BLOCKCHAIN

#Blockchain in Healthcare: Will it or won’t it survive? By Tirupathi Karthik, @TirupathiKarthi


What is Blockchain

Blockchain offers a permanent record of online transactions. Transactions are deemed as a “Block” and a ledger binds them in a “chain” thus earning its moniker “Blockchain”. Each transaction is validated and stored by a network participant based on rules but sans a governing central authority. Information can neither be modified nor copied or deleted.

Every transaction has a time and date stamp, offering a trusted transaction history and allowing verification of such records. Since the information is encrypted, the only way to access the blockchain is with a passcode. This shared ledger system makes Blockchain rather secure. Given this, Blockchain is gaining new use cases for applications that require trusted and immutable data.


Blockchain in healthcare

The disruptions wrought by blockchain technology in the fin-tech industry are all over the news – Healthcare is not immune to this disruption. Healthcare Rallies for Blockchain, a study from IBM, found that 16% of surveyed healthcare executives had solid plans to implement a commercial Blockchain solution this year, while 56% expected to by 2020. (1)

It is projected that 55 % of healthcare applications will have adopted Blockchain for commercial deployment by 2025. (2)


The known use cases of Blockchain in Healthcare

Presently, healthcare transactions are slow, cumbersome and expensive. As with any new technology in the hype cycle, Blockchain also generates a lot of excitement but has few real commercial applications. There are even fewer start-ups with a proven business model. This is both an opportunity and a threat. The threat comes from lack of traction which might eventually lead to Blockchain being ignored by the entire Healthcare industry. However the opportunity to make our own future is exciting. It is really up to our imagination to conjure up innovative solutions. Few key areas of interest seen thus far include

1.     Health Data Exchange and Interoperability

With transfer of data through API’s – Blockchain achieves standardization of data format, which is used to transmit data, irrespective of capabilities of EHRs, to communicate different HL7 versions.

Blockchain provides a foundation for secure, permissioned framework for data exchange thus allowing data to be freed up for enhancing efficiency in care coordination.

2.     Data Security and backups

In 2017, over 50,000 patient records were compromised through a series of breaches resulting in multi-million dollar fines for providers. However with Blockchain, malicious parties wanting to gain access would need to simultaneously breach every participant in the network, not just one. (3)

3.     Billing Management

An estimated 5–10% of healthcare claims are fraudulent as a result of either excessive billing or billing for non-performed services. (4)

Blockchain could reduce this level of fraud and automated billing would reduce admin costs by eliminating the need for intermediaries, ultimately making the process more efficient.

4. Pharmaceuticals and Drug Tracking

Using this technology supply chain management can track drug sourcing to reduce the impact of counterfeit drug on Patient’s health. 

Challenges to Healthcare Blockchain Adoption

Fig: Healthcare executives on barriers to healthcare adoption of Blockchain worldwide in 2016 (5)

Immature technology, insufficient skills and regulatory constraints were cited as a Top-3 barriers to adopting Blockchain technology in healthcare. Some others include:

1.     Existing systems and cultural shift

Presently patient EMR data is already being managed in large legacy systems by Health systems globally. In the absence of an adverse event, Blockchain based solutions don’t have compelling business case for a rip-and-replace strategy. So it will have to evolve over a period of time and large-scale Blockchain based EMR replacement projects are unlikely to be awarded any time soon.

2.     Healthcare stakeholder network is distributed so it’s hard to implement

Insurance payers and healthcare physician providers are all not consistent in terms of how different entities handle records. In the absence of single payer, who could drive data standards, it would be extraordinarily difficult to pull different stakeholders together to adopt Blockchain as a technology. 

3.     Many players aren’t willing to share

For example insurance payers and hospitals actively try to not share data. It is a competitive advantage for hospitals to keep cost data to themselves. If they are forced to share with insurance companies, they might get lowered payouts for patients. It is difficult to share data in an environment in which these entities are for-profit.

Intrinsically Payers and Providers have conflicting priorities. Both try to maximise their returns and hence collaboration that involves data sharing, especially on costs, is not in their interests. Consequently interoperability becomes a casualty.

Can the Dotcom boom serve as a guide to the future of Blockchain?


Blockchain technology may not be the panacea for healthcare industry challenges, but it does provide efficiency in the overall health ecosystem by dis-intermediating some high cost transactions. By now, most healthcare organizations around the world have recognized that Blockchain has the potential to reduce the cost, time and risks associated with the delivery of healthcare services. According to an analysis done by BIS Research, the global Blockchain (Healthcare) market is estimated reach to USD 5.61 billion by 2025. (6)

However as history has shown, not all such exciting technology solutions survive the real-life business. In the late 90s B2B exchanges were supposed to provide similar value by bringing all stakeholders on to a common platform. It did lead to a dotcom boom for a short while but the euphoria died a natural death when there were no takers for such a vision in the real business world. Today some of the big names in B2B tech industry such as CommerceOne, FreeMarkest, Covisint, Ariba are but a pale shadow of themselves or have been completely wiped out by forces of acquisitions. There is a lesson here for us. All solutions that can technically solve a problem may not be practically monetisable!

