Locating the health-related records and transactions of patients across their numerous and different healthcare providers, payers, pharmacy benefit managers and other entities is an expensive and complex problem.
With many years of experience addressing this issue in different healthcare systems and health information exchanges (HIEs), it is apparent that there is now a compelling and relatively straightforward technical solution for this problem: A blockchain-based record locator.
Blockchain’s key characteristics as a decentralized, highly resilient, and secure log of transactions make its architecture a strong fit for the problem of maintaining an accurate association between patients and their records. Blockchain offers a high integrity mechanism for locating data and monitoring precisely how it changes over time.
How to collect patient data and make it accessible to any organization that performs a service for that patient is a long-standing challenge. In the early 2000s, the conceptual architecture of a master patient index (MPI) coupled with a record locator service (RLS) started being considered for HIEs.
By the mid-2000s regional health information organizations (or RHIOs as HIEs were originally called) started springing up as regional or state-wide data aggregators. Almost all of them used some form of the original MPI/RLS model. HIEs ultimately started aggregating data, indexing patients through a master patient index, and storing the data in individual repositories for each organization. The MPI effectively became the RLS, and HIEs could share data with treating providers and other participating organizations.
This solution did not address the issue of how HIEs would communicate with each other, which was increasingly important as individuals relocated around the country, visited multiple providers perhaps in different states, or simply changed insurance. The result was they became disconnected from their health information that was stored in their previous electronic health record or HIE.
The idea of a "network of networks" was long discussed, but it never gained much traction due to implementation costs and lack of an organizational entity that was ready to create this full "open" network. Instead the concept of point-to-point network connections was promoted by select organizations to retrieve documents. While this has been a good first step, it has significant limitations in terms of identifying locations where all patient data exist and scaling the number of connections required for connecting to these sources.
To address the problems identified above, we propose the following concept: a national network of patient identity brokers with a blockchain-based record locator.
Implement a limited number (~6) of patient identity brokers (PIBs) nationwide. Each regional HIE, IDN or other “network” would connect to one or two PIBs for performance and redundancy and send all their patient demographics via ADT messages. Each PIB would have a master patient index. Current patient identity matching logic has its issues and limitations, but it is far better than demographic queries, and MPI matching will improve over time.
Instead of storing the index in the patient identity brokers, the PIB’s can manage the required business logic while the index itself would be stored in a single permissioned patient identity blockchain. The blockchain would not contain any Protected Health Information (PHI) but would be the index to all the locations where the patient’s clinical data exist (nationwide RLS).
Despite the challenges of the MPIs matching logic in the PIBs this is still a viable solution. As we move towards biometrics such as facial recognition or iris scans the matching will greatly improve. What is not a viable solution are broadcast queries to all HIEs and other networks based on demographics.
The fundamental point is that, through collaborations with other disciplines and stakeholders, blockchain offers the opportunity to finally ensure that a complete record of a patient’s clinical data is truly available to the patient and clinician regardless of where the patient received care.
To read a fuller and more comprehensive dive into blockchain for the nationwide patient index, read https://blockchainhealthcaretoday.com/index.php/journal/article/view/28
Michael L. Gagnon is the Executive Director of HealtHIE Nevada the state-wide health information exchange in Nevada and the former Chief Technology Officer of Vermont Information Technology Leaders, the state HIE in Vermont. Michael also serves as the Chair of the Western Member Council of the Strategic HIE Collaborative’s Patient Centered Data Home initiative. Michael has been involved with health information technology for over 27 years and focused on health information exchange for the last 15 years. You can contact Michael at [email protected].
