Michael Ramos

@rambossa

Design Thoughts: Blockchain for Healthcare

December 18th 2017

Developing Blockchain for Healthcare, primer and introduction. This is more of an opinion-piece (it lacks formal citing).

Primer, Table of Contents:

- Intro
- Why does the Healthcare Industry need something like Blockchain?
- What would the solution look like?
- How should it be developed technically?
- What would I focus on developing?

Intro

I’ll be exploring & developing “Blockchain For Healthcare.” This first part serves as a primer, and introduction exploring why the industry needs healthcare, and how developmental efforts should work.

I actually only got started on this path around 3 months ago. I was sent an invite to a Healthcare innovation contest, where six finalists end up pitching-off in Vegas for a $10k prize. I made it to that round, but I didn’t win. Healthcare was never a passion of mine, but I was passionate about the competition (probably for wrong reasons that are out of context here). The point is that I wasn’t prepared to deliver any compelling idea that an insanely complicated industry, such as Healthcare, would consider. It wasn’t until my flight to Vegas, when I was thoroughly reviewing & creating a strategy for my pitch, that I realized how unprepared I was. My submitted presentation offered nothing new beyond already defined buzzwords and a naive solution. Unlike the cryptocurrency environment, I wasn’t going to create considerable hype with a cool slide-deck or demo. I’ve learned a lot though, and think a possible blockchain solution for healthcare would be beneficial for people and the industry.

For those interested — here is my (now outdated) entry, pitch deck, infographic, and a digital-demo that is NOT mobile responsive & runs best in Chrome.

Why does the Healthcare industry need something like Blockchain?

Data in Healthcare is F’d. I’ll start with a notable example: Some critically-ill people carry around thick binders full of their diagnosis, medications, testings, research, insurance, genetics… literally every aspect of their health profile, everywhere they go. They spend hours researching, emailing, and creating networks with anyone who has the potential to help. They do this because the industry is failing them by not providing a means to efficiently store, share, or analyze their data in a globally unified way.

A buzzword you will often hear is “Siloed Data.” Patient’s data is manually on-boarded and placed into whichever Electronic Health Record their providers or health-networks are using. These are typically enterprise solutions that house most of the data collected. A lot of complexity can develop within organizations around their systems and the data collected:

  1. The larger the network or organization, the more likely that patient data is sparsed out by different departments and locations
  2. Data formats are challenging (a ton of old data is still on paper, departments like radiology use images ro even sounds, same data can exist in different systems and even in different formats & datatypes)
  3. EHRs offer consistency, though data is not consistent and can be very complicated. Providers will opt for convenient methods for data collection that don’t always translate into easy system-processing

Providers may handle these, plus many more issues, just fine. However, they end up building castles around their data which leads us into our next buzzword: “Interoperability.”

Data is rarely shared easily between different providers, networks, and EHRs. There are 1000+ EHRs in the United States; with that, EHRs are built without a standard business model. They weren’t built to talk/work with each other, and unfortunately doing so isn’t something that comes quick or cheap. The industry lacks effective standardization that has resulted in too many data-formats/types (here is an article with some insight, though it’s a bit outdated & missing some newer formats). Integrating varying data-formats with different systems isn’t an easy task. Ask any healthcare developer; I’m sure you’ll hear horror stories such as single-columned data fields, like birth-date, which can create hell for someone working on an ETL process. Here is an awesome HealthCatalyst infographic that visualizes some of healthcare’s data problems:

Without efficient sharing of data, patients are missing out on essential studies, trials, and analysis. While Drug makers pay hundreds of thousands to hospitals to try and track down patients for clinical studies, patients might be desperately searching at will and without much avail. Why shouldn’t this be a more natural process for patients, and why can’t they benefit both medically, and monetarily without much effort? Patients aren’t in control of their digital data stores. Patient portals govern the digital accounting for patients (with or without their approval). While your credit data is compiled and analyzed into your credit score that follows you everywhere you go, your health data is disarranged and improperly managed.

