Our healthcare system is sick. We attempt to improve its condition through containing costs and maintaining the standard of care, however when costs are contained quality of care suffers and vice versa. Privacy, inconsistencies in record keeping, inefficient methods of provider communication and efforts to verify insurance and reimbursement add to the burden. Policy is implemented with hopes of fixing things to no avail. It’s time to look away from policy and toward technology as a solution to our healthcare woes. One technology offering promise to nurse sick systems back to health is “Distributed Ledger Technology” (DLT).
DLT is a shared “book” of records in a “database”. Unlike a traditional ledger of which just one exists, in DLT identical ledgers of data are mirrored at all approved locations in a network. Each location is referred to as a “node”. Newer data is “tied” to older data and distributed across the network. The data exists in “blocks”. A chain of blocks or “blockchain” refers to the interconnection of these data blocks. When the data is added to the chain, all records in the ledger are “stamped” with the details of the change; when data is deleted the same thing occurs. The first thing that comes to most people’s mind when they hear “blockchain” is Bitcoin or other “cryptocurrencies”. Cryptocurrencies are not blockchain themselves, but a product of the blockchain. Sophisticated computer algorithms managed by “miners” (people who work to verify blockchain data) help validate the events recorded on the “chain”. When validated, the information is “timestamped” and added to the chain in the order they occurred. Miners are rewarded with cryptocurrency or data they seek for their own research or business purposes (with permission from other participants on the chain). The features inherent in blockchain technology support a totally transparent system where all changes can be monitored and accounted for by each computer attached to the “chain”. This renders the data virtually unalterable in the sense that there is an identical record on each location of the data before and after the changes providing almost perfect transparency and accountability within the chain, making it perfect for conducting transactions. Like a metal chain, the new “blocks” are linked to the older blocks; like a fossil, the record of the happenings on the chain is etched in “digital stone”.
Structure of the Blockchain
A “block” in the blockchain is comprised of data and a code (hash code). The hash code is like a staple, securing data on the block to the data to the previous “block”. If a block on the block-chain is deleted or changed it is imprinted in the hash code and the block-chain is rendered invalid. Anyone with permission can determine whether data was altered and by whom by looking at the hash codes. The distributed ledger is comprised of all the blocks that form the chain and exists on all computers in the network with access. Everyone with access has identical ledgers.
In traditional information technology (IT), each business retains, manages and protects its own data. In the Distributed Ledger, the data set is created by and shared among all participants. The data is continuously synchronized; the nodes “talk” to one another, matching copies of the distributed ledger within each node. This makes all data traceable, shareable and unalterable and it is this trait that results in the technology having significant advantages over traditional IT systems.
Applications of DLT in Healthcare
Smart Contracts and Patient Health Management
Let’s look at how DLT might help with the care of patients with Glaucoma. Glaucoma is a chronic eye disease that requires regular monitoring by an eye doctor. After a thorough evaluation, the doctor generates a treatment plan, goals (target IOP for instance) and patient management plan where follow-up treatment is recommended at specific intervals. It is expected the patient will follow the plan.
Using blockchain, the provider will generate an electronic contract (Smart Contract) that outlines the details of the treatment, follow-up plan, office policies, HIPAA documents, CMS forms, contracts delineating patient responsibility for payment etc. The contract automates the administrative side of things as well. The blockchain technology renders the data permanent and secure. The chain of information in the smart contract is added to a distributed ledger, authenticated by the various parties and then made available to interested, approved parties; the insurance company, CMS, EMR company and practice for instance. Each party has access to the distributed ledger but data requires patient authorization for viewing. With this shared, secure data the receptionist does not have to confirm patients insurance information, eligibility, demographic information, co-pay or other information. The patients can execute the doctor’s plan more effectively. Their wearable healthcare technology will regularly add vital data to their record for physicians to review, all in real time.
Permanency of the Medical Record
Blockchain’s capacity to record and backup medical information will be invaluable in the clinic. DLT offers a cryptographic database that anyone running the software can access – patients, doctors, healthcare organizations. It will be very difficult to alter a record, which will result in doctors being more thorough in their charting. The time-stamp provided by the blockchain will keep doctors from altering records if accused of malpractice or involved in a lawsuit regarding a misdiagnosis. This will cut down on unnecessary lawsuits and the expense they add to our health care system.
Blockchain, Clinical Decision Making, and Patient Outcomes
Imagine databases full of hundreds of thousands of treatment and care regimens including data on outcomes that are connected across continents. Now imagine how a healthcare provider with access to this data may use it to find the perfect treatment for their patients. By entering chief complaint and patient history in the database artificial intelligence (AI) secured by the blockchain can match the data to hundreds or thousands of similar cases, make a treatment recommendation, and analyze the outcome. Machine learning gradually perfects the algorithms and efficiencies in patient care increase saving money and time for physicians and patients alike.
