Continuing our series of conversations with healthcare thought leaders about the burgeoning world of blockchain technologies, Medgadget spoke with Chief Technology Officer of the Nicholson Center, Dr. Roger Smith. The Nicholson Center is a medical research and training center founded in 2001, which operates within the Florida Hospital network. Dr. Smith has been researching blockchain in healthcare and has spoken about how blockchain technology has the potential to impact billing and insurance, drug verification, research distribution, and electronic health records. Notably, Dr. Smith has made an effort to demystify the complexity around blockchain technology with intuitive analogies and a clearer vocabulary to which the average lay person can relate.
Michael Batista, Medgadget: Dr. Smith, thank you for taking the time to shed some light on blockchain technology and its applications in healthcare. To start, can you tell us a little about your background and work at the Nicholson Center?
Dr. Smith: The Nicholson Center is an education and research facility that is best known for our work in robotic surgery. We provide the initial training in robotics for about 1,000 surgeons a year and a much wider array of skills to another 10,000 physicians and surgeons annually. My work is research into the application and effectiveness of robotic devices and training simulators by these surgeons.
In one study for the Department of Defense we explored the potential to conduct robotic telesurgery between US hospital facilities using the existing IT infrastructure. We measured the communication latency that would be experienced between two hospitals located in the same city, then across a state, and finally across the country. We found that communication latency for the data being transferred within our own hospital networks in the same city was just 5 milliseconds. For two hospitals across the state of Florida it ranged from 75 to 200 milliseconds and the same for test intrastate. Then we measured the impact of various levels of latency on experienced robotic surgeons. We found that they were unaware of latency below 200 ms, able to compensate rather well for latency between 200 ms and 500 ms, but struggled when the levels rose above 500 ms. So, it looks like the current communication networks in the US could support safe telesurgery if it were needed and available. That is just one example of the studies we have conducted with robots, simulators, and IT networks.
Medgadget: I know you recently spoke at the Digital Healthcare Innovations Congress in Boston where you broke down blockchain for the average individual to understand. Could you share the analogy for blockchain you used there and help set the scene in terms of what is blockchain technology?
Dr. Smith: The audience in Boston was composed primarily of hospital administrators who were leading business expansion efforts involving new technologies. Of course, they had heard the hype about blockchain, but were still mystified by what it actually was or could do. So, my analogy was from one of the many water parks that we have in Orlando.
Visitors experience all of the exciting water slides, wave pools, and lazy rivers where the water moves and splashes them around. But there is an invisible infrastructure of pipes, pumps, and computers that the visitors never see that make the entire park function. Blockchain is one piece in a hidden infrastructure like a water park. Just as new pumps and machinery make new water rides possible, blockchain enables new business services across the global reach of the internet. Users of these services may be aware that a blockchain is involved, but they will never know how it actually works, nor will they need to. Gradually users will come to understand that something has made the exchange of valuable information via the internet much safer, at much lower operating costs. Just as it took a few years for all of us to trust the internet with our credit card numbers, we will gradually learn that it is safe to trust blockchain applications with other valuable digital objects. These might be the titles to our automobiles, records of ownership of stocks and bonds, or our professional licenses. We will be able to sell our used car to a stranger, receive guaranteed payment, transfer ownership via a blockchain and never need a paper title that is certified by the DMV. The blockchain can be trusted to prove ownership just as via a government office.
Blockchain is a trusted broker for anything that can be represented as a digital file that needs to be recorded and exchanged between people who do not know each other well enough to trust each over. It was created for bitcoin and other digital currencies, but we are realizing that society is full of transactions involving digital files that have real value just like a bitcoin, such as a car title, that can be handled by a blockchain just as it does with bitcoin.
Medgadget: Now that we have a sense of what blockchain technology is, how does it apply to healthcare?
Dr. Smith: Since blockchain is used to protect and exchange digital objects of value between parties that are not part of the same trust circle, we should look for healthcare situations that resemble this. Remember that blockchain is still very new and is still structured for just a few specific business cases. It still needs to evolve to fit most problems that appear in healthcare.
Currently there are hundreds of healthcare organizations, consulting firms, and digital systems integrators that are looking at applications in the healthcare space. These organizations have identified a set of core applications that seem to be well formed for a blockchain solution.
