What is #BlockChain? Implications for Healthcare by @msharmas

In my previous article I discussed about the benefits and barriers to the use of an Integrated Health Information Platform. In healthcare the need for presenting the Information to the Right Person at the Right Time has been proven to improve outcomes in patient treatment.

Will HIE 2.0 benefit from the use of Blockchain in presenting the information to the Right Person at the Right Time? 


What is Blockchain?
Various definitions of Blockchain have been put across based on the context of the use. Some of these definitions are: 

A digital ledger in which transactions made in bitcoin or another cryptocurrency are recorded chronologically and publicly.

“The blockchain is an incorruptible digital ledger of economic transactions that can be programmed to record not just financial transactions but virtually everything of value.” Don & Alex Tapscott, authors Blockchain Revolution (2016)


The Blockchain is a decentralized ledger of all transactions across a peer-to-peer network. Using this technology, participants can confirm transactions without the need for a central certifying authority. Potential applications include, fund transfers, settling trades, voting etc.


Blockchain is a distributed system for recording and storing transaction records. More specifically, blockchain is a shared, immutable record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger. [1]


A Blockchain is a data structure that can be timed-stamped and signed using a private key to prevent tampering. There are generally three types of Blockchain: public, private and consortium. [6]

How is Blockchain different?

Traditional databases are proprietary to the entity that maintains them and owns them. And the information stored within these databases are accessed only by providing access via an application or shared by the entity in some form of a distributed architecture. 

On the other hand, “blockchain is enabling a database to be directly shared across boundaries of trust, without requiring a central administrator. This is possible because blockchain transactions contain their own proof of validity and their own proof of authorization, instead of requiring some centralized application logic to enforce those constraints. Transactions can therefore be verified and processed independently by multiple “nodes”, with the blockchain acting as a consensus mechanism to ensure those nodes stay in sync.” [2]

A quite often stated example for explaining Blockchain is the Google Doc example. Earlier, collaborating on a document involved a serial approach to making changes to a document. Only once the author has completed the document, can it be forwarded to the next person to edit and provide feedback. 

But consider the Google Doc (or any of the other collaboration tools), once you have created a google doc, you can start creating the document and also share the same document with other collaborators who can also make changes to the document at the same time allowing for reconciliation of changes to be incorporated within the document to finalise it. The author takes the comments from the collaborators and generates the finalised document.

Blockchain: How it Works?

A transaction is requested. The transaction is broadcasted to the peer-to-peer network consisting of computer nodes. The network validates the transaction and the initiating entity’s status using relevant algorithms.  The transaction record is then considered to be verified.

Upon verification, the transaction record is added with other transactions to create a new block of data for the decentralized ledger of all transactions across a peer-to-peer network.

The new Block is added to the existing ledger of all transactions, i.e., the Blockchain. The transaction is now complete.

Types of Blockchains

Permissionless or Unpermissioned Blockchain allows anyone to join the network and participate in the block verification. For instance, a permissionless blockchain example is the Bitcoin.

Permissioned Blockchains restricts the nodes in the network who can contribute to the consensus of the system. Only permissioned nodes have the rights to validate the block transactions.

For instance, most enterprise Blockchains are permissioned blockchain and allow for privacy, scalability and fine-grained access control. [5]
Interoperability in Healthcare

There are various use cases that come to mind, when we talk about interoperability in Healthcare. (most are N:N interactions)

  1. HIMS to Lab Equipment
  2. HIMS to PACS
  3. HIMS to HIMS
  4. HIMS to Apps
  5. HIMS to Portals (Patient, Physician, etc)
  6. Portal to Portal
  7. Stakeholders to HIE
  8. Hospitals to Insurance

You can consider the number of stakeholders in the Interoperability ecosystem and continue to add them to the above list of use cases. And that allows one to understand the current fragmented nature of the Patient’s Healthcare Information. 

Each of the above stakeholders, generate the patient care record and have the need at one time or another to share this information with others in the ecosystem. We have already seen the benefits and barriers to information exchange. 

For the purpose of this blog, lets consider the Healthcare Information exchange use case. HIEs’ share the patient information in a network that is accessed by participating entities. The Patient information available on the HIE can be accessed as and when required by the patients’ treating doctor. 

