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One Health Policy Researcher on the Current State of Blockchain in Healthcare, and its Potential Future

October 22, 2018
by Heather Landi, Associate Editor
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Blockchain technology is generating a lot of interest and excitement in healthcare because of its potential to improve transparency, relieve administrative burdens and reduce costly waste within the system. However, there are also those within the industry that caution about the realistic prospects for the adoption of blockchain technologies in U.S. healthcare as well as the challenges of implementing this still-emergent technology.

In August, a Deloitte survey found that most global executives see great value in blockchain’s potential to reinvent processes across the business value chain, while there is interest and investment in a wide range of use cases. The research revealed that 74 percent of all respondents reported that their organizations see a “compelling business case” for the use of blockchain—and many of these companies are moving forward with the technology.

As an academic researcher, Tim Ken Mackey, an associate professor of anesthesiology and global public health at UC San Diego School of Medicine, has been exploring the possibility of leveraging blockchain to enhance supply chain management in healthcare, as well as other use cases.

Mackey is the director of healthcare research and policy at UC San Diego – Extension, and he also is the director of the Global Health Policy Institute. He holds a Ph.D. in Global Public Health from the joint doctoral program at UC San Diego-San Diego State University. His work focuses on a broad array of multidisciplinary topics, including research in disciplines of public health, health technology and innovation, supply chain, pharmaceutical policy, and public policy and law.

Mackey will bring his blockchain expertise to the upcoming Convege2Xcelerate conference taking place Oct. 22 at Columbia University in New Yok City. The conference is sponsored by Partners in Digital Health, publisher of Blockchain in Healthcare Today and Telehealth and Medicine Today, and will feature sessions on transformational technologies including blockchain, telehealth and artificial intelligence (AI).

While Mackey is a proponent of exploring the use of blockchain in healthcare, and sees real-world applications for U.S. healthcare, he also sees a number of ethical, technical, regulatory and business issues that need to be resolved. Recently, Mackey spoke with Healthcare Informatics Associate Editor Heather Landi about blockchain’s potential and challenges in healthcare. Below are excerpts of that interview.

From an academic research perspective, what is your interest in blockchain and what use cases are you exploring?

I was first brought into it because we were exploring how it could relate to combatting counterfeit medication, so using blockchain in the context of supply chain, and seeing whether it’s a good tool to combat the illicit trade of counterfeit drugs. I originally came into blockchain from my public health experience, and from there, I’ve been looking at blockchain in a number of different use cases and different healthcare verticals. The primary one is drug supply chain, but that could be a lot of different things within the drug supply chain; it could be recall management, pharmacovigilance, and it could be track and trace.

Outside of supply chain, we also look at different design principles and different use cases of blockchain and how they are supposed to fit a particular healthcare challenge. Genomics is one area that looks more towards consumers sharing their data. That’s different from a supply chain blockchain, which is more for compliance purposes, versus also an EHR (electronic health record) blockchain, which is intended to share different healthcare records and improve different population health outcomes across different health systems, but at the same time, keeping the patient data within the health system and providing provenance to that data.

Also, medical devices might look at blockchain more for contractual issues like maintenance of products and making sure there is an audit log for recall. Medical devices oftentimes have blockchains to pull in data from other sources to get people to share data with their devices, so they can create more data to hopefully improve the continuity of care across that device. There’s a lot of different use cases out there, and the interesting thing is that a blockchain has to be malleable to whatever healthcare challenge it is trying to address, and the design principles, which are primarily—is it a permissions blockchain versus a non-permissions blockchain, is it a private blockchain versus a public blockchain, what’s the consensus mechanism? Those principles have to map to those use cases, and oftentimes, they don’t.

Could you expand on that idea of mapping blockchain to particular use cases?

A good example of blockchain adoption that is happening pretty rapidly, although it’s not fully into production, is in the clinical trial space. And let’s keep in mind those three principles—public versus private blockchain, permissions versus non-permissions, and consensus mechanism. For a clinical trial, you can have one component of that clinical trial process that is a public blockchain. What I mean by that is, if you want to recruit patients and you want to access patient registries, or you want verified information that patients have certain conditions, then a blockchain would be amenable to that, to match patients and make recruitment a lot more cost effective. That could be a very public blockchain that doesn’t really have any permission structure that allows people to share their data in a verifiable way.

