An introduction to bitcoin and blockchain technology
Instead, anyone who participates is remunerated for handling the encrypted data structure. The blockchain is decentralized across many public nodes that work together to verify and process transactions, resulting in trust that the chain is accurate. They do this without the ability to decrypt private data. The choice of one of these different models, permissioned versus public, is a fundamental decision made early in any blockchain project.
If there is a common undercurrent that runs through almost all blockchain technology companies working in the health sector, it is the desire to enable people to exercise more personal control over the data collected about them.
Physicians are already inundated with more information than they can deal with, and much, much more is coming. A blockchain solution can lighten this burden on the doctor by creating a higher level of organization, accessibility, and amenability to time-saving digital tools while also further engaging the patient in their own care.
As an initial project, Medicalchain has tackled hospital discharge summaries, which include a summary of treatment and necessary follow-up care. Hospitals have incentive to both ensure these documents are free of liability-creating errors and process them quickly to free up beds for the next patient in the queue.
Currently, information is siloed: Medicalchain has introduced a digitized solution that leads doctors through a structured discharge process that reduces errors and omissions and speeds up review by senior staff.
They are currently moving this system to a blockchain, which will enable efficient decentralized sharing of data between stakeholders e. More ambitiously, Medicalchain is currently also developing a permissioned blockchain shared across a network of trusted international healthcare institutions to help patients receive care internationally without complicated collection and transfer of medical records Mo Tayeb, personal communication, August 25, Their proposed solution for enabling international blockchains is an opportunity to discuss another important concept: Some jurisdictions do not allow private healthcare data to be stored externally.
How then can one construct an international shared data structure? The answer may lie in the same type of cryptographic signature that enables each block of the blockchain to uniquely identify the block that it follows. Similarly, each block can contain cryptographic signatures of remotely stored documents that can be used to prove that a document has not been changed in any way.
Data can be kept in each patient's home jurisdiction, and then, when transferred by the patient, proven through signatures recorded and shared through the blockchain to be the complete and accurate record of the patient's medical history.
In this scenario, only proof that the document is genuine is stored internationally on the blockchain; the actual documents can sit in encrypted form in home jurisdictions until the owner of the data the patient decides to share them.
Healthcoin, an initiative that first developed a blockchain-based solution for helping people work together to improve diabetes symptoms has since expanded their vision towards building a system to construct a global electronic health record system.
They identify a value proposition for patient-centred information control that consists of three principles: Healthcoin sees themselves as not being in the healthcare business so much as the data sharing business, with the patient sitting at the control panel. Patientory, with a solution that attempts to bridge existing electronic medical record systems in the United States, appears to be the closest to having a real product in the hands of patients Patientory, BurstIQ presents a vision of what can be done once blockchain technology becomes the major medium to store patients' data.
They see the future of care at the junction of precision medicine, delivering treatments specific to a particular patient's needs, and machine learning, where artificial intelligence is used to learn from health trends and particular patients' histories Frank Ricotta, personal communication, August 25, BurstIQ aims to integrate data streams to gain new insights into individual best health outcomes and help people realize them.
The overt shift to patient responsibility over their own data in these blockchain-based solutions represents a significant change. HealthCombix, in collaboration with PointNurse, is attempting to address this by introducing a nurse-mediated layer to make sure that the data that ends up in the immutable blockchain record is accurate, that it has been transferred correctly to the patient, and that the patient understands how to curate, update, and control access to their records Cyrus Maaghul, personal communication, August 25 Another differentiating feature of HealthCombix is their plan to tie their system into a specialized hardware component that can be used to reliably monitor patients and introduce quality records to the blockchain.
Bowhead is another initiative interested in using a hardware component to feed trusted information to a blockchain. Given that these solutions are developed in parallel and in the absence of standards, a new interoperability problem emerges. QBRICS and Nuco Aion have initiated projects to develop blockchain-based technologies to translate and consolidate information from multiple sources to reconstruct patient data fragmented across platforms.
The dental industry is a highly fragmented market consisting of many independent practitioners. Dentacoin is an initiative that aims to use blockchain technology to connect dentists, patients, and suppliers manufacturers and laboratories globally. Phase I of their project was the implementation of a review platform that relies on the immutability and decentralization of blockchains and the transparency and reliability of blockchain-bound smart contracts to create trust in the review process.
