Blockchain in Healthcare – Cautiously Optimistic

Blockchain as a technology is still in its infancy, however some wide known success story (including Cryptocurrencies namely – Bitcoin) has got it necessary attention of business and technical community. As Blockchain technology evolves, new business cases will emerge for Blockchain to solve some of the complex industry problems. Blockchain revolutions is being compared with Internet revolution few decades ago which changed the face of many industries and businesses forever. Blockchain captured the imagination of Banking & Financial services (BF&S) industry first; All major Financial corporations are experimenting with Blockchain to reimagine processes by removing many existing frictions in workflows and taking the benefits to the customer. Given the buzz around this technology, Healthcare industry has also been seriously thinking of use cases which could be ripe for optimization and disruption by Blockchain. Two of the most famous use cases you will find everyone talking about are “storage/access of electronic medical record” and “interoperability”. Internet is full of reports and research papers on how Blockchain can finally achieve the holy grail of healthcare “interoperability” of medical records and clinical data. I came across this use case about a year ago; From the start this use case has been puzzling me. Can the great promise of trust, openness and speed that Blockchain brings be harmonically aligned with the inherently closed nature of Healthcare IT systems? And therefore, my cautious optimism.

However, before I go and explain my position on the subject let me try level set for readers with non-IT or non-healthcare background. And I promise to keep it less geeky and less boring. Just survive next 2 bullet points. If you are familiar with basics of Blockchain and interoperability problem in USA healthcare IT systems, feel free to skip below two paragraphs.

What is Blockchain? – Blockchain is a digital, distributed transaction ledger, with identical copies maintained on multiple computer systems controlled by different entities. Decentralized Servers, or nodes maintain the entries (known as blocks) and every node sees the transaction data stored in the blocks when created. There is no central authority required to approve transactions, no single point of failure or Outage. The database is an immutable & irreversible record and hence transactions are trusted by every participating node.

What is interoperability problem in healthcare? – Interoperability is a very broader term and works at many levels in USA healthcare system. However simply put, it means patient electronic medical records should be shared between different care Providers, Hospitals and care delivery entities so that efficient coordinated care can be provided at lower cost. So, if a patient goes to hospital A for some medical condition and undergoes few lab tests, his medical records and test results should be available to Hospital B when he goes to another doctor for some other or same medical condition. For this efficient exchange of information, EMR (Electronic Medical record) system of Hospital A should be integrated with EMR system of Hospital B. This will reduce lots of duplicate care and provide a holistic coordinated care to patient; much better than each doctor working in silos which can risk lives at times.

Phewww… If you have survived till here, accept my thank you. It will get easy from here. No more boring definitions…

How will Blockchain solve interoperability? – Out of many theories formulated, one of the major theory suggests -- Instead of keeping electronic record in hospital's private IT system within wall (or keeping in the physical file), every providers/doctors/care givers will start putting information on Blockchain. There you have - an omnipresent medical record accessible anywhere anytime, which no one party can temper but all parties can access obviously with patient’s permission (private key)... Pause for a second… Just read last two sentences again (in italics font) and you will start seeing a cloud of caution floating over booming optimism… Entire theory is based on the assumption that different stakeholders will start putting electronic records on Blockchain which currently they store in EMR systems or in physical files. Pretty simple stuff, right? This level of record exchange might sound simple common sense but this is not reality in USA Healthcare. Not only two different hospitals do not share information, there are cases where different departments of hospital also do not have efficient medical record exchange in place.

And it is such a high stake and complex problem that every time some discussion starts it ends up becoming a giant blame game – Providers are blamed not to share information so that they can keep patients in their networks only. Some providers claim that sharing medical records also exposes their competitive advantage. Many providers still do not see a reason why they should go electronic at first place. EMR vendors (likes of EPIC, Cerner, Allscripts of the world) are blamed to keep their software system closed, again to keep hospitals locked to them by making transition to competing EMR vendor complex and costly affair. EMR vendors says we do what our customer (Hospitals) want us to do. Insurance companies have some other incentives to not participate in All payer claims database(APCD)… So on and on and on and on… bottom line is - although the idea of interoperability is such a noble idea, the incentives of different stakeholders are not aligned and hence any attempt dies before its takeoff, except few successful examples in pockets here and there.

