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At the Health IT Summit in Philadelphia, Industry Experts Agree: Blockchain Is in its Infancy in Healthcare

May 23, 2018
by Mark Hagland
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Industry experts agreed—there is potential for blockchain in healthcare, but numerous obstacles remain

Is there genuine potential for blockchain to transform aspects of U.S. healthcare? That question is one of the most debated of any right now. Some proponents see great potential, but nearly all of those who have explored that potential see major cause for caution. All points of view were discussed on Tuesday afternoon at the Sheraton Downtown Philadelphia, during the Health IT Summit in Philadelphia, sponsored by Healthcare Informatics.

During a session entitled “Use Cases for Blockchain in Healthcare,” healthcare leaders coming from a variety of backgrounds and experience sets discussed the possibilities. Mark Stevens, managing partner at the Philadelphia consulting firm Enable Health, moderated the panel. He was joined by Sri Bharadwaj, director, information services, and CISO, UC Irvine (Calif.) Health; Anthony DiPrinzio, lead, consulting and development, for Blockchain at Berkeley, a student-led blockchain enterprise at the University of California-Berkeley; and John Cappiello, chief technology officer at the Philadelphia-based HealthVerity, a cloud-based data ecosystem vendor.

After a video created by the Waterloo, Ontario-based Centre for International Governance Innovation, a Canadian think tank focused on international governance, was shown, explaining some of the fundamental concepts around blockchain, Stevens noted that, as he put it, “Canada is a hotbed for blockchain development. The largest Meetup group for blockchain globally is in Toronto,” he noted.

HealthVerity’s Cappiello noted that his company has been developing blockchain applications around patient consent issues. “We see blockchain as offering solutions for managing patient consent,” he said.

Then, DiPrinzio, a rising senior at UC-Berkeley, explained that “I help run Blockchain at Berkeley, which started out as a student cooperative, and now is a 501 (c )(3) organization. We have undergraduates, graduate students, postgraduates, and academic advisors involved,” he said. “We work with Fortune 500 companies to build blockchain proofs of concept. Exxon Mobile, Ford, Airbus, BMW, have been clients. We teach courses on campus, including a blockchain fundamentals course and a developers’ course.” As the Blockchain at Berkeley website notes, in terms of education, “We teach an open-source undergraduate cyptocurrency course, organize the largest crypto meetup in the East Bay and host tech talks, developer tutorials, workshops and more”; in terms of consultancy, “We work with companies to develop strategic approaches to implement blockchain technologies. We build Proof of Concepts, and translate new developments into use cases and novel approaches”; and in terms of research and development, “We build side projects and do research with cutting-edge blockchain and crypto technologies. Our projects have won first prizes at collegiate hackathons like TreeHacks and CalHacks. All of our work is open-source.”

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DiPrinzio added that, “Here, I’m also working, with the University of Delaware and the University of Pennsylvania, on a global blockchain initiative. A lot of innovation is coming out of universities. Starting a separate initiative, we already have 50-plus schools. Eventually we hope to bring in companies that actually work on projects.”

UC Irvine Health’s Bharadwaj, who is responsible for “information security and application security areas” at his organization, and who has “spent quite a bit of time with national HIMSS [the Chicago-based Health Information and Management Systems Society] in the privacy and security area,” has been involved in an initiative with the International Olympic Committee around creating data availability for the Olympic athletes, their families, and coaches during the Olympic Games. He agreed that data availability is very important, though he added that “I don’t think IOC is thinking about blockchain.” But, he said, with regard to enhancing data availability to improve care delivery, “It’s our responsibility to figure out how to make this work,” as healthcare IT leaders. Asked about blockchain specifically, he pronounced himself “optimistically skeptical.”

Asked his perspective on the forward evolution of the blockchain concept, HealthVerity’s Cappiello said, “I’m skeptically optimistic. So, for context, we have a blockchain network in production with a large pharmaceutical manufacturer. And a short list of peers in the space interested in participating. Practically speaking, there are a lot of challenges,” he added. “There are a lot of wonderful things you can do with blockchain, but we didn’t do an ICO to raise money; we raised it in the traditional way,” he said, referring to an “initial coin offering,” which Investopedia defines as “an unregulated means by which funds are raised for a new cryptocurrency venture. An Initial Coin Offering (ICO) is used by startups to bypass the rigorous and regulated capital-raising process required by venture capitalists or banks. In an ICO campaign, a percentage of the cryptocurrency is sold to early backers of the project in exchange for legal tender or other cryptocurrencies, but usually for Bitcoin.”

One of the key areas that he and his colleagues are working on developing solutions for, Cappiello said, is the challenge that organizations are having “with patient consent processes. And we wanted to focus on practical deployment. So we said, how do we narrow our focus, and focus on consent even within the enterprise? How do we solve a simple problem and charge clients for this? That’s what we did, we decided to focus on the centralization of management for content. So, within one enterprise, we can distribute the databases across various constituents, the marketing department, the purchasing department, etc. Or we could eventually connect payers and pharmaceuticals.”

