received, however, is what HealthKit does with the document once it has been downloaded, i.e., is it "parsed" in such a way that makes the discreet data elements available for use by other applications, or visible in HealthKit? For example, would blood pressure, weight, or glucose values be added automatically to the appropriate fields in HealthKit?

Currently, the answer appears to be "no." According to the limited documentation of the HKCDADocument Class, the class has 5 instance properties, one of which is the document data as a blob. The other 4 instance properties are parsed from the XML, and include: authorName, custodianName, patientName, and title. These 4 data elements appear to have been chosen to allow the consumer of the data to identify the document and compare with other health documents that might be saved to HealthKit.

At this point it's important to note that each CCDA document saved to HealthKit becomes a distinct entity, and that any de-duplication of data would need to be done by the consumer of the data. For example, if a user downloads a CCDA from their patient portal, then re-downloads the document a month later, those are saved as two, separate documents, and the second document would contain all the information from the first document, plus any additions from the past month.

So, if the user gives your shiny new health app access to these documents, you (as the developer) will need to decide whether you pull only the most recent document or whether you pull all of the documents and harmonize the data yourself (a good bit of work).

In speaking with some of my colleagues, it might also be helpful in a future version of this implementation to have access to additional HKCDADocument properties to facilitate positive patient identification, such as date of birth or phone number (which is increasingly becoming part of our identities!). This will be important because HealthKit does not limit a user to only import his or her own health records. Work on a national patient identifier would definitely be helpful here!

Despite these limitations, the importance of giving patients access to their own data in this way cannot be overstated. This is a watershed moment. Yes, it allows hospitals and users to fulfill the intent of the MU2 requirements, but more importantly, it empowers patients to be stewards of their own data, and to decide when and how it will be used to improve their health.

CDA/CCD Coming to Apple's HealthKit!

HK and HL7, together at last!

Today I was fortunate to be able to attend the keynote presentation for Apple's annual Worldwide Developers Conference, or WWDC (aka, "dub dub"). The presentation itself focused on Apple's four primary OSs: watchOS, tvOS, macOS (bye "Mac OS X"!), and iOS. Personally, the most exciting keynote announcement (besides emojis that are 3x the size!!!) was a new apps called Swift Playgrounds, intended to help teach children to code. My 10 year-old daughters will love it (heck, I will love it)!

But for me, the most exciting announcement did not come as part of the keynote. The most exciting announcement is that for iOS 10, Apple will add support for HL7's Clinical Document Architecture (CDA) and the Continuity of Care Document (CCD) directly to HealthKit. For those unfamiliar with CDA/CCD, it's basically a standard way (using XML) to describe an individual's health history in a single, structured data format.

This means that any app (such an EHR patient portal app) will be able to share a CCD with the user in order to save it to HealthKit, and that any app can then get permission to read the CCD from HealthKit.

In other words, this gives a user more control over his/her medical information than ever before.

This is huge. I've spoken previously about paternalism in medicine and how patients are often the least empowered of their own care team. This needs to change fast, and Apple's inclusion of CCD as a first class citizen in HealthKit will usher in a new breed of health apps that empower patients and give them more choice in what they can do with their health information. The is one of the precise goals of the NIH and ONC's Sync for Science project: to allow individuals to 1) access and 2) donate their data to science.

The contents of the CCD are also informing the work on SMART and FHIR related to the Argonaut Implementation Program, which aims to standardize the way we implement FHIR on various systems, focusing on use cases that represent what the CCD can do.

Ultimately, the more we can put users in control of their own health, the better of they will be. I welcome this significant step in that direction.

Update: The developer documentation isn't yet available, but the placeholders for HKCDADocument and HKCDADocumentSample are on the web.

What is Health Technology Innovation?

Note: This is the first in a special series of posts jointly written by both Katie Donohue McMillan and me. Katie recently joined Duke as our Innovation Portfolio Manger and brings with her a wealth of experience and a unique perspective from outside the stodgy halls of academia.

A new app? A new device? An old device used in a new way? And old interface put to a new use? None of the above?

We bet many of you share our frustration with the term innovation. Overused, cliché, and now practically blasé, the word has clearly lost its way, the meaning diluted through inclusion in overzealous marketing phrases and conference taglines. If we had a dime for every time someone around here used the word innovation, we’d probably have enough funding to build several ResearchKit/ResearchStack apps that incorporated the HoloLens and Scanadu Scout. We’d get all our transplant patients a 3D-printed organ (or two). We’d be able to buy all of Duke Health patients their own Apple Watch.

Yet, with all the overuse and confusion around the term, it still means something to people that is not represented more clearly through use of another word. For us, it’s the belief that we can find new ways to improve health for all humankind. So we’re not advocating that you jettison “innovation” from your vocabulary. At least not yet.

Merriam-Webster defines innovation as “a new idea, device, or method.” Yet in healthcare, we see “new” things all the time that subjectively don’t rise to the level of innovation. Does a new generic drug, another patient portal app, moving data to the cloud, or the implementation of an electronic health record really fit the bill?

Some would argue, though, that something doesn’t have to be groundbreaking to be innovative. Maybe integrating an existing clinical risk calculator into an EHR could be considered innovative - it could save time and improve care. Allowing patients to view their doctors’ notes is breaking down the centuries-old paradigm of paternalism in health care. Giving patients a way to electronically consent for a study with tools like Research Kit can increase study enrollment by orders of magnitude.

Perhaps we’re simply demanding too much of the poor word and the people who use it? Or we’re spoiled by the constant miracles technology has wrought to the extent that the miraculous has become mundane. That one entrepreneur’s great idea has simply become another executive’s IT expenditure.

We will be exploring the concept of innovation over the next year. What is innovation? What does innovation mean? How do you cultivate it within a healthcare system? How do you support innovations and entrepreneurs?

This question may be unanswerable, or there may be a thousand right answers. What do you think? What does innovation mean to you?

About Us: Ricky Bloomfield, MD, is the Director of Mobile Strategy and practicing pediatrician at Duke Health. In his spare time he likes to develop software and play with emerging technologies. Katie Donohue McMillan is the Innovation Portfolio Manager at Duke Health. Together, they’re attempting to accelerate the entrepreneurial spirit within Duke and amplify great solutions that improve healthcare.