Few technologies have been as widely heralded for their potential to solve some of the major challenges IT systems face in healthcare as blockchain. While healthcare has just started to explore the technology, there is some pioneering research work now under way.

Blockchain’s core technology underlies the Bitcoin cryptocurrency; it’s a data structure that can be time-stamped and signed using a private key to prevent tampering, according to the Office of the National Coordinator for HIT. In healthcare, blockchain is envisioned as a solution—among other applications—for protecting, managing and exchanging electronic health information.

Chrissa McFarlane
Chrissa McFarlane

However, skeptics contend that it would take enormous processing power and retooling that would far exceed any benefits derived.

Under the blockchain “distributed ledger” paradigm, when changes are made in one copy of a distributed ledger, each copy held in every other location is simultaneously updated. As a result, in theory, health records can be stored securely in a ledger clinicians, patients and payers can trust, providing instant access to an agreed upon set of data.

It’s this concept on which blockchain startup Patientory created a healthcare app that lets users create a patient profile to keep track of their health history, giving patients an easy-to-use method of tracking doctor visits, medical bills, personal medical information, insurance, immunizations and pharmacy medications.

“We’re one of the first companies to actually introduce blockchain into healthcare,” says Chrissa McFarlane, the company’s CEO. “We’re using the infrastructure to bridge siloed electronic medical record systems. It’s an app for patients so they have access to their own health information.”

McFarlane is urging the federal government “to get behind a blockchain-enabled national IT health system and at the same time help to remove legal obstacles in the movement of data amongst providers.”

“Blockchain is very nascent,” acknowledges McFarlane. “Bitcoin was introduced in 2009 and did not have a mass-scale following until 2012, when the underlying blockchain technology for Bitcoin began to be used by the financial services industry. In the past five years, IT has opened up to other industries such as supply chain management, real estate and now healthcare.”

Security capabilities

In particular, she believes blockchain could eliminate the possibility of having healthcare data encrypted and held for ransom by cyber criminals, such as the recent global WannaCry ransomware attack that devastated the National Health Service in the United Kingdom as well as hundreds of thousands of computer systems worldwide.

“If they had a blockchain-based infrastructure, WannaCry would not have happened,” asserts McFarlane. “The only barrier is really education and knowing how the technology works. That’s the biggest barrier because it is an emerging technology.”

However, Avi Rubin, director of the Health and Medical Security Lab at Johns Hopkins University, doesn’t see how blockchain would be useful in preventing ransomware attacks like WannaCry.

“Ransomware exploits vulnerabilities in software on an end system; nothing about blockchain would prevent these types of attacks from succeeding,” Rubin contends. “Furthermore, ransomware encrypts victims’ data, and if there are no reliable backups, then the information is going to be held hostage, and I don’t see how blockchain would help.”

Blockchain technologies could be used to help the attackers, he adds, in that it provides a mechanism whereby the victims could pay the attackers. “In fact, anonymous e-cash, such as the zero cash system, could be used to facilitate that,” says Rubin. “While blockchain might support the ransomware business model and make the whole attack viable, it does nothing to aid the potential victims.”

Likewise, Kaveh Safavi, MD, senior managing director for Accenture’s global healthcare business, doesn’t believe blockchain technology would have prevented the recent global WannaCry ransomware attack.

“I don’t see that connection at all,” he says. WannaCry “wasn’t a theft of information in transit—or anything close to that; it was an operating system piece of malware—how would a blockchain stop malware?”

Framework needed

Blockchain has inherent qualities that provide trust and security, but it is not a technological panacea for all that ails healthcare when it comes to cybersecurity, believes Debbie Bucci, an IT architect in ONC’s Office of Standards and Technology.

“When I look across other industries, I don’t see any of them really aggressively adopting it,” says Bucci, whose primary focus is on the privacy and security aspects of health information exchange. “There’s a lot of proof of concepts, pilots and use cases being defined. But, I have yet to see major companies stepping up to support blockchain—beyond Bitcoin, of course.”

According to Bucci, ONC continues to keep a close watch on what develops in the marketplace when it comes to blockchain, which is still evolving and maturing, especially with respect to its applicability to healthcare.

