So, how is blockchain being used to solve problems in healthcare? What are the benefits and pitfalls of applying blockchain to healthcare?

This is a list and description of white papers that investigate the relationship between blockchain technology and its use in health IT and/or health-related research from the cryptography and underlying fundamentals of blockchain technology, to recommendations for blockchain implementation.

Click here to see the first part of this article: A Collection of Potential Use Cases for Blockchain in Healthcare

This August, the Office of the National Coordinator (ONC) for Health Information Technology in the US set out a Blockchain challenge with the objective:

‘The goal of this Ideation Challenge is to solicit White Papers that investigate the relationship between Blockchain technology and its use in Health IT and/or health-related research. The paper should discuss the cryptography and underlying fundamentals of Blockchain technology, examine how the use of Blockchain can advance industry interoperability needs expressed in the ONC for Health Information Technology’s Shared Nationwide Interoperability Roadmap, as well as for Patient Centered Outcomes Research (PCOR), the Precision Medicine Initiative (PMI), delivery system reform, and other healthcare delivery needs, as well as provide recommendations for Blockchain’s implementation. In addition to a monetary award, winners may also have the opportunity to present their White Papers at an industry-wide “Blockchain & Healthcare Workshop” co- hosted by ONC and NIST.’

As part of the Ideation Challenge, the following papers were the declared winners:

1. Blockchain: The Chain of Trust and its Potential to Transform Healthcare – Our Point of View:

This paper talks about potential uses of Blockchain technology in healthcare including a detailed look at pre-authorization payment infrastructure in healthcare, counterfeit drug prevention and detection and clinical trial results use cases. The paper also highlights what Blockchain is not. Organization:  IBM Global Business Service Public Sector

2. Moving Toward a Blockchain-based Method for the Secure Storage of Patient Records: 

Use of Blockchain as a novel approach to secure health data storage, implementation obstacles, and a plan for transitioning in increments from current technology to a Blockchain solution. The author suggests a practical first step to moving towards a Blockchain enabled world. Here is a suggested workflow by the author from the submission: Author:  Ivan D.

3. ModelChain: Decentralized Privacy-Preserving Health Care Predictive Modeling Framework on Private Blockchain Networks: 

ModelChain, to adapt Blockchain technology for privacy-preserving machine learning. Each participating site contributes to a model parameter estimation without revealing any patient health information (i.e. only model data, no observation-level data are exchanged across institutions).

‘We integrate privacy- preserving online machine learning with a private Blockchain network, apply transaction metadata to disseminate partial models, and design a new proof-of-information algorithm to determine the order of the online learning process. We also discuss the benefits and potential issues of applying Blockchain technology to solve the privacy-preserving healthcare predictive modeling task and to increase interoperability between institutions, to support the Nationwide Interoperability Roadmap and national healthcare delivery priorities such as Patient-Centered Outcomes Research (PCOR).’ Authors:  Kuo T, Hsu C, Ohno-Machado L.Organizations:  Health System Department of Biomedical Informatics, University of California San Diego, La Jolla, CA Division of Health Services Research & Development, VA San Diego Healthcare System.

4. Blockchain for Health Data and Its Potential Use in Health IT and Health Care Related Research:

A look at blockchain based access-control manager to health records that advances the industry interoperability challenges expressed in ONC’s Shared Nationwide Interoperability Roadmap. In this use case, the authors discuss the use of blockchain technology with a data lake for scalability. All medical data would be stored off blockchain in a data repository called a data lake. Data lakes are highly scalable data repositories which can store a wide variety of data, from images to documents to key- value stores.  When a health care provider creates a medical record (prescription, lab test, pathology result, MRI) a digital signature would be created to verify authenticity of the document or image. The health data would be encrypted and sent to the data lake for storage. Every time information is saved to the data lake, a pointer to the health record is registered in the blockchain along with the user’s unique identifier. The patient is notified that health data was added to his blockchain. In the same fashion a patient would be able to add health data with digital signatures and encryption from mobile applications and wearable sensors. Authors:  Linn L, Koo M.

5. A Blockchain-Based Approach to Health Information Exchange Networks:

Sharing healthcare data between institutions is challenging. Heterogeneous data structures may preclude compatibility, while disparate use of healthcare terminology limits data comprehension.  Even if structure and semantics could be agreed upon, both security and data consistency concerns exist. Centralized data stores and authority providers are attractive targets for cyber-attack, and establishing a consistent view of the patient record across a data sharing network is problematic.  ‘In this work, we present a Blockchain-based approach to sharing patient data. This approach trades a single centralized source of trust in favor of network consensus, and predicates consensus on proof of structural and semantic interoperability.’ The authors describe the Healthcare Blockchain as:

‘Because a blockchain is a general-purpose data structure, it is possible to apply it to domains other than digital currency. Healthcare, we believe, is one such domain. The challenges of a patient record are not unlike those of a distributed ledger. For example, a patient may receive care at multiple institutions. From the patient’s point of view, their record is a single series of sequential care events, regardless of where these events were performed. This notion of shared state across entities, inherent to the blockchain model, is congruent with patient expectations. Also, it is reasonable to assume that each patient care event was influenced by one or more events before it. For example, a prescription may be issued only after a positive lab test was received. The notion of historical care influencing present decisions fits well into the blockchain model, where the identity of a present event is dependent on all past events.

