
Apple is building an operating system for health - nbashaw
https://divinations.substack.com/p/healthos
======
BiteCode_dev
Maybe it's the french in my talking, but I really have a hard time trusting
anything else than the state to handle health data.

Anytime you associate health with financial motivation, you end up with
something twisted on the long run.

Sure, you can say that Apple, right now, is in the proper state to do that
(although given they were part of PRISM, it's debatable).

But what about in 10 years? What if their executives decide that Apple Pay
should lead to the creation of a bank? Then from a bank to an insurance
company? Then they have a conflict of interest.

Simpler than that, what if they change their stance on user data, and decide
to exploit it to understand their customers better? Or sell it? Or just
partner it to labs, insurance companies, hospitals?

Like with facebook, it will of course all be "made anonymous", until it's not
anymore.

Money and health data are not meant to be mixed IMO.

But even without all that, we are adding yet another tracking system on top of
what is already a sensor packed pocket self-spying device.

It's hard to not worry that such concentration of power has a high potential
for suffering.

~~~
Yetanfou
The solution to this conundrum and similar potential problems with other
'smart' devices is to leave them on the (virtual) shelves. If your insurer
starts to promote the use of such a device you change insurer. The same goes
for car insurance which wants to have access to (live) tracking data on your
car, home insurance who demand the installation of and access to 'security
systems', the list gets longer and longer. The way things are going this new
nosy technology is set to create a new class of Luddites, those who while not
averse to technology in itself do not accept their lives to be steered by
profit-seeking entities through the use of such.

Another interesting question is whether law enforcement will be allowed to
access such data and whether it can be used as proof against the wearer. If
your data indicates you were in a higher state of alert with a raised pulse,
the gyroscope and position sensors indicate you were physically active, the
location data puts you in a given area and the microphone picked up suspect
sounds they won't need much more to convict you. Who is the legal owner of the
data? Some countries give people the right to refuse to testify against
themselves so if the data is owned by the wearer I'd expect it to be off-
limits to the law.

The potential good uses of this type of technology are myriad, it just needs
to be made big-brother-proof. That will be a hard task since there are
situations where you'd want some of these easily-abused features to be used -
e.g. call in emergency services if the device detects a life-threatening
condition, etc.

~~~
close04
> leave them on the (virtual) shelves

That's easy today because this option is unpopular. But look back and see how
many things we (as entire populations, not necessarily individuals) starting
accepting that was unfathomable a couple of decades ago.

Without strong government intervention we may end up at the point where you
can take it or forfeit the insurance.

~~~
wmeredith
This is what I see coming as the mega corps eat our society alongside
software. Look at the regulatory capture the telcos have managed with their
negotiated service area monopolies or duopolies. It’s easy to say “buy
something else” until there’s nothing else to buy and the product is a
requirement for functioning in society (insurance, internet connectivity,
healthcare). We need trust busting candidates now.

~~~
jrockway
I don't think trust busting can make the telco problem go away. You can punish
someone for their past wrongdoings, but that doesn't necessarily incentivize
anyone to become an ISP after the fact. You have to look at how we invest in
infrastructure instead. In most of the country, ISPs are responsible for
building their own infrastructure; they have to either dig up streets or beg
the local power company for pole access. If they didn't have to do that, many
more companies would be interested in being ISPs. As it stands right now, it's
too expensive and too risky. Sure, being an ISP is 95% profit once you've paid
for the infrastructure, but the payoff period is many decades. Nobody has that
risk appetite anymore.

In Manhattan, under every street is a subway where you can put power cables,
fiber optic cables, etc. The result is that there are a multitude of business
ISPs around, because someone already dug a hole in the ground where their
cables can go. The actual stringing of cables is a straightforward procedure;
sure you need to buy trucks and cables, but that's a lot cheaper than saying
"hey we're closing 5th Ave. for 3 months" and digging the whole thing up. The
street was dug up once (in 1891!), and now nobody has to do it again. (OK, the
tunnels are pretty full, but it's better than nothing.)