Desirable actions, such as writing a review, are rewarded by transferring cryptocurrency to the patient, which can then be used to purchase dental services from participating practitioners.
Dentists are rewarded for participating through access to market research and cryptocurrency accepted by manufacturers. Dentacoin is banking on the trust and decentralization inherent in blockchains to enable an economy of scale to develop between the participating parties, without requiring additional brokers to manage the interactions between each individual piece of the network.
Of note is that this blockchain technology endeavour is dipping its toes into real waters: Future phases of the Dentacoin project plan to use their incentive strategy to encourage patients to educate themselves about dental care, set up insurance contracts between patients and dentists that reward patients who perform a minimum of dental maintenance, and to serve as a patient health record, analogous to the patient records covered in the previous section.
The creators of Dentacoin chose to implement a public blockchain because they felt that a more centralized private blockchain would be less trustworthy due to the more limited number of verifiers ensuring transaction fidelity. As with most initiatives mentioned in this article, they favour the storing of private information off chain see Medicalchain, above. The storage and sharing of health information presents an enormous challenge, including some important risks to privacy, and fantastic opportunities, including the potential to develop a practical understanding the health of unique individuals instead of generic humanity.
Blockchain technology companies are diving into this space and promising a new era of research and discovery propelled by analysis of aggregated longitudinal health information from individuals in the context of that from the population at large, and by a new ability for researchers to access data they need to gain new insights.
As an example of the scale of experiment possible in the past couple of years, one recent study employed whole genome sequences of over a thousand participants Lippert et al. The application of this scale of data is potentially revolutionary.
The Lo study, for example, found genetic correlations with psychiatric data that may have been impossible to locate with fewer markers. Currently, finding large data sets to better the understanding of interactions between disease and other traits and aspects of human lives is a difficult process filled with many obstacles and much paperwork and bureaucracy. Future understanding of human health may benefit enormously if the data now being accumulated by humans around the world can be made easily accessible to researchers.
This must be done while adhering to ethical standards and with maintenance of privacy through effective anonymization and ownership of the data by the individual whom it describes, including the ability to grant and revoke access to it. There is evidence that people want this control, and also that many want their data to be useful: Although there is evidence that some incentives may be required Pevnick et al.
As with many aspects of this nascent industry, it will be important to get things right: Operators in this space are aware of the challenge and they are attempting to grapple with it Jagadeesh et al. Encryption and keyed access are a first level of protection, but more work is necessary before solutions are ready to be rolled out widely.
It is not a simple problem to store private information into a public space, maintain control of who can access it and how it is applied, and at the same time deal with real-world problems such as key loss and changes in an individual's ability to manage their own data, not to mention navigate the process of carefully defining who should have access to what information and under what circumstances Tanner, Why is blockchain technology an interesting tool for this kind of sharing?
In addition to the baseline level of anonymization afforded by the encryption of data but which non-blockchain solutions could also employ , there are several reasons. The first is the immutability of the data: Second, storage would be transparent: Third, with tested and tried smart contracts in place, owners of the data could have confidence that they control their own data and could both grant and revoke access to it in anonymized form to enable research.
The immutability of smart contracts due to their inclusion in the blockchain is no small thing: The focus here has been on the collection of genetic information from our personal genomes, but this is not the only new stream of information that could contribute vast amounts of data to understanding our individual human health.
Also, with the advent of the Internet of Things, an explosion of devices is collecting longitudinal data about all aspects of our lives, such as heart rate, step cadence, exercise frequency, vocabulary complexity, diet — almost anything that can be imagined.
Clearly, there are privacy issues here that must be considered, but this data, too, could be verified, or at least assigned confidence levels, and used to assess current health and help to inform life decisions for health maintenance and improvement. Governments are eager to determine whether the cost-saving promises of blockchain technology can be realized, and at the same time to encourage patient empowerment and advance medical research and care. In Canada, a Nuco-Deloitte collaboration has engaged with a publically-funded research institute to provide a solution that enables individuals to participate in genetic research, due to be announced in late Kesem Frank, personal communication, August 24, In the United States, The Illinois Department of Financial and Professional Regulation is partnering with healthcare firm Hashed Health to build solutions that take advantage of blockchain and distributed ledger technologies to improve the efficiency and accuracy of cross-state medical licensure Hashed Health, The United Arab Emirates and Estonia have also made investments in storing medical health records using blockchain technology Anderson, ; Hankewitz, These are just a few examples of recent announcements, and the momentum is growing.
