In one of my first blogs on blockchain “What’s blockchain not: some misconceptions” (March 22, 2016), I wrote that this technology was not only for financial services. It can be used for many more areas.

One sector that is already seeing significant activity is healthcare. From the perspective of blockchain  adoption, healthcare organisations are moving fast and “even seem to have a lead” on the financial industry according to a recent Deloitte survey. This study also identified a number of practical use cases that could positively impact healthcare companies such a regulatory compliance, payments and clinical trials. One of the most compelling use cases that was mentioned: enabling truly interoperable electronic health records.

PA Consulting Group

In an article entitled "The Blockchain: The Solution for Healthcare Inoperability", Peter B. Nichol says that the question of whether blockchain technology is going to revolutionize healthcare and its interaction with patients ultimately comes down to solving the medical records interoperability disconnect between payers and providers.

“Revolutionary industry change takes time. Technology isn’t the limiter; it’s business process adoption. Today we witness a similar evolution with blockchain technology and the ability to impact health and wellness. The technology is here; it’s the business process integration we need to get right to solve EMR interoperability.”  Peter B. Nichol

Present situation

The growing interest of healthcare in blockchain technology for medical records management is not that strange.

Medical records and patient information are crucial to the healthcare system around the world. Healthcare organisations, such as hospitals and insurance companies need to share patient information to conduct their business. Medical records however present many challenges to the healthcare system.

Current healthcare record systems are a mess of disconnected databases. Medical history is fragmented and siloed, preventing doctors and patients from building a complete record of health. Records are often spread across different facilities and providers in incompatible databases. The vast majority of hospital systems still cannot easily (or safely) share their data. One of the big problems with the current system is knowing whether the information that has been shared is accurate and that it has not been tampered with.

Interoperability issues continue to be a chief concern throughout the health industry. The lack of interoperability leads to high costs. But it also makes these systems loaded with private patient information very vulnerable for security breaches, fraud etc. Medcare fraud is estimated to have cost around $ 30 billion in the past 20 years.

Blockchain and  health record management

This inadequacy and the inherent complexities of existing healthcare systems, has sparked questions about the potential role of blockchain technology as a digital record-keeping system. Blockchain and other distributed ledger technology have all the ingredients to solve healthcare IT’s most intractable problems: interoperability and securing the integrity, completeness and privacy of health records.

Blockchain has the potential to revolutionise how individuals’ medical records are stored. As a digital record keeping system, whereby data is hashed onto the blockchain, it is considered a much more secure, scalable, tamper-proof alternative to current legacy models. Records on blockchain are secure, almost impossible to manipulate, auditable and easily accessible with public and private keys. Those with the right credentials could verify a record at any time, while the system would be easy to audit, more streamlined and much more effective.  By storing medical records on a blockchain, it is possible to create a longitudinal health record covering every incident and update from childhood to old age. Every event or transaction is time-stamped and becomes part of a long chain, or permanent record, that can’t be tampered with after the fact.

Patients maintain full access and control ….

In this blockchain environment patients are be able to maintain full access and control of their own data, providing access to the healthcare providers they’d like to share it with. This enables hospitals, insurance companies and labs to connect in real-time and share information instantly and seamlessly, in a secured way. This is ideal for medical research, facilitating the kind of longitudinal studies that can really help best understand illnesses.

…. and data can be shared securely ….

Data captured on blockchains can be shared in real time across a scalable group of individuals and institutions. Since data stored on blockchains can be shared securely with a pre-approved and trusted group of individuals, patients can be sure that their data is being used properly, that it is all held in one single place - in one standardized format – and that there can be complete transparency, accuracy, and trust in the information across all of its users.

…. while efficiency gains  and cost reductions be realised

Using blockchain for record management could help healthcare organisations bridge traditional data silos, thereby dramatically increasing efficiencies, keep business and medical data secure and streamline patient’s access to medical data. The quality and coordination of care would be expected to rise, and the costs and risks likely to fall. Costs of transferring medical records between institutions are reduced, compliance costs go down and auditing is much easier. Medicare fraud could also be reduced. Because of its highly decentralised nature which mitigates central points of failure, it is nearly impossible to hack or to alter the data.  

Public or private blockchain?

