The new Apple Watch Series 4® is one of the more recent and sophisticated consumer health engagement tools. It includes a sensor that lets wearers take an electrocardiogram (ECG) reading and detect irregular heart rhythms. The U.S. Food & Drug Administration (FDA) recently approved these functions as Class II medical devices, which generally means that they have a high to moderate risk to the user. The FDA approval letters describe the Apple Watch Series 4 functions as intended for over-the-counter use and not to replace traditional methods of diagnosis or treatment.
Tech developers and HIPAA lawyers often mean different things when describing a health app or medical device as HIPAA compliant. For example, a health app developer will likely focus on infrastructure, whereas the lawyer will likely focus on implementation. When asked about HIPAA, the app developer might rely on International Organization for Standardization (ISO) certification to demonstrate its data privacy and security controls and highlight how the infrastructure supports HIPAA compliance. The HIPAA lawyer, on the other hand, will likely focus on how (and by whom) data is created, received, maintained and transmitted and must look to the HIPAA regulations and guidance documents issued by the U.S. Department of Health and Human Services (HHS) to determine when and whether the data is subject to HIPAA protection. ISO certification does not equate to HIPAA certification; in fact, there is no HIPAA compliance certification process, and it is often difficult from the outset to determine if and when HIPAA applies.
As discussed in this prior blog post, HHS’s guidance on various “Health App Scenarios” underscores that fact that health data collected by an app may be HIPAA-protected in some circumstances and not in others, depending on the relationship between an app developer and a covered entity or business associate. The consumer (or app user) is unlikely to understand exactly when or whether HIPAA applies, particularly if the consumer has no idea whether such a relationship exists.
Back to the Apple Watch Series 4, and the many other consumer-facing medical devices or health apps in already on the market or in development. When do the nuances of HIPAA applicability begin to impede the potential health benefits of the device or app? If I connect my Apple Watch to Bluetooth and create a pdf file to share my ECG data with my physician, it becomes protected heath information (PHI) upon my physician’s receipt of the data. It likely was not PHI before then (unless my health care provider told me to buy the watch and has process in place to collect the data from me).
Yet the value of getting real-time ECG data lies not in immediate user access, but in immediate physician/provider access. If my device can immediately communicate with my provider, without my having to take the interim step of moving the data into a separate file or otherwise capturing it, my physician can let me know if something is of medical concern. I may not want my health plan or doctor getting detailed information from my Fitbit® or knowing whether I ate dessert every night last week, but if I’m at risk of experiencing a medical emergency or if my plan or provider gives me an incentive to engage in healthy behavior, I may be willing to allow real-time or ongoing access to my information.
The problem, particularly when it comes to health apps and consumer health devices, is that HIPAA is tricky when it comes to non-linear information flow or information that changes over time. It can be confusing when information shifts from being HIPAA-protected or not, depending on who has received it. As consumers become more engaged and active in managing health conditions, it is important that they realize when or whether HIPAA applies and how their personal data could be used (or misused) by recipients. Findings from Deloitte’s 2018 consumer health care survey suggest that many consumers are interested in using apps to help diagnose and treat their conditions. For example, 29% were interested in using voice recognition software to identify depression or anxiety, but perhaps not all of the 29% would be interested in using the software if they were told their information would not be protected by HIPAA (unless and until received by their provider, or if the app developer was acting as a business associate at the time of collection).
Perhaps certain HIPAA definitions or provisions can be tweaked to better fit today’s health data world, but, in the meantime, health app users beware.