Master Patient Indexes and Health Information Exchanges are the closest things I’ve seen that address some problems of castled/siloed data. However, they face many of the same data-sharing challenges, and also aren’t immune to our last important buzzword, “security.” 4/5 physician’s offices have already suffered cyber attacks. More massive and centralized databases can leave us vulnerable to breaches at the scale of the last Equifax hack. For those who like more official studies/claims, check out www.hipaajournal.com. The site has many great articles on how serious of an issue cybersecurity is in the industry.

Two beasts still remain when talking about issues with healthcare and data: insurance and regulation. It’s not that they don’t deserve a true spot in this blog, it’s just that the data issues outlined above are the real gut of the problems that blockchain can really start solving. Regulation is definitely an important part, and its clear that the issues above are something everyone wants solved, but government moves slow and sporadically. I think a solution to the problems above would be presented in Government forums and could actually drive legislation forward.

What would the solution look like?

Yes, a “Holy Grail” (full of beer) — At least this is what some are calling blockchain for healthcare. And theoretically, they’re not crazy. If you need a primer on blockchain, here are some brief starters:

I can’t effectively explain blockchain in this blog without it going overboard — So, if you’re truly interested in the development of blockchain for healthcare then you will need to make sure you understand it along with concepts such as “Smart Contracts.” We can move on from here by stating that these technologies offers a consistent, immutable, decentralized, and rule-based solution for the problems described above. Every transaction, or transfer-of-knowledge, is recorded on a distributed ledger that must be computationally & mathematically verified by the blockchain itself. Combining blockchain with a method to store encrypted data could result in something truly worthwhile.

So how could it work for healthcare?

© Datastructr

As you can see, a user in this system would have complete control over their healthcare profile. They dictate who can read and what access another individual may have to their data. Obviously, a primary care physician would want to know as much as possible (and to also add to a person’s health profile), but individuals such as employers or family members might only need to know limited information. Users could walk into any doctors office, emergency room, physical therapist, etc. and immediately be on-boarded into the local system. The user could potentially offer parts of their profile to be queried by interested third-parties, such as researchers or pharmaceuticals. At a global scale, data becomes more reliable and available. Third-parties could formulate big-data analysis, or even provide potential trials to users. It’s not that these things aren’t already happening, but that blockchain offers an efficient, cheaper, and drastically simpler process.

Insurance would have to become a player in this system as well. Currently, health insurance is bloated. Many people pay for coverage they don’t need. A user in the blockchain system could benefit from a smart contract application which analyzes and uses a model to create a cheaper, but more appropriate, coverage plan. This type of application could disrupt the entire health-insurance industry in an unexpected way, though I believe it would be in the best way for users.

The above is just an example of how it could look for a single particular user. The “Holy Grail” aspect of it is the same picture applied to everyone, and for all of healthcare data existing in a single ecosystem that is democratically operated. New applications, models for business, insurance, policy, and big data analysis can all come to thrive on the blockchain. It is a system in which every player, especially the patient, may benefit.

How should it be developed?

Should there be a new cryptocurrency/ICO? Should this be made with enterprise technology? Or open-source tech? Or how about a combination of all these things?

In my opinion, a new cryptocurrency/ICO is the wrong approach to solving the problems outlined. A new coin would need to incorporate extensive smart-contract and other blockchain-based capabilities (ledger, consensus, membership, transactional proofs, etc.). At the point where someone has developed such a thing, then they have built something grander, but more generic than a healthcare-specific solution. They would have created an entire platform and new cryptocurrency, similar to Ethereum (which currently has a market cap around $70B). A healthcare-specific coin with those capabilities doesn’t make much sense, and would be hard to take seriously if it weren't otherwise marketing itself as a platform — blockchain can be thought of in a similar sense as the principles of a car-engine, which is generic enough to be used in all sorts of automobiles. A car maker doesn't drastically change or redevelop the car engine, but rather the parts & body around the engine that make the car unique. A new coin, centered around healthcare, can be developed on existing platforms, and some already are. They market heavily for their ICOs…but so do “Flying Car Coins.” You would need to question the actual motivation of someone trying to develop a currency for niche data-transactions, and how far they could actually take that for the industry.