Blockchain technology is a fledgling endeavour and still must be aligned with current policies and procedures, especially in the healthcare industry. This is viewed as an achievable program that will demonstrate that a public blockchain can be used to hold government data, with a view to learning about, confronting, and addressing administrative hurdles to the framework, and ultimately lay down a path for more complicated data projects e.
Projects like this one may help to establish blockchain technology as an effective method to record and share government data and serve as an important building block for more sensitive initiatives in the future. As Brian Behlendorf, Executive Director of the Hyperledger project, on meeting the sustainable development goals of the World Economic Forum, put it on a recent Hashed Health podcast:.
Effective and trusted tracking of transactional information at each step of a process in a transparent and immutable way is an over-arching trait of blockchain implementations. Therefore, the idea of auditing intersects much of what has already been discussed.
One can imagine many instances where clear auditing of records in healthcare would be advantageous, including such examples as checking medical practitioner credentials, tracking and reconciling errors or ambiguities in patient data, and verifying insurance claims. One example of an initiative that tries to address some of these issues is Pokitdok, which has partnered with Intel to build a blockchain-based solution that provides identity management to validate every partner in a transaction Miller, Two examples of what Pokitdok hopes this might enable are near-instant billing and insurance claim resolution, and instant auditing of pharmaceutical supply chains and provenance.
There are situations where the importance of careful tracking becomes painfully clear. Counterfeit and fraudulent medication is a growing problem, especially in parts of the world where regulation and cooperation between governments is lacking McLaughlin, Pharmaceuticals are part of a much more general case: It is worth bearing in mind that blockchain is not a magical auditing solution that addresses every challenge.
It is a tool that can be used for trusted information storage and sharing, but these initiatives will also require systems to enter accurate and complete information in the first place.
Ultimately, standards will be important to guarantee interoperability between blockchains and to establish rules for the safe storage and transfer of information. Currently, development is dominated by prototypes and initial phases of projects with the primary concerns of functionality and proof of concept. A representative of Dentacoin expressed the general sentiment: For those who wish to have a voice in the future of blockchain, this may be an important avenue for contribution. Intellectual property protection and freedom to operate must be a key consideration for any blockchain technology initiative.
These are early days for the use of blockchain technology in health applications, and exciting new ideas are everywhere. At the same time, fast-moving companies and individuals are taking the opportunity to claim broad swaths of the intellectual property space. A quick patent search reveals that the company EITC Holdings, for example, has 63 granted or pending patents in the United Kingdom with priority dates in early or later; if EITC has been as aggressive in the United States, they will own a significant portion of claims in the blockchain space.
Patent applications do not publish for 18 months after the earliest filing date, so the extent of EITC's filing in the United States will not be known for some time. Companies including IBM, Mastercard, Fidelity, and Bank of America have also been very active at claiming intellectual property in this area. The extent to which these early patents will be allowed in patent offices and upheld when challenged has yet to be tested.
What is clear is that patents are being awarded in the blockchain sector in many worldwide jurisdictions and that forward-looking companies who wish to protect their intellectual property should develop a plan early on, at least to secure their freedom to operate. The effect that the current apparent centralization of control of intellectual property might have on the industry as a whole is unclear, but should be monitored.
Blockchain technology is only as good as its users; if low quality or incorrect information is put onto the chain, then what can be trusted through immutability and decentralization is that low quality and incorrect information will remain on the chain. Blockchain and supporting technologies offer many new opportunities, but care must be taken to evaluate the entire implementation, including what happens to information before and after it is on a blockchain.
Interoperability solutions will have to be diligent about information that is stored, and include solutions for resolution of discrepancies and assigning confidence to different kinds of information. Also, the movement to transfer information and control to the patient is laudable, but must be accompanied by education.
As stated by Nicole Tay, a researcher in public health personal communication , if "the whole point was to empower the patient and address the failures of our current system, which rely exclusively on the patient's trust, [and if we create a new system where patients are empowered to control their data but do not know what to do with it and end up engaging others to manage it for them], are we really moving away from a 'trust-based' management system?