There is the issue, what kind of blockchain is applicable for healthcare: a public or private one. On public or permissionless blockchains, all parties can view all records. Given the privacy that is not the most suited solution. Under private or permissioned blockchains access can be gained only by those who have been granted access. Privacy can be maintained by agreement about which parties can view which transactions – and where desired, by masking the identity of the party.

Because the healthcare industry is subject to unique patient privacy and security regulations, identity management is a critical competency for any provider organization looking to use data for clinical or operational improvements. In private blockchains organized around an individual patient, that patient may be given the ability to authorize all data sharing transactions, making it easier for him or her to manage where data is going and who has access to sensitive information.

Some research papers and surveys

Various interesting research papers and surveys reports have been published by companies like IBM, Deloitte, Tierion and PA Consulting Group, exploring the interest in and potential of blockchain technology for the healthcare sector.

• HHS and ONC Blockchain ideation challenge

Last summer, the US Department of Health and Human Services’ (HHS) and  the Office of the National Coordinator for Health Information Technology (ONC) sponsored an ideation challenge to solicit white papers on opportunities for blockchain in the health care industry and views on the transformational power of blockchain across this industry.

Among the 15 winning papers (including the one of Deloitte) a range of possibilities were identified, including payment models, privacy, interoperability, claims processing, clinical trials, health information exchange, patient reported outcome measures, and many other topics.

• IBM Survey

In an IBM report called “Healthcare Rallies for Blockchains – Keeping Patients at the Center”,  it was said the health industry appears to be setting the pace on Blockchain adoption, slightly ahead of the financial industry. In this survey conducted among 200 healthcare executives in 16 countries, with a focus on blockchains in healthcare they found that:

-       16 percent of the executives told IBM that “experimental phases have come to an end and that their companies are ready to adopt and implement and  expect to have a commercial blockchain solution at scale in 2017”, while an additional 56 percent are likely to follow by the end of the decade.

-       Seventy percent of likely early adopters believe that blockchain will help them improve the management of health record data, while sixty percent anticipate that the technology will help them access new and trusted information that can be kept secure.

-       60% anticipate blockchains will help them access new markets, and new and trusted information they can keep secure.

-       70% expect the greatest blockchain benefits to be in clinical trial records, regulatory compliance and medical health records

-       Benefits are also seen in a number of other organizational areas, including analytics of medical device data (69 percent), billing and claims processes (67 percent), patient safety (63 percent), and asset management (62 percent).

-       Barriers to blockchain adoption included immature technology (56 percent) and insufficient skills (55 percent).  

“How valuable would it be to have the full history of an individual’s health? What if every vital sign that has been recorded, all of the medicines taken, information associated with every doctor’s visit, illness, operation and more could be efficiently and accurately captured? The quality and coordination of care would be expected to rise, and the costs and risks likely to fall. Long data is simply the lifetime history of data related to a person, place or thing”   

“And that is precisely what blockchains can do exceedingly well. Data captured on blockchains can be shared in real time across a scalable group of individuals and institutions. Every event or transaction is time-stamped and becomes part of a long chain, or permanent record, that can be tampered with after the fact”  IBM Survey.

• Deloitte study

A study by Deloitte shows that healthcare stand out as planning the most aggressive blockchain deployments of any industry in 2017. While the level of blockchain interest seems to be pronounced across industries studied by Deloitte, healthcare and life science companies are leading when it came to deployment.

Results from this study show: 

-       35% of industry respondents saying that their company expects to put blockchain into production during 2017.

-       Executives across all industries cite numerous advantages for investing in the technology. More than one-third (36 percent) of poll-takers cited blockchain’ s ability to improve systems operations, by lowering costs or improving speed.

-       Another third (37 percent) point to security features, while a quarter (24 percent) expect it can enable new business models and revenue streams.

There are obstacles to more widespread adoption of blockchain, however – most notably the lack of technical standards for a still-immature technology, according to Deloitte. Regulatory uncertainty represents another challenge.

• Tierion Report

But there are also others with a more cautious approach. Tierion, the first company to complete a blockchain healthcare project through becoming the first partner in Philips Blockchain Lab, recently launched its “Blockchain Healthcare 2016 Report: Promise & Pitfalls”. Goal of this study was to provide a balanced perspective that addresses the opportunities and risks for the use of blockchain technology in healthcare.

