Monday, 16 October 2017

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: cThis 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.
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Manish Sharma
Founder HCITExpert.com, Digital Health Entrepreneur

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