As Captains of the Healthcare IT industry we need to make Blockchain count for the industry and ensure its commercial success. Let’s keep the solutions small and affordable but with a laser like focus on generating lasting benefits for the providers. Once that is done, scale will come as also the eventual benefits that will allow us to monetise our investments.

Source

1.https://www.forbes.com/sites/bernardmarr/2017/11/29/this-is-why-blockchains-will-transform-healthcare/#4aa71a101ebe

2.https://www.statista.com/statistics/759208/healthcare-blockchain-adoption-rate-in-health-apps-worldwide/

3.http://health.oliverwyman.com/drive-innovation/2018/04/is_blockchain_thean.html

4. https://hackernoon.com/how-blockchain-is-set-to-disrupt-the-healthcare-industry-in-2018-5d4fda455911

5.https://www.statista.com/statistics/759312/barriers-to-healthcare-adoption-of-blockchain-worldwide/

6. http://makingthehealthcaresystemwork.com/2018/07/06/beyond-the-buzz-real-opportunities-for-blockchain-in-health-care/

The article was first published on Mr. Tirupathi Karthik’s LinkedIn pulse Blog, the article is republished here with the Author’s permission. 

Author
Tirupathi Karthik

A leader in the Healthcare IT space, Tirupathi Karthik has extensive business leadership experience across Asia, the Middle East and USA, particularly in the enterprise software space. He is a passionate advocate for the innovative use of technology that turns IT investments into competitive differentiators for their stakeholders rather than using IT as a pure cost containment initiative.

In various hospital implementations, he has been championing the use of Mobility as a pervasive information delivery channel. His vision led to the use of themFirst approach with the infusion of HTML5 and Apple’s mobility products across the Napier platform. Napier’s leadership in the global marketplace continues to gather momentum on the back of one of the most modern implementations of such a technology stack.

As an Eldercare thought leader, he has been driving productivity agendas for aged care models globally and seen to the expansion of Napier’s product vision to include elderly care services delivery. Applying technology-enabled solutions for senior care providers offering nursing home, home care and activity-centre services, Napier today enables productivity and improved quality of care.

#Blockchain for HealthCare Equity by Arnab Paul, @iArnabPaul

In a digital Age when cars drive themselves and CEOs hold meetings across continents in virtual reality conference rooms, engagement of the disenfranchised is a less attractive endeavor than the sleek apps, making it an outlier in the realm of tech solutions.

In our endeavour to promote digital india it should be our collective effort to bring healthcare to the disenfranchised and to the people who slip out of the cracks.

Most of us just don’t bother to take care of the elephant in the room, its time all the stakeholders joined hands and come up with a solution. For me personally Equity is of paramount importance in healthcare.The lack of focus on vulnerable populations in patient safety discounts the significance of the many lives lost, all precious to those who love them. we have yet to place strategic emphasis on the need to protect all. A man’s life lost to medical error then disguised as a heart attack, either intentionally or because of unconscious prejudice about the depth of his pocket, is more than a patient safety event. 
For the millions of people who have been exposed to discrimination based on their spending capacity and limited access to resources and denial of equality in humanity, such an event adds insult to tragic injury.We must connect in ridding our health system of all forms of inequality and ensuring that all people are protected from harm equally.
As hospitals and care systems work to improve quality of care and prepare for coming changes in the health care field, the ability to fully understand their patient populations and communities is critical. Collecting and using ethnicity, language, spending capacity data will help hospitals and care systems understand their patient populations and address health care disparities. While many hospitals are successfully collecting REAL data, fewer are effectively stratifying the data to shed light on health care disparities,
We need to systematically collect REAL preference data on all patients. We need to use REAL data to look for variations in clinical outcomes, resource utilization, length of stay and frequency of readmissions within our hospital. We need to compare patient satisfaction ratings among diverse groups and act on the information. Above all we need to actively use REAL data for strategic and outreach planning for the underprivileged.
Patient satisfaction is not a clearly defined concept, although it is identified as an important quality outcome indicator to measure success of the services delivery system
There is no clear consensus between the literatures on how to define the concept of patient satisfaction in healthcare.
In Donabedian’s quality measurement model
patient satisfaction is defined as patient-reported outcome measure while the structures and processes of care can be measured by patient-reported experiences
For everything in life we need some kind of metrics, some tools to measure the clinical outcome and the patient satisfaction. So to make up for it may I suggest we incorporate Tech enabled, Blockchain optimized patient feedback mechanism.
So what is the solution, how do we propose to go about it, well unlike Press Ganey & HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems), Press Ganey has stated that a minimum of 30 survey responses is necessary to draw meaningful conclusions from the data it receives and that it will not stand behind statistical analysis when less than 30 responses are received. 
If we all incorporate a blockchain Ecosystem & go truly real time in the patient feedback mechanism it would greatly enhance the whole patient experience and maybe help to manage solve some of the issues in real time. Wouldn’t it be just great if we incorporate Blockchain in the patient feedback loop, we wouldn’t have to wait for 30 odd surveys to be analyzed we could just go ahead and fix the situation right away if it warrants an action.
Another major issue is NO show and Missed Appointments
One study estimates, in US alone missed appointments cost US healthcare providers up to $150 billion a year.There have been instances that a Clinic loses money because of No Showand missed appointments.Patients not showing up can be costly to the health-care system. Offices lose out on revenue, and delaying care can lead to more expensive treatments later on.

