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.”
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. 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. 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]?”