Blockchain in Healthcare

Jorge A. Ferrer M.D., M.B.A., FAMIA

Informatics Health Systems Specialist U.S. Department of Veterans Affairs
Blockchain in Healthcare Today Editor
Healthcare Information and Management Systems Society (HIMSS) Blockchain Task Force​
IEEE Blockchain in Healthcare and Life Sciences Standards Development Working Group​
Adjunct Assistant Professor UTHealth School of Biomedical Informatics​
Blockchain in Healthcare

• Outline
• Definition Blockchain
• Blockchain Technology in Health Care: A Primer for Surgeons
• Blockchain Technology in Healthcare: A Systematic Review
• ‘Fit-for-Purpose?’ – Challenges and Opportunities for Applications of
Blockchain Technology in The Future of Healthcare
• The Potential for Blockchain to Transform Electronic Health Records
• Blockchain Vehicles for Efficient Medical Record Management
• Interoperability in the Healthcare Ecosystem
• Gartner 2019 Hype Cycle
• Who Will Build the Health-Care Blockchain?
Blockchain in Healthcare

Definition Blockchain
• “Blockchain technology is a subset of distributed ledger technology (DLT),
where the data are distributed across computers or nodes within a network,
and nodes in the network store a copy of the ledger. The term “blockchain”
comes from the characteristics of the technology where each item, or block,
on the ledger contains information regarding the previous block within hash,
creating a chain and limiting the tampering of the data.”
• HIMSS Considerations for Policymakers: The Application of Blockchain
Technology in Healthcare
Blockchain in Healthcare
Definition Blockchain

• “It is shared, continually updated in a reconciled database without a

centralized hub. Decentralization is one of the ways that blockchain increases
security, as hackers do not have one place to target to get information—there
could be thousands, each requiring its own key to access the data.”
• AHIMA What is Blockchain Anyway? And What Does it Mean for
Healthcare?
• “At its core, blockchain technology represents a data structure that makes it
possible to create a digital ledger of transactions and share it among a
distributed network of computers with the potential for increased security,
reductions in cost, decreased transaction times, and greater transparency - all
while eliminating the need for a trusted third-party or intermediary.”
• AcademyHealth Blockchain: You’ve heard of it, your colleagues keep
talking about it, but what is it?
Blockchain in Healthcare
Blockchain Technology in Health Care: A Primer for Surgeons
• “For the health care industry, blockchain technology stands to revolutionize the
interoperability, security, and accountability of electronic health records (EHR)
and health information technology (HIT), medical supply chains, payment
methodologies, research capabilities, and data ownership.”
• Blockchains provide a “common history” or “shared truth” that cannot be altered.
• How could health care benefit from blockchain technology?
• “Interoperability: EHRs lack interoperability and are exceedingly costly.
Because EHRs are unable to effectively communicate with each other,
physicians and surgeons often treat acutely ill patients without access to
medical histories, current medications, and prior imaging studies that could
influence patient care.”
Blockchain in Healthcare

Blockchain Technology in Health Care: A Primer for Surgeons

“What needs to be done to build the health care blockchain?”
• Appropriate software or “middleware” must be built to interface with
blockchain ledgers.
• “For health care, as with other industries, the adoption of blockchain will rely
on the development of innovative applications, or middleware, that harness
blockchain-based coding infrastructure and create meaningful user
interfaces—in this case, for patients and providers.”
• What will be the role of government?
• “The federal government must shepherd innovation and standardization in
this space so that patients and providers alike can benefit from blockchain
technology’s enormous potential.”
Blockchain in Healthcare
Blockchain Technology in Healthcare: A Systematic Review
Benefits of Blockchain to Healthcare Applications
• Decentralization
“The very nature of healthcare, in which there are distributed stakeholders,
requires a decentralized management system. Blockchain can become that
decentralized health data management backbone from where all the stakeholders
can have controlled access to the same health records, without anyone playing the
role of a central authority over the global health data.”
• Improved Data Security and Privacy
“The immutability property of blockchain greatly improves the security of the
health data stored on it, since the data, once saved to the blockchain cannot be
corrupted, altered or retrieved. All the health data on blockchain are encrypted,
time-stamped and appended in a chronological order. Additionally, health data are
saved on blockchain using cryptographic keys which help to protect the identity or
the privacy of the patients.”
Blockchain in Healthcare

