While telehealth has been evolving for some years, it has lacked the impetus to achieve significant adoption.
Before the COVID-19 pandemic, a provider typically needed to see the patient in an in-person visit, which was, in part, dictated by reimbursement policies of the payer (e.g., difference in reimbursement between an in-person and a telemedicine visit), and orchestrating the logistical efforts that the telemedicine visit was secure and private.
However, COVID-19 created the necessity to increase virtual care to facilitate social distancing, and caused healthcare resources to be reallocated to treat COVID-19 patients, limiting access to routine diagnostic imaging procedures and preventative monitoring services for non-COVID-19 patients.
In response, new telehealth services were rapidly deployed to provide clinical health services to patients remotely. In the U.S., federal and state rules and regulations around Medicare and Medicaid telehealth reimbursement relaxed to expand telemedicine visits, which contributed to an enormous uptick in telehealth visits.
While reports may already show its usage declining from earlier in the pandemic, there is little question that this form of virtual clinical encounter will remain in some capacity and has already demonstrated new levels of effectiveness in clinical engagement. Growing consumerism and patient engagement in healthcare will influence the need for providers to support telehealth, remote patient monitoring (RPM) and other digital health solutions as an alternative to current brick and mortar practices.
The tool has also proven to be an additional way to support health systems in their value-based care goals. Given positive experiences by both patients and providers alike, there are calls across the industry to maintain the current reimbursement flexibilities and pave the way for telehealth’s expansion to remain permanent. With the likelihood that telehealth is here to stay, the industry has an opportunity to strategically assess its implementation and improve on the integration of these virtual services into their care delivery. The integration of blockchain-enabled virtual care technology offers opportunities to further improve the impact of telehealth on care delivery through the use of distributed ledger enhancements like smart contracts, digital patient identity and tokenization.
While telehealth solutions have been around for some time, its rapid adoption since the beginning of the pandemic has been crisis-driven and in some ways, rushed. To develop telehealth into a service offering with staying power in the delivery of healthcare, there is a broadly growing consensus amongst both patient and provider groups that there must be a concerted and strategic move to virtual care.
The systemic adoption of virtual care means moving beyond third-party video tools that currently come to mind around traditional telehealth services. It involves adopting a broader program of innovation and strategic engagement with patients, with technologies such as remote patient monitoring (RPM), asynchronous communications (SMS, voice/phone, video, portal), and establishing a chain of trust enabled by digital identities from providers to other remote services. Virtual care also requires rebuilding care delivery and the ecosystem with a virtual first, patient-centered design perspective.
In designing a virtual care model, the concept of a single physical facility or system blurs with the ability to engage virtually with clinicians across multiple offices, groups and even state lines. Most importantly, the concept that one provider or system serves as the “single source of truth” of a patient’s medical history and health data becomes not only less important, but alleviates the existing complexities that exist in the current management of health data at the expense of the patient, requiring primitive faxes, CD images, and reports to be collected (typically by the patient) and captured in the “home” system.
Despite new mandates and regulations to expand access and exchange of information, health data is still managed from a centralized, provider-centric perspective, instead of a decentralized, patient-centric model. This will pose increasing challenges as patients expand the types of encounters and providers they engage in, as well as where their data resides. A broader ecosystem with virtual care is challenging within the limits of current identity management, patient matching and data provenance issues, blocking the trust needed for providers to collaborate on care delivery in this increasingly distributed environment.
In its current form, remote patient encounters generate pockets of data from mobile phones, video/audio applications and monitoring devices. This data is shared inconsistently through application programming interfaces (APIs), interfaces, or even still volumes of paper with authorized entities. Despite numerous market offerings, blockchain technology has demonstrated only limited integration in today’s healthcare services, but adding its capabilities into remote care delivery can offer benefits to patients, providers and payers in their efforts to adjust to an invariably decentralized care delivery system.
Blockchain offers the potential for multiple applications to virtual care delivery, which can improve the healthcare ecosystem: from establishing trusted digital identities, to consent management, to improving administrative and clinical workflows through decentralization, and access to data. As discussed in an evaluation of the technology for supply chain uses, blockchain’s capabilities can help ensure accuracy, verification and immutability in the secured access for the following data types, which also align for data included in virtual care services:
In a telehealth-driven care delivery approach, multiple providers along with diagnostic and monitoring equipment often need to view, share, update, approve and collaborate on the care of the same patient. Blockchain can help create that chain of digital trust from devices to patients and providers and to EHRs and claims management systems.