Hopefully, the industry will take advantage of the current hype to establish itself, but not stop asking difficult questions. There is a risk that consumers will be drawn in by the golden promise of longer and happier lives care of big data, which may be difficult to turn down even if there are risks. A poor outcome is expected for the blockchain industry if it moves too quickly in the early days and products are pushed out that are not ready. Although there are aspects of blockchain technology that protect against unauthorized access, a large breach of private data through a technical oversight could result in fear of what should instead have held only promise.
One interesting problem is that the ability to access data in the blockchain is through a "key", which is a unique sequence of characters and digits. If a key is lost, then the data it accesses becomes irretrievable. Losing access to a lifetime of health information through the loss of one of these keys is unacceptable, and solutions will have to be implemented to reconnect users with their data.
Current solutions to this introduce back doors to accessing the private data on the blockchain, replacing one problem with another. Another challenge is that, if the decentralization of a blockchain is broken, for example, if one company acquires access to most servers more than two-thirds with current enterprise methods , then one agent can become the only agent of consensus and can modify the blockchain, contravening the immutability property.
New technology for consensus and government regulation surrounding blockchain monopolisation may be necessary to protect against this eventuality. Finally, a spectre on the horizon is the emergence of quantum computing and its predicted ability to break current encryption methods Bernstein et al. It is not clear exactly when this will occur, but within the next decade seems possible Kobie, We will have many problems if quantum computing resistant encryption is not solved by then, but if the entirety of one's health data is sitting in blockchains on publically accessible servers, then the privacy of that information will be at risk.
The application of blockchain technology to healthcare is in its infancy, and there are important challenges to face and big decisions to make going forward. Our societal concept of privacy has evolved in the face of challenges over the past decade and blockchain technology may continue to push at these boundaries, but also promises to deliver great rewards if embraced. If people are enabled to choose for themselves whether to adopt blockchain-based solutions, many may deem the risks of information loss minimal compared to the promise of an overall gain in privacy and control of one's data assuming no major data breaches.
They may be willing to risk even more for the promise of longer and healthier lives by releasing their own data into massive new collections of anonymized population health data, which could then be processed by artificial intelligence to develop personalized healthcare strategies.
The promise of blockchain technology is to enable the efficient sharing of information with stakeholders while ensuring data integrity and protecting patient privacy. Proponents hope that it will bring power to the people and enable them to make positive decisions that improve their health and that of others around the world.
They see a world where data is safer than ever before. Skeptics are concerned about the complications beyond the hype; what is envisioned is a massive disruption of the health sector, and there are many installed and invested parties who will act against that change, not to mention ethical, regulatory, and technical details still to figure out.
If the challenges of interoperability continue to be overcome, dependable privacy established, good anonymization protocols developed, and consensus achieved around the kinds of contracts needed to control information, then a new age of healthcare may be around the corner.
These are significant challenges, but as described above, companies have already made significant inroads into addressing them even at this early stage. This century's technology giants have already shown us that they are good at using artificial intelligence to learn from data; the same kind of technology is poised to produce disruptive new insights with the kind of data now being produced around health, with privacy and patient control as an important central tenet.
Some see this as an important step towards the "health singularity": The potential of blockchain technology is currently being explored across many healthcare sector implementations. A close watch on the companies mentioned in this review, many of which expect to make major announcements in coming months, would be a good first step to keep apace of developments.
The technology and its marketing is booming, and care should be taken to look beyond "white papers" and press announcements. Academic literature seems to be lagging, which leaves sources such as the press and critical discussions in online forums such as Reddit as primary options to seek sober second thought. Forbes, August 22, Accessed October 1, Gulf Business, October 5, Annual Review of Public Health , 35 1: International Workshop on Post-Quantum Cryptography: Countering the Problem of Falsified and Substandard Drugs.
Healthcare Dive, January 11, Minister of Justice Canada. JAMA , Exceptional Opportunities in Medical Science: A View from the National Institutes of Health. JAMA , 2: Forbes, August 8, A Systematic Interpretative Review. BMJ Open , 4 9: Estonian World, March 4, Hashed Health , Press Release, August 8, Blockchain and Electronic Distributed Ledger Technologies. Addressing the Risk of Product Fraud: Science , Personalised Health and Care A Framework for Action.
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