It’s no surprise that Blockchain is one of the most talked-about emerging technologies in healthcare. While the tech has been around for a decade now, excitement has grown in the past few years about its potential healthcare applications. A Google search for “Blockchain healthcare” returns almost as many results (15.7 million vs. 15 million, a difference of about 5%) as a search for “EMR healthcare”, despite the latter technology being almost half a century older. This level of interest should make healthcare technology professionals take a step back to consider what’s really going on right now. The hunt is on for Blockchain-shaped problems that can be solved in new and exciting ways, but finding the right fit between the problem and the solution will not be simple or straightforward.
The scale of the hunt is impressive. As of March 2018, more than 65 new companies are developing healthcare solutions using Blockchain, not counting the consultants and advisory services that are also emerging. The proposed solutions address personal health record management, health analytics, medical devices and IOT, identity management, healthcare supply chain, and more. For a deeper dive into the aspects of healthcare shaken up by this technology, check out our Emerging Technology profile guide on Blockchain. Hundreds of millions of dollars are being invested in healthcare applications for Blockchain, and many of these investments will pay out handsomely.
The present environment seems almost like a crowded party where everyone is working furiously to put together a jigsaw puzzle. Entrepreneurs and industry innovators are picking up these new Blockchain-shaped puzzle pieces and searching for the right spot to fit them in. They’re matching colors and shapes—examining the capabilities of the technology and looking for the particular problem-shaped holes in the healthcare picture where they fit. Like in a real jigsaw puzzle, the colors and shapes all have to match to create a working solution—in this case, the solution to a pressing healthcare problem.
In some cases, there are existing partial solutions to these healthcare problems that don’t use Blockchain—holes in the puzzle temporarily filled by awkwardly jamming in not-quite-right pieces, to extend the metaphor. So, the process of finding the right fit sees a lot of startups asking the following questions to find the Blockchain-shaped problems they can solve:
Part of the startup journey is applying new thinking to exciting solutions. Some companies are integrating cutting-edge technologies like AI, machine learning, and Blockchain to solve these problems. But the flashiness of the tech is not really what determines whether a Blockchain solution can be applied to generate value in excess of the overhead.
To be a viable healthcare solution, a Blockchain product must:
Looking at two examples of Blockchain-enabled solutions—wearables and longitudinal health records—shows the challenge of finding the correct place for each puzzle piece. The piece might look right when you pick it up, but finding the exact fit may be more of a challenge.
The pitch: Create a Blockchain-based product that will pull together every Fitbit/Apple Watch data point for my entire life into one central repository that I control.
This pitch idea is a great start for using Blockchain technology in a healthcare setting. Wearables (such as Fitbit) are providing data in the form of small, discrete transactions of information that are more valuable when aggregated than they are individually. Comparing these data points over time can generate valuable information to track a person’s progress or decline, as they already do. Collecting them from different devices and allowing the owner control over the sharing of that information works nicely as a blockchain-based solution.
Currently, Fitbit data is controlled by the Fitbit corporation, and the Apple Watch data is in Apple’s cloud. For people who may use both, the ability to aggregate that data or have secure copies in their control could be valuable.
But how would someone use that data in a healthcare context? First, they might want to share it with their healthcare provider. But a lot of providers don’t want that data. In fact, I haven’t spoken with a single provider who felt that knowing the number of steps I took each day would really change their treatment plan. The Nurse Navigators and Care Coordinators don’t want it. They will ask if the patient was active or sedentary last week, and having fine-grained longitudinal data is not going to be particularly valuable for their treatment purposes. So the Blockchain solution perhaps won’t impact care delivery in the way we might think.
Another application of the data might be with a personal trainer. They might find value in that integrated data set, but it’ll likely only be the concierge trainers, that cost a small fortune, who have the time to compile and analyze that level of longitudinal and integrated data. Perhaps the Hawthorne Effect would be helpful in this scenario. That sense of accountability might alter someone’s exercise behavior in future, but it can’t change their past behavior, so the broader dataset enabled by the Blockchain seems irrelevant to whether or not someone takes those steps today. It would only make a significant difference if a person’s motivation for taking steps today stemmed from knowing that 5 or 10 years from now they would be really disappointed in themselves for not having taken those steps. But it is a rare individual who would be motivated in 5 years by their step count from today.
Another possible use-case for the Blockchain Fitbit solution is to sell that data to a research company. Blockchain could allow users to anonymize and control who sees the data, and perhaps get a little kickback every time they do. Blockchain’s cryptocurrency roots even support forms of payment or token trading for the transaction. While this might seem like a good idea on the surface, the notion that researchers are interested in the tracked steps alone would be a stretch. A deeper clinical data set would most likely be needed to get value from the step data.
Another opportunity might be to provide that data to healthcare insurance companies to demonstrate a commitment to fitness. Again, it’s unclear in this case that the Blockchain solution would be magnificently more valuable than an API to the Fitbit corporation’s data set.
The issue at stake is not the Blockchain solution itself. The added aggregation and control over that data on a Blockchain could be valuable, but that value really only grows as more and more data is added.
