Can Blockchain Liberate Healthcare Data, Improve Efficiency of the Healthcare Industry, and Enable Patient-Centric Care?

This article assumes the reader has a basic understanding of Blockchain technology and how it works. For more information on Blockchain, I recommend starting with “A Gentle Introduction to Blockchain Technology” which gives a good description and provides links to further articles for more information.

The Problem

Working in Health IT, it always seems that the state of play for use of technology and interoperability of data is many years behind other industries. An individual’s healthcare data is still segregated into many disparate databases, “silo’ed” off from each other, with highly variable plans to achieve interoperability amongst different healthcare organizations. And yet, it is commonly held that healthcare quality and outcomes improve when a physician has access to all the patient’s information.

Much has been done in the US and around the world to work towards the holy grail of true, secure healthcare data interoperability. Different approaches to this problem have included massive, centralized repositories such as that implemented by England’s National Health Service; complex health information exchanges (HIEs) set up in every US state (sometimes many HIEs in one state) intended to create a network to exchange patient information between healthcare entities; and on-demand technologies that create links and mine multitudinous niches of healthcare data that then create a “virtual” patient record on demand.

Furthermore, the patient has very little access (much less control) over their entire healthcare record. It is virtually impossible for an individual to retrieve and piece together all their healthcare data. If one can get a healthcare organization to provide their information, it is in a variety of different formats (including paper). How different from an industry like banking, where we can usually access and compile our records completely online.

In spite of the truly impressive collective brainpower that has been trained on this problem over the years, and the many billions of dollars spent by governments and private industry alike, it appears that interoperability of healthcare data on the same level as, say, banking information is still a distant dream. One begins to think that a truly ubiquitous scheme for seamlessly (and securely) sharing healthcare information, so that a consumer of said data receives the right information, at the right time, at the right place, is unachievable.

Could Blockchain Present a Solution?

Into this environment, we introduce the idea of blockchains. Blockchain makes data more portable and complete. It makes transactions highly secure and immutable, and allows various actors to read and write to the same record. It has been applied with a great deal of success to the Finance domain, underpinning the Bitcoin virtual currency. It can enable a user’s complete data record to “follow them around”, potentially giving the individual control over who can access their data. Can Blockchain technology offer the answer to the ongoing challenge of secure, private healthcare data interoperability?

There are many issues facing the secure storage, sharing, and use of healthcare data today. Key issues I have identified and address here include:

• Obtaining a complete patient record, rather than elements of an individual’s healthcare record being held in many different, isolated data “silos”
• Controlling access to the patient record, either in whole or in part, reading and writing
• Ensuring confidentiality, integrity, and accessibility of patient data
• Enabling portability of data, as a patient moves between care providers and between insurance providers
• Patient matching – ensuring data is attributed to the correct individuals
• Empowering the individual – giving patients access and control over their healthcare information and a greater say on who has access and how it is used

It would appear that Blockchain offers the ability to address these issues, providing a secure, portable, and complete “cradle to grave” healthcare record for individuals.

An Overview of Blockchain Technology

Briefly, a blockchain is a distributed ledger that securely records data or transactions and can replicate copies of the ledger amongst a large number of different participants.

Typically, a blockchain is comprised of transactions (blocks), information about those transactions, and a unique “fingerprint” such as a hash that ensures that a given block cannot be altered or duplicated. It provides a robust means to uniquely execute transactions and record them in a publicly accessible manner. Transactions can be executed via “smart contracts”, which are defined programs which the participants in a blockchain can use per predetermined rules.

Centralized vs Peer-to-Peer

There are centralized or peer-to-peer models for blockchains. In a centralized model (or client-server), the data is held on a central server platform and accessed by the different participants in the blockchain (i.e. clients). This provides some of the benefits of the blockchain architecture: the ability to have a comprehensive, immutable, and secure record. But, it still means that the individual’s healthcare record is maintained by a single organization, and opens the door to again fragmenting the record amongst different isolated databases. Plus, there is also dependency upon that single “node” – if it is not available, then the data cannot be accessed.

The peer-to-peer approach employs a distributed architecture, whereby the entire blockchain is replicated amongst the participants with no dependency on a single central repository. In this case, all participants (nodes) store the same data locally in their copy of the ledger. When a new “block” of data is written, it is broadcast to all nodes to be added to their local copies of the blockchain. One corrupted copy can be easily identified and rectified. Peer-to-peer blockchains would be more suited to the concept of enabling a more patient-centric approach to the healthcare record; creating a complete, immutable healthcare record that is not “owned” or controlled by any single healthcare entity, but rather shared amongst all. Plus, the data is more available in the peer-to-peer model than the centralized model, given that if one node goes down, the rest continue to operate independently.