If every street were built like this, it is likely that there would be many
more ISPs. The big risks are gone. (There is a secondary problem in that many
people still like linear TV, and many TV networks are owned by companies that
are also ISPs. AT&T owns HBO. Comcast owns NBC. So that would be the sticking
point after there is infrastructure, and sure... have the government break
them up. They'll probably be dead long before we have the infrastructure,
though.)

The short term solution is probably to invest in better trenching techniques.
I've heard of microtrenches, nanotrenches, and picotrenches. Maybe we need
femototrenches where you just run a fiber to someone's house through their
lawn and cover it up with tape where it crosses the sidewalk. It's better than
nothing. But probably still too risky for anyone to attempt.

------
m12k
The question is, will all these data aggregated together actually give us any
actionable data that we can and will act on? If there's one thing Google
Analytics has taught me, it's that it's quite possible to have a lot of
detailed data at your fingertips, but still not be able to answer any valuable
questions with it.

~~~
alwillis
I’m using the Watch and with my iPhone. The Health and Activity apps work
great together.

The visualizations are clear and understandable. For example, I’m
significantly less active this spring than last spring—average of 2.2 miles
walking per day in 2019 vs. about 1 mile in 2020.

That’s mostly due to stay at home orders due to COVID-19 the past 3 months.
Once the weather got better and the number of cases subsided, I started taking
walks in my neighborhood due to the actionable data I had.

Remember, the Watch and the iPhone can do machine learning on the device.

What’s missing is an easy way to do more advanced health data processing on my
Mac if I wanted to.

I’d like my public health department release an app for COVID-19 exposure
notification, using the Apple/Google API.

You could also envision broad clinical trials of treatments for COVID-19 using
these components.

~~~
paulcole
What valuable question did you answer with the data? You didn’t need a watch
to know you were walking less.

> Remember, the Watch and the iPhone can do machine learning on the device.

Great, what is the machine learning?

~~~
alwillis
It’s not just the amount of walking; it was also calories burned, heart rate
not getting into an aerobic range, my VO2 max and other data that I’d have no
idea about if I didn’t have a device monitory this during my waking hours.

Regarding on device machine learning: [https://developer.apple.com/machine-
learning/](https://developer.apple.com/machine-learning/)

~~~
paulcole
Neat! You managed to not answer either of my questions:

1\. What valuable question was this data answering?

2\. What is the machine learning?

------
P-NP
Many studies show that modern machine learning could revolutionize healthcare.
However, many hospitals and governments are extremely protective of patient
data. And many hospitals don't even know how to exploit their data through
deep learning. Enter Apple and Google and others with big machine learning
departments. They are finding new ways of collecting health-relevant data. For
example:

Through Apple Heart Study, Stanford Medicine researchers show wearable
technology can help detect atrial fibrillation

[https://med.stanford.edu/news/all-news/2019/11/through-
apple...](https://med.stanford.edu/news/all-news/2019/11/through-apple-heart-
study--stanford-medicine-researchers-show-we.html)

[https://www.apple.com/healthcare/docs/site/Apple_Watch_Arrhy...](https://www.apple.com/healthcare/docs/site/Apple_Watch_Arrhythmia_Detection.pdf)

An OS with a focus on health seems to make a lot of sense.

~~~
zyang
That's why it was genius for Apple to bet on privacy. It's the only big tech
company I can trust with my health data.

~~~
brokenc0de
Apple's privacy marketing seems like just that. All of their proprietary
software is highly suspect. And remember, the COVID-19 contact tracing APIs
were built by both _Google_ and Apple. If Apple was so concerned about privacy
they would have implemented the tracing APIs themselves for the iPhone and
released the source code.

------
kine
I hate Apple's approach of doing 70% of the work all the time. If they _truly_
cared about health, they'd make it incredibly easy for any company to add
health data in to their ecosystem and not just try to sell more Apple Watches.
As a Whoop user, it's so much more beneficial than their basic Apple Watch
stats (which btw are fine for most people, I just want more/better HRV data)

~~~
dunefox
> If they truly cared about health

It's a company, it doesn't and cannot care about anything other than profit.

