Why blockchain could transform the very nature of EHRs
The variety of potential blockchain deployments in healthcare is getting wider. When ONC put forth its call for white papers in its blockchain challenge, for instance, it received more than 70 submissions earlier this year, exploring everything from medication reconciliation to alternative payment models.
And as the distributed ledger tool gains ground in other industries, the thinking about how it can help healthcare's many challenges has only gotten more creative.
At the HIMSS Healthcare Security Forum in Boston last week, Maria Palombini, director of emerging communities and initiatives development at the IEEE Standards Association, framed some expectations for the much-hyped technology.
For all the excited chatter surrounding it, blockchain is still an emerging technology and "failures and resets are to be expected," said. "There are still quite a few challenges that need to be resolved in order to make adoption happen."
Blockchain "is not meant to wipe out existing legacy systems," she added, but if deployed wisely, the technology could underpin an array of new innovations that could help reduce costs, enable efficiency, protect privacy and spur interoperability and much more.
The potentials for blockchain and blockchain-like tools – decentralized, transparent, verifiable, secure and private – are everywhere, said Palombini.
By ensuring that any changes in data are made by the participants in a given transaction, she said, the technology's use cases run the gamut from IoT medical device security to supply chain integrity to claims processing and clinical trials efficiency.
"Blockchain is booming in clinical trials right now; it is a big favorite of the pharmaceutical sector,” she said.
A 'utopian' answer to EHR challenges?
But one place where Palombini sees especially intriguing promise is electronic health records.
"When you think about all the data (in and EHR), what do you put in it? Genomic data, hospital records, immunization records, lab results – there's an enormous amount of data," she said. "The question then becomes, ‘Do I have to do this over and over every time I go to the hospital or I go to my doctor?’"
Palombini said a public blockchain could be just the thing to enable more seamless – but still secure – sharing of health data, all within the patient's discretion and control.
"Everything you have in your health record gets put into the blockchain, and then the patient is managing their health record," she said. "I have my health record, and then I go to my doctor I give him a token to access my records.
"How many times have you gone to the doctor and they ask, 'What medicine are you taking? What is your wearable telling you?'" she added. "Why are you spending 15 minutes of your time with your doctor re-reciting something you think is written down in his chart from the last time you were there? Especially if you go to a new doctor, you want him to be able to have your health record."
She remembered a recent visit with her father-in-law – an older gentleman who doesn't speak English – to the hospital emergency room.
"We check into the emergency room, and they ask us why we're here, they start asking him for all of this information: 'What kind of procedure did you have? What medicine are you taking? What's your health history?'
Then, later, the ER doctor started "asking us all of the same questions again," she said. "I thought, 'Didn't you just read all of the information we just filled out at the registrar?'"
After an evaluation, Palombini's father-in-law was eventually told he had to stay overnight.
"So we head upstairs to the next floor, where we get asked the same questions once again," she said. "I'm sitting there, thinking out loud, and I say, 'Blockchain would have solved this problem.'"
In each step of that phase of the patient encounter, "what are we doing? We're verifying data,” she said. “We're making sure that the person before us wrote it down accurately. We're asked again to make it double secure."
Of course, that's usually based on hospitals' policies and protocols. But the root cause for all that double- and triple-checking is that "we're not so confident about the technology and how we're taking down information," she said.
In a recent blog post, Elizabeth G. Litten, partner and HIPAA privacy & security officer at Fox Rothschild, said that "using blockchain technology to reconfigure EHRs makes sense."
Indeed it's ironic, she said, that a "design flaw" in the original HIPAA law – encouraging electronic health transactions that enable portability for patients' who move among various sites of care, while treating privacy and security as an "afterthought" – could potentially be addressed by the same technology underpinning the cryptocurrency, bitcoin, so "favored by ransomware hackers."
Litten pointed to another post, by Ritesh Gandotra, director of global outsourcing for Xerox, who wrote that, "EHRs were never really designed to manage multi-institutional and lifetime medical records; in fact, patients tend to leave media data scattered across various medical institutes … This transition of data often leads to the loss of patient data."
Blockchain, he said, "can be used link discrete patient records (or data “blocks”) contained in disparate EHRs into "an append-only, immutable, timestamped chain of content."
At HIMSS17 in Orlando this past spring, Tamara StClaire, previous chief innovation officer at Conduent Health, spoke at a blockchain symposium sponsored by IEEE and the Personal Connected Health Alliance.
She explained that new approach to patient records: "One way to think about it is the fact that not your identification but your data is hashed to the ledger," she said. "It's an address you're looking for. And there can be multiple addresses. And a patient can hold multiple keys to those addresses in their electronic wallet."
There would be a whole lot of other questions that would accompany such a fundamental change of "transferring ownership of data to patients," said StClair.
"All of a sudden we have a new paradigm about the way we think of privacy. We may need to set default levels for the people who are uncomfortable with the magnitude of that responsibility. There's a lot we need to dig into, and that conversation needs to start."
But blockchain could help lead to a "Holy Grail," she said. A longitudinal view of a patient's health history that incorporates information drawn from hospital stays, outpatient visits, wearable device data and more.
Palombini used similar language when she described a blockchain-built, mobile EHR.
"This is utopia," she said. "It's going to a while for us to get there. But this is why we're so motivated in the application of blockchain. And I say 'challenges,' not 'roadblocks.' Because they can be overcome."