The Po­ten­tial of Blockchain

Pro­po­nents see the tech’s po­ten­tial in health­care.

Health Data Management - - INSIDE - By Greg Sla­bod­kin

How far can the tech­nol­ogy go to cure health­care’s ills?

Few tech­nolo­gies have been as widely her­alded for their po­ten­tial to solve some of the ma­jor chal­lenges IT sys­tems face in health­care as blockchain. While health­care has just started to ex­plore the tech­nol­ogy, there is some pi­o­neer­ing re­search work now un­der way.

Blockchain’s core tech­nol­ogy un­der­lies the Bit­coin cryp­tocur­rency; it’s a data struc­ture that can be time-stamped and signed us­ing a pri­vate key to pre­vent tam­per­ing, ac­cord­ing to the Of­fice of the Na­tional Co­or­di­na­tor for HIT. In health­care, blockchain is en­vi­sioned as a so­lu­tion— among other ap­pli­ca­tions—for pro­tect­ing, manag­ing and ex­chang­ing elec­tronic health in­for­ma­tion.

How­ever, skep­tics con­tend that it would take enor­mous pro­cess­ing power and re­tool­ing that would far ex­ceed any ben­e­fits de­rived.

Un­der the blockchain “dis­trib­uted ledger” par­a­digm, when changes are made in one copy of a dis­trib­uted ledger, each copy held in every other lo­ca­tion is si­mul­ta­ne­ously up­dated. As a re­sult, in the­ory,

health records can be stored se­curely in a ledger clin­i­cians, pa­tients and pay­ers can trust, pro­vid­ing in­stant ac­cess to an agreed upon set of data.

It’s this con­cept on which blockchain startup Pa­tien­tory cre­ated a health­care app that lets users cre­ate a pa­tient pro­file to keep track of their health his­tory, giv­ing pa­tients an easy-to-use method of track­ing doc­tor vis­its, med­i­cal bills, per­sonal med­i­cal in­for­ma­tion, in­sur­ance, im­mu­niza­tions and phar­macy med­i­ca­tions.

“We’re one of the first com­pa­nies to ac­tu­ally in­tro­duce blockchain into health­care,” says Chrissa McFar­lane, the com­pany’s CEO. “We’re us­ing the in­fras­truc­ture to bridge siloed elec­tronic med­i­cal record sys­tems. It’s an app for pa­tients so they have ac­cess to their own health in­for­ma­tion.”

McFar­lane is urg­ing the fed­eral gov­ern­ment “to get be­hind a blockchain-en­abled na­tional IT health sys­tem and at the same time help to re­move le­gal ob­sta­cles in the move­ment of data amongst providers.”

“Blockchain is very nascent,” ac­knowl­edges McFar­lane. “Bit­coin was in­tro­duced in 2009 and did not have a masss­cale fol­low­ing un­til 2012, when the un­der­ly­ing blockchain tech­nol­ogy for Bit­coin be­gan to be used by the fi­nan­cial ser­vices in­dus­try. In the past five years, IT has opened up to other in­dus­tries such as sup­ply chain man­age­ment, real es­tate and now health­care.”

Se­cu­rity ca­pa­bil­i­ties

In par­tic­u­lar, she be­lieves blockchain could elim­i­nate the pos­si­bil­ity of hav­ing health­care data en­crypted and held for ran­som by cy­ber crim­i­nals, such as the re­cent global Wan­naCry ran­somware at­tack that dev­as­tated the Na­tional Health Ser­vice in the United King­dom as well as hun­dreds of thou­sands of com­puter sys­tems world­wide.

“If they had a blockchain-based in­fras­truc­ture, Wan­naCry would not have hap­pened,” as­serts McFar­lane. “The only bar­rier is re­ally ed­u­ca­tion and know­ing how the tech­nol­ogy works. That’s the big­gest bar­rier be­cause it is an emerg­ing tech­nol­ogy.”

How­ever, Avi Ru­bin, direc­tor of the Health and Med­i­cal Se­cu­rity Lab at Johns Hop­kins Univer­sity, doesn’t see how blockchain would be use­ful in pre­vent­ing ran­somware at­tacks like Wan­naCry.

“Ran­somware ex­ploits vul­ner­a­bil­i­ties in soft­ware on an end sys­tem; noth­ing about blockchain would pre­vent these types of at­tacks from suc­ceed­ing,” Ru­bin con­tends. “Fur­ther­more, ran­somware en­crypts vic­tims’ data, and if there are no re­li­able back­ups, then the in­for­ma­tion is go­ing to be held hostage, and I don’t see how blockchain would help.”