Public vs Private

Public blockchains are normally open to any entity – trusted or not. Bitcoin is a good example of this, where anyone can download the software and start using and mining for Bitcoin (although they need significant computing power for the latter). In that model, there is not a central entity orchestrating events or vetting participants. There are rules established for smooth operation, deconfliction, and addition of new information in a decentralized manner encoded into the system, but that is the extent of central management. (For a better understanding of how public, peer-to-peer blockchains manage conflicts, see the article I referenced earlier, “A Gentle Introduction to Blockchain Technology”.)

Private blockchains involve trusted participants and can have some level of central management, so they can employ simpler rules and governance mechanisms.  There can be more centralized orchestration and management. In the case of a patient-centric healthcare blockchain, this control could be placed in the hands of the individual. The patient would enable appropriate access (e.g. read, read/write, or even selected access) to healthcare organizations with which they interact. Entities wishing access to the patient’s information could request it, and the patient would be in control of who sees what data.

Security

Encryption and digital signatures are important aspects of Blockchain technology as well. These measures help keep the data in a blockchain secure, prevent tampering, and ensure that there is an auditable trail of who wrote what data to the blockchain and when. Even in public blockchains where anyone can participate, their unique identities are known and incorporated into the information that they write to the blockchain. Of course, this does not eliminate the need for other cybersecurity practices to protect against unauthorized access. Robust network, infrastructure, and end-point device security is still required. In a healthcare blockchain - just as with any electronic health record system – implementing identity and access management (IAM) and role-based access control (RBAC) is important, so that participants are positively identified and their level of access to the data and what functions they can perform are controlled and audited.

Monetizing Transactions

Currently, Blockchain technology is most commonly used for financial transactions. Bitcoin, which is a cryptocurrency, is probably the best-known application of Blockchain. When a participant adds new blocks to the chain, they are said to be mining for Bitcoins. When they successfully add a new block, they are rewarded with Bitcoins (currently 12 Bitcoins per block). This is how Bitcoins are gradually introduced into the market at a managed rate. A private blockchain can also include a proprietary cryptocurrency that trusted participants can use to pay for products and services amongst themselves.

In a healthcare ecosystem, this raises interesting possibilities for how participants could be incentivized to interact with a patient’s blockchain. Following the Bitcoin model, healthcare organizations could be compensated for each healthcare transaction they add to a patient’s blockchain. Also, the healthcare revenue cycle could potentially be managed via the blockchain. Financial transactions would use the associated cryptocurrency, and be written into and managed in the blockchain itself.

Applying Blockchain Technology to Healthcare Records

The de-centralized nature of Blockchain is a key reason why it could enable the creation of a complete patient record, as well as ensure its integrity, privacy, portability, and interoperability. It can be inherently patient-centric – rather than the data from a healthcare encounter being “owned” by the healthcare provider and stored in their isolated electronic healthcare record, Blockchain technology flips that model on its head. The data from a healthcare encounter would be written to the individual’s blockchain. The healthcare transaction would be added to all the other healthcare encounters stored there, creating an immutable and complete record of a patient’s journey of care. This ledger could be stored in a secure cloud, allowing the individual to interact with it from mobile devices. (This would be preferable to trying to replicate the blockchain on their smartphone, given the storage and network bandwidth requirements needed to participate in a blockchain architecture.)

The model holds for healthcare payors, or insurance companies, as well. The typical healthcare payor sector usually holds a more complete history of patient activity than a given healthcare provider. Many people may stay with a single healthcare insurance company for years, while in that time they will visit several different healthcare providers. However, people and employers do change insurance providers, and rarely do individuals extract all their data from the previous provider and port it over to their new insurance company. Furthermore, insurance providers do not store complete clinical records, they typically only capture claims data. Thus, the insurance providers are contributing to creating more isolated silos of partial information about a patient.

With a Blockchain approach, we see a model whereby healthcare providers and payors (as well as other entities involved in the healthcare ecosystem, e.g. medical device manufacturers, pharmaceutical providers, etc.) would subscribe to a patient’s healthcare blockchain to gain access to their complete electronic healthcare record. As a trusted entity, the individual’s primary care physician could add a new block of information when the patient comes in for their yearly physical. The local ER would be able to append a new block containing clinical data and x-rays when the patient came in with a broken leg. Insurance companies would be able to add blocks containing claims data, and the blockchain would provide a secure mechanism for the provider and payor to interact to ensure proper claim adjudication and payment is processed. If so inclined, the parties could even agree to use a cryptocurrency associated with the blockchain (such as Bitcoin) to process payments.

