The Blockchain in Healthcare
The blockchain is an idea centered around the concept of a secure, digital ledger system that provides a system for efficient, auditable transactions of almost any type between entities . All information related to blockchain transactions is at once both independently verifiable by all (even outside) parties as correct and also inscrutable to entities without explicit permission. The first and probably most well-known implementation of blockchain technology is Bitcoin , but there has been a massive expansion of blockchain use-cases since Bitcoin's initial introduction.
- 1 What is the Blockchain?
- 2 Security
- 3 Potential Use Cases in Healthcare
- 4 Other Blockchain Use Cases
- 5 References
What is the Blockchain?
First, it should be clear that there is no one blockchain to rule them all. "The Blockchain," as it is often referred, really is a concept of a series (chain) of interrelated sets (blocks) of encrypted information. Hence a chain of blocks, or blockchain. There are many such blockchains in existence, and one could choose to do transactions on any one of them or create a new blockchain.
An important aspect of most blockchains is that they are designed to be maintained on a distributed network of multiple nodes. Each node holds a complete copy of the blockchain and adds each sequential new block as it is created. This system allows every transaction on the blockchain to be verified by any or all of the nodes in the network, and also makes it very difficult for the information held in the blockchain to become lost or unavailable if any one or even most of the nodes go offline.
Transactions that are set to be added to the blockchain are added to the newest block as soon as it is created. This makes the continued existence of the blockchain dependent on the creation of new blocks. There are several main methods for the creation of new blocks on the network, and the choice of method depends somewhat on the purpose of the blockchain in question. Bitcoin, the first cryptocurrency, uses a method called Proof of Work, but there are at least two methods currently in use:
The blockchain has moved beyond simply processing transactions of cryptocurrency such as Bitcoin. Any data that can be encoded into a cryptographic hash can be added to a blockchain. Various different ideas have been proposed, and I will not attempt to list them here, but they are wide ranging.
Blockchain Development Groups
Certainly a non-exhaustive list . . .
Potential Use Cases in Healthcare
Though there has yet to be a breakthrough report or use-case for blockchain technology in healthcare, there are many potential ways that the blockchain could be implemented within the current healthcare structure. Any list will likely be incomplete, but these examples represent some of the published and available literature on blockchain implementations in health.
- UPDATE - The Office of the National Coordinator (ONC) Tech Lab issued a Blockchain Challenge in July, 2016.
- The list of submissions and awards can be found here
- Some of the descriptions of potential Blockchain implementations in healthcare below are based on submissions to this challenge.
Health Information Exchange (HIE)
One major area that blockchains may be able to facilitate is the secure access to and communication of patient health records between individuals and institutions. There have been multiple white papers published on the topic, including groups from the Mayo Clinic  and MIT  who described a system for patient information exchange based on blockchain technology that would allow patient-controlled access to records across institutions using HL7 Fast Healthcare Interoperability Resources (FHIR), JSON, or other encoding system. In these models the actual health care data are not encoded in the blockchain, but are merely references pointing to where the data reside, such as at institutions or in a "data lake" . Similarly, a group out of China described an app called Healthcare Data Gateway (HGD) that allows patients to view and directly control rule-based access to their health records with a smart phone interface and authentication provided by a blockchain network . These ideas support the concept of patient-owned medical data, and would have the effect of decentralization of medical records in ways that are as yet undetermined.
Health Research Integrity
Academic research is a major driver of advances in health care, but in the setting of limited funding and publication pressures on researchers significant concerns have been raised regarding research integrity. Organizations such as ClinicalTrials.gov and others have been developed to help drive researchers to define endpoints and analysis prior to conducting clinical trials and other studies. As it represents an immutable, verifiable record of events and transactions, the blockchain has been proposed as a potential decentralized resources for helping to ensure biomedical research integrity. Benjamin Carlisle, followed by several researchers from the UK, proposed in 2014 that researchers could use the blockchain to record pre-specified aspects of their projects, including the study design, analysis plan, and data structure, among others, which could later be verified by consumers of the literature to decrease bias that may be introduced in post-hoc analysis. The blockchain also offers the potential ability to verify the integrity of actual research data and analysis by outside observers, even if the data themselves are not made publicly available. These types of implementations may lead to improvements in both the integrity of biomedical research as well as bolster public trust in medical research.
Personal Health Records
This concept dovetails with the idea of HIE using the blockchain, but focuses more on the secure maintenance of a personal health record (PHR) by patients. No production PHR has been released based on this technology, but concepts such as MedVault  use alternative blockchains such as Colu to store patient data directly on the blockchain. Others such as eHealthWallet have also developed prototype PHRs based on the blockchain. Patients could then share or authorize doctors and other health entities to access and modify their data.
Storage of Health Care Data
Most of the previous examples use the blockchain not as a direct data storage medium, but instead as a secure reference point for identities, access, and data locations. At least one group from a company called Tierion, which partners with the Philips Blockchain Lab , has produced a concept called Chainpoint, which proposes to use a Proof of Existence concept and Merkle Roots to efficiently store actual patient records on the blockchain without imposing excessive transaction demands on the system.
Other Uses and Future Development
- Drug and Pharmacy Verification - VeriPharm has developed a proof of concept that would help track and verify pharmaceuticals from the raw materials to the final product administered to patients.