The availability of a patient information, at the right place and at the right time was (one of) the intended purpose of a Health Information Exchange. HIE frameworks relied on a centralised or federated or hybrid architectures [3] to make the information available to the participants in the exchange. The exchange is maintained by an entity.

In the nationwide Interoperability roadmap defined by the ONC (US) [1]. They define the critical policy and technical components required as

  1. Ubiquitous, secure network infrastructure
  2. Verifiable identity and authentication of all participants
  3. Consistent representation of authorization to access electronic health information, and several other requirements


Additionally, the ONC challenge stated Potential uses to include:[6]

  1. Digitally sign information
  2. Computable enforcement of policies and contracts (smart contracts)
  3. Management of Internet of Things (IoT) devices
  4. Distributed encrypted storage
  5. Distributed trust

In India, an Integrated Health Information Platform (IHIP) is being setup by the Ministry of Health and Family Welfare (MoHFW). The primary objective of IHIP is to enable the creation of standards compliant Electronic Health Records (EHRs) of the citizens on a pan-India basis along with the integration and interoperability of the EHRs through a comprehensive Health Information Exchange (HIE) as part of this centralized accessible platform. 

IHIP is envisaged to enable
  1. Better continuity of care, 
  2. secure and confidential health data/records management, 
  3. better diagnosis of diseases, 
  4. reduction in patient re-visits and even prevention of medical errors, 
  5. optimal information exchange to support better health outcomes

With the understanding of What is Blockchain, What is Interoperability in Healthcare and What are the use cases for Interoperability in healthcare, do you think Blockchain Technology can be used in Healthcare? Do share your thoughts and use cases.

In the next part of the blog, I will explore some of these use cases in healthcare and for the purpose of defining how Blockchain can help interoperability of Patient Transactions across healthcare facilities.


References

1. Blockchain Opportunities for Healthcare: https://www2.deloitte.com/us/en/pages/public-sector/articles/blockchain-opportunities-for-health-care.html


3. Health Information Exchange – Architecture Types https://corepointhealth.com/health-information-exchange-architecture-types

4. Bitcoin is the Sewer Rat of Currencies, interview of Andreas Antonopoulos by Mark Frauenfelder http://ow.ly/XDMe30bumBy

5. Blockchain – What is Permissioned vs Permissionless? by Deva Annamalai on Core Dump https://bornonjuly4.me/2017/01/10/blockchain-what-is-permissioned-vs-permissionless/

6. ONC Blockchain Challenge: https://www.healthit.gov/newsroom/blockchain-challenge
Author

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Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

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The Current Status of 8 Future Technologies on Healthcare by @msharmas

It’s mid-2016, and here is a look at the current status of 8 Future Technologies that might be having a significant impact on Healthcare


Most if not all these technologies will make an impact on Healthcare, and hence it is important to understand the various scenarios and the stories detailing how the experts from across the world are incorporating these technologies in healthcare

1 Internet of Things

By 2020, there are expected to be 50B IoT devices with a total economic impact of $3.9Trillion – $11.0Trillion across all the industries, out of which $1.6 trillion impact in the “Human” segment.

Experts have identified the various areas in Healthcare, where IoT-based solutions can be implemented in healthcare. 

  • IoT refers to any physical object embedded with technology capable of exchanging data and is pegged to create a more efficient healthcare system in terms of time, energy and cost.
  • Dr. Vikram in his article on how IoT can transform healthcare opined the benefits of remote patient monitoring in emergency cases
  • Dr. Pankaj Gupta, noted in his article for IoT-based solutions to be aggregators of healthcare data from primary, secondary and supporting care market will begin to be aggregated. It will be in the interest of Insurance, Pharma and Govt to support IoT driven Healthcare Market Aggregation
Digital Health startups are working on the following categories as showcased in The Map of Healthcare IoT

  • Clinical efficiency, 
  • clinical grade biometric sensors/ wearables, 
  • consumer home monitoring, 
  • brain sensors/ neurotechnology, 
  • fitness wearables, 
  • sleep monitoring and infant monitoring

IoT platforms need to be created to ensure the utilization of data being generated by the IoT devices deployed in healthcare. Absence of platforms to aggregate IoT device data will result in loss of meaningful and contextual insights being drawn for the patients’ conditions.
 