But, once you enter those people into the clinical trial, you’re probably going to have some kind of private or hybrid blockchain where the data is only available to certain entities—the clinical sites, the physicians, and the researchers—that are involved in the study protocol. In that case, that public blockchain turns into a private blockchain, or a very specific permission-structured blockchain, which is really meant to drive the study protocol within the clinical trial. So even within one vertical, you may have different business cases for the structure of a blockchain. However, many people are very much against private blockchains; they want fully public blockchains. Those design principles have to be thought out first within the context of the healthcare use case before we even think of the technology, and that’s the disconnect we often have.

There are some in the industry who believe blockchain is overhyped or that the challenges of implementing it might outweigh the benefits. Do you believe blockchain is showing its potential?

It depends on the vertical, but that doesn’t mean that blockchain can’t work for a particular vertical or that it’s not a good technology for that vertical, but that there may be regulatory considerations, such as GDPR (General Data Protection Regulation) and HIPAA (Health Insurance Portability and Accountability Act), or business considerations that make it hard for more widespread adoption. Blockchain is really primed for proof of concept development, but often the hard part is translating a proof of concept into something that can go into production and can be used by multiple parties, and that’s where the most benefit comes from blockchain; if you are allowed to share data, but keep ownership of it and have provenance of the data and trust in that data. Getting to that phase is going to be harder.

As one example, in supply chain there is much discussion is about how much data are we going to share on the blockchain. This is a fundamental question that is not about the technology, it’s more about different trading partners and how much they want to share data. That issue is not about trust of the data, but it’s about proprietary information that may be contained in the data, and how we govern the sharing of data. Those things are outside technology but rather are core business considerations that are different for supply chain than they are for consumer health. That’s often the roadblock to more widescale blockchain adoption. Proof of concepts and prototypes are pretty easy to stand up, but when it gets to real-world testing, and also the regulatory framework and whether the regulatory framework will absorb that type of technology or incentivize it, those are separate issues.

Those are some of the barriers, and they are not technology-focused. I think that’s why there is a bit of a disconnect between people who are technologists and think, ‘It’s a great technology and we should just use it,’ versus the healthcare space where people say, ‘These are our processes, and blockchain may be good for those processes, but there are inherent regulatory, legal and business issues, that make it hard to adopt.”

The core principles of blockchain are that it is an immutable shared ledger and it establishes provenance and integrity of the data. Those core elements are things we want with health care data. There are a lot of healthcare challenges and issues that could benefit from a shared ledger, such as reining in misuse of healthcare data as it relates to healthcare fraud and abuse and for drug recalls. And then there’s simple things like medical licensure, where the use of blockchain for credentialing could make that process more efficient. Many healthcare use cases relate to some component of data provenance, some level of sharing of data, and also the security of data. But, from a pragmatic view, there are some healthcare challenges where you don’t need those underlying elements, you just need to improve a process. And, if that process doesn’t require those underlying data provenance elements, then maybe this discussion about blockchain is going to distract more than it adds.


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New Blockchain Project Sets to Tackle Provider Credentialing

November 12, 2018
by Rajiv Leventhal, Managing Editor
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A group of five healthcare enterprises—National Government Services, Spectrum Health, WellCare Health Plans, Inc., Accenture, and The Hardenbergh Group—are linking up to participate in a distributed ledger program aimed at resolving administrative inefficiencies related to professional credentialing.

The project, Professional Credentials Exchange, is being developed by ProCredEx and Hashed Health, a blockchain innovation consortium. The exchange leverages “advanced data science, artificial intelligence, and blockchain technologies to greatly simplify the acquisition and verification of information related to professional credentialing and identity,” according to officials.

In an announcement, officials noted that credentialing healthcare professionals “is a universally problematic process for any industry member that delivers or pays for patient care.  The process often requires four to six months to complete and directly impedes the ability for a healthcare professional to deliver care and be reimbursed for their work.”

They added, “Hospitals alone forfeit an average of $7,500 in daily net revenues waiting for credentialing and payer enrollment processes to complete.  Further, nearly every organization required to perform this work does so independently—creating a significant administrative burden for practitioners.”

As such, the groups, via the exchange, will aim to address the time, cost, and complexity associated with these processes by facilitating the secure, trusted exchange of verified credentials information between exchange members.

