What is #BlockChain? Implications for Healthcare by @msharmas

In my previous article I discussed about the benefits and barriers to the use of an Integrated Health Information Platform. In healthcare the need for presenting the Information to the Right Person at the Right Time has been proven to improve outcomes in patient treatment.

Will HIE 2.0 benefit from the use of Blockchain in presenting the information to the Right Person at the Right Time?

What is Blockchain?

Various definitions of Blockchain have been put across based on the context of the use. Some of these definitions are:

A digital ledger in which transactions made in bitcoin or another cryptocurrency are recorded chronologically and publicly.

“The blockchain is an incorruptible digital ledger of economic transactions that can be programmed to record not just financial transactions but virtually everything of value.” Don & Alex Tapscott, authors Blockchain Revolution (2016)

The Blockchain is a decentralized ledger of all transactions across a peer-to-peer network. Using this technology, participants can confirm transactions without the need for a central certifying authority. Potential applications include, fund transfers, settling trades, voting etc.

Blockchain is a distributed system for recording and storing transaction records. More specifically, blockchain is a shared, immutable record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger. [1]

A Blockchain is a data structure that can be timed-stamped and signed using a private key to prevent tampering. There are generally three types of Blockchain: public, private and consortium. [6]

How is Blockchain different?

Traditional databases are proprietary to the entity that maintains them and owns them. And the information stored within these databases are accessed only by providing access via an application or shared by the entity in some form of a distributed architecture.

On the other hand, “blockchain is enabling a database to be directly shared across boundaries of trust, without requiring a central administrator. This is possible because blockchain transactions contain their own proof of validity and their own proof of authorization, instead of requiring some centralized application logic to enforce those constraints. Transactions can therefore be verified and processed independently by multiple “nodes”, with the blockchain acting as a consensus mechanism to ensure those nodes stay in sync.” [2]

A quite often stated example for explaining Blockchain is the Google Doc example. Earlier, collaborating on a document involved a serial approach to making changes to a document. Only once the author has completed the document, can it be forwarded to the next person to edit and provide feedback.

But consider the Google Doc (or any of the other collaboration tools), once you have created a google doc, you can start creating the document and also share the same document with other collaborators who can also make changes to the document at the same time allowing for reconciliation of changes to be incorporated within the document to finalise it. The author takes the comments from the collaborators and generates the finalised document.

Blockchain: How it Works?

A transaction is requested. The transaction is broadcasted to the peer-to-peer network consisting of computer nodes. The network validates the transaction and the initiating entity’s status using relevant algorithms. The transaction record is then considered to be verified.

On verification, the transaction record is added with other transactions to create a new block of data for the decentralized ledger of all transactions across a peer-to-peer network.

The new Block is added to the existing ledger of all transactions, i.e., the Blockchain. The transaction is now complete.

Types of Blockchains

Permissionless or Unpermissioned Blockchain allows anyone to join the network and participate in the block verification. For instance, a permissionless blockchain example is the Bitcoin.

Permissioned Blockchains restricts the nodes in the network who can contribute to the consensus of the system. Only permissioned nodes have the rights to validate the block transactions.

For instance, most enterprise Blockchains are permissioned blockchain and allow for privacy, scalability and fine-grained access control. [5]

There are more types of Blockchains.

Interoperability in Healthcare

The context of discussing Blockchains in healthcare is Interoperability. There are various use cases that come to mind, when we talk about interoperability in Healthcare. (most are N:N interactions)

HIMS to Lab Equipment
HIMS to PACS
HIMS to HIMS
HIMS to Apps
HIMS to Portals (Patient, Physician, etc)
Portal to Portal
Stakeholders to HIE
Hospitals to Insurance

You can consider the number of stakeholders in the Interoperability ecosystem and continue to add them to the above list of use cases. And that allows one to understand the current fragmented nature of the Patient’s Healthcare Information.

Each of the above stakeholders, generate the patient care record and have the need at one time or another to share this information with others in the ecosystem. We have already seen the benefits and barriers to information exchange.

For the purpose of this blog, lets consider the Healthcare Information exchange use case. HIEs’ share the patient information in a network that is accessed by participating entities. The Patient information available on the HIE can be accessed as and when required by the patients’ treating doctor.

The availability of a patient information, at the right place and at the right time was (one of) the intended purpose of a Health Information Exchange. HIE frameworks relied on a centralised or federated or hybrid architectures [3] to make the information available to the participants in the exchange. The exchange is maintained by an entity.

In the nationwide Interoperability roadmap defined by the ONC (US) [1]. They define the critical policy and technical components required as

Ubiquitous, secure network infrastructure
Verifiable identity and authentication of all participants
Consistent representation of authorization to access electronic health information, and several other requirements

Additionally, the ONC challenge stated Potential uses to include:[6]

Digitally sign information
Computable enforcement of policies and contracts (smart contracts)
Management of Internet of Things (IoT) devices
Distributed encrypted storage
Distributed trust

In India, an Integrated Health Information Platform (IHIP) is being setup by the Ministry of Health and Family Welfare (MoHFW). The primary objective of IHIP is to enable the creation of standards compliant Electronic Health Records (EHRs) of the citizens on a pan-India basis along with the integration and interoperability of the EHRs through a comprehensive Health Information Exchange (HIE) as part of this centralized accessible platform.

IHIP is envisaged to enable

Better continuity of care,
secure and confidential health data/records management,
better diagnosis of diseases,
reduction in patient re-visits and even prevention of medical errors,
optimal information exchange to support better health outcomes

With the understanding of What is Blockchain, What is Interoperability in Healthcare and What are the use cases for Interoperability in healthcare, do you think Blockchain Technology can be used in Healthcare? Do share your thoughts and use cases.

And while you share your usecases, do read up on the very interesting two part series from Dr. Senthil N, on the Unintended Consequences of new Technologies in Healthcare, Thoughts on Blockchain

In the next part of the blog, I will explore some of these use cases in healthcare and for the purpose of defining how Blockchain can help interoperability of Patient Transactions across healthcare facilities.