By design, blockchain would inherently support clinical documentation improvement, or CDI, programs with its ability to provide greater accuracy on the confirmation of services rendered and ability to immutably associate health data with the properly matched patient identity. Such an approach would further advance the decentralization of patient health information while also letting patients have control of their data. A patient or provider on a trusted immutable blockchain will benefit from verification of all updates, even in real-time, that happen to their record with an option to control access to approved entities only.
Given the potential of increased security risks involving the interchange of electronic telehealth data as part of virtual care management, blockchain offers a secure mechanism to validate the identity and credentials of providers as well the authenticity of all devices and data sources, clinical and non-clinical, before allowing edits and/or revisions to be applied to the patient’s record.
The increased use of tele-encounters could easily result in digitally recorded consults that increase the data storage for EHRs, which are traditionally not architected to efficiently manage these volumes. Blockchain-supported decentralized storage can help manage audio, large data files and video content while maintaining an immutable record of the transactions associated with the specific patient. Though the feasibility of storage of large amounts of data on blockchain ledgers has been debated, blockchain can orchestrate the distributed storage of such large amounts of data on separate systems—such as storage area networks, or SANs, off-chain—and provide a secure encrypted mechanism for patients to share access to the volumes of telehealth (video) data regardless of where they digitally reside.
Furthermore, there is an opportunity to utilize smart contracts in blockchain to efficiently and accurately manage the revenue cycle associated with conducting telehealth encounters. Verified patient disclosures, insurance policy information, and patient coverage details are also available on the blockchain, along with authorizations for medical procedures, laboratory work and referrals to specialists. The medical documentation and reimbursement process can be governed by code logic embedded in the smart contracts which can be executed in record time. Subsequently, processing of insurance claims and payment transactions (between patient, provider and payer) would happen instantly and at a substantially lower cost, governed by an agreed-upon rule set in the smart contract program. Secure seamless access to information at such speed can decrease consultation times, improve quality of care, and reduce time in revenue recognition by the provider.
With the decentralized technology and smart contract capabilities that blockchain offers, you can imagine a scenario where a patient is able to securely request remote care through telehealth with any provider(s), securely provide access to all their data (history, insurance, personal medical devices, lab results, etc.) within seconds, confirm their insurance coverage, get an instant referral and share the applicable elements of their medical records from their initial consult with other specialists, just as the corresponding payer is able to verify the claim and a payment at the same time. Today, this set of actions and subsequent activities take days, weeks and even months for each encounter.
There are two additional scenarios that further describe how blockchain can add value to care processes that have rapidly grown in their remote delivery during the pandemic: ultrasound imaging and device monitoring.
New ultrasound imaging technology enables clinicians to use a portable device to take a whole-body ultrasound image while connected to a mobile device, running the associated mobile app. The app enables the archiving of the ultrasound images to the supporting cloud storage system, which stores the Digital Imaging and Communications in Medicine, or DICOM, compliant image, and utilizes Transport Layer Security, or TLS, with secured network connection option to allow encrypted communications with the Picture Archiving and Communication System (PACS) and EMR used by the providers. This telehealth service enables providers to offer diagnostic imaging services to remote patients at a reduced cost and without traditional bulky equipment.
While PACS image sharing is already supported by most systems, blockchain can also facilitate a secure exchange outside of networks, by providing an encrypted link with a unique key to another radiologist that may not be part of the health system that the image may have originated from. Blockchain would also enable the proper documentation of codes such as ICD-10 , CPT and HCPCS for each sequential imaging service provided by tagging images with a hash for provenance, a time stamp, and apply appropriate coding based on services rendered. This would ensure accurate billing submissions for full reimbursement of services provided as well accurate patient identification, further validating the revenue cycle management process.
The technology can also connect the sequencing of ultrasound imaging in the captured chronological order, which helps practitioners understand the progression of disease while maintaining coding quality of diagnostic procedures which helps to ensure proper billing and reimbursement.
Another popular telehealth service utilized during the pandemic is remote cardiac device monitoring. Prior to the move to virtual care, a patient was required to visit a doctor for their cardiac implantable electronic device (CIED) data to be collected. Then, it was submitted to the device manufacturer’s website in order to obtain data in a format that can electronically provide a patient’s CIED report.
Now, through the use of a telehealth remote monitoring service, an at-home patient with a remote transmitter can send the CIED data directly to its device manufacturer. Then, the manufacturer can send the formatted data to the remote cardiac device monitoring service vendor for interpretation and provide the CIED report and clinical results back to the attending physician. Adding blockchain to this telehealth service enables a streamlined process where an API can provide access to the raw data from various device manufacturers, thereby eliminating the step to send the CIED data back to its device manufacturer.