Medical device manufacturers and pharmaceutical providers, interested in learning more about patient behavior for marketing purposes, could also subscribe to patient blockchains to access this data. Scale does become an issue in this case, given that these entities would be interested in accessing thousands or millions of individuals’ records, but it is conceivable that a mechanism could be created to orchestrate mass subscriptions for purposes of research, clinical trials, etc.

With the patient in charge of their blockchain, the patient could have the ability (via the appropriate user interface) to control who can access their healthcare record. They could selectively enable their healthcare provider team with full read/write access; they could approve selected read access to their insurance provider to certain elements of their clinical record, and full read/write access to the claims elements of their record. And if they chose, they could provide read access to selected, anonymized data elements for researchers, or the manufacturer of their medications, so they can include that data in their studies.

An alternative model that would better address the scalability challenges faced by researchers and those interested in population health management would be for the healthcare provider network or the payor to maintain their own blockchain, containing information for many patients. This would potentially be a less patient-centric model, but could still be implemented in such a way that the patients themselves where the healthcare provider maintains their own blockchain, storing information for many patients. It could result in “parallel blockchains”, which would not be ideal in terms of efficiency or integrity of data, but orchestration could ensure that the data is kept in sync. But, to achieve a patient-centric, comprehensive healthcare record, the patient-owned blockchain is a better model.

A patient-centric healthcare blockchain could also facilitate patient matching. As patient information is proliferated amongst healthcare organizations and stored electronically in several databases, accurately matching a patient to a record becomes a significant challenge. This is exacerbated in the case of people with common names and a lack of good records or identification, such as with the indigent population. If a blockchain approach is used for these individuals, even though they may not maintain it themselves, the healthcare provider would have a more complete record and better probability of correctly identifying a patient.

The significant computing resource required to update the public, peer-to-peer blockchain and the verification built in to protect against bad actors protect against attempts to alter or corrupt historical data. But in a healthcare blockchain, it would not make sense to make participation very resource-intensive, so there must be an element of trust amongst the users. A private blockchain model would be more appropriate, whereby once a user is vetted and authorized to access a patient’s blockchain, they would be a trusted entity in the private network. In that case, ensuring their identity is secure and not improperly accessed is critical.

The ability of Blockchain to implement a cryptocurrency could have applications in healthcare as well. The revenue cycle within a healthcare ecosystem can be complex and oftentimes frustrating for participants. Insurance claims are not input correctly, or there are errors in processing them, resulting in delayed payments for healthcare providers and inappropriate charges for patients. There is great risk of fraud and abuse.

If the participants in a healthcare system adopted a trusted cryptocurrency associated with the blockchain they employ, they could potentially move the revenue cycle to their blockchain environment. Billing codes and rules could be encoded in the blockchain and used to govern smart contracts covering healthcare transactions. Bitcoin or another existing cryptocurrency could be used for payment, or in theory a proprietary currency specific to participants of the blockchain could be employed. The entire process would be greatly streamlined, with verification of patient eligibility, approval for procedures, billing, and payment executed securely and electronically amongst the participants in a fraction of the time it takes today, and with much higher security and lower error rates.

Conclusion

It would appear that Blockchain technology offers great promise to improve a wide variety of areas of our healthcare system, through more secure and efficient data sharing and processing. Clinical outcomes could be improved by better sharing of patient data, allowing physicians a more complete picture of a patient’s health. The complicated healthcare revenue cycle could be streamlined and sped up (i.e., through the use of cryptocurrency and secure contracts). Patient experience and satisfaction could be improved by giving them greater control and understanding of their complete healthcare record, and by encouraging them to take more ownership of their healthcare data. This in turn would enable patient engagement mechanisms to incentivize healthier behaviors and a focus on prevention. Healthcare providers focused on population health management, researchers, and providers of drugs and medical devices could gain secure access to millions of patient records, yet the control of what data is shared and with whom could remain with the individual, minimizing the risk of improper access or misuse against an individual’s wishes.

Clearly Blockchain technology is not a panacea, and appropriate application to electronic healthcare records would require careful study and design. Business and data governance rules for a healthcare ecosystem must be agreed by all stakeholders, then encoded in the blockchain system. But there does seem promise that Blockchain technology can help liberate healthcare data, facilitate its exchange, enable more patient-centric models, and help address the challenges of improving the quality healthcare, improving the patient experience with our healthcare system, and reducing the overall costs of healthcare.