In June 2016, reporter Sarah Kliff wrote a piece for Vox that started with her own experience in treating a chronic injury. She concluded -- after experiencing the many hassles, runarounds, and frustrations faced by most people seeking care in the US -- that patients function as "free labor" in the American healthcare system.
"For me, this feels like a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high," Kliff wrote. "It's up to me to ferry medical records between different providers, to track down a pharmacy that can fill my prescription, and to talk to my insurance when a treatment gets denied to find out why."
If you have a forgiving job and a household that doesn't necessarily rely on your daily presence to function, then taking on such a part-time job is merely very inconvenient.
For many people, however, all this extra legwork puts too much strain on their families and their work lives. In many such cases, people who need care de-prioritize it, put it off, and let their conditions go untreated.
In other words, the administrative burden healthcare imposes can often limit a patient's access to care.
Making appointments, chasing down records, filling out forms, remembering to refill prescriptions - should this be the patient's job?
Kliff thinks not. "Last winter, I missed a few weeks of a prescription meant to improve bone density. When I arrived at the pharmacy, the refill wasn't there and I hadn't called to check in advance. It took about five days back and forth among my doctor, the pharmacy, and my insurance before I could pick up my pills. You know who would do a lot better at managing all this information? A computer."
We agree. Specifically, we think blockchain and smart contracts are the perfect technologies to mediate and execute these tasks. Further, a greater prevalence of telehealth options would open all kinds of new doors to care.
For patients who feel they have to postpone their own care because of responsibilities elsewhere, the combination of smart contracts and telehealth can close this access gap.
How Smart Contracts Help Solve Administrative Inefficiencies
Smart contracts eliminate unnecessary, inefficient middlemen because the underlying blockchain technology allows the contracts to execute themselves. So, as an example, a smart contract could be written that would automatically send a proof-of-delivery document to an insurance provider on behalf of a patient who just underwent surgery.
No delay, no relying on a family member with power of attorney to call the insurance company. It would all happen instantly in the background.
Now, extrapolate this scenario across thousands of patients in a healthcare system, and you would see massive operational efficiencies.
Sherree DeCovny, co-founder and Research Principal at Chain Business Insights, argues that smart contracts are ideal in supply chains where "current processes involve considerable manual intervention and many intermediaries."
Smart contracts can remove the need for manual intervention, produce better health outcomes, and even save lives.
Where Telehealth Fits In
"The changes necessary to transform the health of any population are simple," says David J. Bailey, president and CEO of Nemours Children's Health System. "Embed healthful behaviors from birth, reward care efforts for outcomes rather than volume, and provide patients with the ability and tools to truly engage in their own health."
Embedding behaviors and rewarding outcomes are still very much works in progress that will require effort across generations. But patients have the tools to truly engage in their own health today.
This is the fundamental promise of telehealth, which empowers patients by:
- moving care provision to a time and place that suits them, and
- introducing tools that allow for the constant monitoring of health data.
No more rushing from the office of one specialist to another just for a consultation. No need to take a day off work for rural patients who have to drive several counties away to visit their doctor. Tools such as video conferencing and remote monitoring bridge those distances.
Patients don't need to do the work that computers are already doing. Instead, we are on the cusp of a world in which patients have access to on-demand health.
Bringing Those Technologies Together Into Specific Applications
The convergence of telehealth technologies and smart contracts will make both general and preventative care more accessible to patients because of all the work it automates.
Three areas where we believe this convergence will produce immediate benefits are:
- Closer and easier cooperation with insurance companies
- Frictionless deployment of health record data (which the patient would control)
- Easier coordination with pharmacists
Let's take these one-by-one.
In the example above, we noted how a smart contract could essentially ping your health insurance provider to activate the payment process the moment you leave surgery. No phone calls, no back-and-forths with the insurance company. The smart contract would simply execute the payment the moment a triggering event occurred.
