The COVID-19 pandemic has put a plethora of new healthcare technologies on the fast track. Telehealth, Contact Tracing, Artificial Intelligence, and advancements in security have all made headlines since March of 2020. Bakul Patel, who runs the Digital Health Center for Excellence says the FDA is working on guidance to continue to bring-to-market things that were fast-tracked during COVID. “But beyond the pandemic and emergency use, to make it permanent, we’ll need data to see if it works or doesn’t work,” he says, “and both industry and the FDA will need to worry more about interoperability.”
And that brings us to blockchain.
We have been writing about the use of different blockchains in healthcare since 2018, as the small country of Estonia looked to put its entire medical records system on the block. Three years later (according to news reports), its entire healthcare billing, 95% of health data, and 99% of prescription information is digitally maintained via blockchain. But Estonia is a country of only 1.3 million people. For wide-scale adoption in the U.S., specifically, as it relates to the myriad number of competing electronic medical records (EMR) systems, blockchain technology is still not ready for primetime.
As readers of this space know all too well, a blockchain is simply a list of blocks; a record that is linked to the previous record and secured by cryptography. The block will have three elements: transaction data, a timestamp, and a hash link to the previous block. As such, a blockchain can be a ledger of all transactions. Each block is recorded and then added to the chain according to when it was completed. This makes it easy for participants to see transactions without having to go through centralized storage of records.
The spreadsheet is not stored in one central location and is accessible to the public. Anybody who wants to know about or verify a transaction can easily do so. What’s more, hackers can’t corrupt the spreadsheet because there’s no centralized version. That makes blockchains inherently secure, durable, and robust. There is no centralized point of failure and as a result, it’s very transparent.
How Can Healthcare Benefit from Blockchain Technology?
With all of these advantages, the healthcare industry with its need to constantly update electronic health records (EHR), should be a prime candidate for blockchain applications. A doctor sees a patient and adds to the record, the patient goes for an x-ray and the radiologist reads the doctor’s notes and adds her own, the x-ray gets added to the record, the doctor writes a prescription into the record, and the pharmacist reads it all to fill the script (and adds his own entry too).
Today, private data is stored on an individual office or hospital database or in a network like a Health Information Exchange (HIE). Blockchain can help but only if interoperability issues are addressed.
- Keeping track of what data was exchanged and determining how it’s to be shared from one point to another.
- Creating a master patient index (MPI) because there are several patient identifiers that have to be taken into consideration. There are privacy issues with MPI as well.
- The use of different standards including file formats, database names, and other factors that make it difficult to ensure compatibility between systems used by different healthcare organizations.
- Limiting access to integrated records.
In theory blockchain technology is able to address all of these issues. For one, with blockchain, you do not need to have a centralized authority for HIE’s. This means that all participants would have access to the public ledger and that exchanging patient data is inherently secure. Without the need for an intermediary, data transfers over blockchain technologies are cheaper.
Blockchain also allows for close to real time updating healthcare information and the data is encrypted, making it secure and accurate. What’s more, you can use smart contracts to have consistent criteria for accessing patient data. These contracts are based on rules and should ensure that the right people access patient data at the right time. Moreover, each block is there and you cannot change, delete, or modify it. Transactions, once completed and recorded, are there forever. In sum, on top of being open, transparent, and permanent, blockchains make records easier to manage.
Challenge to Implementation
While blockchain has a lot of theoretical uses and potential to change the way healthcare professionals and organizations store, deal with, manage, and share information, there is one major challenge that may be impossible to overcome; Data size. Electronic Medical Records are huge. No, they’re bigger than huge. They’re immense.
Blockchain is a great distributed, immutable transaction ledger: it’s great for currency or asset tracking, but even that has scale issues. If you use it for data, everyone participating ends up having to copy a very large database that never gets smaller. That’s okay if you want an asset ledger without a central authority, but not if you want an efficient way to manage access to health records.
And there are other issues:
Permissionless vs. permission-based implementations.
Permissionless blockchain implementation, like Bitcoin, is great for those who want broader access and want to facilitate innovation. However, these are typically hindered by a limit on the number of transactions that can be done in a second. This means that if you want permissionless blockchains, you should be sure to allow for slower processing times. On the other hand, permission-based blockchains do not have this limitation, but you need to make sure that you have enough computing power.
Data scope and standardization.
Not all patient data is suitable to be on the blockchain. This is why when implementing blockchain technologies, determinations must be made on which pieces of information are to be included and what information should be kept off the grid. Consideration must be taken regarding the size of information that you put on the blockchain because as we said earlier, large transaction sizes aren’t ideal for the technology. This is where standardization involving codes for procedures or services rendered must be adopted.
Incentives for participation.
Expect some resistance, as with any major change. But the reality is that blockchains become more useful the more users participate in them. Participation could also be external, such as when you want to make it attractive for individuals to let you use their computers as nodes in a permissionless blockchain network.
Regulations and compliance.
There are several questions that the healthcare industry must ask when implementing blockchain technology, such as who owns the data, and what are the rules in order to grant access to the data stored in it? You should also make sure that you are in compliance with the HIPAA Privacy Rule, and that sensitive patient information is secure.
Blockchain technology has moved from bleeding edge to cutting edge in the last three years but we’re probably a decade from seeing the widespread adoption of blockchain as the primary source of data for EHRs. But here at Liberty Fox Technologies, we do see blockchain being used as a data interchange where each provider will have their own medical data but blockchain will point to the location of that data in a much easier way.
In the end, this may all come down to cost. Blockchains are typically more budget-friendly than traditional information systems because the technology is open source, and it really doesn’t require constant monitoring, configuration, and administration. But because it’s a new technology, the costs of running these systems, in the long run, are not yet known and healthcare providers should probably bear the brunt of the expense. Hospitals and health systems are constantly wrangling with access to proper information for billing and reimbursement. Revenue cycle management is one of the industry’s most critical challenges. If providers could come together to create a beneficial blockchain-based ecosystem, it could have a dramatic effect on their bottom line and a critical long-term investment.
The healthcare industry needs an MVE or Minimal Viable Environment for blockchain implementation. The future of blockchain in healthcare will depend on a minimum number of providers to get together for the betterment of the whole. Without an MVE, then blockchain is worthless. Think of it like the Internet. The power of the Internet is in direct correlation to the number of people using it. The Internet is the Internet because of the number of computers that are on it, not any one particular computer.
It may be up to a major industry association like the Healthcare Information and Management Systems Society (HIMSS) to get the ball rolling and move blockchain in healthcare from bit-player to prime-time reality star.