The first will probably be a tracking system for pharmaceuticals and medical devices. Blockchain can provide a record of the provenance of these products from the manufacturer all the way to the final consumer. Such a record can play a valuable role in curtailing counterfeit products and theft. Today, it is possible for counterfeit or stolen drugs and medical devices to be sold into certain weak points in the supply chain. This is of tremendous concern to the manufacturers and consumers alike, even if these products are a perfect chemical formulary or fully functional device. A blockchain record would require that each device or lot be traceable back to its origins. With a blockchain the validation of the product can be carried out in minutes and is 100% reliable and unforgeable. A supply chain bridges multiple companies where the participants do not know each other well or trust each other completely, which is exactly the environment that blockchain was made for.
A second application is in processing insurance claims that fall across multiple service providers. This blockchain would include all of the injury claims, conditions, expenses, and current actions on a claim. Parties privy to the contents of this chain can all see what has happened and how it is being handled, including the patient who is usually very much in the dark on their own claims. The blockchain will provide a level of transparency that does not exist today. The current opaqueness of the claims process is a problem for everyone involved in the transaction. Insurance companies are primarily concerned with ensuring that a claim is valid, being handled within the terms of the contract, and not an instance of fraud. Accomplishing all of this with traditional systems is very labor and time intensive. Blockchain solutions should be able to reduce the processing costs for these claims, while also speeding up settlements. It is a win-win for all parties involved.
Finally, the most beneficial and most difficult application is in handling a patient’s protected health information (PHI) that currently resides in multiple disparate and barely interoperable Electronic Health Record (EHR) systems. Blockchain idealists envision a future in which a healthcare blockchain exists separately from the medical providers, like other internet services. In this picture, the patient subscribes to a record service online and holds the keys to the data on that chain. Then, every time they visit a medical provider, the patient provides a public key to the provider which allows them to access past medical data and to post a new record on the chain. In this design the patient has ownership, access, and control of all of their own medical data, which they do not have with today’s systems. It would enable better care and give the patient more power in choosing where to go for services. That is a beautiful picture and it may be a reality someday. But the path from where we are today to something like that is long and complicated. There are many baby steps to be taken before we could arrive there.
Medgadget: Where are we in terms of blockchain technology adoption today in healthcare and in general? I understand that the fintech sector is moving more rapidly in terms of implementing blockchain-based applications, with healthcare, not unexpectedly, lagging behind.
Dr. Smith: Fintech has moved much more rapidly because they can see the direct parallels between trading bitcoins and trading traditional stocks, bonds, and derivatives. All are digital objects with value that need to be exchanged between parties that do not know each other. In the past, the entire fintech sector has served as the trusted layer between the buyer and seller. But now a blockchain service can replace much of the trust that brokers provided. So, it is clear that fintech is about to be disrupted in a big way by blockchain. When buyers and sellers can trust the software infrastructure to exchange ownership in stocks and bonds, what do they need a broker for? Add smart contracts to the mix and that enables even more complex financial transactions on a blockchain without the broker as a middleman.
Healthcare has a very different structure in its relationships and data. Blockchain and bitcoin are not immediately a perfect fit, but they do point to designs for customized systems that can handle patient data or the credentials of clinicians. Healthcare systems and startups are all looking for implementations that are safe to pilot and that offer advantages over the current business processes.
In 2016, IBM surveyed healthcare executives and asked them when they thought a blockchain system would be operating within their organizations. Sixteen percent of them believed they would be using it by 2018. We have arrived at that destination and, to my knowledge, there have not been any major blockchain implementations in healthcare. Optimism and media hype got the better of those executives, it was just too early for anyone to make a reliable prediction.
Medgadget: At Medgadget, we’ve recently spoken to companies seeking to leverage blockchain for things like patient verification, prior authorization, genetic sequence documentation and sharing, and even tokenizing cannabinoid products. Any thoughts on some of these applications of blockchain technology?
