Last week, when the Office of the National Coordinator for Health Information Technology (ONC) and the National Institute of Standards and Technology (NIST) announced a challenge soliciting white papers on the topic of the use of blockchain technology in healthcare, it got me interested in trying to understand the concept a little better.
Besides Healthcare Informatics, I also write for a publication about IT in higher education called Campus Technology, and a few weeks ago I wrote about a talk about the potential for blockchain in education as it applies to transcripts. Phil Long, chief innovation officer and associate vice provost for learning sciences at the University of Texas at Austin, noted that a transcript is the record of what a student has accomplished at a university. The document is managed and controlled by the institution, not the student. In contrast, Long said, blockchain has the potential of providing an immutable record of an individual learner's accomplishment that can be disclosed in a public context. "The single thing that attracted me most is the potential it has to reaffirm the learner's ownership of their own record," he said.
As I noted for Campus Technology, last year, the MIT Media Lab began issuing digital certificates to the participants in its Director's Fellows program. The authentication behind the certificates relies on blockchain technology, best known for its connection to the cryptocurrency bitcoin. In a blog post, Philipp Schmidt, director of learning innovation at the Media Lab, described how blockchain works: "In essence, it is a just a distributed ledger to record transactions. What makes it special is that it is durable, time-stamped, transparent and decentralized. Those characteristics are equally useful for managing financial transactions as for a system of reputation. In fact, you can think of reputation as a type of currency for social capital, rather than financial capital."
So how might this apply to healthcare? To get a better picture, I called up Micah Winkelspecht, founder and CEO of Gem, a Venice, Calif.-based startup developing blockchain application platforms. One of the company’s main focus areas is healthcare, and its first partner is the Philips Blockchain Lab.
Winkelspecht said that whether we talk about the higher education transcript or the patient health record, it really boils down to the fact that we have always kept records in some kind of a centralized system and we give very little access or control to the people who should be owning their records. “There is a major push toward a more patient-centric focus in healthcare, yet your data is stored all over the place in kind of a Frankenstein concoction of records with very little interoperability of file formats between systems.
He said the project Gem is working on with Philips is not meant to replace EHRs. “But we are exploring the ways we can provide real-time access to data across multiple providers and caregivers. We are looking at how we move medical-related data on a blockchain.”
One of the misconceptions about the blockchain is that you store the data on the blockchain, Winkelspecht said. Blockchains are actually inefficient as data stores, he explained, because by their very nature, all the data is replicated on every node across a network of nodes. That is how they work. “So it is highly redundant, but that means it is very inefficient for storing large amounts of data. We use the blockchain as a document registry for data stored in external data stores.” So you can kind of think of it as like a library catalog that tells you where in the library your book is. But they are also using it to record a permanent time-stamp of the fingerprint of every piece of data that goes into the system as well. “You can make very strong guarantees about the underlying data’s integrity, and furthermore we apply an identity layer so that anytime anyone performs an action on that blockchain, it is an authenticated action. And we can go back and look at every modification to a piece of data, every addition. We can say with precise definition who did what at what time.”
So I asked Winkelspecht what I would see if I were a patient who had recently seen a few doctors. He said the blockchain would point me to a universal patient case file, with a universal identifier for me as the patient. “So no matter which doctor is interfacing with the system, they are recording information against the same universal patient identifier, which is recorded on the blockchain,” he said. When you go to primary care doctor, they create a visit report, and prescribe you see a radiologist. That all goes into your patient case file as a visit. Then when you go to the radiologist, they leverage the same identifier for that patient, and they upload their scans, and their report gets tracked against that identifier. When the patient goes back to the primary care doctor, all that data is available to that physician under the same record.
There is no centralized data store. The data can be stored in different systems. But the blockchain controls the access and permission layer for who should have access at what time, Winkelspecht explained. “It serves as the library catalog that points you to where the data is, and it also serves as the permission layer for all that data.” Each data store is using the blockchain to determine whether it should grant access or not to a particular provider. “It becomes your integrity layer, in terms of keeping a time-stamped registry of every document, so no document can be modified without others knowing. And it provides the authenticity layer because every action is authenticated and recorded on the blockchain, so you know who is doing what with the data and at what time. That allows for a perfect audit history. External data stores can use the blockchain as the universal source of truth about who should have access to what.”
What you have today is a bunch of disparate data silos, he said. With the blockchain, you could have a complete, full accurate history of a patient from beginning to end across multiple different systems. “This becomes the interoperability model for how EMRs should work.”
Winkelspecht admits that there are a lot of hurdles to overcome in healthcare, including getting buy-in from the EHR vendors. “I am not sure whether they will or not. The approach we are taking is working with the largest companies in this space. We fully recognize that Gem, as a startup company, can’t just build a better mousetrap and everybody is going to flock to it. We are building a consensus with a lot of the major companies in the healthcare space, and that was what our Gem Health initiative is all about. Philips is one of our first partners, but we are working with a lot of other large companies we haven’t announced yet. We are trying to get a bunch of key stakeholders.”
Finance was the first vertical market in which blockchain took hold with Bitcoin, because it was marketed as a financial technology, “but the way we are leveraging these blockchains is not really financial, it is data management,” Winkelspecht said. “So it has a much broader base of applications. Now other verticals are starting to look at this. The biggest verticals we see are healthcare, but also supply chain. It is also a big deal for the Internet of Things (IoT). We have billions of devices coming online. And now the only way we know how to manage those is to create IoT device aggregator systems. This might be the answer to allow devices to speak to devices directly with no intermediaries.”
I asked him what kind of issues would need to be worked through in terms of governance. He said if you look at Bitcoin and Ethereum, these are attempts to build permissionless, public iinfrastructure where anybody can join and participate in the process of managing the ledger. “In most of these cases on the enterprise side, that is a bit of a stretch for them,” he said. “They are looking to create consortium models, where 10 different healthcare companies come together and manage this blockchain network.” That is going to be a pattern for the next few years as they get more comfortable with it and regulators get more comfortable, he added. “Then in the long run, a lot of this ends up shifting to public infrastructure very similar to how in the beginning of the internet, people focused on building intranets that were insulated and well protected, but using internet technology to do that. Eventually they decided to open themselves up to the internet, and now they are putting infrastructure in the cloud. I see the same transitions happening in this space as well.”
So where does Gem fit into all this? He said Gem is not building the next great blockchain system. “There are a lot of great projects such as Ethereum to the Hyperledger project being managed by the Linux Foundation,” he said. Gem has a core product called GemOS designed to make the blockchain usable for enterprise clients. “We add in the other things you need to create great applications that use the blockchain such as document management and identity layers, and we provide an abstraction layer on top of multiple blockchains, so with one platform you could integrate with multiple blockchain systems underneath.”
Gem is one of the sponsors of the first conference devoted to addressing blockchain healthcare applications. Called Distributed: Health, the conference will be held Oct. 3 in Nashville and will address how blockchain and distributed ledger technology will affect multiple layers of the healthcare system including payments, medical records, inventory management and data collection.
“Gem has been talking about the applications in healthcare for a while now,” Winkelspecht said, “and I think it is starting to catch on.”