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…)