In 2017, several companies staked their claims for a piece of the blockchain enabled healthcare universe through various white paper publications, announcements, and even ICOs creating numerous tokens that purport to create efficiency and rewards for better healthcare. The companies announced blockchain solutions for use cases ranging from pharmaceutical supply chains, conversational AI, opioid tracking chains, and value based healthcare blockchains. The market is still in an embryonic stage and there is nothing close to a market leader or “800lb gorilla” that we see in the existing centralized digital health market that includes over 1100 health IT related companies competing in a $27 billion market. (Leventhal, 2017)
In addition to the Frost & Sullivan June 2017 Report: “Blockchain — Ecosystem Participants For Healthcare Industry,” additional research has been performed relating to the potential competitive landscape of the healthcare blockchain by Axel Schumacher (Schumacher PhD, 2017) and STAT. On December 27, 2017 STAT featured a review of the new industry players (ICO and non ICO) that are in various stages of development and implementation. (Coravos & Warner, 2017) A Github “Open-source landscape map for healthcare-related blockchains” has been created as well.
As of January 1, 2018 there were 42 “announced” Initial Coin Offerings (ICOs) in healthcare according to Vince Kuraitis, Principal, Better Health Technologies, LLC., (@VinceKuraitis ), “Listing of Healthcare ICOs (Initial Coin/Cryptoasset Offerings) / Token Offerings.” Anyone interested in this market should check out the whitepapers.
The vast majority of the current ICOs in healthcare (and outside of healthcare) are utilizing their tokens as “currency” in what looks like a patient reward programs, just like “racking up” airline miles in loyalty programs. The successes of “rewards programs” for patients have been questionable in the “centralized world,” where insurance companies like Oscar Health hand-out wearable devices to promote health amongst its members. (Bertoni, 2014) Furthermore, the belief that patients should pay for storage space to support a token as stated in the Patientory White Paper will certainly be found to be a flaw in their strategy going forward.
To be sure, the incentives paid to patients must align with the healthcare that is received. Incentives where patients know that they actually have an influence on care and respect the actions, integrity, and insights of the patient will have the greatest impact going forward, as demonstrated by the 7x return on investment seen by an insurer that provided direct cash incentives ranging from $25 — $500 to patients for investing additional time and energy in making better healthcare cost decisions. (Mangan, 2016)
A common theme amongst recent healthcare blockchain entities and ICO white papers is the reliance on Fast Healthcare Interoperability Resources (FHIR). (HL7, 2017) As discussed in section 1, FHIR is owned by HL7 and is a developing standard for interfacing clinical systems with third parties (ie: physicians, patients, other health systems) and has very little adoption except for major big budget hospitals and healthcare systems. The most damning statement regarding the current failure and future status of the FHIR Standard adoption comes from the CEO of HL7, Charles Jaffe, MD, on November 27, 2017:
“Fundamentally, I consider the biggest impediment the business case. Why would I do it?” he continued. “You can’t expect the for-profit vendors to connect everyone on their own dime… Why would I want to share data with my competitor when I’ve been trying to keep data from him for about 10 years?” (Davis, 2017)
Imagine Satoshi Nakamoto (Bitcoin), Vitalik Buterin (Ethereum), Joe Lubin (Consensys) , Muneeb Ali (Blockstack), Diego Gutierrez Zaldivar (RSK), Brock Pierce (Bitcoin Foundation), Brian Armstrong (Coinbase), or Barry Silbert (Digital Currency Group), stating that there is NO business case for blockchain. Any ICOs or healthcare blockchain projects that are dependent on FHIR as an interface standard will face a long hard road, and patients do not have that kind of time to wait.
The competitive landscape for the healthcare blockchain is just beginning. The players have various strengths and weaknesses and may or may not be around in 2019. One of the critical aspects that will be required is interoperability between healthcare blockchains to prevent the current state of data silos that are arguably “killing” patients around the world. The issues surrounding healthcare blockchain interoperability were presented in September 2016 in a whitepaper presented as part of the ONC Blockchain Challenge.
Prior to any implementation of Blockchain for patient care, entities must recognize the existing drawbacks of the platform, as well as opportunities to proactively incorporate interoperability across multiple competing and cooperating versions of the blockchain. (Bukstel & Coli MD, 2016)
In addition to implementing interoperability between competing and cooperating blockchains that are focused on healthcare and the life sciences, one of the more interesting aspects of any Clinical Blockchain will be the degree of interaction and interoperability with non-healthcare (horizontal markets) blockchains that track identity (ie: Civic, Uport, Blockstack), address decentralized storage (Storj, Ties.DB), create interoperability between blockchains (RSK), and track online activities of consumers (Brave Browser, Basic Attention Token, BAT)