“We very much believe it’s going to take a collaborative effort, and we think that this kind of technology integration is going to be a critical path for being successful in terms of breaking down those barriers for access to transportation for the patient community.”  David Baga, CBO, Lyft

Allscripts, Lyft and few other companies have joined hands to address this problem. The companies said they hope working together will reduce the number of people who miss medical appointments because of transportation issues.
But interesting it was found in another study giving poor people free use of ridesharing services like Uber and Lyft for doctor appointments doesn’t make them any less likely to become no-shows than patients who have to find their own way there, a U.S. study suggests.
So what are we missing here, I believe incentivising ( tokens ) is the key and Blockchain could play a major role. Blockchain in itself is not a panacea for all things healthcare but it certainly holds the key to transform the current healthcare service delivery mechanism and make it more transparent and efficient.
Ehealth or no ehealth, if its not able to solve the issues of equity & empathy than its no value prop only noise, maybe it would help become a excellent facilitator in healthcare delivery but it sadly would not be able to solve the core issue of equity and empathy.
The concluding part follows:
How Blockchain could be a gamechanger for healthcare

Author

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[content title=”About Arnab Paul”]

Arnab Paul, CEO, Patient Planet

Globally-minded systems thinker, action-oriented and inspired toward optimizing health outcomes through innovation, creativity, cooperation. Passionate about facilitating the alignment among technology, people and processes to ultimately improve patient experience and the functioning of healthcare.

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The potential of #blockchain in #EHR by Danielle Siarri – @innonurse

The article is re-published here with the author’s permission. The article was first published on the author’s LinkedIn pulse blog.

A person by the pseudonym Satoshi Nakamoto published a white paper in 2008, introducing bitcoin and applications of the blockchain. The blockchain is a decentralized digital ledger, the technology underlying bitcoin: a distributed network, a shared ledger, and digital transactions. In healthcare such could mean “… blockchain technology as a way to streamline the sharing of medical records in a secure way, protect sensitive data from hackers, and give patients more control over their information.

Estonia was the first country to implement a blockchain into their electronic healthcare record (EHR) system with the collaboration of a local company established in 2008 named Guardtime, using keyless signature infrastructure (KSI). The integrity solution KSI means in short: verifying the data without a third party, keys or credentials to access the ledger and compromise the ehr.

YouTube – “Implementation of blockchain-projects in Estonia”


In Tallinn, Estonia at eHealth Tallinn, Mirko De Maldè will moderate Blockchain: Unleashing the Power of Free-Flowing Data with speakers Dr. Catherine MulliganJaan Priisalu, and Dr. Christian Dierks.

I recently had a conversation with Mirko, he stated:
“The blockchain is likely to have a profound impact on the future of healthcare, making it possible to move forward from volume-based to value-based healthcare. Concrete patient empowerment, with unprecedented control over personal datasets, together with enhanced interoperability, could particularly benefit the most fragmented healthcare systems, as the Italian one, facilitating data portability and patients’ mobility, and enabling – especially when it comes to chronic disease – the shift to personalized, proactive and participatory care by” Mirko De Maldè.

The blockchain in healthcare via Periscope with Mirko De Maldè, HIMSS Italy session in Malta

As healthcare technology evolves globally, accuracy becomes even more crucial. Data entered in electronic healthcare records need to be as accurate as possible because future clinical decision making will be based on prior and real-time information. The blockchain is a ledger to secure healthcare data, one of its main values are benefits associated with having a unique identifier for each patient that go beyond healthcare programs, jurisdictions.
This article was originally published on the HIMSS Europe Blog.

