Blockchain Theory

Blockchain Can Start a Cascade of Improvements

Making changes to healthcare–its delivery, its costs, its administration–always seem to focus on pushing providers around. While surgery is performed with a scalpel, healthcare reform is bluntly pursued by means of obtuse financial incentives: lower pay for doctors who don’t play ball, and day-to-day survival for those who go along to get along.

The motivation to change, adapt, and evolve shouldn’t come from fear or pressure; that is no way to generate momentum–something desperately lacking from every stage of EHR adoption and implementation, as well as efforts to curb prices, expand access, or shift to value-based measurements of performance and care.

Momentum comes from cascading benefits, not a series of flaming hoops. When potential benefits aren’t realized, expanded, and distributed, each stage of change can feel more like an obstacle than an accelerated pathway. It isn’t a question of solving problems more easily, so much as creating a cultural imperative rather than a financial incentive to embrace and advance change. To illustrate the concept, one can look at the promise–and hype–of the blockchain model.

More Than Money

For the uninitiated, blockchain is the technology that powers bitcoin, and similar digital currencies. It is, to oversimplify, a distributed digital ledger: it documents the movement of digital entities, be they “coins” or anything else in electronic form. The distributed model trades a centralized, third-party record for one in which every user or account on the chain provides anonymous computing power and transparency to the transactions.

What this means is that blockchain can facilitate the sharing of any data–not just of economic transactions, but of information sharing and recording in general. Applying this model to the EHR universe in healthcare reveals how challenges have been compartmentalized, rather than streamlined in our current configuration. Health data is formatted according to proprietary rules, stored in a centralized, institution-specific (or even departmental) location, guarded by privileged access rules.

Under the blockchain formula, interoperability would be intrinsic to the creation and storage of the data; access governed by patient-centered rules, and recorded in a transparent, accessible ledger; and perhaps most importantly, security enabled by the entire network, rather than one solely accountable stakeholder.

Private Security Through Open Programming

The cascade of benefits is potentially lucrative: decentralizing security would lift liability, rather than adding work, time, and non-clinical considerations to the workflow of doctors. This, in turn, would facilitate reduction of the administrative sector, improving the ratio of providers to administrators, and putting the focus back on patient service rather than bureaucratic compliance. Not only is this a positive change in the balance of power where clinicians are concerned, it may be at least partially responsible for trends in healthcare costs. Less administrative overhead means lower overall costs for patients, insurers, and government to cover.

Simplifying the record-keeping, managing, and sharing system by means of a distributed EHR blockchain might alleviate questions of EHR “ownership” to an extent. Patients could set their own rules for access, enabling family, physicians, specialists, counselors, insurers, and even employers to read and/or add to the record. Any changes would be subject to acceptance along the digital chain, and personal details could be anonymized or withheld using simple binary logic.

In recent years, health data and hospitals have become top targets for cyber attacks, because they blend scale with centralized storage, and all sorts of access points scattered around various users. Rather than heaping all privacy and security concerns on hospitals and doctors, the system would distribute security.

In a blockchain system, multiple signatories–digital users–would have to “sign-off” on any attempted access, or else access would be impossible. Thus, hackers or data thieves would have to disrupt the entire chain to attempt any sort of ransom of data, as opposed to targeting a single hospital for an enormous payoff. Likewise, multiple nodes would have to provide electronic consent to enable any additional party to access sensitive data, offsetting the risk of careless individuals compromising an internal network. This model becomes even more important as healthcare incorporates more smart devices, one of the top issues in cyber security today.

For the Sake of Change

Philosophically, if not practically, blockchain represents what the destination in healthcare ought to be: distributing, rather than concentrating, responsibility and change management. By their very nature, patients outnumber providers as stakeholders in the evolution of the healthcare system, because medical caregivers are an exclusive group, but everyone is a patient at some point. If the destination is a truly patient-centered system, then each development undertaken ought to reflect that goal, rather than distract from it.

Unlike so much of what passes for innovation in healthcare, blockchain wouldn’t require doctors to significantly sacrifice their normal workflow, approach to care, interaction with patients, or expectations for compensation. The center of the target for blockchain deployment is administration, not caregiving. That alone ought to recommend it.

It isn’t necessary to solve every problem at once to make good ideas worthwhile, valuable, or transformative. Progress is a trajectory, not destination. Anything that enables clinical focus to shift–especially toward patient care–can be seen as progress. But in the current environment, administrative growth is a routine precondition for change management or the adoption of new policies and procedures. Challenging provider autonomy is the new normal for advancing experiments in next-generation healthcare systems.

Blockchain is no silver bullet. It is an idea as much as it is a possibility–one founded on achieving interoperability before, rather than after, committing to an EHR platform. Realizing the many benefits would require organizations to actively pursue changes to administrative makeup, IT, security, and EHR integration. It would require tangible as well as cultural adaptation. The point isn’t that blockchain can do everything, but that it models how benefits can cascade–compounding at each stage of change–rather than be a fight at every stage.

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