Since the formatted data can be shared with authorized vendors for the purpose of interpretation and CIED report generation, providers can choose to utilize the services of the lowest-cost vendor, thereby facilitating market competition and price negotiation to drive down the cost of this service. Leveraging blockchain with the CIED data exchange provides an immutable transaction record of the data between the device, manufacturer, vendor physician and patient, reducing the time to process and providing near-immediate feedback to the patient about their cardiac health.
As other virtual care services like these continue to increase in usage and demand, it is important to also consider the scalability of the storage architecture, especially on devices with minimal memory that reside on the edge of the clinical network. As previously discussed, a blockchain-enabled decentralized storage model will enable the ability to securely manage the location, accessibility and auditability of edge medical devices and the Internet of Medical Things (IoMT).
Since blockchain-enabled telemedicine entails a more patient-centered model, it is essential to understand the attitudinal social and mental barriers that may hinder patients from active participation.
It is often assumed that patients are willing to adopt these solutions as long as applications are available, however, such an assumption may not be valid. For example, although a blockchain-enabled telemedicine system may provide patients with more control of health data and enable them to share data with healthcare providers in a secured manner, patients may be wary about losing the private key or mismanaging data access, and therefore be reluctant or unwilling to adopt the system, especially their comfort with mobile apps and electronic wallets commonly used to manage blockchain systems.
So far, academics and industry experts have mainly focused on the technical design of blockchain solutions for healthcare, but very little attention is given to the barriers that may hinder patient adoption. Thus, we call for the research on the barriers faced by patients, which we believe can bring about patient-friendly systems that are more conducive for mass adoption and movement toward a patient-centric model.
The current and prospective future pandemics will hasten the move to a virtual care-first approach in the treatment of patients. Blockchain's unique structure of cryptographically secured transactions can allow the shared information and healthcare data to be trusted by the providers and provide managed consent and privacy by the patient to support this virtual care. This is of particular importance when patients need to seek care outside of the immediate network to meet surge capacity during a healthcare crisis, like COVID-19. If the provider can trust the data and incorporate the data into their clinical workflow, then less tests and studies will be needed—reducing duplicate patient testing—allowing for significant time savings, a reduction in costs to the health system, along with a reduction in costs to the patient.
As we look further in the future, evolving technology such as AI and machine learning and 5G will not only complement blockchain, it may also accelerate the pace of adoption due to expanded use cases and adoption. AI can enhance learning from the patient, from a network of individuals including care providers, to enhance the quality of the virtual experience and serve as an always-on management layer for chronic care management. The connection between 5G and blockchain is multi-layered. 5G is powerful through its reduced latency, high speeds and capacity, enabling wider use and adoption of IoMTs. Blockchain is the foundational layer offering the security, decentralization, and immutability of portable, autonomous-generated patient data.
Given the ongoing issues of fragmented and unstructured data in the typical healthcare information system, coupled with challenges in acceptable methods of patient matching and consent, this is the time to secure them with use of blockchain, where the patient can enforce ownership and consent-based access to their immutable data and by using a secure, private key, they will be able to share it with a trusted third party, such as their provider, caregiver, etc. The transparent and decentralized construct of blockchain means the patient can monitor every node that is being added to their network, and data immutability prevents data from being added without being associated with an episode of care.
There is a lot on the horizon for innovative advancements in healthcare, and the current pandemic has only hastened the need to move faster on such innovation, especially freeing up the patient from the physical boundaries or in-person encounters and interventions. As our industry embraces virtual care as an ongoing component in patient-centric care, healthcare systems and developers have the opportunity to strategically think about how emerging technologies such as blockchain can increase the value and staying power of these solutions in the long-term.
By Roger Boodoo, Health Informatics, Defense Health Agency; Thompson Boyd, Consultant; Wilson Choi, Sr Director, Information Services, NYC Health+Hospitals; Jorge Ferrer, Medical Informatician, U.S. Department of Veterans Affairs; Chang Lu, Healthcare Blockchain Postdoc Research Fellow, UBC; Satish Malnaik, Chief Executive Officer, Next Services; Michael Marchant, Director, System Integration & Health Information Exchange, UC Davis Health; Chrissa McFarlane, Chief Executive Officer, Patientory; Maria Palombini, Director, Emerging Communities & Opportunities Development, IEEE Standards Association; Sandip Ray, Project Manager, Strategy/Physician Services, St. John’s Medical Center; Jim St Clair, Chief Technology Officer, Dinocrates Group and Stephanie Zawada, Student, Mayo Clinic Graduate School; HIMSS Blockchain in Healthcare Task Force Members
The views and opinions expressed in this content or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.
Blockchain and distributed ledger technology are taking hold in healthcare as the industry learns more about the potential to improve patient care and reduce costs. Better understand the basics and the potential application of blockchain in healthcare with our Blockchain in Healthcare Guide.