Apple and Amazon’s moves in health signal a coming transformation

THE past decade has seen the smartphone become a portal for managing daily life. Consumers use their pocket computers to bank, buy and befriend. Now this array of activities is expanding into an even more vital sphere. Apple has spent three years preparing its devices and software to process medical data, offering products to researchers and clinical-care teams. On January 24th it announced the result. The next big software update for its iPhone will include a feature, Health Records, to allow users to view, manage and share their medical records. Embedded in Apple’s Health app, the new feature will bring together medical data from participating hospitals and clinics, as well as from the iPhone itself, giving millions of Americans direct digital control of their own health information for the first time.

Apple’s fellow tech giants are also on the march into medical services. On January 30th Amazon announced a partnership with Berkshire Hathaway and JPMorgan Chase to create a not-for-profit health-care company for their own employees that promises to employ technology to provide cheaper care than conventional health insurers offer. For the past year, the e-commerce giant has also been exploring a venture to use its logistical prowess to start selling drugs online.

Alphabet, Google’s parent, has just launched a third health-care firm, Cityblock Health, to operate alongside Verily, a subsidiary based in San Francisco, and DeepMind Health, an arm of its London-based artificial-intelligence (AI) firm (a fourth company, Calico, is working to extend human lifespans, but does not provide health-care services). Alphabet already claims to be able to use AI to predict possible deaths of hospitalised patients two days earlier than current methods, for instance, allowing more time for doctors to intervene. Facebook and Microsoft are preparing to add health care to their core businesses of social networking and software.

Until now the tech giants’ foray into health care has not gone much beyond wearable devices to track fitness or the provision of cloud-computing services to incumbent providers. In future they aim to deliver real medical services that directly affect individual patients. All five firms have secretive health-care skunk works, are hiring medical talent and are buying or backing external health-care startups. Undeterred by recent claims that their own products may be harmful to mental health, they want not only to be indispensable in customers’ lives but to prolong them, too.

The revenues of the industries they could disrupt are enormous. Health-care costs make up about a tenth of any country’s GDP on average, worth in total $7trn in 2015, according to Deloitte, a consultancy. Two insurers, UnitedHealth Group and CVS Health, are among America’s largest firms by revenue, bringing in $185bn and $178bn respectively in 2016. That is more than any tech firm except Apple. Shares in the two insurers fell by 4% on the news of the new Amazon-led health venture.

Apple and Alphabet, however, are likely to have the biggest impact in the near term. Amazon’s three-headed health-care venture will cover roughly 1m employees in the first instance, whereas Apple and Alphabet have the potential to generate or enable valuable health insights for hundreds of millions of users, collecting a small slice of that value in return.

There are two broad routes into health care. The first is doing business with hospitals and health-care companies in the existing system. Alphabet provides software services to hospitals, for example; Apple sells smartphones, tablet computers and wearables to medical professionals and hospitals. A second route is for tech firms to use their various platforms to create entirely new channels through which medical care can be delivered to patients. Such channels include watches that use machine-learning algorithms to monitor the wearer’s health, phones through which clinical trials can be run and apps that provide medical-grade care to people managing chronic conditions such as diabetes.

Deploying bedside manner

Start with the existing system. Alphabet’s business here comes through Verily and DeepMind, and has focused on Britain’s National Health Service, which offers a single, standardised market. DeepMind has partnerships with four large hospital groups, to which it provides an app called Streams. This uses the hospitals’ data to generate alerts that draw doctors’ attention to the potential deterioration of patients. In May, meanwhile, Verily switched on data processing for a hospital—the NHS Heywood, Middleton and Rochdale Clinical Commissioning Group, near Manchester. It crunches through the hospital’s pseudonymised patient records, looking for patterns that suggest the emergence of long-term diseases like diabetes and alerting doctors if they are found. (In September Microsoft started a health-care division in Cambridge, which will devise medical algorithms of its own.)

None of this is straightforward. Health records generated in conventional clinical settings are immensely valuable—no amount of smartwatch accelerometer data is going to take the place of an MRI or an X-ray. Such records are increasingly available in digital form (see chart) but they are often messy and hard to process. DeepMind has had to spend months cleaning up data flows from a British hospital, the Royal Free, for instance, and has not yet delivered any AI-driven insights.

Apple’s approach is more focused on hardware. It is working to make its devices into trusted, secure channels through which medical data can flow. Third parties, rather than Apple itself, then build useful health services on top. Putting patients’ health records on iPhones will make these far more effective.

Millions of people around the world have already joined medical studies using this infrastructure, participating through iPhones. Hints are emerging of the power of the approach. An app called mPower, built by Sage Bionetworks, a non-profit research organisation, studies Parkinson’s disease by getting iPhone users to perform tasks and measuring the tremor in their hands using the phone’s internal accelerometer. The data so far suggest that Apple’s platform may soon enable medics to spot Parkinson’s digitally, over the internet, before it is symptomatic in a patient.