Blockchain Technology in Healthcare: A Systematic Review

Benefits of Blockchain to Healthcare Applications
• Health Data Ownership
“Patients need to own their data and be in control of how their data is used.
Patients need the assurance that their health data are not misused by other
stakeholders and should have a means to detect when such misuse occurs.
Blockchain helps to meet these requirements through strong cryptographic
protocols and well-defined smart contracts.”
• Availability/Robustness
“Since the records on blockchain are replicated in multiple nodes, the availability of
the health data stored on blockchain is guaranteed as the system is robust and
resilient against data losses, data corruption and some security attacks on data
availability.”
Blockchain in Healthcare
Blockchain Technology in Healthcare: A Systematic Review
Benefits of Blockchain to Healthcare Applications
• Transparency and Trust
“Blockchain, through its open and transparent nature, creates an atmosphere of
trust around distributed healthcare applications. This facilitates the acceptance of
such applications by the healthcare stakeholders.”
• Data Verifiability
“Even without accessing the plaintext of the records stored on blockchain, the
integrity and validity of those records can be verified. This feature is very useful in
areas of healthcare where verification of records is a requirement, such as
pharmaceutical supply chain management and insurance claim processing.”
Blockchain in Healthcare
Blockchain Technology in Healthcare: A Systematic Review
• Use Cases
• Electronic Medical Records Interoperability
• Clinical Reconciliation
• Provider Directory
• Prior Authorization
• Health Insurance Claims
• Medication Reconciliation
• Of the Identified Use Cases, What Blockchain-Based Applications Have Been
Developed?
• “In general, the technology is still maturing and even when prototype
applications are developed, in some cases, they are just for experimental
purposes with very basic functionalities.”
Blockchain in Healthcare

Blockchain Technology in Healthcare: A Systematic Review

On Going Research
• “Research still needs to be conducted to better understand, characterize and
evaluate the utility of blockchain technology in healthcare.”
• “Further research is also needed to supplement ongoing efforts to address
the challenges of scalability, latency, interoperability, security and privacy in
relation to the use of blockchain technology in healthcare.”
• “A substantial portion of the research (48%) concentrates on the application
of blockchain in the management of electronic medical records. Traditionally,
patients’ records are stored separately in different databases across different
service providers, with little or no interoperability.”
Blockchain in Healthcare
‘Fit-for-Purpose?’ – Challenges and Opportunities for Applications of
Blockchain Technology in The Future of Healthcare
• “Despite blockchain’s potential as an emerging technology to be innovative and
disruptive, it remains immature, particularly in healthcare.”
• “Reflecting the fact that it is still early days for health blockchains, there are few
real-world examples of blockchain systems that have gone into production and
that also have strong commercial or user adoption in healthcare.”
• “Healthcare record management is one of the most important application
domains for blockchain technology.”
• “Blockchain healthcare record management focuses on the sharing of data across
different healthcare stakeholders, while preserving the source, provenance and,
oftentimes, privacy of such data in a way that can enable more powerful data
analysis and insights from population health analytics.”
Blockchain in Healthcare
The Potential for Blockchain to Transform Electronic Health Records
• “A vexing problem facing health care systems throughout the world is how to
share more medical data with more stakeholders for more purposes, all while
ensuring data integrity and protecting patient privacy.”
• “Traditionally, the interoperability of medical data among institutions has
followed three models: push, pull, and view (discussed below), each of which has
its strengths and weaknesses. Blockchain offers a fourth model, which has the
potential to enable secure lifetime medical record sharing across providers.”
• “All of these approaches work technologically, but the policies surrounding them
are subject to institutional variation, local practice, state laws, and the rigor of
national privacy policy enforcement.”
• “Blockchain is a different construct, providing a universal set of tools for
cryptographic assurance of data integrity, standardized auditing, and formalized
“contracts” for data access.”
Blockchain in Healthcare
The Potential for Blockchain to Transform Electronic Health Records
• “Today humans manually attempt to reconcile medical data among clinics,
hospitals, labs, pharmacies, and insurance companies. It does not work well
because there is no single list of all the places data can be found or the order in
which it was entered.”
• “The rationale for considering a blockchain in electronic health care records is
twofold. First, it avoids adding another organization between the patient and the
records. Second, it adds due consideration to a time-stamped, programmable
ledger. That opens the door for intelligent control of record access without having
to create custom functionality for each EHR vendor. The ledger also inherently
includes an audit trail.”
• “Blockchain for health care is very early in its lifecycle, but it has the potential to
standardize secure data exchange in a less burdensome way than previous
approaches.”
Blockchain in Healthcare

Blockchain Vehicles for Efficient Medical Record Management

• “Despite significant advances in the use of technology in clinical medicine and the
large sums of money recently diverted into the National Health Service,
administrative systems in healthcare remain in want of interoperability.”
• “After multiple attempts and delays at becoming fully digital, the NHS has now
released a ten-year plan, in which it introduces the basis for a new twenty-first
century service model.”
Blockchain in Healthcare