Here is an Infographic, by Team HCITExperts, IoT in Healthcare, Types of Opportunities

2 Augmented Reality

Pokemon Go happened and augmented reality has triggered the imaginations of the innovators to work on bringing the technology to Healthcare

By 2020, an IDC report states AR – VR revenue will hit $162Billion by offering major applications for healthcare and product design.

In a recently concluded Intel developer conference, Microsoft’s Windows chief Terry Myerson announced a partnership with the chip maker that will make all future Windows 10 PCs able to support mixed reality applications.

For instance, Live 3D imaging is one of the hottest topics in optics today, transforming medical imaging capabilities and delivering the immersive experience behind augmented and virtual reality.  

Tim Cook in a recent interview indicated Augmented Reality to be a bigger market than virtual reality.

3 Virtual Reality

With VR technology projections reaching $3.8Billion by 2020, there will be an increase in the use of VR technologies in Healthcare

Virtual reality has an increasing number of implementation opportunities in Healthcare for education, training and patient treatment.

While the cost of using VR in healthcare is still something that needs to be dealt with, partnerships like the one with Intel and Microsoft only bodes well for bringing the technology mainstream and be cost effective.

VR tech is currently being used to 

  • virtually zoom around the patient’s brain to pinpoint an aneurism before the operation. 
  • 3D virtual renderings of the patient’s anatomy lets physicians get a very real experience before operating on the patient
  • the Virtual Reality is being used to present the patient a virtual human agent that replicates a Doctor & Patient communication, where patients can get their questions answered in an environment free from judgement
  • train surgeons how to use new or unfamiliar devices
  • presenting medical images such CT-Scans and MRIs as 3D renderings for improved accuracy of diagnosis 
  • and as an alternative treatment for seniors

4 Blockchain 
Interoperability in Healthcare is a big topic for debate and a sore unsolved puzzle. With the US HHS and ONC seeking research on Blockchain for Healthcare, there seems to be growing interest in the technology. 

For instance, “By combining the blockchain with the peer-to-peer business model, this creates the potential for a near-autonomous self-regulated insurance business model for managing policy and claims. No single entity would control the network. Policyholders could “equally” control the network on a pro-rata basis” 
– Cyrus Maaghul in Why out of hospital Blockchains matter

Blockchain technology is being researched to be the super secure healthcare data aggregator of EHR data and IoT devices data

Blockchain technology is supposed to benefit healthcare 

  • in population health and clinical studies, 
  • interoperability, 
  • patient centricity, 
  • security,
  • supply chain management 
  • Merck has already announced its exploring the use of Blockchain technology for clinical trials. For instance, if a patient is enrolled for multiple clinical trials, a single blood test common to all the clinical trials needs to be done only once and can be shared across the clinical trial studies the patient has enrolled for.
  • In a recently concluded challenge, ONC in the US announced 15 winners for the use of Blockchain in Healthcare

5 Artificial Intelligence
Artificial Intelligence has been a topic of research all these years, but with the advent of the Data Age, Artificial Intelligence is fast moving mainstream and presents a viable business opportunity. 

“By 2025, AI systems could be involved in everything from population health management, to digital avatars capable of answering specific patient queries.” — Harpreet Singh Buttar, analyst at Frost & Sullivan.

In a recently published report, AI adoption by enterprises is imminent. 38% of respondents are already using AI, another 28% will adopt it by 2018. 

The AI ecosystem is projected to be worth $5.5Billion by 2020

Artificial Intelligence ecosystem consists of:

  • Deep Learning
  • Evidence Based
  • Machine Learning Systems
  • Prescriptive Analytics
  • Natural Language Generation
  • NLP/ Text Mining
  • Predictive Analytics
  • Recommendation Engines

Artificial Intelligence has already started making its way into healthcare, with 90+ AI startups getting funding to deliver solutions like; 

  • helping the oncologist define the best treatment plan specific to each patient
  • a virtual nursing assistants, to follow-up with patients post discharge
  • drug discovery platforms, for new therapies
  • Medical Imaging and diagnostics 
  • The use of AI in diagnosing diseases, patient education and reducing hospital costs
  • You can also find a great discussion on machine learning, wherein how machine learning could replace/ augment doctors via the health standards podcast with Fred Trotter.