Dr. Smith: Those are all interesting applications. Patient health records are one of our most valuable digital products that healthcare systems possess, and one of the most complex. As a patient, you may have noticed that when you visit a doctor, every office posts your results to an EHR and every one of them is using a different system. Even within large healthcare networks and systems, there are multiple EHRs in use because those systems got large through multiple acquisitions, each of which had its own legacy EHR. In this picture, literally no single organization has the ability to access all of the medical data about a specific patient. The patient can’t do it, the physician practice can’t do it, the hospital can’t do it, no one can do it.
A very powerful application would be in unifying all of the disparate records that exist within a large healthcare system where a single IT team has the ability to actually work on the problem from every angle. Hospital systems know that thousands of patients have multiple records in their IT systems, but they do not have a means of unifying those. A blockchain is one place where references to individual medical records can be collected for each patient. Such a chain might begin as a layer above all of the EHRs that store the actual records, it would just contain pointers and enough metadata to make it possible to traverse the chain and identify records of interest to the clinician who is about to deliver treatment.
From the perspective of the blockchain idealist, this application misses the point of giving patients control of their own data and it does not provide the cryptographic security that is inherent to real blockchain storage. But it does address a real problem that exists in the current EHR environment, one that healthcare networks are seeking solutions for right now. Once a system can find and unify the records of its patients, it is in a position to provide better and cheaper care. Eventually this modest start might grow into something with more patient empowerment and ownership.
Medgadget: Are there any specific examples of healthcare organizations or companies using blockchain technology in a way you find particularly compelling?
Dr. Smith: Hashed Health is supporting a project called ProCredEx (Professional Credential Exchange) on which all clinicians, doctors, nurses, and technicians, can post the professional credentials that allow them to provide specific healthcare services. When a clinician is hired into a hospital or clinic, the new employer has to verify all of that person’s professional credentials, a process that can take months. During this time, the clinician is not able to perform some of these services, so there is significant cost for every day that this process takes. ProCredEx would keep a current record of all credentials and an employer could verify those records in minutes, allowing a clinical employee to become fully productive almost immediately. This system would provide immediate value with little or no risk to the healthcare system. Focused projects like this are a great start and will allow us to become comfortable and proficient with the technology.
Imagine a blockchain service that unifies data that is collected by multiple health trackers and sensors. This service might contain the data from your cell phone step tracker, FitBit, Garmin GPS watch, Strava, blood oximetry, food consumption, and all of the minutia of your daily physical actions. That is real “health data”, as opposed to hospital visits which are actually “sickness data.” Understanding what people do with and to their bodies all day every day would be very powerful in prescribing better behaviors and diagnosing the triggers that cause a sickness.
Medgadget: Is the hype real? Is blockchain technology going to be the next big thing in healthcare technology? Is it going to be a flop, or are we going to land somewhere in the middle?
Dr. Smith: The hype around blockchain is off the charts. We hear the term applied to absolutely every kind of data storage and exchange process. There have been statements like, “blockchain will be bigger than the internet,” which is just insane. This technology is starting up the roller coaster ramp of the Gartner Hype Cycle graph and it will come swooping down into the trough of disillusionment as people realize that it is not the solution to every problem their organizations face. But while that shakeout is happening, real applications will be built that will solve some of the real problems described earlier. It is going to make a positive contribution to a number of healthcare processes, and will enable new businesses that don’t exist today.
Medgadget: Thank you again for your time Dr. Smith. To close, what do you think the next few years will hold for blockchain-based healthcare applications and/or healthcare innovation in general?
Dr. Smith: Just as we saw an explosion in fitness trackers a few years ago, blockchain is going to power the creation of new data collection and exchange services that are impractical today. Many of these will be very simple, but very useful. They will bring blockchain into peoples’ lives in an invisible form. People will benefit from the apps and not really understand or care how the blockchain enabled them.
I have not seen much discussion about the conflict between the nature of blockchain and the recent European GDPR regulation. One of the tenets of GDPR is that a customer has the “right to be forgotten” upon request. But one tenet of blockchain is that nothing that is placed on the chain can ever be removed or erased. How are these two going to coexist?
We are about the reach the crest of the Gartner Hype Cycle rollercoaster, so get ready for the plunge down the other side. It is not a sign that blockchain has failed, merely that the global hype is being shaken off so the really valuable business applications can be created.