- Appointment Scheduling on the Blockchain - dhva-apointment-blocks
- Care Coordination - Projects such as simplyvitahlth are geared toward coordinating care between multiple providers and at different institutions to ensure that complex care pathways are being followed appropriately.
There are many more potential use-cases for blockchain technology within healthcare, and undoubtedly we will continue to see development in this area in coming years. In fact, in 2016 a consortium of sponsors led by Gem (Whitepaper) held the first healthcare oriented blockchain conference, Distributed: Health in Nashville, TN. As the healthcare blockchain community grows, gatherings such as these will likely increase and blockchain technologies will increasingly be introduced at major medical conferences.
Other Blockchain Use Cases
Bitcoin (BTC) was the first cryptocurrency based on the blockchain, and was developed by someone calling himself Satoshi Nakamoto. The protocol was introduced in 2008 after the publication of a white paper describing the algorithm and the mechanisms for generation and distribution of BTC. At this point there are hundreds of cryptocurrencies in circulation according to Wikipedia, many of which are based on the Bitcoin blockchain, but only a few have gone into widespread use.
One of the major potential functions of blockchain technology is through the creation of smart contracts. Various components of contracts, including proof of the involved parties, requirements for completion, and actions upon completion of the contract can be encoded in blocks. These can then be added to a blockchain and become available for independent verification, which can even lead to automatic processing of contracts when their requirements have been fulfilled.
Smart contracts are basically little "if this then that" functions, but they are importantly different in the sense that they are stored on a distributed network and they can be verified as true without knowledge of the contract specifications .
Securities Exchanges and Finance
One of the hottest arenas for blockchain development currently is in the financial markets, an extension of the original cryptocurrency use cases for the blockchain. Multiple stock markets and other financial firms have initiated investigations and pilot projects into the feasibility and utility of the blockchain for contracts and tracking of financial instruments. NASDAQ has been one of the first major markets to put blockchain technology into use, and has released some information on its implementation, called Linq . The cryptocurrency website Coindesk has also produced a list of 10 exchanges using or investigating blockchain technologies.
Additionally, financial firms such as Visa have been experimenting with the blockchain for keeping track of transactions as well as with proof of concept applications such as remittance.
- Tapscott D, Tapscott A. Blockchain Revolution: How the Technology Behind Bitcoin Is Changing Money, Business, and the World. United States: Portfolio; 2016. 1-368 p.
- Nakamoto S. Bitcoin: A Peer-to-Peer Electronic Cash System. WwwBitcoinOrg [Internet]. 2008;9. Available from: https://bitcoin.org/bitcoin.pdf
- Peterson K, Deeduvanu R, Kanjamala P, Boles K. A Blockchain-Based Approach to Health Information Exchange Networks. (1):1–10.
- Ekblaw A, Azaria A, Halamka JD, Lippman A, Original I, Vieira T. A Case Study for Blockchain in Healthcare: “ MedRec ” prototype for electronic health records and medical research data MedRec: Using Blockchain for Medical Data Access and Permission Management [Internet]. 2016. Available from: https://www.healthit.gov/sites/default/files/5-56-onc_blockchainchallenge_mitwhitepaper.pdf
- Linn LA, Koo MB. Blockchain For Health Data and Its Potential Use in Health IT and Health Care Related Research. 2014;1–10.
- Yue X, Wang H, Jin D, Li M, Jiang W. Healthcare Data Gateways: Found Healthcare Intelligence on Blockchain with Novel Privacy Risk Control. J Med Syst [Internet]. 2016 Oct;40(10):218. Available from: http://dx.doi.org/10.1007/s10916-016-0574-6
- Titus SL, Wells J a, Rhoades LJ. Repairing research integrity. Nature [Internet]. 2008 Jun 19;453(7198):980–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18563131
- Carlisle BG. Proof of prespecified endpoints in medical research with the bitcoin blockchain [Internet]. 2014. Available from: http://www.bgcarlisle.com/blog/2014/08/25/proof-of-prespecified-endpoints-in-medical-research-with-the-bitcoin-blockchain/
- Irving G, Holden J. How blockchain-timestamped protocols could improve the trustworthiness of medical science. F1000Research [Internet]. 2016;5:222. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866630/
- Slade E, Drysdale H, Goldacre B, COMPare Team. Discrepancies Between Prespecified and Reported Outcomes. Ann Intern Med [Internet]. 2016 Mar 1;164(5):374. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26720309
- Baxendale G. Can Blockchain Revolutionise EPRs? [Internet]. Vol. 58, ITNOW. 2016. p. 38–9. Available from: http://itnow.oxfordjournals.org/lookup/doi/10.1093/itnow/bww017
- Vaughan AW, Bukowski J, Wilkinson S, Sporny CM, Shea R, Allen C, et al. Chainpoint: A scalable protocol for anchoring data in the blockchain and generating blockchain receipts [Internet]. 2016. Available from: https://tierion.com/chainpoint
- Merkle RC. PROTOCOLS FOR PUBUC KEY CRYPTOSYSTEMS. In: IEEE Symposium on Security and Privacy [Internet]. 1980. p. 122–34. Available from: http://www.merkle.com/papers/Protocols.pdf
- Wood C, Winton B, Carter K, Benkert S, Dodd L, Bradley J, et al. How Blockchain Technology Can Enhance Ehr Operability [Internet]. 2016. Available from: http://research.ark-invest.com/blockchain-and-healthcare
Submitted by Ben Orwoll