Some of the other areas where AI is being implemented in Healthcare. Microsoft, Apple, IBM and other major players are all looking to AI help in curing people. And they are forming a group that creates the standard of ethics for the development of AI.

Finally have a look at the AI in healthcare: Category Heatmap

Source: CBINSIGHTS


6 3D Printing 
3D Printing in Healthcare is making fast inroads in many disruptive ways. The projected market size for 3D Printing in Healthcare as suggested in the IDC report:

“Global revenues for the 3D printing market are expected to reach $US35.4 Billion by 2020, more than double the %US15.9 Billion in revenues forecast for 2016.

This represents a compound annual growth rate (CAGR) of 24.1 percent over the 2015-2020 forecast period, IDC research reports that while 3D printers and materials will represent nearly half the total worldwide revenues throughout the forecast, software and related services will also experience significant growth”

Gartner expanded the number of profiles from 16 in 2014, to 37 technology and service profiles in their latest Hype Cycle for 3D Printing 

3D Printing in Healthcare is being used in the following ways: 

  • 3D Printing and Surgery. All surgical and interventional procedures with complex pathology, extensive resection and/or extensive reconstructions could benefit from this technology: Orthopedics, Cardiovascular, Otorhinolaryngology, Abdominal, Oncology and Neurosurgery.
  • A bespoke 3D Printed model of the patient’s forearm changed the standard course of a 4 hour surgery to a 30 min less evasive soft tissue procedure
  • Affordable prosthetics
  • the FDA has touted the use of 3D Printing in personalised medicine, ans has already cleared 85 medical devices and one prescription drug manufactured by 3D Printing.

Researchers are also exploring the use of 3D Printing which could come mainstream in the future such as Printing prescription drugs at home, Synthetic skin, 3D Printing and replacing body parts.

7 Drones

Last year in a conference a researcher proposed the use of Drones for delivering healthcare in much the same way Katniss receives medicine in the Hunger Games movie or for that matter in the movie Bourne Legacy, UAVs are shown to retrieve the blood samples of Jeremy Renner.

The worldwide market for drones is $6.8 billion anticipated to reach $36.9 billion by 2022

Similarly, there is an active interest in the use of drones to be monitoring traffic, to delivering pizza and products ordered online. 

In context of Healthcare, UAVs are being field tested for transporting samples and blood supplies, medical drone manufacturer Vayu is using UAVs to deliver cutting edge medical technology in Madagascar. In Rwanda, estimated 325 pregnant women per 100,000 die each year, often from postpartum hemorrhage. Many of these deaths are preventable if they receive transfusion via drone delivery in a timely manner. 

In India, Fortis hospital plans on using drones during Heart Transplants, to cut the travel time and save lives. An estimated 500, 000 are in need for organ transplants in a year in India.

Drones & UAVs are also being tested for delivering emergency medical supplies during accidents and natural disasters.

8 Robotics

Robotics in healthcare has been used for sometime now, for instance the Da Vinci surgery system is being used for a myriad of surgeries. 

Just the other day i came across an article on robots being used for some of the tasks at the reception of the hospital.

“Cloud robotics can be viewed as a convergence of information, learned processes, and intelligent motion or activities with the help of the cloud,” the report explains. “It allows to move the locus of ‘intelligence’ from onboard to a remote service.”Frost and Sullivan report on Cloud Robotics.

The overall world market for robotics in healthcare will reach $3,058m in 2015, and expand further to 2025.

The global robotics industry will expand from $34.1 billion in 2016 to $226.2 billion by 2021, representing a compound annual growth rate (CAGR) of 46%.

I was reviewing the articles on Robotics in Healthcare and came across this very comprehensive article Robots/ Robotics in Healthcare by Dr. Bernadette Keefe, MD which provides a comprehensive look at the current and future trends.

Other areas robots are being used in healthcare in addition to the above scenarios are: 

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Forrester’s Top Emerging Technologies To Watch: 2017-2021 http://bit.ly/2dmVRkZ  via @GilPress

And there you go, we look forward to you sharing your experiences and thoughts regarding these Future Technologies and share them with our community of readers. 