Blockchain tech­nolo­gies could be used to help the at­tack­ers, he adds, in that it pro­vides a mech­a­nism whereby the vic­tims could pay the at­tack­ers. “In fact, anony­mous e-cash, such as the zero cash sys­tem, could be used to fa­cil­i­tate that,” says Ru­bin. “While blockchain might sup­port the ran­somware busi­ness model and make the whole at­tack vi­able, it does noth­ing to aid the po­ten­tial vic­tims.”

Like­wise, Kaveh Safavi, MD, se­nior manag­ing direc­tor for Ac­cen­ture’s global health­care busi­ness, doesn’t be­lieve blockchain tech­nol­ogy would have pre­vented the re­cent global Wan­naCry ran­somware at­tack.

“I don’t see that con­nec­tion at all,” he says. Wan­naCry “wasn’t a theft of in­for­ma­tion in tran­sit—or any­thing close to that; it was an op­er­at­ing sys­tem piece of mal­ware—how would a blockchain stop mal­ware?”

Frame­work needed

Blockchain has in­her­ent qual­i­ties that pro­vide trust and se­cu­rity, but it is not a tech­no­log­i­cal panacea for all that ails health­care when it comes to cy­ber­se­cu­rity, be­lieves Deb­bie Bucci, an IT ar­chi­tect in ONC’s Of­fice of Stan­dards and Tech­nol­ogy.

“When I look across other in­dus­tries, I don’t see any of them re­ally ag­gres­sively adopt­ing it,” says Bucci, whose pri­mary fo­cus is on the pri­vacy and se­cu­rity as­pects of health in­for­ma­tion ex­change. “There’s a lot of proof of con­cepts, pi­lots and use cases be­ing de­fined. But, I have yet to see ma­jor com­pa­nies step­ping up to sup­port blockchain—be­yond Bit­coin, of course.”

Ac­cord­ing to Bucci, ONC con­tin­ues to keep a close watch on what de­vel­ops in the mar­ket­place when it comes to blockchain, which is still evolv­ing and ma­tur­ing, es­pe­cially with re­spect to its ap­pli­ca­bil­ity to health­care.

“It’s just way too early to lock into what we think,” says Bucci, who adds that there are sig­nif­i­cant hur­dles that must be over­come be­fore wide­spread adop­tion is pos­si­ble in health­care. “There will be a num­ber of dig­i­tal ledger tech­nolo­gies, and that it­self be­comes an in­ter­op­er­abil­ity is­sue. They are just work­ing on tech­niques now in how you talk cross-chain and off-chain. There’s a lot of work there still to be done.”

When asked if ONC should play a sig­nif­i­cant role in help­ing to cre­ate a na­tion­wide blockchain net­work for elec­tronic pa­tient records and es­tab­lish a frame­work for early adopters, Ru­bin re­sponds, “There are prob­a­bly higher pri­or­i­ties for health­care right now, but this would not

“If they had a blockchain-based in­fras­truc­ture, Wan­naCry would not have hap­pened.” —Chrissa McFar­lane

be a bad thing.”

Nonethe­less, Safavi be­lieves that such a blockchain frame­work is bet­ter suited com­ing from the pri­vate sec­tor.

Ac­cord­ing to Safavi, blockchain needs “some kind of gov­er­nance around it— there is no for­mal gov­er­nance.” To­ward that end, he points to Hyper­ledger, a vol­un­tary open source as­so­ci­a­tion cre­ated to ad­vance cross-in­dus­try blockchain tech­nolo­gies. “They rec­og­nize that some process needs to oc­cur in order to ac­tu­ally use a dis­trib­uted ledger for some­thing mean­ing­ful.”

In Oc­to­ber 2016, Safavi notes, Hyper­ledger launched a work­ing group ded­i­cated to ex­plor­ing ap­pro­pri­ate ap­pli­ca­tions for blockchain tech­nol­ogy in the health­care in­dus­try. By hav­ing tech­ni­cal and busi­ness-level con­ver­sa­tions, the group—which in­cludes par­tic­i­pants from Ac­cen­ture, Gem, Hashed Health, IBM and Kaiser Per­ma­nente—in­tends to help the in­dus­try adopt open source blockchain tech­nolo­gies and re­al­ize its full po­ten­tial.

