AUTHOR: Tom Bowden, CEO HealthLink & Vice President MSIA
Recently we have been hearing a lot about blockchain, the distributed digital system seen by some as a ‘silver bullet’ for addressing information security and interoperability challenges. It is tempting to see blockchain as something of a fad which is currently going into Gartner’s famed ‘Hype Cycle’[i], about to mount the Peak of Inflated Expectations before plunging into the Trough of Disillusionment. But the hype around blockchain isn’t entirely unwarranted.
In concept, blockchain is similar to other internet protocols such as HTTP, SMTP and TCP/IP. Many, many services based on these protocols (Google, Facebook, Tinder etc) have indeed been transformational. In terms of electronic commerce, decentralised blockchain protocols have the potential to create a similar platform for disruptive innovation, removing intermediary organisations and allowing parties such as healthcare providers and patients to manage the creation and storage of information.
It is highly likely that blockchain will provide some value to our sector. The amount of energy and effort expended will almost certainly create some beneficial results. I suggest that anyone with an interest in healthcare IT take a close look at blockchain and what it may be able to achieve and which problems it might solve and how. Firstly though, let’s try and get a common understanding of blockchain technology at a conceptual level.
Blockchains store linked information across a network of computers making the information (a medical record for instance), not just decentralised, but distributed. This means that no central person or company owns or controls the information but every approved party can access it and help run it. The people that use the system own bundles of records submitted by others. These are “blocks” of information, assembled in a chronological chain. The “blockchain” uses sophisticated cryptography to ensure the integrity of the records, i.e. ensuring that they can’t be changed by anyone.
Rather than having one central administrator that acts as a gatekeeper to data—there’s a shared ledger, spread across a network of synchronized, replicated databases which are visible to anyone with the right to access them. Blockchain’s distributed nature creates obvious security benefits. Hacking one block in the chain is impossible without simultaneously hacking every other block in the chain’s chronology.
A major attraction for use of blockchain in healthcare is the idea that it could provide a platform for creation and maintenance of a distributed healthcare record. This is creating a lot of interest. There are potentially other uses for it as well in areas such as pharmaceutical management and medical claiming applications. However, as ‘the shared record dilemma’ is both a major unsolved problem in today’s health sector and a topic of particular interest to me, I intend to focus on that in this article.
In an ideal world, a distributed longitudinal health record that is co-created by a number of parties, securely held across their computer systems and accessible by all of them, with no middleman or gatekeeper to hold things up, makes a lot of sense. However there are significant challenges to making this a reality. Among them the fact/problem that all parties to a blockchain can see everything. The somewhat naïve assumption that all providers and other parties to a patient’s care should be able to see every detail of it does not fit with a current overhaul of privacy laws such as the GDPR (General Data Protection Rule) currently being introduced by the European Union and likely to spread to all Western economies.
On the other hand, there is however a very strong sentiment that significant change to current healthcare IT systems is needed. In the US there is a significant backlash against current medical records systems. They are widely viewed as cumbersome and inefficient.
“We’ve turned physicians into data entry clerks,” says Tom Price, until recently US Secretary of Health and Human Services. The ‘wicked problem’[ii] of how to use IT to improve healthcare is nowhere more acute than in the US where 50% of US clinicians’ time is often spent on administration and record keeping. This is disappointing news for US taxpayers and law-makers who have spent the last decade waiting for their huge (US$36 Billion) investment in ‘meaningful use’ of information technology to sweep the health system’s many inefficiencies aside. Thus a Blockchain based medical record that can be easily accessed by all parties in the care delivery chain, perhaps even including the patient, may provide an improved alternative.
Healthcare Industry luminaries such as Dr John Halamka, chief information officer at Boston-based Beth Israel Deaconess Medical Centre are hailing blockchain as a possible path forward. Halamka has been heavily involved in health care data standards development over the past decade. He sees a blockchain-underwritten future in which a patient’s every health care interaction goes into a ledger every provider can see. “The EHRs may be very different and come from lots of different places,” Halamka says, “but the ledger itself is standardized.”
I have no problem with Dr Halamka’s scenario, it sounds ideal. However I fear that it is also idealistic in the present context. This is because the primary problems that beset health IT are not technological. They relate to the reluctance of interested parties with non-aligned/competing commercial interests to share information.
To make blockchain suitable for wide-scale medical record deployment in a world of commercial healthcare, we will either need to a) hammer out a mechanism whereby competing healthcare provider organisations can share data within the blockchain in a manner that still supports their business goals or b) change the manner in which they compete so that they are able to share information willingly.
These are two great challenges. Perhaps a technological leap forward such as blockchain will provide us with the opportunity we need to make progress of that kind.
I believe Gartner sums up the current prospects for Blockchain very well.
“Blockchain technologies are extremely hyped, evolving at different trajectories but should not be ignored. They offer the potential for substantial change in technology development and delivery as well as in how the economy, business and society operate. “ [iii]
In the final blog in this series I will look at where I think we should go to from here? – this will be my attempt to take a realistic look at what our options are to go forward with information exchange and record sharing. Happy New Year everyone.