Blockchain Vehicles for Efficient Medical Record Management

• “The concept of Blockchain-based medical record management has been
considered and implemented on a small scale by a number of companies
however, only very few healthcare systems have begun to incorporate the
technology into their nationwide infrastructure.”
• “Blockchain represents an innovative vehicle to manage medical records,
ensuring interoperability but without compromising security. It also protects
patient privacy, allowing patients to choose who can view their data. Investments
into this technology would be outweighed by returns as the interfacing of
systems leads to increased collaboration between patients and healthcare
providers, and improved healthcare outcomes.”
Blockchain in Healthcare
Interoperability in the Healthcare Ecosystem (HIMSS)
• “Interoperability is the ability of different information systems, devices and applications
(‘systems’) to access, exchange, integrate and cooperatively use data in a coordinated manner,
within and across organizational, regional and national boundaries, to provide timely and
seamless portability of information and optimize the health of individuals and populations
globally. Health data exchange architectures, application interfaces and standards enable data to
be accessed and shared appropriately and securely across the complete spectrum of care, within
all applicable settings and with relevant stakeholders, including by the individual.”
• Four Levels of Interoperability:
• Foundational (Level 1) – establishes the inter-connectivity requirements needed for one
system or application to securely communicate data to and receive data from another
• Structural (Level 2) – defines the format, syntax, and organization of data exchange including
at the data field level for interpretation
• Semantic (Level 3) – provides for common underlying models and codification of the data
including the use of data elements with standardized definitions from publicly available value
sets and coding vocabularies, providing shared understanding and meaning to the user
• “New” Organizational (Level 4) – includes governance, policy, social, legal and organizational
considerations to facilitate the secure, seamless and timely communication and use of data
both within and between organizations, entities and individuals. These components enable
shared consent, trust and integrated end-user processes and workflows
Blockchain in Healthcare
Gartner 2019 Hype Cycle
Blockchain in Healthcare

Who Will Build the Health-Care Blockchain?

• “There are 26 different electronic medical records systems used in the city of
Boston, each with its own language for representing and sharing data.”
• “Critical information is often scattered across multiple facilities, and sometimes it
isn’t accessible when it is needed most—a situation that plays out every day
around the U.S., costing money and sometimes even lives.”
• “But it’s also a problem that looks tailor-made for a blockchain to solve, says Dr.
John Halamka, chief information officer at Beth Israel Deaconess Medical Center
in Boston.”
Blockchain in Healthcare

Who Will Build the Health-Care Blockchain?

• “Technologists and health-care professionals across the globe see blockchain
technology as a way to streamline the sharing of medical records in a secure way,
protect sensitive data from hackers, and give patients more control over their
information.”
• “But before an industry-wide revolution in medical records is possible, a new
technical infrastructure—a custom-built “health-care blockchain”—must be
constructed.”
• “Either way, blockchain’s potential for the health-care industry depends on
whether hospitals, clinics, and other organizations are willing to help create the
technical infrastructure required. Right now, that means prototyping and testing
fundamental concepts.”
Blockchain in Healthcare
References
• HIMSS Considerations for Policymakers: The Application of Blockchain Technology
in Healthcare
• AHIMA What is Blockchain Anyway? And What Does it Mean for Healthcare?
• AcademyHealth Blockchain: You’ve heard of it, your colleagues keep talking about
it, but what is it?
• Blockchain Technology in Health Care: A Primer for Surgeons
• Blockchain Technology in Healthcare: A Systematic Review
• Procuring Interoperability
• ‘Fit-for-Purpose?’ – Challenges and Opportunities for Applications of Blockchain
Technology in The Future of Healthcare
• Blockchain vs. FHIR in Healthcare Integration
• The Potential for Blockchain to Transform Electronic Health Records
Blockchain in Healthcare
References
• Blockchain Vehicles for Efficient Medical Record Management
• Interoperability in the Healthcare Ecosystem (HIMSS)
• Gartner 2019 Hype Cycle
• Who Will Build the Health-Care Blockchain?
• Will blockchain save the healthcare system?
• 9 Things to Know About Blockchain in Healthcare
• Let's be Practical: Consider “here and now” Uses for Blockchain
• Blockchain Playbook for the U.S. Federal Government
• With FHIR in Place is there Room for Blockchain in Healthcare?
• As blockchain matures, stakeholders should weigh competition vs. partnership
Blockchain in Healthcare

Resources
Textbook
• Blockchain in Healthcare: Innovations that Empower Patients, Connect
Professionals and Improve Care (HIMSS Book Series)
Journal
• Blockchain in Healthcare Today
Health Informatics Society (HIMSS)
• Blockchain in Healthcare (HIMSS)