~~~
crispyporkbites
A company is just a group of people working together.

It can care about whatever those people choose to care about.

~~~
dunefox
That has nothing to do with the position of the company, though. The employees
can care about what they want.

~~~
akg_67
Companies used to serve multiple stakeholders that included, employees who
worked for them, communities they were present in, customers they served, etc.
in addition to stock holders. Slowly, slowly, the definition of stakeholders
has been shrunk and reduced to stock holders and responsibilities reduced to
maximizing profit. Of course these stakeholders and responsibilities are being
further reduced slowly slowly to where companies only exist to benefit large
shareholders and corporate executives.

I am guessing you might be young and may not be aware of history of
corporations.

------
weisser
Apple Health is one of those products that's useless until it suddenly isn't.
We're reaching that point for some folks and I only expect that group to
expand rapidly in the coming years.

~~~
kine
Sort of like Evernote. It's a note taking app until it's your 2nd brain.

~~~
person_of_color
Why not OneNote?

------
dloss
Ever since I heard Mary Lou Jepsen (OLPC/Oculus Rift) talk about her work on a
revolutionary holographic medical imaging system, I've been expecting Apple to
buy her Openwater startup, add resources and introduce cheap, safe MRI-like
body/brain scanners for the masses. If it works, it could be bigger than the
iPhone.
[https://www.openwater.cc/technology](https://www.openwater.cc/technology)

~~~
germinalphrase
She did a talk at the Long Now Foundation about the possible implications of
this work. Definitely a bit out there - but fascinating.

[http://longnow.org/seminars/02018/oct/29/toward-practical-
te...](http://longnow.org/seminars/02018/oct/29/toward-practical-telepathy/)

------
totalZero

      Traditionally, these data sets have lived in silos.
      But what could happen if it all was aggregated safely
      in one place?
    

It seems unwise IMO for me to give a large corporation (Apple, Equifax, etc)
rich data with which to characterize my lifestyle and physical health.

~~~
someguydave
Which is why Apple is not looking at your data?

~~~
VLM
Not yet.

------
seesawtron
What happened to Palantir handling NHS data in UK? There was some privacy
concern there but it happened anyways. Call me a pessimist and this a rant but
it seems like the public doesn't really control what their governments decide
to do with their data. The best the tech firms do is issue an apology for
infringing on privacy or pay a light fine while they get to keep majority of
their profits.

~~~
VLM
Its not much of a rant. Its taken centuries of hard work for the average
person's body to mostly not be the owned property of other people or
governments.

The battle's barely been started for self determination and self ownership of
our data.

------
david-cako
Apple has a talent for putting themselves right at the center of important
technologies. I wonder if this strategy plays out as integrated medical
devices and a full-blown healthcare platform. Their reputation for top-notch
hardware, good UX, and their shift towards in-house SoCs gives them a serious
edge there. Everything about their brand feels well suited for healthcare, and
IMO they still don't have a killer enterprise app. This could be what Watson
was promising to be.

~~~
dariosalvi78
Top notch hardware, like their top notch keyboards?

~~~
the_other
No, not like their recent keyboards. But exactly like almost every model of
their laptops, most of their desktops, their servers, their phones, tablets,
watches, NAS/routers and set-top boxes. Every year, for >30 years.

~~~
FireBeyond
Which laptops? The ones that could be made to repeatedly kernel panic due to
GPU issues, that Apple denied was an issue until shown otherwise? Or the ones
with the logic board issues? Or the ones with battery issues that caused
burns? Or the SSD failures? Or the T2 issues that cause repeated kernel
panics?

> their servers

As novel as the Xserver might have been, let's not pretend it was anything
more than an unimaginably small surface area for a product

Apple makes well-designed products, mostly. But let's pump the brakes on the
idea that everything that comes out of Cupertino is flawless, as you seem to
imply.

~~~
david-cako
Apple's got a lot of surface area, and a pretty damn good track record.