This is the follow-up Periscope from ehealthtallin in Tallinn, Estonia

Research, thoughts, and opinions are my own. Further references can be found on my personal sites innonurse.info and ammende.info
Author
Danielle Siarri

Speaker | Moderator | HealthIT Advisor | Social Media Practitioner | Clinical Marketer | SM Ambassador. Danielle has a Master of Science in Nursing Informatics and is a registered nurse with experience ranging from hospital setting of transplants and trauma to case manager in the corporate environment. Danielle is a contributor to the Philips Innovation Matters Blog, Microsoft Intel in Health Nurse Blog, Healthcare Information and Management Systems Society (HIMSS), the European Union of HIMSS and LinkedIn published author. Danielle is very active on social media and is #44 of the Top Health Information Technology 100 (#HIT100)

A collection of Potential Usecases for #Blockchain in Healthcare

Every once in a while a new technology finds its way in the Gartner Hype Cycle for Technologies (in Healthcare) and its effectiveness and usability is applied to the management and interoperability of Healthcare Records. For instance, access to the Healthcare records by various stakeholders in the care continuum: care providers and patients. 



Gartner in their recent report defines Blockchain as a Digital Platform. And healthcare industry has been perennially on the lookout for a Digital Platform that will allow for an efficient and secure way to share patient data. Providing access to the healthcare data involves providing access to the patient data to relevant stakeholders at the right time and to the right person, not only ensuring the privacy but also providing the patient control of their data. 

Another problem that remains evasive in healthcare is driven by privacy of the patient data, and has been at times been seen to be impeding the flow of patient data between disparate systems, (i.e., Interoperability). 

We now have the Blockchain Technology and various companies are working to apply the technology to help solve not only the interoperability problem but also applying the same technology to solve various usecases in the Care Continuum, to save costs, improve efficiency, ensure privacy.

So what are the problems Blockchain is being applied to in the Healthcare context? What are the benefits one would accrue by applying Blockchain to Healthcare and what are the pitfalls.

The past august, ONC in the US setout a Blockchain challenge with the objective, 

The goal of this Ideation Challenge is to solicit White Papers that investigate the relationship between Blockchain technology and its use in Health IT and/or health-related research. The paper should discuss the cryptography and underlying fundamentals of Blockchain technology, examine how the use of Blockchain can advance industry interoperability needs expressed in the Office of the National Coordinator for Health Information Technology’s (ONC) Shared Nationwide Interoperability Roadmap, as well as for Patient Centered Outcomes Research (PCOR), the Precision Medicine Initiative (PMI), delivery system reform, and other healthcare delivery needs, as well as provide recommendations for Blockchain’s implementation. In addition to a monetary award, winners may also have the opportunity to present their White Papers at an industry-wide “Blockchain & Healthcare Workshop” co- hosted by ONC and NIST.”

As part of the Ideation Challenge, the following papers were the declared winners:

1. Blockchain and Health IT: Algorithms, Privacy, and Data: This papers discusses the need to create a peer-to- peer network that enables parties to jointly store and analyze data with complete privacy, based on highly optimized version of multi-party computation with a secret-sharing. An auditable, tamper-proof distributed ledger (a permissioned blockchain) records and controls access through smart contracts and digital identities. We conclude with an initial use case of OPAL/Enigma that could empower precision medicine clinical trials and research. 
Authors:  Ackerman Shrier A, Chang A, Diakun-thibalt N, Forni L, Landa F, Mayo J, van Riezen R, Hardjono, T.
Organization:  Project PharmOrchard of MIT’s Experimental Learning “MIT FinTech: Future Commerce.”


2. Blockchain: Securing a New Health Interoperability Experience: Blockchain technologies solutions can support many existing health care business processes, improve data integrity and enable at-scale interoperability for information exchange, patient tracking, identity assurance, and validation. This paper suggests these processes can be supported by three most important applications: Creating secured and trusted care records, linking identities and recording patient consent decisions and patient directives within the secured patient record.
Authors:  Brodersen C, Kalis B, Mitchell E, Pupo E, Triscott A.
Organization:  Accenture LLP


3. Blockchain Technologies: A Whitepaper Discussing how Claims Process can be Improved: Smart contracts, Blockchain, and other technologies can be combined into a platform that enables drastic improvements to the claims process and improves the health care experience for all stakeholders. The healthcare industry suffers from an inability to clearly communicate costs in a timely and easy-to-understand format. This problem is a symptom of interoperability issues and complex agreements between providers, patients, health plans/payers and government regulators. These agreements are encoded in legal language with the intent of being defensible in court. However, the focus on legal enforceability, instead of understandability, creates problems resulting in hundreds of billions of dollars spent annually to administer an inefficient, outdated and complex process for adjudicating and paying health plan claims. 