Included in the collaboration are WellCare Health Plans, which serves about 5.5 million members, and Spectrum Health, a 12-hospital health system in western Michigan. National Government Services is a Medicare contractor for the Centers for Medicare & Medicaid Services (CMS), and processes more than 230 million Medicare claims annually.

"A fundamental component of developing the exchange lays in building a network of members that bring significant verified credential datasets to the marketplace," Anthony Begando, ProCredEx's co-founder and CEO, said in a statement.  "These are the leading participants in a growing group of collaborators who bring data and implementation capabilities to accelerate the deployment and scaling of the exchange."

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Google Taps Geisinger CEO David Feinberg to Assume Healthcare Leadership Role

November 9, 2018
by Rajiv Leventhal, Managing Editor
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Top healthcare execs continue to leave the hospital and health system space to move into tech

Geisinger Health System CEO David Feinberg, M.D. has been tapped by Google to assume a leadership role over its healthcare initiatives.

According to a report from CNBC, “Feinberg's job will be figuring out how to organize Google's fragmented health initiatives, which overlap among many different business groups.” The report, from CNBC’s Christina Farr, added, “The search has been underway for months, according to several people familiar with the search process. Artificial intelligence head Jeff Dean has been deeply involved in the process and personally interviewing candidates.”

Earlier this year, it was rumored that Feinberg—the lead at the Danville, Pa.-based Geisinger for the last four years—could join the Amazon/Berkshire Hathaway/JP Morgan Chase  healthcare initiative, but that was put to bed when Feinberg released a statement in June, provided to CNBC’s Farr, in which he said, “I personally remain 100-percent committed to Geisinger and remain excited about the work we are doing and the opportunities ahead as we continue to deliver exceptional care to our patients, our members and our communities." Amazon, Berkshire Hathaway, and JPMorgan Chase ended up hiring Atul Gawande, M.D., as CEO of the initiative.

David Feinberg, M.D.Google has made several forays into the healthcare space over the years, and most recently tapped former Cleveland Clinic CEO Toby Cosgrove, M.D., to join the team has an executive advisor. Interestingly, the Cosgrove hiring was announced by Gregory Moore, M.D., Ph.D., vice president of Google Cloud’s healthcare division, who is also a former clinical IT executive at Geisinger.

As Healthcare Informatics reported on in its Top Ten Tech Trends package a few months ago, new business and technology combinations and ventures are heralding a new era of disruption in U.S. healthcare delivery. As Editor-in-Chief Mark Hagland wrote in his story, “Alphabet, Google’s parent company, is leveraging its extensive cloud platform and data analytics capabilities to hone in on trends in population health, [a] Business Insider report noted. The company plans to drive more strategic health system partnerships by identifying issues with electronic health record (EHR) interoperability and currently limited computing infrastructure.”

Indeed, these new “disruptors” are not only making major moves in the healthcare space, but also hiring some of the smartest minds from hospitals and health systems—a trend that some might see as troubling for the traditional healthcare player.

What’s more, the research firm Kalorama Intelligence recently reported that three companies—Google, Apple, and Microsoft—have filed more than 300 healthcare patents between 2013-2017—among them, Google’s 186 patents, mainly focused on investments for DeepMind, its artificial intelligence and Verily , its healthcare and disease research entity.

Feinberg also had some interesting comments about his vision for healthcare at the “HLTH: The Future of Healthcare Conference” this past May. Healthcare Informatics’ Hagland, who was at that event, reported this from Feinberg’s keynote: “For us, what really matters is so much about what’s happening outside the clinics or the hospitals,” he said. “We have 13 hospitals in our system. And I think my job is to close all of them. I know that out of 2,000 beds we have, if people ate right, used alcohol in moderation, didn’t use illegal drugs, wore seatbelts, ate healthily, had access to broccoli and blueberries, and didn’t shoot people with guns, 1,000 of those beds could be gone…”

As it relates to Google, Farr noted in her recent report, “Among the groups interested in healthcare are Google's core search team, its cloud business, the Google Brain artificial intelligence team (one of several groups at Alphabet working on AI), the Nest home automation group and the Google Fit wearables team.”

She added, “One particular area of interest is building out a health team within Nest to help manage users' health at home, as well as to monitor seniors who are choosing to live independently. Nest had been an independent company under Google holding company Alphabet, but was absorbed back into the Google Home team earlier this year.”

