By Abha Agrawal, MD, FACP, FACHE
CJ was a 50-year-old man sent to a hospital’s emergency room (ER) from a long-term care facility for severe difficulty in breathing. The ER physician discovered that the patient was suffering from angioedema – a severe swelling of the lips, mouth and the upper airways – that can be life-threatening if not treated promptly. This condition was caused by a very commonly used blood pressure medication the patient was on – the Lisinopril. In the ER, the patient was put on a ventilator (breathing machine) and treated for angioedema successfully. He was transferred back to the long-term care facility with a notation in the chart about the severe reaction to Lisinopril and that he should never be given this or a similar medication (e.g. Ramipril) again. The same evening, in the long-term facility, a different shift of doctor and nurses somehow didn’t get this information and the patient was again given Lisinopril. This time he had an immediate fatal reaction and died with no time for a further intervention.
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This event took place about 6 years ago in when I was serving as the Chief Medical Officer of a 700-bed hospital in New York. Ironically, both the hospital and the long-term facility were using advanced electronic health records (EHRs) but the EHRs didn’t communicate with each other leading to this tragic outcome.
The important question today is: could blockchain technology have saved this man’s life.
Blockchain is an emerging technology made famous (or notorious based on your perspective) by Bitcoin or cryptocurrency. Many people still think of blockchain only as the technology behind bitcoin. However, just as the Internet as a technology backbone can be used for banking, shopping or healthcare, blockchain technology has many potentials applications including in finance sector, supply chain management, land registry management, healthcare etc.
In this essay, I would share some perspectives and use cases for blockchain technology in health care.
What are the key problems in healthcare?
As illustrated by the patient story above, access to the right information by the right person at the right time is still an unsolved challenge in healthcare in-spite of decades of progress leveraging technologies such as EHRs, the Internet, mobile technology and data analytics etc. This will qualify as a “wicked’ problem due to several factors:
- Healthcare delivery system is very fragmented. Patients get care at many different physician offices, hospitals, long-term care facilities etc. that may be dispersed across cities or even countries. Most of the times, these providers are local or regional business entities with no relationship with each other. Therefore, there are numerous barriers to sharing medical information amongst these providers.
- Patients’ medical records and data are stored in a variety of non-standardized, not easily interoperable EHRs and clinical databases making it very difficult to port data across platforms.
- There is a lack of clear business relationships and financial incentives so that no party (except the patient) has a clear stake in pushing for the interchange of data. Further, to date, many health information exchanges have floundered due to lack of a monetization model.
What is Blockchain and How Can it be Useful?
Blockchain is an emerging technology that has the potential to address a number of these challenges. There are three key concepts in blockchain that can be summarized as PAT.
P = Participants. Clearly, healthcare has multiple participants including patient and multiple healthcare providers.
A = Assets. In case of healthcare, information is the most important and valuable asset.
T= Transactions. Every episode of clinical care or review of information such as lab results or x-rays, or a prescription is a transaction.
Blockchain has a variety of attributes that make it attractive to solve the challenge of data sharing in healthcare.
- Decentralized distribution. Blockchain technology can provide the backbone for all transactions and data points. This then becomes the “information highway” for various care providers and patients (who would be the nodes) to access the data as and when needed. This backbone or information highway can then be connected to existing EHR or healthcare applications that will provide the end-users (e.g. patients, provider, payors etc.) the information needed at the right time.
- A clear and strong system of authentication and authorized access. This helps solve a number of issues faced in sharing health information:
- An appropriate owner of information such as the patient can clearly and unambiguously define who is authorized to access which part of the information. This helps protect unauthorized access to sensitive information such as the HIV status or behavioral health issues.
- Further access can be limited by role. For example, a claims processor may not need and get access to detailed clinical information.
- Transparent ledger with an immutable audit trail
- This provides a strong level of trust with regard to anyone who has ever accessed clinical information of the patient. At times, clinical information of the patients has been used for secondary purposes without appropriate consent and approval of the patient. Blockchain technology can prevent that from happening.
- Resistant to hacking. Because of the very nature of the blockchain where each piece of data is tagged with a “hash” (a specialized code) and all subsequent pieces of the data are linked to the previous hash, a potential hacker will need to ‘hack’ almost an infinite number of data pieces or blocks to get unauthorized access to information or alter it. Given an increasing number of ransomware attacks on health care organizations, this is yet another valuable feature of blockchain in healthcare.
- Data integrity. Given the above features, blockchain technology provides a strong basis to ensure the integrity of medical data.
What are Key Use Cases of Blockchain in Healthcare?
- Access to clinical data from anywhere by properly authorized and authenticated persons as discussed above in details. MedRec application developed by MIT is an excellent example in this direction (https://viral.media.mit.edu/pub/medrec).
- Clinical trials and research. Fabrication of consent is one of the commonest types of frauds in clinical trials. With blockchain, data cannot be removed or cannot be released unless a certain trigger has been achieved, and data can be managed disparate geographic locations.
- Supply chain management for pharmaceuticals. Cost of counterfeit medications is estimated at $200 billion annually. It is believed that 10% of the US pharmaceutical industry is counterfeit; the problem is even worse in developing countries such as India. Given its feature of immutable audit trails and decentralized distribution of information, blockchain has the potential to provide inalterable proof of authenticity from the source manufacturer to the point of consumption by the patient.
- Medical device tracking. Similarly, billions of dollars are lost and countless hours spent in trying to track medical devices in healthcare organizations. Tagging the device information on blockchain can save both money and time.
Conclusion
Blockchain is an emerging technology with a very unclear regulatory framework, and how it will evolve and be adopted is still uncertain. IBM conducted a study of 200 healthcare executives in 16 countries in December 2016 and found that 16% of the executives fell in the “trailblazer” category – already using or have clear plans about using blockchain in their organization.
Blockchain is transforming the conversation from “big data” (focused on data analytics) to “long data” – every single transaction about a patient stored immutably and unalterably on a technology backbone available to the right people at the right time with proper authorization. I think this could have saved CJ’s life and as a physician, this is what I am most excited about.
Dr. Abha Agrawal is an experienced healthcare executive and a practicing physician. She has served in numerous impactful roles in diverse sectors in healthcare including non-profit hospitals, public hospitals, and for-profit health IT industry. In recognition of her role as a rising healthcare leader, she was invited to the White House in 2011 to meet with President Obama’s health and economic policy advisor and to provide testimony at the US Senate. She is the author of two books: “Patient Safety: A Case-based Comprehensive Guide” (Editor), published by Springer and released in October 2013, and Health IT and Patient Safety: A Clinical Case Series (Editor); published 2016.
