In 2015, the Office of the National Coordinator for Health Information Technology (ONC) published the Shared Nationwide Interoperability Roadmap, laying out a path for the health care industry to improve interoperability over the next 10 years. The ONC acknowledged that the industry had made advances in precision medicine, telehealth and adoption of electronic health records and big data analytics, but there is still progress to be made.
To achieve this future state, the roadmap put forth 16 areas of focus for the industry going forward, including identity, authorization and access, data formats, data transmission, longitudinal health information and provider workflows. This future will only be achieved by an open technology infrastructure that enables and supports sharing, collaboration and connectivity.
Blockchains, by providing a trusted environment for data recordation and exchange, are network enablers, providing a foundation and set of technology standards that connect stakeholders, and support the applications used by clinics, hospitals, pharmacies and insurance companies to manage the wealth of data created by the industry.
Blockchain technology will fundamentally change how:
- Payers and providers share claims information
- Provider data is updated and matriculated through a network
- Medical records are shared and updated
- Population health data is aggregated and analyzed
- Clinical trial data is recorded
- Prescription drugs are tracked and monitored through the supply chain
Overview of blockchain technology
Database technology is not new; distributed databases have been around for a decade, and relational databases have existed for even longer. Blockchains are another form of database, and while they share many elements with more traditional forms, it is the differences that make them truly innovative.
By design, blockchains are intended to be shared by individuals, organizations, even devices. In a digital world, where databases are the infrastructure, blockchains are common infrastructure — shared “plumbing” through which many data types can be stored, referenced and transferred — and a mechanism by which that activity can be immutably recorded. The unique aspects of a blockchain include:
- Identity: Blockchains contain a built-in identity mechanism — a cryptographically secure public-private key pair — used to associate activity on the network with a specific participant. In a health care context, blockchains’ unique identity mechanism could provide the foundation for a unified patient ID across payers and providers.
- Permission gradient: Using the identity system as a foundation, permissions can be assigned to participants on a network. Due to the fact that these permissions are also stored on the blockchain, a participant in the network can be certain that the data he or she has uploaded is only accessible by the party to whom access was granted, despite this data being hosted in a decentralized manner.
- Immutability: One of the most valuable features of a blockchain-based network is the audit trail or transaction record. Transactions, or actions (in a nonfinancial context), on the network are grouped together into blocks for batch processing. Over time, the blocks of actions form a chronological chain, where each new block references information contained in the previous block. This chain of activity is shared — everyone participating on the network can maintain a complete activity history. In a financial context, this would mean multiple parties can collectively maintain a shared copy of a transaction ledger.
- Transparency (public vs. private): A blockchain-based system can either be open and public, or private and permissioned. Public blockchains are open to anyone — no permission is required to join and participate in the network. They are also inherently transparent; all actions on the network must be validated by, and visible to, all participants on the network. Private, permissioned blockchains are quite the opposite. Permission is required before a participant can join and participate in the network. The ability to assign a variety of permissions to network participants is suited for use in more commercial contexts like health care, where certain actions and information are not intended to be public.
Limitations
For all of its promise, blockchains today are limited by the nascent state of the technology and certain design elements inherent to distributed systems, including:
- On- and off-chain data
Because a blockchain is technically a shared ledger, a copy of the ledger is maintained by each node on the network. This means that any data stored on the blockchain is duplicated at each node. For this reason, it would be inefficient, and unnecessarily duplicative, to store large amounts of data on a blockchain. Instead, blockchain technology can be used to connect off-chain data stores, acting as an identity and permissioning fabric between parties on the network.
- Scalability
Activity on blockchain networks has increased every year since bitcoin was released in 2009, but the protocols that exist today are not quite ready to support the speed and volume requirements of the health industry. In a blockchain context, speed and security are often inversely related — more of one means less of the other. In the context of a distributed payer network, we look for consensus as to the state of payer access permissions to provider data files across the network. In either case, consensus requires some amount of computation and time.
- Technology standards
Before blockchain-based applications can be widely adopted, a set of technology standards must be developed. At the moment, there are several competing protocols that exist — bitcoin, Ethereum, Hyperledger, etc. There are also a handful of other proprietary middleware and application development suites for each protocol. The health care industry would be well served to experiment with different protocols and testing environments, but meaningful vertical development and scalability will only be achieved once a standard has been established.
- Impact dependent on middleware and application layers
The internet as we know it is built on foundational protocols such as TCP/IP and DNS (internet and domain name protocols, respectively). These protocols support and enable consumer-facing applications such as the web and email. Like TCP/IP and DNS, blockchain is an infrastructure technology, and its value for health care will only be realized by the middleware and consumer-facing applications it supports. The provider data management approach we propose is one example of an application, and there will be countless others, but development takes time.