We appreciate you considering sharing your knowledge via The HCITExpert Blog

Suggested Reading

  1. The Future of Healthcare Is Arriving—8 Exciting Areas to Watch | Daniel Kraft, MD | Pulse | LinkedIn http://ow.ly/KrGS304kGjs
  2. Why the A.I. euphoria is doomed to fail | VentureBeat | Bots | by Evgeny Chereshnev, Kaspersky Lab http://ow.ly/CMKu304kGyU
  3. Looking Back At Today’s Healthcare In 2050The Medical Futurist http://ow.ly/4Dl6304kVZZ
  4. Incisionless robotic surgery offers cancer patients better chances of survival: StudyTech2 http://ow.ly/gpMS304l3wq 
  5. Robots/Robotics in Healthcare | Bernadette Keefe MD http://ow.ly/wRbb304lz44
  6. By 2020, 43% of IT budgets will be spent on #IoT: Jim Morrish, Machina ResearchThe Economic Times http://ow.ly/VKuT304lFi9  
  7. Forrester’s Top Emerging Technologies To Watch: 2017-2021 http://bit.ly/2dmVRkZ  via @GilPress
  8. Are killer bots about to do away with smartphone apps? – http://www.bbc.com/news/technology-37154519 
  9. Where machines could replace humans–and where they can’t (yet) | McKinsey & Company http://ow.ly/v9BY100dNn6 
  10. 2016’s hottest emerging technologies | World Economic Forum http://ow.ly/Jq2R100m4AS 
  11. The Top 10 Emerging Technologies 2016list, compiled by the Forum and published in collaboration with Scientific Americanhttp://www3.weforum.org/docs/GAC16_Top10_Emerging_Technologies_2016_report.pdf 
  12. Rwanda’s hospitals will use drones to deliver medical supplies http://money.cnn.com/2016/10/13/technology/rwanda-drone-hospital/index.html?iid=hp-toplead-intl 
  13. 4 Trends Shaping The Future Of Medical Events https://t.co/rUUUJ7oqkK #digitalhealth #hcsm https://t.co/KuPgGW4k9Z 
  14. Post-PC Tech Rules at Intel Developer Forum 2016 https://lnkd.in/fKux3Ek 
  15. House MD vs Doctor #AI- Who will turn out to be the better by @RoshiniBR http://ow.ly/elXy304mYpv

    Author

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    Why Out-of-Hospital Blockchains Matter by Cyrus Maaghul @Pointnurse

    Bitcoin and blockchain technology will be game changers too


    This article was first published in Mr. Cyrus Maaghul’s LinkedIn Pulse post here . The article is published here with the author’s permission.
     
    I bought my first bitcoin in May 2013 while on a vegan retreat in Asheville, North Carolina. Going through the purchase process reminded me of when I first downloaded Mosaic and surfed the net. I thought to myself, “this is going to be a game changer”. It was.


    Bitcoin and blockchain technology will be game changers, too.

    Bitcoin, its underlying blockchain and evolving peer-to-peer networks with Turing-complete smart contracts such as Ethereum will have a disruptive impact on many industries for years to come. Financial services, payments, supply chain logistics, insurance, and healthcare are just a few that will be disrupted with these new technologies.

    Out-of-hospital blockchains

    Healthcare will be a primary beneficiary of these new technologies, especially outside of the walls of hospitals.

    As more and more health and preventive care is provisioned in virtual environments, at home, in cars, at work, etc, the need for open and accessible tracking, verifying and provisioning of care will become extremely critical for patients, payors, providers, scientists and regulators.

    These new out-of-hospital (OOH) blockchains developed in the non-clinical community will set the pace for how patient behavioral and inter-clinic visit vital data is tracked in the future for provider reimbursement, regulatory compliance, safety monitoring and patient adherence.

    The blockchain is a near-perfect technology (not necessarily the current implementations) to securely and safely make OOH data easily accessible with relatively minimal privacy and hack risk to all patient stakeholders, including the patient themselves, family, caregivers, clinics, providers, insurance companies and all those with a stake in their patients’ health.

