HL7, FHIR, Multiple Standards and Formats: One Healthcare Blockchain

(Part 1 of 2)

Have you ever stood on stage at a comedy club during open mic night? That’s where I was last night. I asked the audience if anyone understood the term blockchain. Surprisingly, three hands were raised. I then proceeded to ask the audience if anyone had read the March 2017 HBR article on how blockchain has the potential to transform health records: only ten hands went up. It was immediately apparent that the crowd was going to be tough. I was only armed with a career of healthcare jokes.

Integrity without human intervention

The HBR article discussed an imaginary world where patient information could be shared among providers and link seamlessly to a blockchain — a community wide trusted ledger. Unfortunately, this article missed the point of the true beneficiary of blockchain for patient records. Blockchain enabled patient records fueled by interoperability will primarily benefit patients by introducing a degree of freedom not found within today’s healthcare environment. The HBR article stated:

Imagine that every EHR sent updates about medications, problems, and allergy lists to an open-source, community-wide trusted ledger, so additions and subtractions to the medical record were well understood and auditable across organizations. Instead of just displaying data from a single database, the EHR could display data from every database referenced in the ledger. The result would be perfectly reconciled community-wide information about you, with guaranteed integrity from the point of data generation to the point of use, without manual human intervention.

A new entrant into the blockchain community

I tried to imagine the CIO of Partners Healthcare, located Boston, when he informed the Board of Directors that $1.2 Billion were wasted on the EPIC electronic medical record (EMR) system. For some reason, I imaged that Gwyneth Paltrow was a healthcare Blockchain expert. Then I decided to review the file structures in the Bitcoin blockchain versus the multiple standards, lexicons, and data types that had created interoperability problems in healthcare.

Gwyneth is famous for her Maple Syrup “cleanse,” Does she know blockchain too?

Cracking open a blockchain transaction

Bitcoin is the most popular blockchain with over 213,740,161 total transactions (as of April 14, 2017), equating to 271,000 daily transactions (averaged over the past one year), and the number of unique addresses used to commit transactions has increased from 404,000 in April 2016 to 520,000 unique addresses in April 2017. People aren’t just talking about the Bitcoin network — they are actively using it.

We hear mentions of hashes, Merkle trees, and other cryptographic things, but what does a single bitcoin transaction look like?

Figure 1: The Bitcoin Blockchain was Built for Financial “Ledger” Transactions, Not a Patient Record

Yes, this is the basic file structure of a Bitcoin blockchain transaction. Where do we put the lab results, medication information, and patient allergy data? The bitcoin blockchain is simple and retains only a limited amount of financial data.

Healthcare standards such as Health Level 7 International (HL7), Fast Healthcare Interoperability Resources (FHIR), and other clinically focused standards, consume thousands of pages of detailed information. However, an individual bitcoin blockchain transaction can be summarized onto a single page, thanks to John Ratcliff.

Figure 2: The Bitcoin Blockchain File Format Explained in One Page

Compare Figure 2.0 above, the bitcoin blockchain transaction, with Figure 3.0 below, a single fragment of HL7 — “shockingly” they don’t align. This also isn’t surprising as blockchains were never designed for healthcare interoperability. Blockchains were designed as a trusted digital ledger — a ledger of trust. Unfortunately, “truth” in healthcare is diffused across multiple fragmented silos which rarely if ever, connect. At least, these days, patient information is eventually, accessible, a step forward for healthcare interoperability — a process that could be more efficient.

Figure 3: The Trusty HL7 File Format with a Lab Order / Result

Utopian examples of idealism thrown into a practice world

The Bitcoin blockchain standard and the HL7 standard have version numbers in common. However, that’s the extent of the similarity. In healthcare, we have multiple standards, versions, data types, and file formats to juggle. HL7 recently published release three of its Fast Healthcare Interoperability Resources Standard for Trial Use (STU).

FHIR is yet another healthcare interchange standard mapped to HL7. FHIR is supposed to be the savior of healthcare interoperability to allow universal access to patient data across various healthcare ecosystems. Akin to the term “world peace,” FHIR is an interesting concept worth exploring; however, real world applications are more complex. HL7 has appeared ubiquitous throughout healthcare environments (with multiple version offered like ice cream flavors). Despite FHIR’s progress to-date, FHIR has yet to establish a significant foothold or scale effectively across the healthcare landscape.

What does all this mean for blockchain interoperability? Why do these standards obfuscate complexity?

Figure 4: A slice of a FHIR File for a Lab Result

The United States healthcare system, within the next five years, must tackle the monumental challenges of multiple file formats containing patient information, scattered across 2.3 billion acres of land. These formats may be placed on or referenced by a blockchain. One primary advantage of blockchains is their ability to standardize identity. Even if, the only benefit blockchains offer healthcare was the establishment of a unified patient identity platform standardization, this accomplishment would be historic. Huge progress would be made when blockchain is used across multiple data silos to link various format records to a single patient.

Patient-centricity in practice

The blockchain is not going to replace the billions required to modernize legacy centralized electronic record architectures, installed at healthcare provider’s locations across the United States. However, blockchain does have the potential to solve patient data portability.

Imagine a near-future where patients have the ability to view, access, and update their medical records in collaboration with their physician in real time.

This future isn’t a fantasy — it’s a reality. OpenNotes, today provides access for patients to collaborate with doctors using an EMR for document retention, and OpenNotes has surpassed 12 million patients. Interaction systems like OpenNotes, work great when the majority of a patient’s data is centrally located.

What happens to the patient lab reports from Quest? Where do prescriptions and over the counter medicines from say Walgreens end up? How does medical information become integrated for the patient and doctor to utilize?

We still have more problems to solve. Blockchains solve a piece of this complex puzzle.

Figure 5: Medication Data Contained in Portals Represent another Silo

Edward Bukstel

@ebukstel