Who else is doing what they're doing? No other consumer hardware company goes
top-to-bottom from the software to the chip, and no other company has such a
cohesive ecosystem. Google EOLs a product once a week, Microsoft is making
some nice stuff these days, but is nowhere near the same experience ("Windows
is like a bundle of drivers", as in the article).

There is value to being prescriptive over their platform. It gives them skin
in the game to make things good; they are much less willing to just blame a
vendor.

------
b34r
The notion that the industry isn’t exposing any data is patently false. FHIR
and HL7 have been around for years now and I’ve connected many data sources
into both Apple and other services that use those APIs.

~~~
prepend
FHIR helps quotes a bit, but I think the challenge is that HL7 is expensive to
work with and that integrations are point to point.

I’ve also connected sources using HL7, but it’s hard to scale because it’s
like everyone creating import/export interfaces to their system.

I think the benefit of Apple health is that it’s a common, trusted
intermediary. Me, the patient.

I think it’s easier for me to pull data from multiple sources and show it to
my doctor than for all those medical systems to share with each other so my
doctor can see data. If I have 5 health services, it requires 5 export to
Apple interfaces for me to collect my data, securely store it, and show it to
my doc or to any one of those 5 providers.

To have provider interoperability it requires 30 interfaces (maybe my math is
off 2^5-2).

There is stuff like Project Blue Button [0] that tries to make a standard
interface to export data.

The complaint that it’s easy to export data is only true if you want to pay
some consultant to make an interface. In the US, there’s a report on
information blocking [1] that called out areas in healthcare with blocking and
proposed some changes to lessen it.

[0] [https://www.healthit.gov/topic/health-it-initiatives/blue-
bu...](https://www.healthit.gov/topic/health-it-initiatives/blue-button) [1]
[https://www.healthit.gov/topic/information-
blocking](https://www.healthit.gov/topic/information-blocking)

------
dariosalvi78
I really welcome the Health Kit or Google Fit approach for sharing data among
health app, I actually want to use that for health research. The main problem
is that as soon as you mention the fact that patients data is going to be
shared with a company (besides in the US) doctors shy away because of data
protection, regulations etc. We need the data to be on the device and possibly
outside of the control of one (or 2) companies. I know Apple says that data is
encrypted end to end, and I wish Google did the same, but even so it is still
problematic. When you add the fact that _every_ manufacturers of wearables
obliges users to share data on their dodgy platforms... I don't see a solution
to this. At least not until the mindset changed completely.

------
specialist
Feature request: Heat stroke prevention.

Just heard an interview with author of recent paper about global risk of
increased mortality due to climate change. (Radio, no cite, sorry.) Research
team has clarified impact of "wet bulb", which is somehow combo of both
ambient temperature and humidity, and prevalence of heat related deaths.

Not just the Middle East, but also provided examples from Europe, Toronto,
Louisiana.

While wet bulb temp of 35 °C is life threatening, paper shows that with higher
humidity even 27 °C can be dangerous for at-risk persons and has led to
greater mortality.

While the risk will certainly get worse, people have no intuition for it.
Especially for outdoor work and activities.

Any way.

My immediate thought was my watch can alert me to wet bulb risks, a
combination of weather and health monitoring.

[https://en.wikipedia.org/wiki/Wet-bulb_temperature#Wet-
bulb_...](https://en.wikipedia.org/wiki/Wet-bulb_temperature#Wet-
bulb_temperature_and_health)

~~~
ben_bai
Feature request: Connect Diabetes Insulin Pump, and Sugar level measurement
devices.