Microsoft India, in collaboration with eye clinics including L V Prasad Eye Institute, Bascom Palmer, and others has launched Microsoft Intelligent Network for Eyecare (MINE)². It is a global consortium of institutions in the eye care space who came together to apply artificial intelligence (AI) to assist in eliminating avoidable blindness and helping to scale delivery of eye care services in the third world. They will be utilizing distributed networks to come up with predictive models for eye disease. They plan to look at the rate of change in myopia in children, conditions that impact children’s eyesight, predictive outcomes of refractive surgery etc by studying data and applying analytics.
Accenture estimates that blockchain applications can create $150 billion in annual savings in healthcare in the US by 2025¹. Areas that impact patient outcomes such as medical imaging are key targets of distributed ledger technology and promise to provide tremendous benefits in image and information sharing among specialist doctors such as radiologists and optometrists, orthopedists and others. The increase in efficiencies around image sharing decrease the chances of misdiagnosis and wrong treatment. Add data scientists to the picture and the value increases as they are able to learn more from our images than we could solely depending on our clinical acumen. New treatment algorithms generated by the volumes of aggregated data will improve clinical decision making, reduce costs, enhance speed, precision, and quality of outcomes currently “buried” in today’s siloed EMR’s.
Blockchain, Data, and EHR
The data in our healthcare system in our country in different EHRs and privacy laws protecting that data are tighter here than in other countries. To complicate matters, the insurers collect and store their data in databases with totally disparate standardless architectures. This siloing of data creates bottlenecks in efficiency and level of care that result in increased costs to our healthcare system. There are many vendors, programs written in different code and differing capabilities between platforms. Because of these dissimilarities, there are limits how effectively the government can implement healthcare changes that benefit everyone. There is a drastic need for technological advancement in this area that improves efficiency, sets standards and enables doctors to deliver a higher quality of service.
Many healthcare data scientists see DLT becoming the software backbone of a national healthcare system. It might work like this; you have a back problem and have seen different providers for different treatments. Communication by providers is by snail mail, fax or email. Accessing the information is cumbersome as it has to be pulled up and viewed or read, then clinical impressions manually transcripted into the record. Your radiologist sends a letter to your orthopedist, your orthopedist provides written treatment plans to your physical therapist and chiropractor but the data is structured differently in each separate EHR, fragmented and disorganized, not to mention the security risk that exists. Inability to share and interpret data in different formats or from different systems poses a significant health and security risk. With blockchain, the data is organized and accessible to everyone you permit resulting in a more effective treatment plan with increased efficiencies through the entire process.
Storing Patient Data on Distributed Ledgers
Think of blockchain not as a replacement for healthcare databases or EHRs but as a backbone for them, enabling secure sharing of data and records, confirmation of record accuracy, easier collaboration between providers and opportunities for patients and healthcare organizations to control and use the shared medical data.
It’s theorized that DLT will be used to tighten up personal healthcare information protection. With identical copies of data distributed to all users the security of the data is confirmed through the permanent and reliable digital fingerprint the blockchain provides. Only those authorized can gain access to the data providing a deeper layer of security.
Healthcare consumers will own and control their own data and control its distribution via DLT’s. They will be able to send their medical records (anonymously) to artificial intelligence (AI) algorithms which will analyze their charts. Doctors will also have access to this data and overlay it with data from other healthcare providers to get a more thorough and accurate picture of the patient’s health. They will be able to anonymously communicate with “new” doctors until such time a degree of trust is created prior to the visit. Platforms will allow patients to receive speedy consultations from doctors who specialize in treating their condition if they are located elsewhere or even across the world. The blockchain will safely store records, providing one single version of the truth of our health and medical history. Blockchain technology enables healthcare providers to exchange information quickly at dramatically reduced costs in terms of time and resources which is beneficial to the entire healthcare system.
Releasing of Patient Data
When we seek healthcare we really have no idea where our personal data ends up; EHR companies have access to it as might insurers and in some cases, even vendors might be able to access it. This is especially worrisome in some industries such as eye care, where insurers are also vendors to clinics who serve the lives they cover. These companies have required us to provide access to personal data and are undoubtedly using our business data and patient’s data for their own business purposes without compensating us or our patients and no guarantees on where that data ends up and for what purposes it is used for. Blockchain is structured so that patients will control who gets their data. The hash codes show where it came from and where it goes, so a record exists that keeps members of the chain with access accountable for the data they use. That, plus it enables patients who share their data with for-profit organizations to be compensated for what is rightfully theirs.
