Distributed Ledger Technology and Blockchain Solutions for Interoperability

Achieving a scalable nationwide health information exchange among various stakeholders is the primary premise of the Trusted Exchange Framework (TEF) and Common Agreement. The TEF creates six principles to facilitate trust between the participants of the health information exchange. While the Common Agreement component provides the governance necessary to scale a functioning system of connected health information networks.

Previously, we discussed how blockchain, or more broadly, distributed ledger technology, can help achieve these principles by supporting a network of nodes that rely on the associated consensus algorithm, cryptography and the data on chain. This network becomes a system of secure exchange that leverages standardized datasets, common agreements and consents based on cooperation and nondiscrimination. These technologies could not only provide the backbone of identity for participants, but also outline governance rules through smart contracts and associated application programming interfaces (APIs) to enforce standards of exchange supported on the network, not just structured data as in the past.

Allow Progress by Acknowledging Barriers

While we feel blockchain has ample promise to address many of the components that drive interoperable exchange, it is important to acknowledge the current challenges to its broader adoption. Thanks to the global phenomenon of cryptocurrencies (e.g., Bitcoin [BTC], Ethereum [ETH], Ripple [XRP]), distributed ledger technology has been the focus of media hype and misunderstanding. This has created pervasive confusion due to the coverage of the cryptocurrency use cases, as opposed to its uses as a distributed database and orchestration mechanism.

More specifically to healthcare, there is also a mismatch in the evolution of the technology within this industry. Blockchain technology and applications have evolved rapidly, but general understanding amongst the healthcare industry remains low. This has complicated the ability to move beyond how the technology works and into why, where new solutions can be presented to address current business problems.

Furthermore, blockchain electronic “tokens,” similar to cryptocurrency, have the ability to offer new economic incentives for wellness and healthcare participation, but currently these incentives aren’t easily accounted for in today’s economic market and revenue cycle model. This limits the ability to shift the cost curve and incentivize behaviors, and social determinants of health that may reduce healthcare expenditure.

Perhaps the greatest barrier to adoption has been a lack of updates to regulations reflecting the progress in digital technologies. For example, the HIPAA administrative safeguards have not evolved to support newer paradigms such as the principles of decentralized identity and consent management, which are the technology’s strongest capabilities. Arguably, HIPAA blocks further adoption of information sharing and hinders consent and participation by the patient and family. As HIPAA serves as a backbone in health IT regulations and guidance, including TEFCA, this is a critical barrier to address.

Global Application

Despite these challenges to widespread adoption, other countries and industries are finding significant value in applying distributed ledger technology, which may provide lessons for the healthcare industry and U.S. government as we work to optimize our information sharing and IT systems.

Several governments around the world have embraced blockchain for healthcare purposes. While their healthcare delivery models and architecture may be more conducive to its adoption than the complex system within the U.S., these countries may still offer lessons that can allow for innovative uses within U.S. systems.

Asia-Pacific countries such as Singapore are leading adoption in healthcare with strong government promotion of innovation conferences and blockchain research initiatives. A PWC survey revealed that 82% of executives in Singapore are implementing blockchain and, of those, 13% are already live. A key differentiator in Singapore is the government’s involvement and funding of startup ecosystems, working hand-in-hand to assist with innovation and regulatory changes as needed. The Singapore government has been a catalyst for adopting deep technology and horizontally adopts innovative technology across industries including healthcare. For example, the government has invested in start-ups that explore patient data sovereignty.

Estonia is another country that provides benchmarks for policy and infrastructure advances as the first country to use blockchain for healthcare on a national scale. The Estonian E-Health Foundation launched a project aimed at safeguarding patient health records using technology to log and track data processing activities performed on those records. The main goal is to mitigate risks of data compromise by an unwitting or malicious hacker or fraudulent insider. Estonia's e-Health Record retrieves data from various providers who may be using different systems and presents it in a standard format. Patient identification is secured by a unique national ID, which provides digital access to all of Estonia’s secure e-services including healthcare. This system provides a tool for clinicians to access a patient’s records easily from a single electronic file, read test results as they are entered, including image files even from remote hospitals.