This doesn't mean that blockchain economics wouldn't play a role in a healthcare solution. I believe that proven smart-contract based currencies/platforms, such as Ethereum, would play a significant part in the financial dealings of a healthcare blockchain, but not the underlying structure.

I believe that the development of underlying blockchain infrastructure is a large enough problem that a one-off team would have trouble creating a considerable solution.

Anyone developing a blockchain solution would be wise to take advantage of what is already available vs. developing a “unique” approach. Capable technologies are actively developed & open-sourced by the enterprise and alike. My favorites are Linux Foundation’s Hyperledger, Microsofts’s Coco, and GemOS. If you spend any time investigating those technologies, you’ll see that all of them are offering “open” solutions. GemOS started as a healthcare-specific platform years ago. They’ve already experienced many pain-points and have sufficient knowledge of how blockchain can work in healthcare. Their platform has apis, integrations with tech such as Hyperledger & Ethereum, and have developed ETL processes that developers could utilize for initial data collection (granted they can establish partnerships with EHRs/health-networks/existing business)... Any new development on these efforts would basically be recreating the wheel.

One big concern will be data at rest. Obviously most data will need to be encrypted and stored in a decentralized way. Smart contracts could possibly be the single-enabler in this fashion. From the Ethereum blog:

We create an obfuscated smart contract which contains a private key, and accepts instructions encrypted with the corresponding public key. The contract stores account balances in storage encrypted, and if the contract wants to read the storage it decrypts it internally, and if the contract wants to write to storage it encrypts the desired result before writing it. If someone wants to read a balance of their account, then they encode that request as a transaction, and simulate it on their own machine; the obfuscated smart contract code will check the signature on the transaction to see if that user is entitled to read the balance, and if they are entitled to read the balance it will return the decrypted balance; otherwise the code will return an error, and the user has no way of extracting the information.

Or a technology specifically made for decentralized storage could be utilized. Smart Contracts will still play an important role in as encryption key holders, but something like IPFS could house and share encrypted data.

These open-source projects and platform offerings are perfect to bootstrap a “backend” for what would then be a patient-centric developmental effort.

What am I focused on developing?

Enterprise, & even B2B, solutions are beginning to hit the market and are the focus of big dawgs like IBM, Accenture, Deloitte, Microsoft, +20 more huge firms. The industry moves slow though, and not always in the right direction for patients. This to me means there is major value-potential to be unlocked.

Since most of the hardcore blockchain work is provided to developers, then that would leave us with creating a solution for patients to willingly and actively utilize — This is the most significant challenge in my opinion. Questions like “Who is paying for it all?”, “Why would the enterprise (Health-Networks, EHRs) want to adopt or integrate?” wouldn’t matter because the patient would govern usage and participation by holding the key to their data.

Any solution that is adopted by a mass user base could end up disrupting the entire enterprise and healthcare landscape without their input. To do this patients & their data must be won over in non-standard ways. I realized that my initial idea of creating a data exchange platform was too naive. This also seems to be the approach that others are taking (along with their own ICO…):

While these applications seem rational, the reality is that they will most likely fail at getting users to engage or participate in a meaningful way. They seem to lack a genuine experience and empathy for users. I believe that a data-exchange could positively thrive in blockchain, but not a specifically focused one in which the user sells aspects their life on a transactional market. Whoever enjoyed paid survey sites, anyway?

My focus is abstracting away any transactional market, and providing an experience that builds trust and engages participation. Patient focus & empathy will always be the most important driving factor, but I think the healthcare focus needs to also be abstracted in order to win over a large user base. Terms like “patient”, “data”, “healthcare” are non-starters for me and any solution I want to develop… but they will definitely come to play a part.

My team is Datastructr, and we’ve worked (with collab of others) on this idea together. Reach out if you would also like to collaborate in anyway.

Dallas and I at the competition

Thanks to Josh Stein, Dallas Nix, and JT for their provided edits

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