The data aggregation and control solutions offered by Blockchain can provide great value—perhaps not in this instance, but the wearables context may not in and of itself be a problem worth solving for the healthcare industry. Perhaps what is needed is a richer dataset.
This use-case offers an opportunity to explore the implementation use of Blockchain in healthcare. One premise of Eric Ries’s Lean Startup Methodology is the BUILD-MEASURE-LEARN methodology cycle. And a lot of startups are operating on this approach. These startups build a new solution, measure the outcomes, and then learn from the response by the industry. It may turn out that the healthcare industry won’t need this exact solution, but the learning acquired in the process of building a new solution will enable innovators to pivot to a new idea or customer segment that finds more value in the revised solution.
The pitch: Create a longitudinal patient health record with information on every provider visit, vital signs, lab results, and medication prescribed and taken (or at least prescriptions filled at the pharmacy). Right off the bat, this solves a very real aggregation problem. Your current health record lives in too many places and is immensely difficult to collect in aggregate. If you did aggregate it on paper, it would be unwieldy or impossible to use. But having a Blockchain solution to provide a layer of validated transactions to the data could make collating, and providing secure control of and access to, that data much more viable.
An example from the hospital I work with highlights some of the challenges to this idea, however. Recently, a patient arrived at our Sleep Center for a sleep apnea test with a hard copy of their medical record for the provider. It was 250 pages long and filled multiple notebooks. The patient went through a great deal of effort to amass all those records of past visits and test results, and indeed that would have been a difficult challenge for anyone. Unfortunately for the paper-wielding patient, the provider in charge of the Sleep Center did not have the time, or the need, to read through that massive chart to locate pertinent information. A few simple answers to screening questions were all that was needed.
Making all of that data available through the Blockchain would have made it much easier for the patient to collect that information. Control over access would have helped both the patient and the facilities because Release of Information requests would no longer have to be generated for a patient to obtain their charts and results. Also, as patients get older they tend to see multiple specialists, greatly increasing the amount and complexity of data in their health records. With 10,000 adults turning 65 every day in the US, the need to collect and control access to medical records is exploding.
But in the case of the provider, the use of Blockchain does not increase their need to access that data. Making all that data available through the Blockchain could be increasingly valuable in certain situations, though, especially when follow-on software solutions become available. This data would need to be searchable, with decision support algorithms to help organize and filter the information. And just as provider electronic documentation templates need to be customized to a provider’s specialty of practice, so would this software. Different results should be returned depending on the specialist’s needs and practice preferences. With a true longitudinal record, it would be nearly impossible for providers to utilize such data without this solution.
While the longitudinal patient health record may aid patients in their treatment plans, there are potential liability risks to the providers. I became aware of this issue when a patient of two of our providers arrived at our laboratory with a different lab test request from each provider. The lab entered the orders and drew the blood. Both results were electronically sent to both providers. Each received the one they ordered and the one ordered by the other provider. As the individual was a patient of both providers, it was not a HIPAA issue, so we expected everything to be fine. But it wasn’t.
The orthopedic provider called me after receiving the results for the test she didn’t request, and explained the liability problem these unsolicited results created. She was now aware of these results, and was therefore potentially liable for failure to treat the patient based on all of the results now residing in her EHR. So, the idea of having all of the data could create serious liability problems for providers.
If one set of lab results created a problem, what would a complete longitudinal record do? Would the provider only be liable for treatment based on the specific results they requested or viewed? Could an audit log demonstrating which results were viewed—and therefore which were not—ameliorate the risk? Only case law or legislation will answer this question, but the Blockchain solution to medical data access does open up a discussion that needs clarification. The treatment value of a longitudinal patient health record needs to be created without massively expanding the liability and risk to the provider.
There are a lot of reasons to be excited about Blockchain technology, and the new solutions that it opens up in healthcare. The unique feature set of this technology—which you can learn more about in our Emerging Technology profile—makes it different from the tools that existed in the past. If patients controlled their medical data, they could donate or sell this research anonymously to medical research companies. That is a clear win. Getting to those clear wins may be a challenge, though, as the startups and other companies work to find the right fit between the technology and the immediate problems.
Blockchain gives the healthcare industry a whole bunch of new puzzle pieces to play with, and many problems that were previously difficult to manage may soon find resolution. The process of creating these new solutions will take some time, however, and will require some pivots and flexibility from companies working in the healthcare space. Similarly, organizations whose work will be impacted by the implementation of new layers of technology will need to become more flexible. At the end of the day, the pivots and flexibility of the industry will determine how well these companies succeed in finding solutions to problems that matter, as well as solutions that don’t cause more headaches than the value they provide.
Blockchain will change healthcare; it’s just not clear yet how the transformations will manifest.
John Ulett is the VP at Toehold Learning. He has over thirty years experience working with innovations in software technology, and eighteen spent in the healthcare industry. John’s experience provide him a unique perspective on the challenges of integrating new technologies into the framework of existing healthcare technologies.