Lessons Learned from the Financial Sector

Like most other revolutionary technologies when they were first introduced, such as the World Wide Web in the early 1990s, and social media in the early 2000s, there will be a lot of paths that don’t lead to the final goal. Barriers and challenges are inevitable, and are needed for the technology to further refine itself through standardization and development of common service interfaces such as APIs.

As an industry further down the path of blockchain adoption, we can look to the fintech industry and European standards of Open Banking to inform a path forward in healthcare. Fintech, short for Financial Technology, is the application of new applications, processes, products, or business models in the financial services industry. Instead of focusing on a broad number of services like a bank, they focus on a small group of complementary services.

RELATED: Blockchain Technology in Fintech and What Healthcare Can Learn

Blockchain-enabled solutions make extensive use of APIs based on use cases and data interchange to provide services. Their growth mechanism is through partnerships and cooperation based on complementary service offerings utilizing them. Unlike healthcare, which has primarily focused on structured data interchange via standards like HL7, fintech standardizes on APIs, which reduces the time to build solutions and allows modularity. Blockchain is also fundamentally based on APIs.

In the fintech sector, distributed ledger technology supports many functionalities such as global payment, digital identity, audit and regulatory compliance. Many blockchain-enabled APIs have been developed to support the required payment and invoicing functionalities defined in use cases.

This approach can be transferred to healthcare and the needs of TEFCA. As seen in fintech solutions, focus can be placed on use case-specific solutions instead of trying to address all healthcare interoperability needs. These use cases can then utilize distributed ledger technology solutions to provide integrity, availability, logging and auditing, while avoiding duplicative work. APIs can be leveraged to abstract away direct usage of every individual data repository, and integrate tools that combine health data standards with distributed ledgers (such as FHIRChain, developed at Vanderbilt University) to provide the critical integration piece between EHR and Qualified Health Information Networks (QHIN) systems.

By focusing on a small set of use cases initially, derived from the TEFCA framework, the critical issues of access and consent management can be addressed in a standard process-based way, instead of a case-by-case basis. Using complementary tools such as FHIRChain—instead of trying to build another set of duplicative services—speeds the time to usage and allows organizations to reap the benefits.

A Path Forward

Blockchain has the capability to serve as a component of trusted, secure interoperability for an efficient healthcare ecosystem, both regionally and globally. As traction continues to gain momentum, regulations and initiatives, such as TEFCA, can serve as a catalyst for the adoption of blockchain as a normalized form of health data transactions.

The TEF builds on achievements in health information technology development, adoption and implementation over the last decade. Connecting disparate systems will significantly reduce both financial and resource burdens on providers and health IT developers for complex and costly point-to-point interfaces (development and maintenance). In the next five years, the global market size for blockchain technology use in healthcare is estimated to reach $5.61 billion. During this period, its adoption is expected to save the healthcare industry up to $150 billion per year in data-breach-related costs, including information technology, operations and personnel costs.

As QHINs develop and operationalize, this technology can serve as an underlying foundation for these activities including drug traceability and supply chain initiatives that revolve around credentialing and proof of authenticity, clinical trials data management as it relates to consent management, and patient data management in accurate and secure patient identification.

Technology itself is never the exclusive answer to complex undertakings such as TEFCA. However, rapidly maturing technologies such as blockchain can help facilitate the actions needed to be successful.

By Jim St. Clair, Chief Technology Officer, Dinocrates Group, LLC; Mitchell Parker, Chief Information Security Officer, Indiana University Health; Chrissa McFarlane, CEO, Patientory; Ann Ingraham, PhD, Principal CEO, Exponential HealthTech Advisors, LLC; Rakesh Sreerambhatla, Chief Digital Officer, Exponential HealthTech Advisors, LLC; David Metcalf, Director, METIL, University of Central Florida, Institute for Simulation & Training; Wilson Choi, EMBA, Lean Six Sigma Black Belt, Senior Director, Information Services, NYC Health + Hospitals; Kalyani Yerra, MBA, MHA, PMP, CPHIMS, FHIMSS, Senior Software Architect, Premier; Thompson Boyd, MD, Independent Consultant; HIMSS Blockchain in Healthcare Task Force Members

Updated February 12, 2020