Every few years or so the health information technology world seems to be obligated to pass through yet another fad or phase around the next disruptive or innovative approach to data access, analytics or interoperability. For those of you around my age, you may remember that concept called a "CHIN" or community health information network? This was followed by RHIOs, HIEs, and let's not forget the electronic medical/health record run over the past decade. HIMSS this year was its usual cavalcade of bright lights and rich dashboards, but there was something slightly different lurking against the back wall in the small booth section. There was a small company extolling the virtues of something called "Blockchain" technologies and how this platform was going to finally open healthcare information once and for all in a secure and governed manner.
Many of you reading this blog post probably have heard of Blockchain with all the media swirl around a product called "Bitcoin" which was the first open source cryptocurrency that supported a global peer-to-peer distributed ledger for financial transactions. At its most basic level the Blockchain technology consists of three components; 1) a shared ledger of operations that occur on component two 2) a distributed network which is designed to support part three 3) the digital transaction. The Shared Ledger is simply a record of digital transactions. Members of a network have algorithms that run for verification and veracity of any transaction. If members of the network agree that the transaction is valid that transaction will be added to the shared ledger immediately. Once a transaction is added it becomes final and no member can change or tamper with the data within that transaction and subsequent place on the chain. The Distributed Network is simply a peer-to-peer network with each member of the network represented by a node on that network. Each member of any network stores an identical copy of the Blockchain and participates in the certification and validation of all transactions on their network. The Digital Transaction is the information stored in the Blockchain. The information within any transaction is defined by the network participants. Each transaction is digitally signed and encrypted to guarantee provenance and authenticity. Because each block has its cryptographic hash maintained by the block preceding it and blocks are added in a linear and chronological order the chain is virtually immutable without access to all previous blocks. Any attempts to break into a chain is ineffective without all blocks from the history of the chain from the inception of the network from all nodes ever participating.
The Healthcare Conundrum
There have been the usual protestations that Blockchain will be the answer for all access to the electronic medical records island of data and the provide the platform for access control to all PHI (Ekblaw, Azaria, Halamka, & Lippman, 2016). The MIT proof of concept (POC), used Blockchain architectures to manage authentication, confidentiality, and accountability in a modular design that leveraged the providers existing information systems architecture (Ekblaw, Azaria, Halamka, & Lippman, 2016). As part of this POC “miners” that are required to authenticate transactions were incentivized through access to aggregate data that today they do not have ready access such as researchers in the academic healthcare environment (Ekblaw, Azaria, Halamka, & Lippman, 2016). Other research not related to any production proof of concepts relays concerns about scalability and vendor neutrality (Linn & Koo, 2016). For a moment imagine either unilateral implementation of a Blockchain solution by EPIC or Cerner requiring base system purchase to achieve any level of interoperability and then any economic barriers to protect legacy application install base.
While many vendors will be sporting Blockchain solutions to solve all healthcare IT interoperability at the 2018 HIMSS conference, it is important to understand the realities of using Blockchain. Like all the solutions proffered before the advent of Bitcoin as the “Rosetta Stone” a complete understanding of the challenges from a business and technical perspective should be considered. Blockchain has yet to address the real-world challenges of scalability, resolution of various levels of role-based security, privacy and business architecture to support the current construct as we know it today. None of these are insurmountable but need to be further explored on a larger scale POC.
Scalability has and always will be a concern when the need to aggregate various types of data in a comprehensive view of an individual’s medical record information across multiple sources. Any vendor who approaches the deployment of Blockchain from the vantage point that it will solve interoperability challenges probably should not be considered a viable partner. If, however, Blockchain is positioned as an inexpensive and capable access control mechanism for on-demand access to a subset of data required timely across a regional health care system this could fill a critical gap in communications. On demand lab results, radiology results, referral information or pre-authorizations might be areas of focus. Much like the “Record Locator Services” the Blockchain would serve as the index to an individual’s health record information no matter where the source resides (Linn & Koo, 2016). As part of the “map” t the patient's information, no health information but the data and metadata about the patient's record would be indexed and encrypted as a link to the information requested (Linn & Koo, 2016). This would require either a central data store or a tightly federated model of network communication to work effectively.
Instead of focusing on all the medical record information requirements perhaps a focus on a smaller but critical aspect of the health record the laboratory tests result. Leading market research firms have placed the percent of physician’s diagnosis based on lab results at 80% (Schmidt, 2017). Consider the new clinical laboratory receiving a new order on a patient never encountered by that lab. When a patient record was created by the Laboratory Information System (LIS) a digital signature could also be set up to verify results requests for that patient. Instead of the LIS having to support portals for results that have less than friendly search and integrate functions around those results the Blockchain could create the index for a particular test and result for that patient that could then be shared across the trusted network. The consumer could now safely be given the responsibility of who and when to share those results with as they navigate wellness all the way through chronic care. This is a bit of an oversimplification, but the use case is sound.
At the end of the day, Blockchain does hold some promise for being a large part of a solution that is still under construction. Companies like Ethereum, Brontech, GemOS, and HealthCombix are working secure communications and interoperability from many different angles. While this work is good for the industry, the hope is that Blockchain will not become the next big hit at HIMSS to see companies taking investment money and spinning up big booths at HIMSS next year only to be missing the following year after the hype cycle runs its course. Application of Blockchain will require ONC involvement and some market oversight to ensure that every technology vendor in the market can easily participate in the effort to create interoperability in a safe and secure manner. If this becomes another barrier to entry created by the larger HIT companies the only looser will be the patient and the small provider.
Ekblaw, A., Azaria, A., Halamka, J. D., & Lippman, A. (2016). A Case Study for Blockchain in Healthcare: “MedRec” prototype for electronic health records and medical research data. Open & Big Data Conference (pp. 1-11). Boston: IEEE.
Linn, L. A., & Koo, M. B. (2016). Blockchain for Health Data and Its Potential Use in Health IT and Health Care Related Research. HealthIT.gov. Washington DC: HealthIT.gov.
Schmidt, S. (2017, March 28). 12 Leading Companies in Clinical Laboratory Services. Retrieved May 28, 2017, from MarketResearch.com: http://blog.marketresearch.com/12-leading-companies-in-clinical-laboratory-services.