The process results in errors and often leaves the patient unclear on how much they need to pay. If these agreements were instead translated into computer code (smart contracts) leveraging Blockchain technologies, the claim process would not only be interoperable, but also drive standardization, research and innovation. Transparency and trust can be injected into the process when both the logic and the data driving these decisions is stored permanently and made available to all stakeholders through a peer-to- peer distributed database like blockchain. The result will be a paradigm shift toward interoperability and transparency, enhancing the speed and accuracy of cost reporting to patients. This paper discusses how smart contracts, blockchain and other technologies can be combined into a platform that enables drastic improvements to the healthcare experience for all stakeholders.
Author:  Culver K. 


4. Blockchain: A new model for Health Information Exchanges: Presentation of an implementation framework and business case for using Blockchain as part of health information exchange to satisfy national health care objectives.


Authors:  Krawiec RJ, Barr D, Killmeyer K, Filipova M, Nesbit A, Israel A, Quarre F, Fedosva  K, Tsai L.
Organization:  Deloitte Consulting LLP

5. A Case Study for Blockchain in Healthcare: “MedRec” Prototype for Electronic Health Records and Medical Research Data: A long-standing focus on compliance has traditionally constrained development of fundamental design changes for Electronic Health Records (EHRs). We now face a critical need for such innovation, as personalization and data science prompt patients to engage in the details of their healthcare and restore agency over their medical data. 

In this paper, the authors propose MedRec: a novel, decentralized record management system to handle EHRs, using blockchain technology. The system gives patients a comprehensive, immutable log and easy access to their medical information across providers and treatment sites. Leveraging unique blockchain properties, MedRec manages authentication, confidentiality, accountability and data sharing—crucial considerations when handling sensitive information. A modular design integrates with providers’ existing, local data storage solutions, facilitating interoperability and making our system convenient and adaptable. 

MedRec incentivize medical stakeholders (researchers, public health authorities, etc.) to participate in the network as blockchain “miners”. This provides them with access to aggregate, anonymized data as mining rewards, in return for sustaining and securing the network via Proof of Work. MedRec thus enables the emergence of data economics, supplying big data to empower researchers while engaging patients and providers in the choice to release metadata. 

The purpose of this paper is to expose, in preparation for field tests, a working prototype through which we analyze and discuss our approach and the potential for blockchain in health IT and research.
Authors:  Ekblaw A, Azaria A, Halamka J, Lippman A. 
Organizations:  MIT Media Lab, Beth Israel Deaconess Medical Center


6. The Use of a Blockchain to Foster the Development of Patient-Reported Outcome Measures (PROMs): This paper suggests the use of Cognitive Behaviour Therapy as a modality to treat Mental Health disorders. This the author suggests is achieved by the use of various applications that allow the patient to record information using SMS or applications. These applications keep track of any emergencies, provides patient coaching and guidance, recording of daily progress and medication adherence. While many patients feel ashamed of their mental state and feel a stigma associated with conditions such as depression and anxiety, the anonymous nature of these applications may make it more likely for them to seek help. 

These types of use cases are the first step in implementing blockchain technology as they help identify the system requirements and looks at the interactions between users and systems. In this case, the focus would be on personal health information that is highly sensitive and coming from mobile applications that require direct interaction between the patient and providers, as well as those involved in the care of the patient. 

Each scenario that involves a transaction, or data being transferred from the application to those who have “signed” the transaction would be documented so the information flow and usage is understood. In this manner, the appropriate permissions would be granted and provenance could readily be established. Use of the Internet of Things in combination with Blockchain technology for Patient Reported Outcome Measures (PROMs).
Author:  Goldwater JC.
Organization:  National Quality Forum

7. Powering the Physician Patient Relationship with ‘HIE of One’ Blockchain Health IT: ‘HIE of One’ links patient protected health information (PHI) to Blockchain identities and Blockchain identities to verified credential provider institutions to lower transaction costs and improves security for all participants. 

HIE of One, (Health Information Exchange of One) shifts the trusted intermediary role away from the hospital and into the blockchain. The blockchain can also provide the link between physician credentials and patient identity.
Author:  Gropper A.