“We have this chal­lenge of ad­vanc­ing the tech­nol­ogy while still try­ing to un­der­stand what the rules of en­gage­ment are go­ing to be,” Safavi says. “A clas­sic ex­am­ple right now is the do­main of blockchain, the con­cept of a dis­trib­uted ledger—it seems like it has lots of util­ity, but within a dis­trib­uted ledger con­cept, there still has to be a cer­tain au­thor­ity be­cause there is an ul­ti­mate prove­nance for the in­for­ma­tion that con­trols cer­tain things. How you go about cre­at­ing that is not clear. So what you see right now are con­sor­tiums be­ing cre­ated of or­ga­ni­za­tions try­ing to fig­ure out this prob­lem.”

Sim­ple trans­ac­tions

Ini­tially, the work­ing group—which does not re­quire Hyper­ledger mem­ber­ship— will fo­cus on fun­da­men­tal dis­trib­uted ledger ap­pli­ca­tions.

“We have some in­di­vid­ual pi­lots go­ing on, mostly around its ap­pli­ca­tion in the pay­ments process,” says Safavi. “Blockchain by its cur­rent na­ture works bet­ter for smaller amounts of in­for­ma­tion. Chain of cus­tody for pay­ments seems to be a re­ally good place. There is this be­lief that blockchain might be a vi­able method of trans­port for elec­tronic health records. But, the prob­lem is that blockchains—be­cause of the com­plex com­pu­ta­tion—can re­ally only con­tain rel­a­tively sim­ple in­for­ma­tion. And, you can’t con­vey a med­i­cal record with the cur­rent blockchain tech­nol­ogy. So, peo­ple are think­ing that maybe it’s the iden­tity part of a record—sort of a federated med­i­cal record and au­then­ti­ca­tion around ac­cess that a blockchain would be use­ful for, not the record it­self.”

For its part, the gov­ern­ment of Es­to­nia is lever­ag­ing blockchain to se­cure its cit­i­zens’ med­i­cal data. Es­to­nia’s eHealth Au­thor­ity has signed a deal with soft­ware se­cu­rity ven­dor Guard­time, which de­vel­oped a dig­i­tal sig­na­ture sys­tem based on blockchain tech­nol­ogy, to se­cure the health records of more than a mil­lion Es­to­ni­ans.

“We’re keep­ing a close watch” on Es­to­nia,” com­ments ONC’s Bucci. She makes the case that the coun­try is a “small state that stan­dard­ized on one spe­cific fla­vor of blockchain,” ad­ding that it’s too early to spec­u­late on what the im­pli­ca­tions might be for sim­i­lar use cases in the U.S. health­care sys­tem.

Far-reach­ing pos­si­bil­i­ties

Last year, ONC an­nounced win­ners of its blockchain chal­lenge, which gar­nered more than 70 white pa­pers sub­mit­ted by in­di­vid­u­als, or­ga­ni­za­tions and ven­dors. Ul­ti­mately, the agency picked 15 win­ners, in­clud­ing sub­mis­sions from Ac­cen­ture and IBM—both mem­bers of Hyper­ledger.

Ac­cen­ture’s pro­posal was for blockchain tech­nol­ogy so­lu­tions that “can sup­port many ex­ist­ing health­care busi­ness pro­cesses, im­prove data in­tegrity and en­able at-scale in­ter­op­er­abil­ity for in­for­ma­tion ex­change, pa­tient track­ing, iden­tity as­sur­ance and val­i­da­tion.”

IBM’s Global Busi­ness Ser­vice Pub­lic Sec­tor sub­mis­sion in­cluded po­ten­tial uses of blockchain tech­nol­ogy in health­care, in­clud­ing a de­tailed look at health­care preau­tho­riza­tion pay­ment in­fras­truc­ture,

“Blockchain by its cur­rent na­ture works bet­ter for smaller amounts of in­for­ma­tion.”

coun­ter­feit drug pre­ven­tion and de­tec­tion, and clin­i­cal trial re­sults use cases.

“The power of open source is the power of col­lab­o­ra­tive ideas,” says IBM Blockchain Prod­uct Leader Merve. “The Hyper­ledger Health­care Work­ing Group en­ables health­care en­ter­prises, providers and users to fo­cus re­sources on a scal­able open source project to lever­age col­lab­o­ra­tion. The beat­ing heart of the emerg­ing health­care blockchain will be pow­ered by Hyper­ledger en­abling data shar­ing, pri­vacy and in­ter­op­er­abil­ity.”

Says Safavi, “Right now, the use cases for it are still be­ing dis­cov­ered, and so I’ve de­scribed blockchain as still be­ing in re­search and devel­op­ment.”

There are so many po­ten­tial use cases for blockchain tech­nol­ogy to sup­port health­care, he adds, “We think prob­a­bly pay­ment will go first, and then there will be some R&D and evo­lu­tion be­fore we fig­ure out ex­actly how to use it in other places.”

—Kaveh Safavi

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