In the healthcare space, interoperability is important across systems and organizations for information to flow seamlessly between actors like patients, doctors, hospitals, payers, etc. However, it has been one of the hardest challenges healthcare has faced as vendors, providers, policies, payers and patients have, at times, set roadblocks up and created misaligned incentives to achieve true exchange of data between disparate systems
Realizing the benefits of blockchain technology depends on the associated network of healthcare organizations being able to share data and collaborate via the blockchain. These net-new requirements increase the scope of interoperability challenges that pre-dated blockchain.
When systems are not interoperable, the cost of verification and networking of the information is very high. The same is true for the cost of settlement and reconciliation of the transactions of information.
Blockchain technology is distributed by nature. In addition, at its core, the technology is a shared ledger, which allows participating organizations to have a common view of the status of digital assets and transactions. This allows systems and organizations that participate in the network to be somewhere between the foundational and structural degrees of interoperability. A basic blockchain solution isn’t fully at structural interoperability because it is very flexible as to what types of data it can store and what formats, code sets, identity systems and so forth are used.
Existing healthcare interoperability standards such as IHE (Integrating the Healthcare Enterprise) and HL7 FHIR® (Fast Health Interoperability Resources) should be used to the maximum extent possible to ensure healthcare organizations can communicate and collaborate efficiently via the blockchain. Pilots underway are leveraging existing IHE frameworks within the blockchain infrastructure to support standardized exchange protected health information (PHI). Peng Zhang et al.  discuss some of these challenges in the proposed FHIRChain architecture. However, adding standards like FHIR® to the blockchain will allow the participating systems and organizations to reach semantic interoperability within a given network.
Gordon and Catalini  also discuss how blockchain technology could be used to help enable patient-driven interoperability where the patient is more in control of the information pertaining to him/her.
The specific types of healthcare organizations in the network, the blockchain use case(s), and types of data shared via the blockchain are key factors in identifying existing applicable interoperability standards. Interoperability should be enforced in the writing or appending of new transactions and blocks to the blockchain. This can be done through APIs and smart contracts. Blockchain can also enable the discovery, record location, and subsequent direct peer-to-peer exchange of healthcare data.
For reasons like privacy, storage, security, or scalability, not all the data should reside on the blockchain. This means that other activities occur off-chain. Sidechains or state channels could be used to improve scalability, data could be stored in a separate database and queried outside of the blockchain realm by other organizations. Interoperability standards established for a blockchain network should also cover such off-chain direct peer-to-peer exchanges, again to maximize the efficiency of collaboration across the blockchain and network of healthcare organizations   . There is also the necessity to enforce interoperability when new information is appended to blockchain .
In addition to the interoperability of healthcare related data on and off a blockchain, one also needs to look at the interoperability of the blockchains’ networks. Many healthcare related solutions are forming based on different blockchain platforms. These platforms may be public or private, and organizations may be participating in multiple networks. Interoperability within a blockchain does not guarantee interoperability across blockchains. As an example, payers participating in blockchains of clinical and claims metadata may have interoperability within each chain but not between both the clinical and claims, a consideration as many organizations seek to integrate clinical and administrative data. Several projects have started to create bridges between blockchain platforms to allow for the flow of assets between them .
In conclusion, blockchain technologies seem to be an additional valuable component that organizations and networks can leverage to achieve healthcare interoperability.
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