Blockchain technology involves a ledger of data, similar to how financial transactions have been recorded for years. Applied to the various stakeholders involved with a medical practice’s disparate data ledgers, blockchain goes beyond usual push, pull or view models of making data available to providers, payers and patients.
Instead of storing data across disparate systems and requiring transmission from one party to another, a blockchain ledger allows permissioned access to a specific part of the shared data ledger for each user in a secure, synchronous environment. The full ledger is decentralized and distributed to each user, meaning there is no single owner of the blockchain. The security permissions ensure that access and changes are only made by verified users.
“I call it the CPU for health, much like you have a central processing unit in your computer,” said Ted Tanner Jr., co-founder and chief technical officer for PokitDok, a cloud-based application programming interface platform provider based in San Mateo, Calif., in December 2016.
Blockchain technology was originally developed as a deployment method for bitcoin, a cryptocurrency featuring peer-to-peer transactions.
“What it was created for … [was] to reduce double charges for a cryptocurrency,” Tanner said, referring to the risk of digital currency being fraudulently duplicated and spent multiple times. “The technology was created to secure as well as reduce the double-charge syndrome that happens in legacy ledgers.”
As more healthcare organizations adopt EHRs and work toward interoperability, Tanner sees the development of blockchain technology by financial technology organizations colliding with the HIT world. When integrated with an EHR, blockchain technology allows for secure, synchronous storage of patient data. The technology already has shown promise in other industries for streamlining product supply chains and tracking assets throughout the process of bringing them to consumers.
John D. Halamka, MD, chief information officer, Beth Israel Deaconess Medical Center, Boston, believes that using a blockchain in HIT poses an opportunity to move beyond a scattered data landscape for healthcare organizations.
“EHRs were never designed to manage multi-institutional, lifetime medical records. Patients leave data scattered across various organizations as life events take them away from one provider’s data silo and into another,” he wrote in a white paper for MedRec, a prototype blockchain system developed at the MIT Media Lab. Time delays, record maintenance and interoperability challenges “pose additional barriers to effective data sharing,” causing health records to become “fragmented rather than cohesive.”
In a recent Deloitte survey, 21% of executives across multiple industries say they already use blockchain technology, and 25% say that 2017 will be the year they begin using it.
In Halamka’s case study of MedRec, a blockchain was applied to an EHR, with new pieces of the health record appended as blocks of data and time-stamped.
Changes were tracked via “smart contracts” containing metadata on ownership of health record information, permissions and the data’s integrity.
Tanner said that beyond EHR integration, one of the largest areas of promise for blockchain technology in HIT is in its application between providers and payers, specifically regarding eligibility and benefits verification, and giving the patient more access to that process.
“The consumer literally has a wallet. It has a token. Jane Doe decides to go to the doctor and schedules the appointment and grants the respective provider whatever the provider wallet is requesting,” Tanner said. “This gives the provenance of the data, the ID of both the provider and the consumer, and the ability for the consumer to control the access grant.”
With eligibility then processed through a blockchain, a smart contract governing the process is updated, and the patient is issued an eligibility response for the appointment scheduled — all digitally signed and part of the health record blockchain.
Tanner added that this secure, digital system helps move the industry away from billions of dollars spent on paperwork while also minimizing fraud.
“The amount of paper waste has gone through the roof … knowing who Jane Doe is, knowing a verified provider, knowing a verified payer — historically, that was physical proof. That does not scale. When we talk about scalability [in blockchain], when we have algorithmic proof … and I know exactly who that person is, things like fraud go away. Fraud is no longer an issue.
“This is the Rosetta stone for interoperability,” Tanner said, adding that a blockchain system only becomes more valuable to consumers, payers and providers alike as more data is added and the chain grows. Once developed and deployed, a blockchain for an EHR could track patient data “from womb to tomb,” he said.
While blockchain technology does have many promising applications for the healthcare industry, it also is used for digital cryptocurrencies such as bitcoin. The same level of encryption that could potentially shield healthcare data is applied between a bitcoin payer and payee. This helped mask whomever was responsible for the WannaCry ransomware attack in May, affecting tens of thousands of computers across the globe, including England’s National Health Service (NHS).
The attack, which has been cited as using malware stolen from the U.S. National Security Agency, locked physicians and other NHS staff out of patient records on the condition of paying a certain amount of bitcoin currency. Nearly 50 NHS trusts — constituent healthcare organizations serving a defined area of England — reported ransomware issues at their hospitals, as well as 13 NHS groups in Scotland.
Be sure to read the September issue of MGMA Connection magazine for more on cybersecurity in the healthcare industry and how to manage the risks associated with digital records.
Halamka views blockchain’s potential with EHRs as a significant architectural change for healthcare organizations’ data structure, decentralizing control mechanisms so that no one entity owns the records, while also lowering overhead related to processing eligibility and providing for a simple audit trail.
“Blockchain for healthcare is very early in its life cycle,” Halamka wrote. “But it has the potential to standardize secure data exchange in a less burdensome way than previous approaches.”
Although these applications remain in their infancy, studies such as Halamka’s already have researchers and HIT experts hopeful for its use throughout the healthcare industry. A distributed stream of de-identified patient data via a blockchain could help pinpoint larger public health concerns, and simplified consent for patients to share results could aid research and clinical trials. Patients also may be able to report their own health data generated from wearable personal health devices.
The long list of hyped applications for blockchain technology is being tempered by some observers based on the computational power and requisite energy for storing and processing such large volumes of data eventually adding up. As the complexity of health record data grows — for example, genomic data — the scalability of the system is taxed compared with storing simpler data fields such as patient identifiers or summaries of episodes of care.
Adding further uncertainty to blockchain’s potential in healthcare is the lack of any formal standards for the use of the technology, as well as the need to meet the wide range of existing regulations for HIT system implementation, including HIPAA’s Privacy Rule, Security Rule and Cloud Computing Guidelines.
One of blockchain’s most-often touted features — immutability of data, so that it cannot be deleted or altered — may also be a significant flaw in certain circumstances. While stored information is encrypted, there’s no way to remove sensitive data if a decryption key is leaked. This would present “a persistent, uncorrectable leak” of data.
As the number of startups focused on integrating blockchain into HIT grows, the rollout of the technology on a limited scale is on the near horizon. In a Deloitte survey in recent months, 21% of executives across multiple industries say they already use blockchain technology, and 25% say that 2017 will be the year they begin using it. Still, 39% of those senior executives surveyed reported having “little or no knowledge about blockchain technology.” For executives in the life sciences and healthcare fields, only 17% responded as having blockchain technology currently deployed — and only 35% said they expect to deploy blockchain technology in 2017.
Despite the concerns regarding blockchain, the ability of medical groups to deliver value-based care and be reimbursed accordingly under new models will depend heavily on their HIT infrastructure allowing their data to tell that story. Blockchain technology, once implemented beyond the nascent startup phase it is in, will be aimed to facilitate the deployment of that data in expanding ways.
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