“So, we’re learning that we have to start small in healthcare, with proof-of-concepts and pilots,” Stevens said. “Anthony, you’re working on some bigger projects. What are other industries experiencing, and what might we in healthcare experience, too, in a few years?”

“One application that a lot of other industries have gone to is creating decentralized marketplaces,” DiPrinzio said. “Driver is a healthcare startup based in San Francisco; they wanted to create a decentralized marketplace for cancer patients. The idea was that you’re a cancer patient looking for some sort of treatment, and you have to go to a specific hospital, and see a specific physician, who might have limited awareness of other treatment locations or possibilities. So someone could post in this network and have a lot more access to more treatment options.”

Meanwhile, DiPrinzio continued, “Another use case people are looking into right now is around supply chain and provenance. In my personal opinion, supply chain and provenance use cases aren’t the best ones for Blockchain; but over time, they’ll be improved. One way you could apply this to healthcare is around the provenance of prescription medication. You could track the process of producing the medication, from ingredients to putting the ingredients into containers, etc. A few of our members were talking with FedEx, and were finding that it was difficult to ship prescription medication, because they were having to produce proof that the medication hadn’t been tampered with at all.”

DiPrinzio went on to say that “I just came back from Berlin; while I was there, I visited one of their co-working places. It’s interesting in Germany—on a social level—the government there works more closely with the people, and everybody has free healthcare. So the German government is pursuing this much more closely than in the U.S., and so is the Canadian government; and so is China. It has to do with the nature of the political systems involved. And in China, they’re developing something called ‘Neo,’ and are replicating things like Ethereum through that.” Ethereum, as Wikipedia notes, is “an open-source, public, blockchain-based distributed computing platform and operating system featuring smart contract (scripting) functionality.[3] It supports a modified version of Nakamoto consensus via transaction based state transitions. Ether is a cryptocurrency whose blockchain is generated by the Ethereum platform. Ether can be transferred between accounts and used to compensate participant mining nodes for computations performed.[4] Ethereum provides a decentralized Turing-complete virtual machine, the Ethereum Virtual Machine (EVM), which can execute scripts using an international network of public nodes. "Gas", an internal transaction pricing mechanism, is used to mitigate spam and allocate resources on the network. Ethereum was proposed in late 2013 by Vitalik Buterin, a cryptocurrency researcher and programmer.” Still, the Wikipedia article notes, “In 2016, as a result of the collapse of The DAO project, Ethereum was split into two separate blockchains – the new separate version became Ethereum (ETH), and the original continued as Ethereum Classic (ETC). The value of the Ethereum currency grew over 13,000 percent in 2017.”

“Do you see a more rapid adoption of blockchain abroad, that will drive us to adopt blockchain as well, or make it more difficult for us to catch up?” Stevens asked.  “I don’t think that there’s one specific industry that’s all about blockchain abroad,” DiPrinzio responded. “If you look at the technology today, and I hate to say this, because I love blockchain, but we’re not anywhere close to implementing these applications at scale. Deloitte said that 92 percent of these 26,000 applications had failed. Meanwhile, privacy, security, and scalability will be a huge barrier to adoption in healthcare, especially privacy and scalability. But once the other countries adopt blockchain at scale, the U.S. will begin to catch up.”

“Much of the software is open-source, too, correct?” Stevens asked. “Yes,” DiPrinzio responded. “Most projects are open-source. But in terms of the tools and infrastructure involved Ethereum, the program they use, is completely broken. I’m not a developer myself, but developers say that language is horrible. We’re honestly very early on here.”

Speaking of some of the barriers to blockchain adoption in healthcare, Bharadwaj said, “If tomorrow, I as a patient want to share my patient with a particular physician from whom I need care—for example, I want a second cardiology opinion—I don’t want to share that I had a hip replacement surgery or knee replacement five years ago. I want to share my cardiac information only. That’s a good way of using Blockchain to manage my data. It’s a great thing to say you’re going to make it available,” he said, “But this is public information. Think of it this way: you have the keys, and will only give the information you want to share it. So it can be parsed and used at specific times and for specific purposes. Let’s take CareEverywhere from Epic. Anyone can connect to that who is an Epic customer.”