Meanwhile, at Geisinger, Feinberg—who will remain at the health system through the end of the year—will be replaced by Jaewon Ryu, M.D., as interim president and CEO.

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University Hospitals Applies Homegrown Discharge Planning Workflow Solution to Opioid Prescribing

November 1, 2018
by David Raths, Contributing Editor
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Seeks to commercialize logistics platform powering UH Care Continues
Eric Beck, president of UH Ventures

Cleveland-based University Hospitals is taking advantage of an internally developed technology platform to re-imagine the discharge process, including identifying patients at risk for opioid misuse and dependence.

Ohio has been described as “ground zero” for the opioid epidemic. According to the Ohio Department of Health, drug-related deaths eclipsed auto accidents as the state’s top cause of injury deaths in 2007 and that trend has continued ever since. Earlier this year the UH Care Continues discharge planning process was awarded $200,000 from the Ohio Opioid Technology Challenge for its technology solution to help health professionals in the fight against the opioid epidemic. 

In an interview with Healthcare Informatics, Eric Beck, D.O., M.P.H., an emergency medicine physician and president of UH Ventures, the business innovation arm of the UH system, explained the genesis of UH Care Continues and the health system’s intention to commercialize the solution.

“We began a journey earlier this year to re-imagine our care transitions process — how we get patients out of the hospital and thinking intentionally about where they go and what happens to them afterwards,” Beck said. “We were developing new roles, new processes, and new technology. One of our core tools is a logistics platform.”

Applying the platform systemwide to opioid prescribing, Beck said 18-hospital UH sought to put a reflective pause in the process to try to limit controlled substances, particularly opioids, to only the patients who really need them. There was a fair amount of inertia and “muscle memory” in terms of prescribing opioids for certain conditions, he added. In some cases, they are being prescribed as needed or prophylactically. “To the extent we can stem some of that, contain it, or add a little bit of conditionality, that was the opportunity we saw.”

The technology solution surveils patients as they are leaving the hospital, and as it identifies a patient with an opioid prescription, the pause asks if it is really necessary. Is the patient still having pain? Is it uncontrolled? To the extent that the answer is not an obvious yes, Beck said, are there alternative therapies available? “Or perhaps the patient only needs a couple of pills for an urgent issue and then they can call us for more active management of their pain.”

The platform manages both work flows and resources. “To the extent that the patient is leaving the hospital on opioids or may benefit from alternative resources, such as acupuncture or massage, how do we bring those resources to bear at the point of service?” Beck asked. “Part of the effort is trying to contain inappropriate prescriptions, but also marrying that with a set of alternative resources that the patient can be navigated to, based upon their needs and clinical condition.”

Besides triggering workflow and optionality around alternatives, the reflective pause also deploys an algorithm to risk-stratify whether the person is at high risk of becoming dependent.

“To the extent they need the opioid, let’s risk-stratify them,” Beck said, “and put them into a surveillance workflow and make sure that any excess opioids are disposed of properly. To the extent they don’t need it, let’s navigate them to something else.”

How will UH assess whether the platform is having a beneficial impact? By measuring follow-on behavior related to all opioid prescriptions, Beck explained. “Following them into post-acute space, did they take the opioid? Was it disposed of? When we look at patients offered alternatives, did they use those and was their pain controlled? We are engaging with resources within UH and the community to track the utilization of those services that we are navigating patients to.”

Although the opioid module meets a pressing need, Beck stressed that UH Care Continues has many other potential use cases, including driving care coordination between all the various actors in the hospital: the therapists, social workers, medical teams and nurses, as well as the off-site administrative support for getting patients out of the hospital and setting up resources, whether they are going to a facility or back home. “It also enables new choices like hospital at home – alternatives to hospitalization or getting patients home more quickly,” Beck said. “We think we have a winner here because it has a broader value proposition than just the opioid work flow. The opioid module is just one element that can be deployed. We are moving down the path of our commercialization milestones, and we will want to bring it to market.”

In fact, Beck said, UH Ventures has a queue of things it is looking to bring to market, some spun out as new companies.  “We are the innovation and commercialization engine for the system,” he said. “We are engaged with our digital health accelerator here in Cleveland and are working with early stage companies to provide them usability and validation support.”



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