Much like the Bitcoin approach, our block is a Merkle Tree-based structure. The leaf nodes of this tree represent patient record transactions, and describe the addition of a resource to the official patient record. Transactions, however, do not include the actual record document. Instead, they reference FHIR Resources via Uniform Resource Locators (URLs). This allows institutions to retain operational control of their data, but more importantly, keeps sensitive patient data out of the blockchain. FHIR was chosen as a exchange format not only because it is an emerging standard, but also because it contains inherent support for provenance and audit trails, making it a suitable symbiotic foundation for blockchain ledger entries. FHIR in conjunction with the blockchain can serve to preserve the integrity and associated context of data transactions.’

A Blockchain-based approach to sharing patient data that trades a single centralized source of trust in favor of network consensus, and predicates consensus on proof of structural and semantic interoperability. Authors: Peterson K, Deedvanu R, Kanjamala P, Boles K.
Organization:  Mayo Clinic

6. Adoption of Blockchain to Enable the Scalability and Adoption of Accountable Care:

A new digital health care delivery model that uses Blockchain as a foundation to enable peer-to-peer authorization and authentication.

The recent trends in Accountable Care based payment models have necessitated the adoption of a new process for care delivery that requires the co-ordination of a “network” of care providers who can engage in shared risk contracts. In addition, the need for sharing in the savings generated equitably is key to encourage the network providers to invest in improved care paradigms.

Current approaches to digitize healthcare focus on improvement of operational efficiency, like electronic records as well as care collaboration software. However, these approaches are still based on the classical centralized authorization model, that results in significant expense in implementation. These approaches are fundamentally limited in their ability to fully capitalize on the peer-to-peer digital work- flow revolution that is sweeping other segments of industry like media, e-retail etc.

In this paper the author formulates a new digital health care delivery model that uses block chain as the foundation to enable peer-to-peer authorization and authentication. The author will also discuss how this foundation would transform the scalability of the care delivery network as well as enable payment process via smart contracts, resulting in significant reduction in operational cost and improvement in care delivery.

In addition, this block-chain based framework can be applied to enable a new class of accountable tele-monitoring and tele-medication devices that would dramatically improve patient care adherence and wellness. Finally, the adoption of block chain based digital-health would enable the creation of verifiable “personalized longitudinal care” record that can form the basis of personalized medicine. Author:  Prakash R. 

7. A Blockchain Profile for Medicaid Applicants and Recipients: 

A solution to the problem churning in the Medicaid program that illustrates how health IT and health research could leverage Blockchain-based innovations and emerging artificial intelligence systems to develop new models of health care delivery. The solution envisions a Smart Health Profile by thinking of the blockchain profile simply as a broker that can answer questions about you as the need arises, your identity remains distributed. No one can ever see everything about you at once, including yourself.

What makes the profile smart is that the services it provides can be quite intelligent. It can make sophisticated queries and actually trigger an action when certain conditions are met. For example, suppose you had a smart drug dispenser that recorded every dose you take as a transaction on the blockchain. A profile service might check every day to see if you’ve taken your pill and automatically order a refill when you’ve used up all the pills. Over time, however, an AI service might become much more sophisticated to use a combination of information about your vital statistics from your wearable device and population studies of people using the various medications for your condition and either recommend a different regimen to your physician or simply cut out the middleman and direct your pharmacist to deliver you a new prescription.

The solution goes on to discuss the use of Blockchain in a medicaid scenario and a much more comprehensive solution as a distributed infrastructure for health. Authors:  Vian K, Voto A, Haynes-Sanstead K.
Organization:  Blockchain Futures Lab – Institute for the Future 

8. Blockchain & Alternative Payment Models:

Blockchain technology has the potential to assist organizations using alternative payment models in developing IT platforms that would help link quality and value. Author:  Yip K.


The content provided in the examples above have been collated from the various submissions to the ONC’s Blockchain Ideation Challenge. You can write to me or connect with me, in case you are interested in receiving the copy of the documents.
Alternatively, you could follow the links here
You can also review the various articles on Blockchain on the HCITExpert Blog.

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