------
stefan_
What is all this "health data" people are talking about? When I go to a new
doctor that has none of this apparently super complicated, dense health data,
they give me a single page form to fill out where just about 90% of people
below the age of 50 will tick every box with "no" or leave the field empty.

~~~
VLM
Lets say they want to raise premium revenue by 25%. The solution will be to
increase premiums on smokers, because everyone hates smokers, by 25%.

How does that math work, you're asking? Right now you and I can check "non-
smokers" on medical documents. And that's true, at least for me, medically
speaking.

However after we fuse all sources of data we can punish everyone. I bought two
packs of cigars in the 90s when I was a dumb young kid. Medically speaking a
quarter century later I'm a non-smoker from a health perspective. However,
from a revenue generation perspective...

Big brother is not going to fund this out of the goodness of their heart to be
revenue neutral or (gasp) positive for the public. The only purpose for this
expensive initiative will be to screw over the general population even more to
increase income inequality a little more and make the rich just a little
richer.

------
dangus
Apple could be planning to make an EHR system, like Epic and Cerner. Google is
supposedly working on one, too. (I don’t think the article really arrives on
that possibility)

Most electronic health record systems are really terrible software, and
they’re also very profitable pieces of software. Google, Apple, and Microsoft
are probably the only companies with enough money and software engineering
talent to start from scratch and disrupt that space.

Some interesting further reading: [https://medium.com/design-and-tech-co/how-
google-ehr-could-f...](https://medium.com/design-and-tech-co/how-google-ehr-
could-fix-one-of-healthcares-epic-flaws-280036a988e3)

~~~
npunt
Rather than go through the trouble of entering a new complicated market
building an EHR to unseat some very entrenched players and force retraining of
millions of healthcare workers, which would be relatively antithetical to
Apple’s consumer-not-enterprise approach, they could focus behind the scenes
efforts on data portability and interoperability via EHR customers (hospitals)
so that those EHRs worked better with Apple Health.

You really don’t want to build an EHR if you can avoid it.

------
rapjr9
If you want to learn more about where research in this area is headed:

Santosh Kumar has been heading a large NSF research center investigating
wearable medical sensing and how to turn sensor data into actionable health
advice:

[https://md2k.org/](https://md2k.org/)

Tanzeem Choudhury has been doing some work at the intersection of AI and
sensing and health:

[https://pac.cs.cornell.edu/](https://pac.cs.cornell.edu/)

Deborah Estrin's Small Data Lab is doing some interesting work too:

[https://smalldata.io/#portfolio](https://smalldata.io/#portfolio)

------
atlasunshrugged
I really wish Apple would get on with it - the process for trying to upload
medical records was super broken for me (plus as an American, I can't even
find most of my medical records since they're in different doctors offices
across the 4 states and many cities I've lived in). That said, I am nervous
about just how much data they'll own. Does anyone know if there are government
backed open systems that someone from another country could use? I know that
Estonia for instance has an okay patient health portal where you can see all
your info but it's not useful unless you live there.

------
gumby
Just last night I read an essay by Galloway where he pointed out that the
really huge companies (Apple, Google, etc) have a hard time maintaining growth
so have to move into different sectors where there are huge pools of money.
Health is the most obvious one.

------
carapace
The epistemology of the thing...

In the immediate human sense recall that this was the health app that launched
with no way to record your menstrual cycle (a very important aspect of health
for about half of humanity, the half that makes new humans I should add.)

In the deeper sense, we might encode "humors" into the design of our system.
Our knowledge is incomplete. (E.g. the microbiome, or the "interstitium" which
has been called "a new organ" [https://www.livescience.com/62128-interstitium-
organ.html](https://www.livescience.com/62128-interstitium-organ.html) )

It's important that our data systems handle _open-world_ rather than closed-
world data, eh? [https://en.wikipedia.org/wiki/Open-
world_assumption](https://en.wikipedia.org/wiki/Open-world_assumption)

(As a practitioner of Reiki I can attest that scientific medicine does not yet
capture all relevant variables.)

Last but not least, the crux of the issue turns on what Martin Buber called "I
and Thou":
[https://en.wikipedia.org/wiki/I_and_Thou](https://en.wikipedia.org/wiki/I_and_Thou)

> Buber's main proposition is that we may address existence in two ways:

> The attitude of the "I" towards an "It", towards an object that is separate
> in itself, which we either use or experience.

> The attitude of the "I" towards "Thou", in a relationship in which the other
> is not separated by discrete bounds.

There is a subtle trap in thinking of the body as "it" (and also a trap in
thinking of the body as "thou", and another as "I"). It behooves us to be
careful what we automate.

