It would be diplomatic to say that the rise of open standards and APIs in the healthcare industry has yet to truly pay off in the form of better widespread patient data portability, reduced complexity in the systems behind payments and claims, better quality metrics and outcomes, or better automation of menial paperwork or other manual process. Our health IT systems are only getting more and more silo-ed and disintegrated, and there’s always a new venture-backed SaaS provider or software vendor who just wants to solve that by centralizing (er, “vertically integrating”) all data and processes on their systems, adding to the problem rather than solving it. The client-server model for applications just doesn’t work for an industry as complex, heterogenous, and political as healthcare. Could blockchain technology be helpful here?
Blockchain technology first rose to prominence as the data and networking architecture underpinning cryptocurrencies like Bitcoin. We believe the decentralized ledger and smart contract features will have the most significant impact on society. A blockchain can reinvent any multi-party system of record from one that depends on a central trusted third party to maintain integrity and trust, into a decentralized, distributed, and auditable networked database. Pilot projects are underway in financial markets settlement, supply chain tracing, intellectual property and even property title. Increasingly, the healthcare sector is looking at blockchain too.
So, what’s a blockchain, really?
Let’s start with the basics. A blockchain is a stream of data - a distributed ledger - that is written to, shared with and confirmed by a collection of nodes on a common network, run by different companies or organizations. The software used to build a chain ensures that everyone on the network sees, validates, and confirms each proposed next “block” of data in the chain, with links to the prior and/or next block in the “chain”.
This blockchain validation step is the key that allows a blockchain to replace a trusted intermediary. For example, if any node on the network tries to transfer a particular asset twice, to two different parties, that transaction would not be validated by others on the network, and there would be no agreement to add it as a new block on the chain. This validation, this immediate confirmation from the whole of the network, and this distributed-at-all-times nature of the chain is what builds trust in the system as a whole - the same rules apply to everyone, and we don’t need to depend upon just one party to set those rules and keep the ledger consistent and honest.
Also important here are “smart contracts” on a ledger - these are simple software programs that run across all nodes in the network, and can extend the validation logic at each node, in a way that is automatable and undeniable. In the financial world, an example might be an insurance contract, or an offer to buy a share of stock in the future for a certain price set today. In a healthcare setting, where a chain is being used to share personal data, this can be used to implement an authorization process and confirmation step that notifies the patient - or even put them in control - when their data is shared from one address to another.
Confidentiality and privacy on a chain
Since all data is copied to every entity on the chain, confidentiality and privacy need to be carefully designed in. Furthermore, this widespread distribution means space is at a premium, so small data or metadata is preferred. That means the way you design your blockchain application is important - what you decide to store “on-chain,” so you can get it everywhere and with high integrity, versus what you store “off-chain” because of size constraints or confidentiality, is key. In healthcare we sometimes deal with very large files (such as X-ray scans) - there’s no need to store those entirely on the chain, but storing links to those as well as a “hash” to ensure that it hasn’t been changed, would likely be right.
Not all ledgers are publicly available. Just as you might have a private network at your house, or use a VPN to connect to the office, there will be private or “consortium” chains running between specific organizations, perhaps with a legal or regulatory agreement binding the participants. For example, a healthcare data chain may limit its network nodes to only HIPAA-covered entities, in addition to encrypting some data and leaving other data “off-chain”, so as to provide multiple layers of security.
Which solution/improvement has the most potential to drive blockchain adoption across the healthcare industry?
Source: January 2017 Hyperledger Healthcare Working Group Survey, N=28
Current blockchain healthcare efforts include:
- Blockchain Health is implementing permissions management for data from clinical trial patients, easing the burden for recording agreements and demonstrating audit compliance.
- MedRec, aMIT-based winner in the recent HHS/ONC blockchain use cases contest, is implementing a patient-centric EHR on a permissionless blockchain.
- The Estonian Government has put its citizens’ health identity data on a blockchain, to ease access to services.
- Gem and Capital One are partnering on blockchain-based healthcare claims management
Other ideas for blockchain in healthcare include:
- More efficient billing and payment – benefits being automation, transparency, better records management. Could lead towards better outcomes-based payments.
- Provenance tracking of pharmaceuticals, from manufacturing (anti-fraud, public health) all the way to consumer adherence (imagine smart pill bottles that help the elderly and caregivers with dosages).
- Provider directories, perhaps even provider certifications, could be published and maintained via a blockchain.
Blockchain’s future in healthcare:
Blockchain technologies hold the promise to unite the disparate processes in healthcare, increase data flow and liquidity, reduce costs and improve patient experience and outcomes. Blockchains depend upon ecosystems of peers participating in a network, and are designed to avoid the need for any to have to be the gateway at the center. The health information industry must start thinking and planning for chains, building proofs of concept, running pilots, and organizing itself to take advantage.
How long before [healthcare] first adopters utilize blockchain in large scale solutions?
Source: January 2017 Hyperledger Healthcare Working Group Survey, N=29
How long before blockchain solutions realize mainstream adoption?
Source: January 2017 Hyperledger Healthcare Working Group Survey, N=29
Like we saw with the HIE debate, there will be a natural tendency to build small, regional or use-case-specific chains; this would be a mistake, as the more participants and nodes on a chain, the greater the overall utility for the patients and greater economic value you can create for other participants.
Hyperledger is committed to helping the healthcare industry realize the full potential of open source blockchain technologies. So, as this industry investigates this space, we should focus on pilots, but also, on how to quickly grow them into full-fledged production systems for a large number of participating organizations. We hope to see you out there!
Looking for more HIMSS resources on blockchain?
- Brian Behlendorf was one of our speakers at the Winter Quarterly Interoperability & HIE Community Roundtable – Click here to watch the recording of this webinar.
- Learn more about Blockchain at HIMSS17!