According to their research, the majority of blockchain technology isn’t ready for deployment, though worthwhile experiments are underway. Tierion argues that analysts and professional experts are overselling blockchain, and that most of blockchain technology is experimental and untested.

It seems clear that health IT leaders will continue to explore blockchain options, given its potential for sharing data securely and flexibly.

“If the winning submissions are any indication, blockchain may support new approaches to health data interoperability, claims processing, medical records, physician-patient data sharing, data security, and even the growth of accountable care” Tierion research.

Blockchain projects and initiatives

Since early last year the number of blockchain related activities in the health industry including projects and trials have intensified significantly.

• Philips Blockchain Lab

One of the pioneers exploring the potential of blockchain and distributed ledger technology in the health industry was Dutch-based multinational Philips. Already in October 2015 Philips partnered with blockchain recordkeeping startup Tierion on an “unspecified” project to examine how the technology could be applied to use cases in healthcare.

In March last year the Philips Blockchain Lab was founded in Amsterdam to investigate how blockchain could be applied to healthcare. Thereby they were seeking collaborators and developers to conduct the project.

• Gem Health initiative

US blockchain startup Gem also partnered with Philips to launch Gem Health, an initiative for building a “patient-centric approach to healthcare” using blockchain technology. Gem thereby provides the data infrastructure to support a network, connecting companies that work in all levels of healthcare.

“Blockchain technology addresses the trade-off between personalized care and operational costs by connecting the ecosystem to universal infrastructure. Shared infrastructure allows us to create global standards without compromising privacy and security.” Gem

• Estonian Health Records

One country that has taken the early lead in pursuing a blockchain-based case study to facilitate the management of medical records is Estonia. The Estonian eHealth Foundation thereby partnered with the data security startup, Guardtime, to develop a blockchain-based system that will secure the medical records of more than 1 million patients. The Estonian e-Health Authority is thereby ensuring the integrity of data for its residents.

For this initiative Guardtime employed a Keyless Signature Infrastructure (KSI), a blockchain technology solution integrated into an Oracle database engine that delivers mass scale data authentication without dependency on a centralized trust authority. Estonian citizens have in their possession a unique identifier which links them to their personal medical record. The system files and signs the data, with new signatures generated whenever the information is altered. The data itself is not stored on the blockchain, just the hash values that indicate when files have been updated. Because the system only allows for the passing of a signature to secure access, patient privacy is assured.

• Pilot MedRec

Boston-based Beth Israel Deaconess Medical Center recently teamed up with researchers at the MIT Media Lab to test a blockchain application pilot called MedRec. The authentication log was put to work at Beth Israel, tracking six months of inpatient and outpatient medication data with MedRec code deployed through virtual machines at MIT. They recorded blood work records, vaccination history, prescriptions, and other therapeutic treatments, simulating data exchange between institutions by using two different databases within Beth Israel. The results were so positive that the team is already starting to plan more pilots with larger networks of hospitals. MedRec is however still an early prototype, not ready for widescale deployment any time soon.

• FDA-IBM project

In January this year, the US Food and Drug Administration (FDA) announced a research partnership with IBM Watson to study blockchain tech and explore how data from electronic medical records, clinical trials and health data from wearable devices could be better shared and audited using the blockchain approach. Initial tests will focus on clinical trials and real-world evidence data related to oncological data.

"By keeping an audit trail of all transactions on an unalterable distributed ledger, blockchain technology establishes accountability and transparency in the data exchange process." FDA

IBM and the FDA will work together for two years, with the aim to publish their findings in 2017.

Going forward

The virtues of blockchain are clear and the core strengths of blockchain could be a solution to the present inefficiencies, frictions and pain points that the healthcare sector urgently need to address.

The sector will certainly intensify its activities in the blockchain area looking for solutions. It is very likely that this year should see the development of some new and interesting healthcare blockchain applications. But it seems also likely that blockchain in the health industry will take some years to achieve scale.

There are several obstacles standing in blockchain’ s way for an early widely adoption throughout healthcare.

The reality is that it is still a relatively new technology and untested in many practical applications. Blockchain technologies have only really been experimented with for the last couple of years. In most sectors, startups are still in the proof-of-concept phase rather than applying real-world practical applications.

And there is still lack of clarity how blockchain is to be regulated, particularly in an area with such complex data security issues as healthcare.

May be the most important challenge will be to overcome the “notoriously” resistant to major change in the health sector.