On Wednesday morning at the Florida Health IT Summit, sponsored by Healthcare Informatics, and being held at the Hilton St. Petersburg Bayfront in St. Petersburg, Benjamin D. Schanker, M.D., M.P.H., director of the American Board of Medical Quality and a practicing physician at the Zuckerberg San Francisco General Hospital and Trauma Center, as an employee of the Department of Public Health of San Francisco.
Dr. Schanker’s morning keynote address, “Blockchain and the Future of Digital Health and the Clinical Experience,” covered a range of questions and issues around that timely topic. He began by giving his audience a very broad overview of blockchain itself, explaining the concept of blockchain, some of its uses in other industries, and its current, still-emergent state in U.S. healthcare.
Moving into the subject of the use of data in healthcare, Schanker noted that “Data is overwhelming in healthcare. Deloitte published a study that found that it takes a physician 50 minutes per patient to adequately review a single patient medical record. I know as a clinician that I don’t have time for that. In healthcare,” he said, “we’re very good at putting data into [information] systems, but very bad at taking it out of them.” One of the initiatives he’s involved in at the Institute for Human Optimization/the Precision Medicine Research Group, he noted, is that “We’re looking at tying together personalized medicine and broad research around populations.”
Moving onto some specifics about Bitcoin, Schanker asked, “Is Bitcoin really the promised land of healthcare? Will it solve all our problems? I say, hold your horses.” After explaining the fundamental theories behind the use of blockchain—it is a distributed, decentralized ledger database that uses “blocks” of data, linked together in a chain,” and accessed by a peer-to-peer network of equal partners—he went on emphasize that the “immutable distributed database” undergirding any chain “engenders trust. When Alice and Bob want to share information,” he said, referring to two archetypal individuals involved in a blockchain community, “they can share that information with other parties who are on the chain. The data is immutable. It can’t be changed, because a number of different parties have validated it.” And, importantly, any new block of data added to the ledger must be validated by a consensus protocol, typically meaning 51 percent of the parties involved in that particular chain. “There is no single point of failure,” he emphasized. “If Alice falls off the face of the earth, there are still multiple copies in existence. In practice, this means having a backup of your database.”
All of those elements hold major implications for the adoption of blockchain in healthcare, Schanker noted. On the one hand, he conceded, “Blockchain is very difficult to implement, because it’s a democratic database. Oftentimes, there are hierarchies in organizations, and they are necessary to make things happen.” And that factor works against blockchain adoption in healthcare.
Also, there are many types of data in healthcare that are simply too big or complex to be used well in healthcare. For example, he said, “You would never want to put an MR”—magnetic resonance scan—“on a blockchain, because you’d have massive data that would have to be validated.” Instead, in many cases, clinical data in healthcare might be incorporated through the use of digital pointers, which can lead trusted parties to the digital locations of such data.
Still, some organizations are beginning to experiment with blockchain technology for some niched purposes. One project that he himself is involved in is “CareCoin, one I’m working on at UCSF,” Schanker noted. “It’s designed to incentivize patients to ‘act better.’ It is a tool to align incentives among doctors and patients, where both parties are incented to work together.” It provides rewards to both physicians and their patients for engaging in certain behaviors.
Elsewhere, Schanker noted, “In South Korea, there’s a project called MediLedger, in which they’re using blockchain for medication supply chain purposes, validating data from the pharmaceutical producer to the manufacturer, to the distributor. MediLedger shares information across that supply chain of medications among the parties.”
He also noted the development taking place of something called the Robomed Network, which is described on its website as “a revolutionary medical blockchain project connecting healthcare providers and patients via smart contracts and ensuring output-based approach in the relationship. Launched in Dubai and Russia, this is a great step towards value-based healthcare,” the Network’s website states.
He further referenced SolveCare, being sponsored by the government of Estonia, and Universal Health Coin, a U.S.-based initiative.
“We should focus less on who owns the data, and more on how it is used,” Schanker emphasized to his audience. He also noted that “We’ve got financial, social, professional, and spiritual incentives, in everything we do. We should focus on the non-financial incentives.” And, in that regard, he said, “We’ve got a lot of both ‘carrot’ and ‘stick’ incentives in healthcare. I don’t think one or the other is better,” he opined. “Both are tools that can be used as incentive mechanisms. When we think about personalized medicine and population health, those concepts seemed contrary to me. But I’m going to quote Adam Smith, he said, and then went on to quote a passage from The Wealth of Nations, the seminal 1776 book on macroeconomics by that author: “By pursuing his own interest he frequently promotes that of the society more effectually than when he really intends to promote it.”
Afterwards, Dr. Schanker spoke with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.
What should the CIOs, CMIOs, and other healthcare IT leaders of hospitals, medical groups, and health systems, be thinking about in all of this?
Version control is most important. You have an existing version of clinical data. You can keep that copy and add a specific piece to it that can always revert back if needed. So overnight, as databases are updated, you can add pieces to it that can be reverted back. As you’re iteratively experimenting with blockchain, you always have the option to revert back to a prior version.
Do you see any potential related to electronic health records [EHRs] in this?
Yes. Access control to patient records is a phenomenal blockchain use case.
In other words, one might wrap clinical data inside a blockchain? How would that work?
An example initially would be empowering patients to control who accesses their records and for them to see an audit trail of when clinicians access their records. That feedback loop of patients being able to see when clinicians access their records could be support the patient-clinician relationship and empower patients.
Since patient records are so large in terms of the data involved, might that involve more ‘portable’ pieces of data, such as the most recent notes and updates on a patient?
Yes, a basic patient synopsis that the patient can control and update.
That could be better than the PHR [personal health record] as it now exists?
Yes, that’s really the use case. EHRs in this day and age are meant for clinicians to communicate with each other. But we need to communicate better with patient and empower them to have control of their records, and to facilitate that process. The single most under-utilized resource in HC is the patient. The appeal of a PHR is lacking, and things like blockchain can excite people.
Will physicians really want to participate?
I think if the clinician is asked to do anything additional that involves taking any active steps, it will be a challenge to get them to participate. On the other hand, anything that’s going to streamline their workflow is a viable target. So if a patient is answering digital questions on an in intake, or in their PHR, and it’s auto-populating that PHR and it’s partially writing a note for them, physicians would be interested. It’s a matter of optimizing the clinical workflow.
So one might be potentially creating a separate piece, then, involving one element of the overall patient record?
Yes, that’s right. One area with great potential involves the patient intake process. To do the digital intake through a blockchain-based record system, has significant potential. I don’t know whether Epic or Cerner is trying to do it, but the current process of patient intake is one of the most inefficient processes that exists in healthcare. We do paper intake and then manually input the data to make it electronic. It’s a very wasteful and inefficient process, and there’s real potential for blockchain to be adopted in order to improve it.