“It’s just way too early to lock into what we think,” says Bucci, who adds that there are significant hurdles that must be overcome before widespread adoption is possible in healthcare. “There will be a number of digital ledger technologies, and that itself becomes an interoperability issue. They are just working on techniques now in how you talk cross-chain and off-chain. There’s a lot of work there still to be done.”

When asked if ONC should play a significant role in helping to create a nationwide blockchain network for electronic patient records and establish a framework for early adopters, Rubin responds, “There are probably higher priorities for healthcare right now, but this would not be a bad thing.”

Nonetheless, Safavi believes that such a blockchain framework is better suited coming from the private sector.

According to Safavi, blockchain needs “some kind of governance around it—there is no formal governance.” Toward that end, he points to Hyperledger, a voluntary open source association created to advance cross-industry blockchain technologies. “They recognize that some process needs to occur in order to actually use a distributed ledger for something meaningful.”

In October 2016, Safavi notes, Hyperledger launched a working group dedicated to exploring appropriate applications for blockchain technology in the healthcare industry. By having technical and business-level conversations, the group—which includes participants from Accenture, Gem, Hashed Health, IBM and Kaiser Permanente—intends to help the industry adopt open source blockchain technologies and realize its full potential.

“We have this challenge of advancing the technology while still trying to understand what the rules of engagement are going to be,” Safavi says. “A classic example right now is the domain of blockchain, the concept of a distributed ledger—it seems like it has lots of utility, but within a distributed ledger concept, there still has to be a certain authority because there is an ultimate provenance for the information that controls certain things. How you go about creating that is not clear. So what you see right now are consortiums being created of organizations trying to figure out this problem.”

Simple transactions

Initially, the working group—which does not require Hyperledger membership—will focus on fundamental distributed ledger applications.

“We have some individual pilots going on, mostly around its application in the payments process,” says Safavi. “Blockchain by its current nature works better for smaller amounts of information. Chain of custody for payments seems to be a really good place. There is this belief that blockchain might be a viable method of transport for electronic health records. But, the problem is that blockchains—because of the complex computation—can really only contain relatively simple information. And, you can’t convey a medical record with the current blockchain technology. So, people are thinking that maybe it’s the identity part of a record—sort of a federated medical record and authentication around access that a blockchain would be useful for, not the record itself.”

For its part, the government of Estonia is leveraging blockchain to secure its citizens’ medical data. Estonia’s eHealth Authority has signed a deal with software security vendor Guardtime, which developed a digital signature system based on blockchain technology, to secure the health records of more than a million Estonians.

“We’re keeping a close watch” on Estonia,” comments ONC’s Bucci. She makes the case that the country is a “small state that standardized on one specific flavor of blockchain,” adding that it’s too early to speculate on what the implications might be for similar use cases in the U.S. healthcare system.

Far-reaching possibilities

Last year, ONC announced winners of its blockchain challenge, which garnered more than 70 white papers submitted by individuals, organizations and vendors. Ultimately, the agency picked 15 winners, including submissions from Accenture and IBM—both members of Hyperledger.

Accenture’s proposal was for blockchain technology solutions that “can support many existing healthcare business processes, improve data integrity and enable at-scale interoperability for information exchange, patient tracking, identity assurance and validation.”

IBM’s Global Business Service Public Sector submission included potential uses of blockchain technology in healthcare, including a detailed look at healthcare preauthorization payment infrastructure, counterfeit drug prevention and detection, and clinical trial results use cases.

“The power of open source is the power of collaborative ideas,” says IBM Blockchain Product Leader Merve. “The Hyperledger Healthcare Working Group enables healthcare enterprises, providers and users to focus resources on a scalable open source project to leverage collaboration. The beating heart of the emerging healthcare blockchain will be powered by Hyperledger enabling data sharing, privacy and interoperability.”

Says Safavi, “Right now, the use cases for it are still being discovered, and so I’ve described blockchain as still being in research and development.”

There are so many potential use cases for blockchain technology to support healthcare, he adds, “We think probably payment will go first, and then there will be some R&D and evolution before we figure out exactly how to use it in other places.”

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