Bharadwaj continued, “But just imagine if there were no Epic or similar, and you wanted to share the information with someone else. So Blockchain could be helpful. But how are we going to educate millions of people that this information is secure and can be shared? And that you share it with only one person? So there’s a lot of ambiguity in how it’s implemented. The second use case: I’m going to a doctor, I need authorization from a payer, the payer already knows I’m authorized. But by the way, I don’t want them to know that I’m going for a breast implant while seeking services that are covered. How do I separate that? The authorization process is simple; and the payer can approve the process, and it’s available to the physician and payer in a matter of minutes. But is that something we want to do? Something the industry will want to adopt? And value-based care is not there yet, we’re struggling with all those things. So why would we adopt this technology hen we’re struggling with so many other things? There are a lot of potential use cases for blockchain, but we have to make sure the information is secure. Everyone says the information is secure, but as a CISO, I don’t think so, and I’m sure the panelists will agree as well.”

“Yes, that’s a big misperception about blockchain,” DiPrinzio responded. It’s absolutely not true that the data is secure. Ethereum is a public blockchain, so as the video described, the ledger is replicated on every single node of the network, and even though the data is encrypted to some extent, and you can trace a walled address to an individual. And in terms of privacy, that is a huge area that people are focusing on, and once these protocols are implemented, we can start engaging in applications like transferring patient data between hospitals, doctors, and insurers. But today, the information still isn’t secured.”

In the meantime, the panelists agreed, focusing on small-bore use cases seems to be the right approach. Asked why his company has focused on patient consent, Cappiello said, “Our strategy is really around the interconnectedness of the industry across various players. Blockchain has a use and a purpose. For the record, we use Hyperledger Fabric from IBM, not Ethereum. But how do you bootstrap this? Blockchain is by definition a distributed ledger. And if not everyone is using the ledger, the value of the network is virtually nil. So we said, how can we isolate the network, bootstrap it ourselves, and [exploit its benefit]?”

 

 

 

 


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EHR-Compatible Pharmacist Care Plan Standard Opens the Door to Cross-Setting Data Exchange

September 14, 2018
by Zabrina Gonzaga, R.N., Industry Voice
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Pharmacists drive information sharing towards quality improvement

Pharmacists work in multiple environments—community, hospital, long term care, clinics, retail stores, etc.—and consult with other providers to coordinate a patient’s care.  They work with patients and caregivers to identify goals of medication therapy and interventions needed, and to evaluate patient outcomes.  Too often, pharmacy data is trapped in a silo and unavailable to other members of the care team, duplicated manually in disparate systems which increases clinical workloads without adding value.

To address these issues, Lantana Consulting Group and Community Care of North Carolina (CCNC) developed an electronic document standard for pharmacist care plans—the HL7 Pharmacist Care Plan (PhCP). The project was launched by a High Impact Pilot (HIP) grant to Lantana from the Office of the National Coordinator for Health Information Technology (ONC).

Before the PhCP, pharmacists shared information through paper care plans or by duplicative entry into external systems of information related to medication reconciliation and drug therapy problems. This documentation was not aligned with the in-house pharmacy management system (PMS). The integration of the PhCP with the pharmacy software systems allows this data to flow into a shared care plan, allowing pharmacists to use their local PMS to move beyond simple product reimbursement and compile information needed for quality assurance, care coordination, and scalable utilization review.

The PhCP standard addresses high risk patients with co-morbidities and chronic conditions who often take multiple medications that require careful monitoring. Care plans are initiated on patients identified as high risk with complex medication regimes identified in a comprehensive medication review. The PhCP is as a standardized, interoperable document that allows pharmacist to capture shared decisions related to patient priorities, health concerns, goals, interventions, and outcomes. The care plan may also contain information related to individual health and social risks, planned interventions, expected outcomes, and referrals to other providers. Since the PhCP is integrated into the PMS or adopted by a software vendor (e.g. care management, chronic management, or web-based documentation system), pharmacist can pull this information into the PhCP without redundant data entry.

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The PhCP allows pharmacists for the first time to share information with support teams and paves the way for them to support value-based payment. The project goals align with the Center for Medicare & Medicaid Services’ (CMS’) value-based programs, which are part of the Meaningful Measure Framework of improved care team collaboration, better health for individuals and populations, and lower costs.

Scott Brewster, Pharm.D., at Brookside Pharmacy in East Tennessee, described the PhCP as a tool that helps them enhance patient care delivery. “From creating coordinated efforts for smoking cessation and medication utilization in heart failure patients, to follow up on recognized drug therapy problems, the eCare plan gives pharmacists a translatable means to show their value and efforts both in patient-centered dispensing and education that can reduce the total cost of care.” (The eCare plan reference by Scott Brewster is the local term used in their adoption of the PhCP).

The pilot phase of the project increased interest in exchanging PhCPs within CCNC’s pharmacy community and among pharmacy management system (PMS) vendors. The number of vendors seeking training on the standard rose from two to 22 during the pilot. Approximately 34,000 unique care plans have been shared with CCNC since the pilot launch.