Now since everyone is hailing Blockchain to be the panacea of this deep problem in USA healthcare, I thought of getting my head around it. And hence my optimism surrounded by caution. Let’s talk about Optimism first – Blockchain no doubt has potential of bringing incredible value to inefficient transactional system which has multiple parties involved. Sometime a complex and evolving technology can solve problem which we cannot even imagine and hence giving the benefits of doubt to a new technology will not hurt anyone.

And then let’s talk about Cautious part. First of all in healthcare, any new technology specially on care delivery side needs to have enormous adoption challenge just by design. Care delivery such as doctor seeing a patient, surgeon doing knee replacement etc… is different than front end user experience such as booking an appointment, doing insurance eligibility check or backend process like claims processing, denial management. Technology to be used during care delivery will always be judged (and rightly so) with a higher scrutiny and standards. Second (in my view is more critical) reason is -- a new technology can solve a “technical” problem, technology will be handicapped in solving a problem which in reality is an “economical” or “behavioral” problem. I am not suggesting that Blockchain cannot be used in Healthcare, I agree many useful cases will evolve. My only submission is that marrying the hottest technology to biggest problem without considering the business context might not last.

In our current example, Interoperability is a challenge not because technology is inadequate, if all stakeholders agree to share information they can do it very much with existing internet technologies. The problem is all stakeholders do not have enough incentives to cooperate; this is a classical game theory problem. To understand this better, imagine a small neighborhood with 4 families. If these 4 families do not want to talk because of XYZ reasons, invention of landline phone and then mobile phones will not make them start talking. First they have to have enough motivation or incentives to talk(or may be strong disincentives for not talking), and once you have incentives aligned, no technology will be needed, a simple opening of window will suffice to make the conversation happen. Telephone just makes their conversation more efficient. Look at another example of technology adoption - All of us might have used video chat some 15-20 years ago, however video visit to doctor is still not a reality in most part of USA healthcare (except few successful examples such as Kaiser Permanente being an integrated system or new digital native insurance company such as Oscar). It’s not when technology becomes better and mainstream, it’s much more complex in Healthcare specially when it comes to care delivery.

Federal government has tried incentivizing various stakeholders in past with initiatives such as payment for Meaningful use of EMR systems few year ago, incentivizing ACO via Obamacare, some of the provisions of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and push to value based care. Changes to physician workflow and new models of care – working in parallel with technology such as EHRs, patient portals and care management tools – are necessary for interoperability to be fully achieved. More of a business model change than a simple technology change. But then “have patience, its healthcare”.

Last week I went to see a doctor for allergic infection in my right eye. This hospital is one of the big hospital in bay area (just to highlight that interoperability has nothing to do with rural-urban divide). Once the doctor was done with the diagnosis and explaining me the treatment, he pulled a prescription pad and pen and wrote the prescription. Being in healthcare IT for few years now, I could not stop wondering what happened to “e-prescription” which is a basic module in most of the EMR system and not very complicated (fortunately, after experiencing the result of medication he prescribed, I do not even care about electronic prescription - Did you just say "Customer expectation"?). If a big hospital in Silicon Valley doesn’t see a value of electronically sending prescription to the pharmacy, it would need a killer salesman to explain this hospital that Blockchain is not some metal chain to be physically tied around computer. After saying parting goodbye to doctor, I folded the prescription paper and kept in my left pocket and said in my head, slowly, “Dear Blockchain, please pack some extra bottles of water and few snacks bar… You are up for a very very long journey on the street of interoperability… Possibly pack first aid box also, the road is not going to be smooth”.

Agree? Disagree? I welcome your comments/feedback.

Disclaimer – Views are personal, no association with any current or past professional affiliations.