------
cheschire
Microsoft's almost always either too late, or in this case too early.

[https://en.wikipedia.org/wiki/Microsoft_HealthVault](https://en.wikipedia.org/wiki/Microsoft_HealthVault)

~~~
toast0
Often, they'll come in again, and be both too early and too late.

------
elchief
Reminds me of The New, New thing!

[http://michaellewiswrites.com/index.html#the-new-new-
thing](http://michaellewiswrites.com/index.html#the-new-new-thing)

------
mister_hn
I would be happy if they would still support older machines with macOS. A
macmini of 2010 that is still working good can't be left without security
updates!

------
rapjr9
The USA has been making plans for widespread sharing of Electronic Health
Record data for many years:

[https://www.healthit.gov/hitac/committees/health-it-
policy-c...](https://www.healthit.gov/hitac/committees/health-it-policy-
committee)

This is seen as desirable for more than one purpose, including allowing people
to move their medical records to a new doctor or hospital easily, and for
doing research on what makes for the best care, as well as giving doctors the
ability to look at case histories similar to that of a patient they are
treating.

Computerization of medicine has been resisted by doctors for a long time,
which has meant that all the data and observations and diagnosis made over the
years has essentially been lost when it could have been informing doctors
decisions and being used in research. There are definitely privacy and abuse
problems with putting everyone's health data in a central database run by the
government, and it is very difficult to de-identify health data (how many
people have your height, weight, age, and diseases?), but without some way to
gather all the knowledge and experience and data from the practice of medicine
we have been missing important correlations and creating harm due to each
doctor making their own decisions instead of having a set of best practices
informed by hard data. Whether the police, FBI, NSA, courts, and politicians
should have access to this data are difficult questions and hard to implement
so they are not subject to abuse. The police already can make some kinds of
queries at hospitals for medical data.

The UK has started a large scale Precision Medicine project that is collecting
health data on 500,000 people:

[https://en.wikipedia.org/wiki/UK_Biobank](https://en.wikipedia.org/wiki/UK_Biobank)

There are other ongoing large scale projects collecting health data also:

[https://www.hdruk.ac.uk/](https://www.hdruk.ac.uk/)

and I'm sure there are others, in many countries. A lot of this is part of the
move towards Precision Medicine, medicine based on data and personalized to an
individual, rather than treating all people as being identical and letting
each doctor make their own guess on how to treat a patient (I've been in
meetings where doctors say that 80% of the time they are guessing, though
guesses get better as they see what works and what doesn't for any one
patient):

[https://en.wikipedia.org/wiki/Precision_medicine](https://en.wikipedia.org/wiki/Precision_medicine)

The space Apple is aiming to dominate is currently one small part of all this.
One big question is what do doctors do with all this data? It's too much to
look at it all. They have no experience with such detailed info also. What is
normal for the way your blood pressure changes as you go about your day? Your
doctor doesn't know and hence even if she had continuous blood pressure
measurements from you 24/7 wouldn't know what to do with it. What is a
reasonable blood pressure while having sex? When climbing stairs? The only
measurements like this that we've had historically are from astronauts.
Machine Learning may help, but what do you do with an opaque message from an
algorithm that there is a 75% chance you have some abnormality in some obscure
biological parameter? The chance of 25% of those notifications being wrong
means you can't use it as the basis of a diagnosis. Maybe it suggests
something you can investigate further, but then how much time will you waste
following up on those 25% of notifications that are in error? Was the ML
trained for your age, weight, and specific set of health conditions or will it
fail to detect anything for people outside the scope of the training data, yet
be used to evaluate your health (incorrectly) anyway? And using ML also
creates yet another path for bad actors to steal and tamper with your data.

There are a lot of complicated questions surrounding medical data.

------
m0zg
I don't see why I'd need Apple to tell my personal trainer I have a herniated
disk. I can tell them myself, and I'm looking to be less locked into the Apple
ecosystem, not more.

If that's what they're doing (which I bet it's not), I'd consider it as a good
sign that Apple has run out of good ideas.