    Each and every one of these stakeholders or network peers approved by the patient can easily join OOH blockchains as either nodes or buyer or seller of tokens or payments to gain access to patient data, utilizing a variety of open access methods and smart contracts that store and monitor real-time contractual conditions agreed to by and between various stakeholders.

    There will be many OOH blockchains developed to address the myriad of use cases in healthcare, including tracking the development of drugs, doctor and nurses credentialing, real-time population health data analysis and alerts, insurance peer-to-peer risk pooling, telemedicine and home health visit data sharing, decentralized autonomous organizations, verification and audits, and remote device monitoring commonly addressed today under the Internet of Things category.

    These open and viable peer-to-peer healthcare blockchains will open the door to new business models in healthcare, including analytics-for-healthcare products and services, flash malpractice insurance and friction-less claims processing hence shorter revenue cycles.

    Healthcare insurance claims processing

    It is no secret that healthcare claims processing is a nightmare for all parties involved. Reimbursement is opaque, fraud is prevalent, and transactions frequently difficult to reconcile.

    For example, home health, a great OOH blockchain example, is possibly one of the greatest sources of fraud in the US healthcare industry today. Smart contracts powered by a blockchain could provide consumers and payors with the means to manage claims in a transparent, immutable and responsive fashion.

    Insurance contracts, premium payments and their respective claims could be recorded onto a blockchain and validated by node consensus, preventing fraudulent claims from being processed. Smart contracts could enforce claims triggering payments when due or dispatching specialists, nurses or doctors to follow up with patients when anticipated claims are not recorded by presumptive dates.

    Managing “super-utilizers”

    The term super-utilizer describes individuals whose complex physical, behavioral and social needs are not well met through the current fragmented health care system.

    These individuals go from emergency room to emergency room, to admission and re-admission, in a chaotic and costly manner. Mental health, substance abuse, poverty and education are frequently cited as common characteristics of many but not all in this group. Many researchers and experts postulate how more “community support” and “real-time engagement” is needed to manage this socially isolated population of healthcare super-utilizing consumers.

    Smart contracts powered by an OOH blockchain utilizing the bitcoin payment system could be used to create a rewards and incentive system to manage super utilizer behavior.

    Behavioral contracts could be developed between payor and patient to trigger rewards denominated in BTC for attending support groups, regularly engaging a telehealth professional, reporting health conditions (possibly at kiosks with bitcoin point-of-care devices), and meeting agreed upon health goals.

    Payors would fund reward payouts via efficient BTC accounts established at commercial digital currency exchanges. A smart contract would trigger a reward payment (or loss) when goals are met near real-time to the patient’s public bitcoin address which in turn could be tendered at local participating outlets equipped with BTC point-of-contact devices including community centers, supermarkets and apartment complexes to pay bills, purchase healthy foods and meet rent obligations.

    Medical malpractice insurance DAOs

    In theory, decentralized autonomous organizations (DAOs) are entities that are self-governing. DAOs on a OOH blockchain could enable trust and provide an immutable record and audit trail of an agreement without a single controlling body.

    Doctors and nurse practitioners could collaborate to establish a peer-to-peer malpractice DAO and record each peer’s premium payments and claims on the blockchain. All premiums paid in would create a pool of capital to pay claims.

    By combining the blockchain with the peer-to-peer business model, this creates the potential for a near-autonomous self-regulated insurance business model for managing policy and claims. No single entity would control the network. Policyholders could “equally” control the network on a pro-rata basis.

    But, these are just a few examples of how bitcoin and blockchain technology will change the face of healthcare in the future.

    The blockchain is a new and exciting technology, and we are now just beginning to see both small and large players dip their toes into the water. I personally would discourage any entrepreneur from pursuing the use of blockchain technology inside the walls of clinics and hospitals today, as the those lanes are laden with painful obstacles – the OOH blockchain is your winning lane today

    Author
    Cyrus Maaghul

    Cyrus Maaghul is a thought leader in healthcare, technology, and finance with experience in markets around the globe. He is keenly interested in the blockchain, cryptocurrencies, and healthcare particularly the intersection of physical and behavioral health and provider empowerment