This precedent-setting pilot design offered two pharmacy care plan specifications: one specification is based on the Care Plan standard in Clinical Document Architecture (CDA); the other standard is a CDA-on-FHIR (Fast Healthcare Interoperability Resources). The latter specification directly transforms information shared using the FHIR standard into CDA. FHIR is straight forward to implement than CDA, so this is an appealing option for facilities not already using CDA. The dual offerings—CDA and CDA-on-FHIR with lossless transforms—provide choice for implementing vendors while allowing consistent utility to CCNC.

What’s on the horizon for the pharmacy community and vendors? With the support of National Community Pharmacists Association (NCPA), the draft standards will go through the HL7 ballot process for eventual publication for widespread implementation and adoption by vendors. This project will make clinical information available to CCNC and provide a new tool for serving patients with long-term needs in the dual Medicare-Medicaid program and Medicaid-only program.  This is a story about a successful Center for Medicare and Medicaid Innovation (CMMI)funded project that started out as a state-wide pilot and is now rolling out nationwide as Community Pharmacy Enhanced Service Network (CPESN)USA. 

The PhCP is based on a CDA Care Plan standard that is part of ONC’s Certified EHR Technology requirements, so it can be readily implemented into EHRs. This makes the pharmacist’s plan an integral part of a patient’s record wherever they receive care. 

Adoption of the PhCP brings pharmacies into the national health information technology (HIT) framework and electronically integrates pharmacists into the care planning team, a necessary precursor to a new payment model and health care reform. In addition, receiving consistently structured and coded pharmacy care plans can augment data analysis by going beyond product reimbursement to making data available for, utilization review, quality assurance and care coordination.

Troy Trygstad, vice president for Pharmacy Provided Partnerships at CCNC, described the strategic choice now available to pharmacists and PMS vendors. “Fundamentally, pharmacy will need to become a services model to survive. Absent that transformation, it will become a kiosk next door to the candy aisle. The reasons vendors are buying into the PhCP standard for the first time ever is that their clients are demanding it for the first time ever."

The move to value-based payment will continue to drive the need for pharmacists, as part of care teams, to provide enhanced care including personal therapy goals and outcomes. Sharing a medication-related plan of care with other care team members is critical to the successful coordination of care for complex patients.

Zabrina Gonzaga, R.N., is principal nurse informaticist and director of health informatics at Lantana Consulting Group and led the design and development of the PhCP standard. 

Email:  zabrina.gonzaga@lantanagroup.com

Twitter: @lantana_group

 


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Health IT Now Pushes for Information Blocking Regulation, Says Administration “Must Uphold its End of the Bargain”

September 13, 2018
by Rajiv Leventhal, Managing Editor
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The executive director of Health IT Now, a coalition of healthcare and technology companies, is again criticizing the Trump administration for not yet publishing any regulation on information blocking, as required by the 21st Century Cures Act legislation.

In an op-ed published recently in STAT, Health IT Now’s Joel White wrote, “More than 600 days after the enactment of the Cures Act, not a single regulation has been issued on information blocking.” White added in frustration, “Health IT Now has met with countless officials in the Trump administration who share our commitment to combat information blocking. But those sentiments must be met with meaningful action.”

The onus to publish the regulation falls on the Office of the National Coordinator for Health IT (ONC), the health IT branch of the federal government that is tasked with carrying out specific duties that are required under the 21st Century Cures Act, which was signed into law in December 2016. Some of the core health IT components of the Cures legislation include encouraging interoperability of electronic health records (EHRs) and patient access to health data, discouraging information blocking, reducing physician documentation burden, as well as creating a reporting system on EHR usability.

The information blocking part of the law has gotten significant attention since many stakeholders believe that true interoperability will not be achieved if vendors and providers act to impede the flow of health data for proprietary reasons.

But ONC has delayed regulation around information blocking a few times already, though during an Aug. 8 episode of the Pulse Check podcast from Politico, National Coordinator for Health IT Donald Rucker, M.D., said that the rule is "deep in the federal clearance process." And even more recently, a bipartisan amendment to the U.S. Senate's Department of Defense and Labor, Health and Human Services, and Education Appropriations Act for Fiscal Year 2019 includes a requirement for the Trump administration to provide Congress with an update, by September 30.

White, in the STAT piece, noted a June Health Affairs column in which Rucker suggested that implementation of the law’s information blocking provisions would occur “over the next few years.” White wrote that this is “a vague timeline that shows little urgency for combating this pressing threat to consumer safety and stumbling block to interoperability.”

Health IT Now is not alone in its belief that the rule should have been published by now, nor is it the first time the group is bringing it up. Last month

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By the end of this year, ONC’s implementation and interpretation of data blocking will also be published and available for comment, as was the case with the TEFCA proposed rule. The TEFCA final rule is also anticipated by the end of 2018.

HOWEVER…there’s still time to prepare for TEFCA and the data blocking regulation, and final rules for both in the coming months will set concrete timelines, and for TEFCA it will be interesting to see how ONC reacts to stakeholder comments, internal and external.

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