8. Blockchain: The Chain of Trust and its Potential to Transform Healthcare – Our Point of View: This paper talks about Potential uses of Blockchain technology in health care including a detailed look at health care pre-authorization payment infrastructure, counterfeit drug prevention and detection and clinical trial results use cases. The paper also highlights what Blockchain is not. Some of the additional usecases as presented in the paper are listed below:


Organization:  IBM Global Business Service Public Sector

9. Moving Toward a Blockchain-based Method for the Secure Storage of Patient Records: Use of Blockchain as a novel approach to secure health data storage, implementation obstacles, and a plan for transitioning incrementally from current technology to a Blockchain solution. The author suggests a practical first step towards moving towards a blockchain enabled world, here is a suggested workflow by the author, from the submission: 

Author:  Ivan D.

10. ModelChain: Decentralized Privacy-Preserving Health Care Predictive Modeling Framework on Private Blockchain Networks:   ModelChain, to adapt Blockchain technology for privacy-preserving machine learning. Each participating site contributes to model parameter estimation without revealing any patient health information (i.e., only model data, no observation-level data, are exchanged across institutions). 

We integrate privacy- preserving online machine learning with a private Blockchain network, apply transaction metadata to disseminate partial models, and design a new proof-of-information algorithm to determine the order of the online learning process. 

We also discuss the benefits and potential issues of applying Blockchain technology to solve the privacy-preserving healthcare predictive modeling task and to increase interoperability between institutions, to support the Nationwide Interoperability Roadmap and national healthcare delivery priorities such as Patient-Centered Outcomes Research (PCOR).
Authors:  Kuo T, Hsu C, Ohno-Machado L.
Organizations:  Health System Department of Biomedical Informatics, University of California San Diego, La Jolla, CA Division of Health Services Research & Development, VA San Diego Healthcare System.


11. Blockchain for Health Data and Its Potential Use in Health IT and Health Care Related Research: A look at Blockchain based access-control manager to health records that advances the industry interoperability challenges expressed in ONC’s Shared Nationwide Interoperability Roadmap.
In this usecase the authors discuss the use of blockchain technology with a data lake for scalability. All medical data would be stored off blockchain in a data repository called a data lake. Data lakes are highly scalable and can store a wide variety of data, from images to documents to key- value stores

When a health care provider creates a medical record (prescription, lab test, pathology result, MRI) a digital signature would be created to verify authenticity of the document or image. The health data would be encrypted and sent to the data lake for storage. Every time information is saved to the data lake a pointer to the health record is registered in the blockchain along with the user’s unique identifier. The patient is notified that health data was added to his blockchain. In the same fashion a patient would be able to add health data with digital signatures and encryption from mobile applications and wearable sensors.



Authors:  Linn L, Koo M.

12. A Blockchain-Based Approach to Health Information Exchange Networks: 
Sharing healthcare data between institutions is challenging. Heterogeneous data structures may preclude compatibility, while disparate use of healthcare terminology limits data comprehension. 

Even if structure and semantics could be agreed upon, both security and data consistency concerns abound. Centralized data stores and authority providers are attractive targets for cyber attack, and establishing a consistent view of the patient record across a data sharing network is problematic. 

In this work we present a Blockchain-based approach to sharing patient data. This approach trades a single centralized source of trust in favor of network consensus, and predicates consensus on proof of structural and semantic interoperability.

The authors describe the Healthcare Blockchain as: 

Because a blockchain is a general-purpose data structure, it is possible to apply it to domains other than digital currency. Healthcare, we believe, is one such domain. The challenges of a patient record are not unlike those of a distributed ledger. For example, a patient may receive care at multiple institutions. From the patient’s point of view, their record is a single series of sequential care events, regardless of where these events were performed. This notion of shared state across entities, inherent to the blockchain model, is congruent with patient expectations. Also, it is reasonable to assume that each patient care event was influenced by one or more events before it. For example, a prescription may be issued only after a positive lab test was received. The notion of historical care influencing present decisions fits well into the blockchain model, where the identity of a present event is dependent on all past events.

Much like the Bitcoin approach, our block is a Merkle Tree-based structure[21]. The leaf nodes of this tree represent patient record transactions, and describe the addition of a resource to the official patient record. Transactions, however, do not include the actual record document. Instead, they reference FHIR Resources via Uniform Resource Locators (URLs). This allows institutions to retain operational control of their data, but more importantly, keeps sensitive patient data out of the blockchain. FHIR was chosen as a exchange format not only because it is an emerging standard, but also because it contains inherent support for provenance and audit trails, making it a suitable symbiotic foundation for blockchain ledger entries. FHIR in conjunction with the blockchain can serve to preserve the integrity and associated context of data transactions.


A Blockchain-based approach to sharing patient data that trades a single centralized source of trust in favor of network consensus, and predicates consensus on proof of structural and semantic interoperability.
Authors:  Peterson K, Deedvanu R, Kanjamala P, Boles K.
Organization:  Mayo Clinic


13. Adoption of Blockchain to enable the Scalability and Adoption of Accountable Care:  A new digital health care delivery model that uses Blockchain as a foundation to enable peer-to-peer authorization and authentication.

