Blockchain and the EHR
The beginning of medical school is filled with long hours spent memorizing biochemical pathways and dissecting cadavers, farther removed from patients and medicine than most medical students would like. The “real learning” starts when as bright-eyed, overeager and sleep deprived students, we begin the clinical year. At last, we have a chance to participate clinically in patient care in hospitals and clinics. One of the most valuable skills we will learn: the time-honored healing science of… faxing. Sarcasm aside, faxing is essential to patient care with minimal interoperatibility between electronic health records (EHRs). Columbia University Irving Medical Center (CUIMC) for example had two major EMRs that necessitated a third system to allow some semblance of communication between the two prior to their transition to Epic in January 2020. Faxing is often the only acceptable way to transfer records, so staff and medical students spend hours on the phone trying to obtain or send vital records. In our globalized world, a patient rarely receives care at just one hospital system, and rarely leave the hospital with easy access to records. This leaves medical students, among others, the task of spending hours on hold, faxing, re-faxing, and uploading of records that often come too late to be useful.
Blocks, chains and keys instead of faxes
Healthcare systems currently own and store patient information, although patients have certain legal rights to that information. Blockchain-based EHRs propose to reverse much of that control, giving patients the ability to grant and deny access to as well as more easily view and share their records. This would not only be empowering to patients, but would also allow providers to much more accurately and quickly access a patient’s medical record from other institutions with that patient’s permission. When a patient presents for care during an emergency (or a global pandemic), a hospital could waste less time trying to verify a patient’s medical history and more time actually caring for patients. There are many more benefits to blockchain in the EHR (increased accuracy and security, patient access to their medical information, and ease of billing and collaborative clinical research to name a few), but less faxing is the most poignant to me as a medical student.
Blockchain is a form of distributed ledger (data is stored in a decentralized fashion). As “transactions” of data occur, they are verified across the system at all “nodes” and bundled into a “block” of data that is labeled with a “hash” and added to the chain (hence the name “blockchain”). Copies of the entire chain are stored across the system, and blocks can only be added if the entire system agrees on its validity; blocks are labeled with the hash of the block before them as well as their own hash. This creates a timeline of data in the chain showing how the data has changed over time as blocks are added, and makes it (nearly) impossible to delete or edit blocks. Public “keys” allow for transfer of data between users, but that data cannot be extracted without the matching private key known only to an individual who owns the public key. Cryptocurrency was the initial application of blockchain. If all this seems confusing, it is because blockchain is confusing. The main takeaway for EHR applications: blockchain can provide an essentially unalterable, highly secure record of data and alterations to data over time, and allows for more user control through keys.
The decentralization with high security and privacy make blockchain the ideal technology for sensitive information such as medical records. In addition, it could increase transparency and accessibility for patients. While scalability and social acceptance of blockchain are concerns, the largest barrier is one already plaguing EHRs: it would require universal standards to allow for interoperability between all parties, as a recent literature review found. Before blockchain can be meaningful scaled for use in EHRs, the infrastructure would need to be in place to allow such interoperability to be meaningful.
Current Applications: A Sampling
However, these concerns have not stopped companies from forging ahead. Medicalchain is actively collaborating with the National Health Service in the United Kingdom, aiming to overhaul medical records there and abroad. Recently, they decided to make their project open source to increase accessibility and adoption of their software and became an approved NHS supplier, paving the way to launch their MyClinic.com for providers and patients. Dovetail Lab has similar aspirations and has launched a small pilot study with the NHS to evaluate their software among providers and patients with type 2 diabetes. Korean-based startup MediBloc has partnered with multiple health systems in South Korea as well as Massachusetts General Hospital in the United States to launch a blockchain-backed patient-centered health record. Their apps MediPass (released November 2019) and Panacea integrate existing and new records onto a patient’s smartphone and allow for health insurance billing (processing claims within 10 seconds according to their blog), all backed with blockchain. Many of the applications of blockchain to healthcare that were dreams several years ago are here; the next challenge will be finding ways to integrate them effectively into the mess that is the current US healthcare system.
