Blockchain for Healthcare

Instruments of trust and value such as currency, letters of credit, stock certificates, deeds to property, and contracts form the foundation of the global economy. Critical infrastructures such as stock exchanges, point-of-sale credit transactions, and electronic currency transfers between banks have brought the economy into the modern era. Control of the instruments and the infrastructure to use them is in the hands of nation-states and megacorporations. This centralized global infrastructure of trust and value was severely tested in the 2008 global financial crisis.

During the height of that crisis, a paper published by a pseudonymous author described the fundamentals of a new technology called blockchain that could be used to build a peer-to-peer electronic cash system independent of the global financial infrastructure.(1) This concept was used to create the first decentralized cryptocurrency—Bitcoin—in 2009.

Bitcoin gained notoriety as a potentially anonymous, democratic, untraceable, and international mechanism to transfer value in a trustless system. These features attracted the attention of nation-states concerned about the potential of enabling illegal commerce, tax evasion, money laundering, and disruption of the established financial infrastructure. Despite these concerns, Bitcoin demonstrated the potential of blockchain as a way to transfer value in a decentralized, automated, trustless system on a global scale.

The financial system quickly recognized the potential value of the underlying blockchain technology to improve and accelerate economic infrastructure with distributed ledger systems. These distributed ledger systems quickly spread beyond the financial industry into supply chain management and asset verification.

The distributed ledger of blockchain serves as a decentralized consensus-driven collaborative and verifiable record of transactions. Analogies used to frame the blockchain hyperledger with more familiar examples include a spreadsheet in the cloud or Google Docs for Banking.(2) Collaboration on a document is not done one person at a time by sharing files through e-mail with a consensus document compiled by a centralized and trusted editor in a blockchain-based world. Instead, the blockchain records modifications, records verified authorship of any changes or alterations of the data, and encodes the exact time that any modification took place. The decentralized consensus mechanisms in blockchain continuously define and disseminate an authoritative and revised document.

The Anatomy of a Blockchain

A blockchain is a data structure built out of bundles of data (i.e., blocks) that are linked to the most recent existing block in the chain with a cryptographic link. This cryptographic link is made using data components from the most recent existing block and added to the new block to create a tamper-resistant link between the new block and all other previously created, existing blocks in the blockchain. Any alteration to the new block or any existing block will break the cryptographic links. This feature makes the blockchain inherently tamper-resistant, a feature that makes blockchain very attractive to the healthcare profession.

The data content of the blocks can include entire digital files such as documents or images. This approach is data and energy intensive, so most blockchains are designed to store a combination of transactional data and location of information in blocks. This allows for a much smaller, responsive, and potentially less energy-intensive blockchain.

Blockchain Creation

First, data are bundled to form blocks and time-stamped so that any alternations of the block can be easily identified. A cryptographic signature is then created for the information in the block. This signature is used, in conjunction with the signature of the most recent existing block, to create a cryptographic link between the new block and the existing blockchain.

For many blockchains, the process for adding a new block is referred to as blockchain nodes. Nodes validate each transaction to ensure the legitimacy of any transaction that is added to the blockchain. This distribution provides data redundancy and builds consensus for the content of the blockchain throughout the nodes. This process is called blockchain mining, which has high computation and energy costs. For cryptocurrency blockchain, the energy costs are staggering, approaching the energy consumption of entire countries.(3) Distributed and public blockchain systems such as cryptocurrencies incentivize mining by awarding virtual tokens or “coins” for successfully adding a new block to the blockchain. These tokens may have a market value (e.g., Bitcoin, Ethereum) or may be required to submit new data to the blockchain.(4)

Most blockchains are private and are run without incentive tokens. This allows enterprise users to leverage the data integrity, security, and fault tolerance characteristics of blockchain technology without the energy and computational costs of running a public blockchain.

Smart Contracts

Some blockchain implementations, such as Ethereum and the Hyperledger Project, include provisions for logical operations that allow the enforcement of smart contracts. Smart contract logic is used to facilitate, verify, and carry out the terms of digitally specified contracts. Smart contract transactions often are verifiable and irreversible. This layer of complexity allows automation of routine business operations in a medical practice, such as insurance verification, posting charges for services, and verifying payment for healthcare services.(5)

Data Integrity Features of Blockchain

Blockchain was designed with an understanding that the integrity of the data and the entire blockchain would be subject to cyber attacks. The cryptographic signatures forged during the blockchain mining process make this data structure inherently tamper-resistant.

The distributive features of blockchain improve data redundancy and fault tolerance, allowing nodes to replace corrupted blockchains with a consensus blockchain. Creation of a consensus-based blockchain system reduces but does not eliminate the risk of a malicious actor adding false or unverified blocks to the blockchain.(6)

How Can Blockchain Transform Healthcare?