The same would be true for a simple telehealth video consultation with a psychiatrist, or a nurse who is following up with you after a procedure. Once the blockchain records that a consultation has taken place, the smart contract would execute a request for payment from the insurance company without any need for manual intervention.
Just the idea of auto-executing payments opens up several opportunities. For example, the law firm Frost Brown Todd is prototyping a smart contract tool that will hold payments in escrow. The firm simply sees this as a move to keep pace with trends across all industries, healthcare and otherwise. "In five to ten years, everyone will be using blockchain technology for many of their business transactions, including contracts and agreements," a member of the firm's blockchain team says.
Smart contracts also open up new opportunities for patients to engage with their own health outcomes a little more closely, and the incentive to do so would come from the insurance side. As Christine D. Chang and Sam Friedman at Deloitte point out, insurance companies could reward customers for their healthy behaviors. An exercise tracker, for example, could upload data that would trigger a smart contract to adjust premiums or initiate a discount when a certain exercise threshold is met.
Or, smart contracts could simply facilitate a model of healthcare that looks and acts much more like traditional consumer markets. "Imagine a smart contract between you and your doctor," writes Tincture's Kim Bellard. "She promises to, say, fix your broken leg and, if she does, you promise to pay her $X. The two of you would agree how and when to decide if the leg is, in fact, fixed. All that goes in the smart contract."
"No ICD-10 or CPT codes, no unknown charges, no payment for care that doesn't work; just mutual agreement about what each party will do. You fund a virtual currency account, she provides the services, the smart contract monitors when the conditions are met, and issues payment once they are."
2. Controlling Access to Personal Health Records
Smart contracts can also define what approvals are required before a new care provider can access a patient's health record. Should the patient grant approval, the smart contract can automatically execute access from the new provider's side.
This would give patients unprecedented control over their own health records. Further, this could be a huge boon for rural patients, who already have to commit a great deal of time just to visit a doctor in person. Should that doctor refer the patient to a specialist several miles away, it's up to the patient to make that appointment, drive to the new clinic, and likely update his or her information manually on intake forms.
The combination of telehealth technology and automated access protocols would save that patient a lot of time and effort.
Already, pilot projects are underway to make these efficiencies a reality. In August 2016, researchers from MIT Media Lab and Beth Israel Deaconess Medical Center published encouraging results from a proof-of-concept study that showed Ethereum-based smart contracts were successful in "providing patients with comprehensive record review, care auditability and data sharing" -- all while working with the systems providers already had in place.
3. Improving Complex Pharmaceutical Supply Chains
Perhaps the biggest administrative knot that patients face is in trying to get the medicine that their doctors prescribe. Think about the drug supply chain: the manufacturer, the wholesaler, the pharmacy, the physician who writes the prescription, the payer.
This is where the "considerable manual intervention" that DeCovny talks about takes place. And remember: As Kliff noted in her piece, a slight human error delayed her ability to get the medicine prescribed to her by five days.
That's why we think smart contracts could codify all the relationships in the pharmaceutical value chain and pancake lag times caused by administrative inefficiencies.
Just consider one single problem that complicates that chain: Counterfeiting. According to Reenita Das, partner and SVP of healthcare and life sciences at Frost & Sullivan, 30 percent of drugs sold in developing countries are considered counterfeit drugs.
"A blockchain-based system could ensure a chain-of-custody log, tracking each step of the supply chain at the individual drug/product level," she writes. "Furthermore, add-on functionalities such as private keys and smart contracts could help build in proof of ownership of the drug source at any point in the supply chain and manage the contracts between different parties."
For the patient, all of this would be something running in the background. As far as the patient experience would be concerned, this would simply serve to ensure that patients could get the drugs they needed when they needed them.
Taking these three pieces as a whole -- easier payments, control of record authorization, simplified pharmaceutical supply chains -- it's easy to imagine an industry in which technology removes a massive administrative burden from patients.
As a result, it would free everyone involved to focus more time and energy on what's important: Better health outcomes for each and every patient.
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