The recent trends in Accountable Care based payment models have necessitated the adoption of new process for care delivery that requires the co-ordination of a “network” of care providers who can engage in shared risk contracts. In addition, the need for sharing in the savings generated equitably is key to encourage the network providers to invest in improved care paradigms. 

Current approaches to digitize healthcare focus on improvement of operational efficiency, like electronic records as well as care collaboration software. However, these approaches are still based on the classical centralized authorization model, that results in significant expense in implementation. These approaches are fundamentally limited in their ability to fully capitalize on the peer-to-peer digital work- flow revolution that is sweeping other segments of industry like media, e-retail etc. 

In this paper the author formulates a new digital health care delivery model that uses block chain as the foundation to enable peer-to-peer authorization and authentication. The author will also discuss how this foundation would transform the scalability of the care delivery network as well as enable payment process via smart contracts, resulting in significant reduction in operational cost and improvement in care delivery. 

In addition, this block-chain based framework can be applied to enable a new class of accountable tele-monitoring and tele-medication devices that would dramatically improve patient care adherence and wellness. Finally, the adoption of block chain based digital-health would enable the creation of varifiable “personalized longitudinal care” record that can form the basis of personalized medicine.

Author:  Prakash R.



14. A Blockchain Profile for Medicaid Applicants and Recipients: A solution to the problem churning in the Medicaid program that illustrates how health IT and health research could leverage Blockchain-based innovations and emerging artificial intelligence systems to develop new models of health care delivery. The solution envisions a Smart Health Profile by thinking of the blockchain profile simply as a broker that can answer questions about you as the need arises, your identity remains distributed. No one can ever see everything about you at once, including yourself. 

What makes the profile smart is that the services it provides can be quite intelligent. It can make sophisticated queries and actually trigger an action when certain conditions are met. For example, suppose you had a smart drug dispenser that recorded every dose you take as a transaction on the blockchain. A profile service might check everyday to see if you’ve taken your pill and automatically order a refill when you’ve used up all the pills. Over time, however, an AI service might become much more sophisticated to use a combination of information about your vital statistics from your wearable device and population studies of people using the various medications for your condition and either recommend a different regimen to your physician or simply cut out the middleman and direct your pharmacist to deliver you a new prescription.

The solution goes on to discuss the use of Blockchain in a medicaid scenario and a much more comprehensive solution as a distributed infrastructure for health.
Authors:  Vian K, Voto A, Haynes-Sanstead K.
Organization:  Blockchain Futures Lab – Institute for the Future


15. Blockchain & Alternate Payment Models:  Blockchain technology has the potential to assist organizations using alternative payment models in developing IT platforms that would help link quality and value.
Author:  Yip K.


References
The content provided in the examples above have been collated from the various submissions to the ONC’s Blockchain Ideation Challenge. You can write to me or connect with me, in case you are interested in receiving the copy of the documents.

In my previous article on Blockchain I shared whats Blockchain and types of Blockchain. I also discussed some of the usecases companies and startups have focussed on developing Blockchain based solutions. In this article I will share some of the usecases based on Blockchain technology, in healthcare. 

Alternatively, you could follow the links here

You can also review the various articles on Blockchain on the HCITExpert Blog.

[1]: Blockchain Articles by David Houlding:
https://www.linkedin.com/in/davidhoulding/detail/recent-activity/posts/

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Manish Sharma

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Why Out-of-Hospital Blockchains Matter by Cyrus Maaghul @Pointnurse

Bitcoin and blockchain technology will be game changers too


This article was first published in Mr. Cyrus Maaghul’s LinkedIn Pulse post here . The article is published here with the author’s permission.

I bought my first bitcoin in May 2013 while on a vegan retreat in Asheville, North Carolina. Going through the purchase process reminded me of when I first downloaded Mosaic and surfed the net. I thought to myself, “this is going to be a game changer”. It was.



Bitcoin and blockchain technology will be game changers, too.

Bitcoin, its underlying blockchain and evolving peer-to-peer networks with Turing-complete smart contracts such as Ethereum will have a disruptive impact on many industries for years to come. Financial services, payments, supply chain logistics, insurance, and healthcare are just a few that will be disrupted with these new technologies.

Out-of-hospital blockchains

Healthcare will be a primary beneficiary of these new technologies, especially outside of the walls of hospitals.

As more and more health and preventive care is provisioned in virtual environments, at home, in cars, at work, etc, the need for open and accessible tracking, verifying and provisioning of care will become extremely critical for patients, payors, providers, scientists and regulators.