Blockchain technology has the potential to make healthcare more safe, effective, patient-centered, timely, efficient, and equitable through the inherent features of the technology.

Let’s look at the value of patients’ healthcare records. Stolen medical records are worth more than financial data. If someone’s Social Security number gets into the wrong hands, the cost to society is a dime. If your credit card is hacked, that loss is worth a quarter. However, if your medical records are hacked, the value is more than $1000. Hackers scour medical records for personal information that can be used to file fake insurance claims, open credit accounts, obtain prescription drugs, and a lot more. With healthcare increasingly under cyber attack, blockchain has emerged as one of the leading technologies to safeguard patients’ privacy, protect their identities, and provide financial security.

Blockchain has the potential to modernize the delivery of healthcare while also preserving patient privacy.

One of the challenges facing American healthcare is the lack of interoperability of patient’s medical records. Other countries such as Denmark and England, which functions on the National Health Service, have a universal medical record program that allows patients’ records to be shared among medical providers.

Let’s look at how blockchain has the potential to modernize the delivery of healthcare while also preserving patient privacy. Imagine a patient seeing a doctor where tests and studies are conducted, and medications are prescribed and a diagnosis is made that become part of the patient’s electronic record. It is very difficult for the patient to access his or her own record, because the data are managed by the healthcare provider. If the patient sees another provider out of the network, moves to another city, or travels to another country, it is nearly impossible for him or her to access their own data and share the data with another provider.

Blockchain makes it possible for patients to access their own records wherever they on a 24/7 basis without requiring permission from the healthcare provider.

Blockchain makes use of a distributed ledger technology, which tracks the transaction of assets or, in this case, the patient’s own healthcare data. Distributed ledgers in healthcare require permission or passwords to access, and only approved people can read, modify, or eliminate transactions.

Blockchain enables seamless peer-to-peer communication with no single doctor or institution controlling access to the data.

This is one of the unique advantages of blockchain in healthcare. Patients often have multiple doctors, multiple diagnoses, and comorbid conditions, are on multiple medications, and have studies or tests that have been duplicated because each physician has difficulty finding the data from multiple medical records. It’s very important that the several care teams communicate with each other. By making use of blockchain, no single authority or doctor controls the records—it’s at the patient’s discretion who has access to the data. The patient has the same exact copy that the doctor has. Blockchain enables seamless peer-to-peer communication with no single doctor or institution controlling access to the data.

So what does it look like? It looks like a string of blocks, with each block consisting of a packet of data connected to another block that is added to the chain. These blocks have specific, identical structure. In the case of a medical record, each block describes the transmission of medical data. Each block has a header, and the header identifies the block belonging to a patient. Anyone with access can easily locate the chain or any point or block in the chain. If the block is the last one in the chain and it is not connected to another block, that means it is the last data that has been entered.

Another unique advantage of the blockchain is the time stamp, which indicates which block was entered first and which blocks were added later on. As a result, blockchain can be trusted because any change in any content in each block will have a time and date that the data were entered. And, finally, the blockchain contains an electronic signature, which tells who generated the block.

So the benefits of blockchain’s value to the electronic medical record and to healthcare include the following:

1. It digitally tracks data transactions.

2. It provides a tamper-proof system where no one can modify, adjust, or delete data because anyone changing any of the data content of the transaction will be identified. As a result, the data in the blockchain can be trusted.

3. It has established transparency. Because of those benefits and features there is trust between parties.

Today people don’t share information because they don’t trust how others are going to use the data or if the data will be used for nefarious purposes. We don’t share the data because we are not certain that others will protect the data at the same level of safety that the data’s owner would. With the use of blockchain, the owner of the data will know how the information is being used and who is accessing the data. In this manner the patient maintains ownership of his or her data.

Other Uses of Blockchain

Demonstration projects show blockchain technology has the potential to improve safety via enhanced security for the pharmaceutical supply chain,(7) improve the traceability of informed consent for clinical trials,(8) and improve data integrity and reproducibility in clinical trials.(8,9) The verification and authentication features of blockchain have the potential to be instrumental in ensuring the right patient gets the right treatment at the right time. Supply chain improvements, particularly for the pharmaceutical industry, are likely to be the first areas with patient safety improvements because of blockchain technology.

Gains in efficiency for the healthcare industry will likely come from the implementation of blockchain to facilitate data sharing between applications and institutions and the use of smart contracts for many aspects of the healthcare revenue cycle, such as insurance verification, authorization, and payment.

Blockchain technology will, for the first time, make electronic records interoperable.

