In late 2016, we announced the launch of DokChain, one of the healthcare industry's most concrete steps toward building a blockchain-based system for resolving patient identities, giving patients control over their health records, and automatically adjudicating claims, among other applications.
Still, a blockchain -- an idea that's not yet 10 years old -- represents the bleeding edge of technologies poised to change America's most important industries, including banking and real estate alongside healthcare. It can honestly be a bit complex to decipher, however, so we'll do our best below to explain how blockchains can solve some of the most pressing issues of healthcare IT, namely patient data security and interoperability.
Securing Patient Data
Blockchains keep any information stored on their distributed ledgers secure and tamperproof by essentially keeping that data locked away in a place that requires two keys: a public key and a private key.
PokitDok co-founder and CTO Ted Tanner, Jr. explains that this style of security isn't new; in fact, it's ancient. "Multi-signature has been used for thousands of years to protect the security of crypts holding the most precious relics of saints," he says. "The superior of a monastery would give monks only partial keys for gaining access to the precious relics. Thus, no single monk could gain access to and possibly steal the relics."
Blockchains take things one step further. To continue the relic metaphor, a blockchain can provide verifiable proof that the relic is actually in the crypt, to anyone who is interested in knowing that information.
But to access that relic/patient data, at least two keys are needed.
The implications of public-key cryptography are very important. Blockchains finally give patients unique control over their own health records while making it easy for healthcare providers to retrieve the information they need from those health records (if patients grant them permission, of course).
"Imagine if you only had to fill out registration once," Tanner says. "And you owned your medical data, like you manage your bank accounts and private email. Every time it is accessed or updated, it creates a reference hash. These requests generate a series of events, recorded on the secure distributed ledger. The sequence in a chain is implicitly encoded. It is about protecting your data instead of worrying about EMR systems getting hacked or locking up information that belongs to you."
How Blockchains Keep Sensitive Data Safe
Researchers Laure A. Linn and Martha B. Koo, MD, at HealthIT.gov, have published an excellent report that explains how blockchain can handle patient data. First, they proposed an on-blockchain index that would contain metadata about each record; it would work like a card catalog system in a library.
The medical data itself could be stored off-blockchain in a data lake. Whenever data is stored in the lake or data repository, a matching record would be added to the blockchain. That way, a buffer is created between sensitive data and the metadata that can timestamp an event taking place.
Projects Are Already Under Way to Secure Patient Data on Blockchains
In late 2016, the Bill and Melinda Gates Foundation awarded a grant to Austin-based blockchain company, Factom, to make data more secure for patients in developing nations.
"The Bill and Melinda Gates Foundation specifically envisions Factom-secured records benefiting developing nations in which paper-based medical records or information stored on local servers are often compromised by geopolitical instability," writes Neil Issar, an associate at the law firm Haynes and Boone, LLP. "Technology that relies on distribution and decentralization is well-suited to maintain the privacy and security of medical records in an affordable and practical way, even in environments with poor web connectivity."
Even the US government is exploring blockchain applications for patient data. As tech writer Joseph Young reported in April, the Office of the National Coordinator for Health Information Technology has been inviting blockchain-focused proposals for creative ways to thwart ransomware attacks and data breaches in healthcare IT systems.
Successful proposals received grants of between $1,500 and $5,000, Young reported.
Maintaining and Verifying Data Integrity
Another important implication of having a universal ledger to check patient records against is that data-entry irregularities become a thing of the past. Megan Molteni at Wired explains:
"Say [...] one medical record shows a patient takes aspirin. In another, it says they're taking Tylenol. Maybe another says they're on Motrin and Lipitor. The problem today is that each EHR is only a snapshot; it doesn't necessarily tell the doctor what the patient is taking right now. But with blockchain, each prescription is like a deposit, and when a doctor discontinues a medication, they take a withdrawal. Looking at a blockchain, a doctor wouldn't have to comb through all the deposits and withdrawals--they would just see the balance. And crucially for patient privacy and security, hospitals and pharmacies don't have to send data back and forth to see it. They just all have to point to the same common ledger."
This makes for a collaborative health record, but one that still puts the patient firmly in control and at the true center of their care for the very first time.
Providers can add a new record associated with a particular patient, and patients can authorize sharing of records between providers," Elizabeth Snell writes at HealthITSecurity.com. "Furthermore, members can enter information to their own ledger copy, rather than the data being held in one location. No new transactions can be approved unless a majority agrees that the requested action is accurate."
Health Record Interoperability (and Scalability)
Here is where things get really interesting: With blockchains, you don't need to create multiple medical records or fill out multiple forms just to create legible data for every clinic's walled garden of data. Instead, each provider just links onto that record.
"The implications for population health management, patient matching, and care coordination are staggering," Jennifer Bresnick at HealthITAnalytics.com writes. "Healthcare organizations do not have to fight for a data-driven competitive advantage, because they all have exactly the same information."
What's more, blockchains can streamline many health records processes. Imagine a world in which healthcare providers could refer patients to a specialist, then simply pass along access to that patient's data without any friction at all.
As Phoenix Health Systems VP of Industry Relations D'Arcy Guerin Gue [login required] points out, this would allow doctors and other care providers to collaborate asynchronously across a patient's entire lifetime by co-developing plans "based on full histories, patient genetics, lifecycle, and environment."
Consensus ledgers can create a very scalable system of keeping health records. Factom underscored this point when the company announced its Gates Foundation grant. CEO Tiana Laurence provided the example of patients in remote parts of a developing nation, where healthcare provisioning itself might be scarce, to say nothing of the scarcity and difficulty of recordkeeping.
But with a blockchain, she writes, a medical professional anywhere can look up a baby's vaccination records, "or an HIV-infected person can access their viral load measurement results."
Whether in the developing world or in America, the time has come for value-based care models to step to the forefront and take the lead with smarter technology. "Healthcare has largely skipped the internet and has been slow to embrace the cloud," Tanner wrote last summer. "High operational costs, inefficiencies, and legislation are forcing the industry to re-think their technology strategy."
We believe blockchains, which create new efficiencies and have the capacity to dramatically shrink operational costs, will be a big part of this new technology strategy.
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