These new out-of-hospital (OOH) blockchains developed in the non-clinical community will set the pace for how patient behavioral and inter-clinic visit vital data is tracked in the future for provider reimbursement, regulatory compliance, safety monitoring and patient adherence.

The blockchain is a near-perfect technology (not necessarily the current implementations) to securely and safely make OOH data easily accessible with relatively minimal privacy and hack risk to all patient stakeholders, including the patient themselves, family, caregivers, clinics, providers, insurance companies and all those with a stake in their patients’ health.

Each and every one of these stakeholders or network peers approved by the patient can easily join OOH blockchains as either nodes or buyer or seller of tokens or payments to gain access to patient data, utilizing a variety of open access methods and smart contracts that store and monitor real-time contractual conditions agreed to by and between various stakeholders.

There will be many OOH blockchains developed to address the myriad of use cases in healthcare, including tracking the development of drugs, doctor and nurses credentialing, real-time population health data analysis and alerts, insurance peer-to-peer risk pooling, telemedicine and home health visit data sharing, decentralized autonomous organizations, verification and audits, and remote device monitoring commonly addressed today under the Internet of Things category.

These open and viable peer-to-peer healthcare blockchains will open the door to new business models in healthcare, including analytics-for-healthcare products and services, flash malpractice insurance and friction-less claims processing hence shorter revenue cycles.

Healthcare insurance claims processing

It is no secret that healthcare claims processing is a nightmare for all parties involved. Reimbursement is opaque, fraud is prevalent, and transactions frequently difficult to reconcile.

For example, home health, a great OOH blockchain example, is possibly one of the greatest sources of fraud in the US healthcare industry today. Smart contracts powered by a blockchain could provide consumers and payors with the means to manage claims in a transparent, immutable and responsive fashion.

Insurance contracts, premium payments and their respective claims could be recorded onto a blockchain and validated by node consensus, preventing fraudulent claims from being processed. Smart contracts could enforce claims triggering payments when due or dispatching specialists, nurses or doctors to follow up with patients when anticipated claims are not recorded by presumptive dates.

Managing “super-utilizers”

The term super-utilizer describes individuals whose complex physical, behavioral and social needs are not well met through the current fragmented health care system.

These individuals go from emergency room to emergency room, to admission and re-admission, in a chaotic and costly manner. Mental health, substance abuse, poverty and education are frequently cited as common characteristics of many but not all in this group. Many researchers and experts postulate how more “community support” and “real-time engagement” is needed to manage this socially isolated population of healthcare super-utilizing consumers.

Smart contracts powered by an OOH blockchain utilizing the bitcoin payment system could be used to create a rewards and incentive system to manage super utilizer behavior.

Behavioral contracts could be developed between payor and patient to trigger rewards denominated in BTC for attending support groups, regularly engaging a telehealth professional, reporting health conditions (possibly at kiosks with bitcoin point-of-care devices), and meeting agreed upon health goals.

Payors would fund reward payouts via efficient BTC accounts established at commercial digital currency exchanges. A smart contract would trigger a reward payment (or loss) when goals are met near real-time to the patient’s public bitcoin address which in turn could be tendered at local participating outlets equipped with BTC point-of-contact devices including community centers, supermarkets and apartment complexes to pay bills, purchase healthy foods and meet rent obligations.

Medical malpractice insurance DAOs

In theory, decentralized autonomous organizations (DAOs) are entities that are self-governing. DAOs on a OOH blockchain could enable trust and provide an immutable record and audit trail of an agreement without a single controlling body.

Doctors and nurse practitioners could collaborate to establish a peer-to-peer malpractice DAO and record each peer’s premium payments and claims on the blockchain. All premiums paid in would create a pool of capital to pay claims.

By combining the blockchain with the peer-to-peer business model, this creates the potential for a near-autonomous self-regulated insurance business model for managing policy and claims. No single entity would control the network. Policyholders could “equally” control the network on a pro-rata basis.

But, these are just a few examples of how bitcoin and blockchain technology will change the face of healthcare in the future.

The blockchain is a new and exciting technology, and we are now just beginning to see both small and large players dip their toes into the water. I personally would discourage any entrepreneur from pursuing the use of blockchain technology inside the walls of clinics and hospitals today, as the those lanes are laden with painful obstacles – the OOH blockchain is your winning lane today

Author
Cyrus Maaghul

Cyrus Maaghul is a thought leader in healthcare, technology, and finance with experience in markets around the globe. He is keenly interested in the blockchain, cryptocurrencies, and healthcare particularly the intersection of physical and behavioral health and provider empowerment
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