Effective healthcare relies on accurate and comprehensive data about patients, diagnostic results, and the healthcare delivery system. Current systems do not provide this level of integration, forcing waste and inefficiency because parts of a comprehensive view of a patient or his or her records are inaccessible because they exist in the data infrastructure of another healthcare entity. Thus blockchain technology will, for the first time, make electronic records interoperable. Blockchain can serve as an intermediary for healthcare data exchange, mitigating this problem. Healthcare analytics can be employed on this complete overview of patient data to gain insight into the improvement and standardization of healthcare delivery.

Blockchain has the unique potential to strengthen traditional healthcare delivery systems such as insurers and hospitals while giving individuals control over their healthcare data, improving transparency, and driving the industry to a more patient-centered focus. Blockchain will result in competition between providers of healthcare and, ultimately, in a cost reduction.

Blockchain has the ability to improve the timeliness of healthcare services by improving communication, reducing delays on receiving diagnostic results, and providing potential improvements in the overall efficiency of health care systems. Automated insurance tasks such as verification, authorization, and approval would significantly accelerate the pace of referrals and interventions, resulting in marked improvement of efficiency of medical care.

Equity in the healthcare system could be enhanced by greater efficiency of care, better identification of social determinants of health, and giving individual patients a greater voice in health resource allocation. Discussions of leveraging blockchain mining incentives to fund universal healthcare are underway and have the potential to radically alter the healthcare financing landscape.(10)

Barriers to Blockchain in Healthcare

The advantages of blockchain come at the cost of additional complexity and energy consumption. The blockchain industry is making significant research and development commitments to address these issues by reimagining the blockchain for efficiency, scalability and less energy consumption.

Significant challenges related to cross-jurisdictional governance, security, and patient privacy must be addressed to maximize the potential transformation of the healthcare data infrastructure with blockchain.

Bottom Line: Blockchain technology is in its infancy. However, there soon will be applications in the healthcare industry where blockchain will improve the efficiency, the transparency, and the security of moving large amounts of data. We suggest that you begin by examining current problems that are impacting your practice or your hospital. Then decide whether blockchain might be a solution to that problem. You may find that blockchain can be a viable solution problem solver that is impacting the delivery of healthcare. Excitement is growing about the role that blockchain technology might play in the long-term transformation of U. S. healthcare.

References

1. Nakamoto S. Bitcoin: a peer-to-peer electronic cash system. Bitcoin.org . October 31, 2008. https://bitcoin.org/bitcoin.pdf .

2. Hyperledger Project. What is Hyperledger? The most comprehensive guide ever! Blockgeeks.com . https://blockgeeks.com/guides/hyperledger/ .

3. Why bitcoin uses so much energy. The Economist. July 8, 2018. www.economist.com/the-economist-explains/2018/07/09/why-bitcoin-uses-so-much-energy

4. Coindesk. Ethereum. https://coindesk.com/price/ethereum .

5. Smart contracts are here. APTTUS. https://solutions.apttus.com/rs/902-TNK-191/images/Apttus_Blockchain_Smart_Contracts_IACCM_CommonAccord_White_Paper.pdf

6. Orcutt, M. Once hailed as unhackable, blockchains are now getting hacked. MIT Technology Review. February 19, 2019. www.technologyreview.com/s/612974/once-hailed-as-unhackable-blockchains-are-now-getting-hacked/ .

7. Sylim P, Liu F, Marcelo A, Fontelo P. Blockchain technology for detecting falsified and substandard drugs in distribution: pharmaceutical supply chain intervention. JMIR Res Protoc. 2018;7(9):e10163.

8. Benchoufi M, Porcher R, Ravaud P. Blockchain protocols in clinical trials: transparency and traceability of consent. F1000Res. 2018;6:66. Published 2018 Feb 1. doi:10.12688/f1000research.10531.5

9. Maslove DM, Klein J, Brohman K, Martin P. Using blockchain technology to manage clinical trials data: a proof-of-concept study. JMIR Med Inform. 2018;6(4):e11949. Published 2018 Dec 21. doi:10.2196/11949

10. Till BM, Peters AW, Afshar S, et al. From blockchain technology to global health equity: can cryptocurrencies finance universal health coverage? BMJ Global Health. 2017;2:e000570.

Further Reading

Blockchain Tutorial—How To Become A Blockchain Developer. https://blockgeeks.com/guides/blockchain-developer/

Blockchain in Healthcare Today (www.blockchaininhealthcaretoday.com ) is the preeminent open-access international peer-review journal for strategic thought leaders, new-era practitioners, and future society stakeholders engaged in blockchain technology and intersecting