Blockchain in Insurance, Billing, and Payments
Inefficiencies exist in the insurance verification process. That, combined with people’s fear of sharing information create a constraint that results in delays, frustration, and poor patient service. Blockchain provides the privacy, control, and structure to make the verification process simple. In the future, using DLT, once data on a patient is verified it’s transmitted to all providers via the secure blockchain removing the need to repeat the process at each and every provider a patient goes to and possibly future providers as well.
Improving accuracy and accessibility of health care credentials will be required to move healthcare forward in most healthcare verticals. Using blockchain it is possible to better manage provider credentials and other types of employee verification methods, enabling business owners to seamlessly and promptly navigate the process of verification and hiring in their offices.
Providers often seek employment at multiple institutions and institutions with different locations and often need to complete the process numerous times, especially if they change jobs. Delays in credentialing can cost healthcare organizations hundreds of thousands of dollars in lost revenue. The reason why hospitals and other medical organizations require repeated credentialing verification is there is not a totally trusted and reliable place where this data exists, can be verified and extracted from. With credentialing information on a distributed ledger, healthcare organizations are assured the data required is up to date, precise, secure and valid. Currently, the technologies we use to credential our doctors are phone calls, faxes, snail mail and email. The distributed ledger connects entities and eases data exchange.
Claims Processing and Denials
Not only do delays in payment cause us cash flow problems, but our money in someone else’s hands decreases in value the longer they have control of it. Claims processing is time consuming, frustrating and requires a significant amount of resources for healthcare practices. We spend payroll dollars on staff time invoicing, waiting for payments to clear and dealing with claim rejection which decreases our bottom line. Why is it that we can transfer money anywhere in the world in milliseconds, yet our insurance claims can take more than a month to be paid on?
Claim denials at US hospitals cost hundreds of billions of dollars each year. Add that to the cost of denials in all other health care settings and you have an astronomical expense. The administrative expenses make up the bulk of these expenses as is the actual payment process which includes secure transactions.
Blockchain promises to dramatically simplify this process. Conceptually, a healthcare smart-contract application powered by blockchain technology could help payers reduce the time needed for claims processing and payment from seven to 14 days to as little as seven to 14 minutes. The smart contract would contain the payer-provider contract terms and, as soon as the claim is submitted, the claim is processed in real-time and payment is then transmitted to the provider.
Fraudulent claims cost our healthcare system tens of billions of dollars per year. Since the blockchain provides a permanent record of transactions, it is a perfect tool to help reduce the amount of fraud that occurs on both sides of the insurance aisle.
Blockchain in Pharma and Clinical Trials
Billions of terabytes of healthcare data exist in separate EMR’s across the world. Think of the limitless possibilities of what researchers and scientists could glean from that data if it was conjoined, synched and secured.
DLT has the potential to effortlessly feed healthcare data into important healthcare applications where it can be analyzed. Data for clinical outcomes, lab results, and medication regimens are just a few examples. Blockchain enables the use of the data from hundreds of thousands of patient records to drive clinical trials, enhancing the science behind our care for the benefit of all.
Clinical Trial Recruitment
In some cases, up to 30% of the length of a clinical trial is dedicated to finding and enrolling suitable subjects. Using artificial intelligence tied to blockchain holding patient data those subjects becomes much easier to identify. The blocks with the data can be layered with standardized digital permissions and paperwork that would only need to be submitted once. This provides limitless data for pharma companies and dramatically eases challenges related to subject recruitment.
DLT has applications across healthcare that offer to alleviate some of the major burdens and costs of our current system while improving privacy and security simultaneously. Look for DLT to have a significant impact on our healthcare systems in the coming years.
Well said, Alan. I am currently in a Blockchain Entrepreneurship course at this moment and have my capstone project around this very idea. I know it’s still in its infancy but I strongly believe that blockchain and EHR are the waves of the future. Each stakeholder on the healthcare record blockchain with forms a smart contract with everyone else on this permissible blockchain DLT and the health record becomes immutable, transparent, pseudonymous, and verified by an untold number of nodes. In essence, each person’s health record becomes its own NFT (non-fungible token). The possibility of creating such an ecosystem where everyone can contribute to this person’s blockchain, from PCP, OD to pharmacist and insurance companies would create a much more efficient system of healthcare. Of course, regulations would have to be considered for such a project but that is true for anything that might be a grey area around HIPAA laws. I do strongly feel that the chain can be even more robust than just this though. I think the addition of a cryptocurrency to act as an internal reward system would take this idea to another level. That is what I plan to do with some colleagues of ours in the next few months. In either case, healthcare is sick and this new blockchain tech is the answer.