All this makes money for Apple by increasing the perceived value of its devices, says Anurag Gupta, a health-care analyst at Gartner, an IT research firm. The firm also hopes that clinicians and insurers will buy and use Apple devices in their work.

Algorithms v arrhythmia

Delivering medical services through brand-new channels—the second route into the industry—holds equal promise. The new non-profit venture from Amazon, Berkshire Hathaway and JPMorgan Chase fits into this category. Details are scarce, but the three firms might, for instance, use Amazon’s data-processing skills to build tools to monitor and care for patients outside hospitals and surgeries. Some speculate that the firms might build an app that makes booking a doctor’s appointment as easy as reserving a table at a restaurant. Whatever is built for their own employees, it seems likely that the services will end up being made available to the public, too.

Another recent innovation is Alphabet’s Cityblock Health. Its mission to care for low-income city-dwellers in their own homes does not rely on existing health infrastructure at all. It plans to send its own health-care professionals to the homes of people needing care, with the visits paid for by insurance, often Medicaid, the social-insurance system that covers America’s poorest. Cityblock Health will trawl data to spot where care is needed. It plans to hire some 55 people over the next six months, including data scientists, software engineers and a lead physician, as well as a team to interact directly with patients.

Smartphones and watches are channels for new services in their own right. In this realm, Apple would become a direct provider of actual care to patients. It holds patents to turn its phones into full medical devices, using a bundle of sensors around the camera to let users measure their blood pressure, body fat and heart function by pressing a finger to the screen, for instance. Other patent filings envisage putting sensors into both phones and smartwatches to collect electrocardiograms to monitor heart health more precisely, and even doing biometric monitoring through AirPods, the firm’s wireless headphones.

Apple has also tinkered with sensors which gauge stress or measure blood oxygenation, and is reportedly working on ways to measure blood glucose through its watch, helping it get a handle on diabetes. Late last year it said it would join up with Stanford University to develop algorithms to spot irregular patterns in heartbeat data gathered by its watch. This research could produce what is known as a “digital therapeutic”, which goes through a full regulatory approval process (see article).

Verily’s eclectic range of ventures includes building new kinds of surgical robots in a joint venture with Johnson & Johnson, a drug firm. It is also working on cutlery containing self-stabilisation technology, to help those with tremors to eat. The firm has two joint ventures to try to tackle diabetes, one with Dexcom, a medical-device-maker, and another with Sanofi, a drugs company. Verily also seeks to organise health information so that it can be queried for useful insights. Project Baseline, a research study, will gather data from 10,000 people over four years to do this.

Facebook’s work in the field has been discreet and focused on two areas—mental health and clinical trials. In November the firm said it had started to use AI to monitor its users’ online behaviour for patterns which indicate depression, and to reach out in an effort to prevent suicide. The photos a user posts on Instagram may signal depression, for example, depending on the colours they contain, the times at which they are posted and whether they show faces. Google is trying something similar.

Facebook is also hoping to formalise and monetise an activity which is already common on its platform—namely, groups of patients discussing their symptoms. One plan is to help drug companies recruit people from these online gatherings for clinical trials, and to manage groups of patients who sign up, presumably in return for payment from the drug firms.

This time may be different

It is worth remembering that the prospect of technology firms transforming health care has been heralded in the past, only to disappoint. Google started a health-records initiative in 2008, but shut it down by 2011, citing poor adoption. Microsoft made similar efforts with similarly low take-up. Yet ten years on, the centrality of the smartphone, with its potential to give patients access to their data whenever they want and wherever they are, changes the game.

So too does the inexorable logic of the data economy. Data sets that contain information about human health are hugely valuable. At a time when health-care budgets around the world are stretched, payers are desperate for insights that might enable them to cut costs while maintaining quality. The more data the tech firms can handle, the more they will learn about human health, and the better the services they can offer will become.

That raises some familiar concerns. Privacy is an obvious one: the tech world’s mindset of “move fast and break things” works less well when it comes to health data. And the same competition issues that dog Google’s search business and Facebook’s social-networking service would arise in health care, too, if a particular AI diagnosis platform, say, were to became dominant. DeepMind’s work in Britain is already on the radar of the EU’s competition watchdogs. Meanwhile, Amazon’s partnership with Berkshire Hathaway and JPMorgan Chase will lure in huge quantities of patients’ data, leading to continual improvement of its services and, potentially, fears about dominance.

Apple’s entry into the field offers some answers to these worries. Its efforts in health so far have been cautious. The only patient data it processes now come from its partnership with Stanford University, and in future the firm is likely only to analyse medical information from those patients whose trust it has fully secured. Its services will be opt-in; patients who find themselves in hospitals working with Alphabet’s DeepMind, by contrast, are offered opt-out consent mechanisms.

Earlier attempts by Google and Microsoft to offer patients a home for their digital records obliged people to consider whether they trusted the two companies enough; many decided the answer was no. If they only have to decide whether their own iPhone is sufficiently secure, many will believe that it is. Apple has so far lagged behind other technology giants in earning revenues from the booming market for data. It may yet strike gold in the most sensitive personal-data category of all.