Pradeep: “Blockchain will put me – or people I trust – firmly in charge of my healthcare”
Why is blockchain an appropriate technology for use in healthcare and in what ways do you see blockchain technology affecting the sector?
Blockchain is a technology which can help us to fundamentally re-imagine the healthcare IT system architecture. You can imagine it being a bit like tipping a mainframe on its side. Current healthcare IT systems are mostly custom-built within their own silos, their own data structures and using their own business logic. They are all confined vertically and the owner dictates everything from back office functions to scheduling, access to care, delivery of care, payments, quality measurement and so on. By definition, this type of vertical architecture creates multiple, duplicative information and huge overheads. Since the consumer is not an empowered owner of their own data, it also leads to lack of access and lack of say for patients and many frustrations for doctors too. Both remain at the mercy of the system. By tipping the mainframe on its side, as I call it, to create a horizontal system, blockchain technology is allowing us to build healthcare systems that are not system-centric but relationship-centric. There will be no need for call centres or 3rd party intermediaries once we have these systems in place. That means we will be able to decentralise relationships and disintermediate the middlemen in healthcare. I believe blockchain’s impact on healthcare is not so much about data but much more exciting if it is instead viewed as a new way of organising healthcare relationships.
What are some of the bigger uses cases in healthcare that could benefit from blockchain technology?
There are probably 3 major use cases that are exciting to us right now and that we are also working on at Solve.Care Foundation:
Scheduling – In healthcare, scheduling appointments is currently a huge problem. No matter which country you live in, you have probably experienced the nightmare of trying to book a doctor’s appointment: engaged phone lines, inconvenient appointment hours, difficulty of rescheduling etc. The list goes on. Our approach is to create a frictionless scheduling system where a family doctor or specialist could share their available appointments and a smart contract would set out the terms of the appointment contract – e.g. what happens in the event of a cancellation, agreed length of appointment, complaints procedure, fee for appointment and/or cancellation etc. Automating the system in this way avoids the need for annoying phone calls, allows either the patient or the doctor to reschedule, facilitates smooth payment processes (if required) and provides transparency to all sides. There are so many smaller uses cases and efficiencies just within this one single procedure of scheduling – it’s amazing how much time, money and hassle this could save to patients all over the world.
Care Utilisation/Care.Protocol – This use case relates to how we access care and the quality of care we receive. So, let’s say we see our family doctor or a specialist and get some advice but we want a second opinion (or even a third opinion). How can we easily access that information and get analysis and advice at a price we can afford? Our Care.Protocol allows for storage of different types of ‘Сare.Сards’ stored in a personal digital healthcare wallet. These cards represent different types of new online services – for example, a 2nd Opinion Card could give you access to a marketplace of possible providers of second opinions. The 2nd Opinion card would notify providers the patient is looking for advice and their budget. A 2nd Opinion Smart Contract (a kind of computer program that executes agreed actions when agreed conditions are met) would then kick into action to offer the user the right advice at a price of their choice. The same type of innovation could also be used to fill prescriptions in a kind of prescription marketplace – would you prefer the medication to be delivered to your home at price A or collect from a local pharmacy at price B, or perhaps filled on a repeating, regular basis at price C, for example? Such services give the patient much more control and choice over their own care.
Billing and Payments – A large part of the administrative burden of healthcare relates to billing and payments, especially (but not exclusively) in insurance-based systems. Bills need to be checked so we need the ability to analyse and compare the bill to make sure it is accurate and fair. We may also want to enter a pharmacy marketplace to get better price discovery on the medication we buy – much quicker and easier than having to physically go to a whole bunch of different pharmacies in person. We may have medical reasons for checking prescriptions too – like avoiding dangerous drug interactions. What if the system could automatically check back on your medical history to make sure you don’t have prescriptions for medications that may be dangerous to take in combination? This type of innovation could save many many lives.
Is there a need for some kind of healthcare information architecture to be defined so that all the solutions being built on blockchain have some degree of commonality? If so, who should design this architecture – government or the private sector?
In my view, the role of government is not to design such an architecture but rather to set the rules of the game, such as ensuring compliance with data protection regulation like HIPAA in the USA or GDPR in Europe. The history of government-run healthcare IT systems is otherwise littered with failures so the best approach to creating such an architecture would be if thought leaders in the blockchain industry were to lead by example and/or if they could form a consortium to define industry standards and terminology. No healthcare IT infrastructure is ever static but perhaps regional architectures could be created. These architectures would meet the needs of different types of systems such as the UK/EU, or the US system and maybe a different type of architecture again is needed for less developed countries who may not have existing health IT infrastructure to battle with – that can even be a strength in building something new from the ground up.
In your past experience, when you were building healthcare IT systems, did you use a well-designed architecture and what did it look like? Is it applicable to blockchain?
Existing standards in healthcare are already there but they were designed for centralised systems not for blockchain-based systems so we need to take what works from the best of existing standards and then see what can be applied to a decentralised multi-party system. Solve.Care Foundation is already working on some ideas about creating such an architecture with the intent to publish it in 2018 as a common resource and we hope others will contribute to it as well.
How are you at Solve.Care implementing your own architecture? What are the key principles that you are using to design your own platform?
Information architecture is both a science and an art form. There are certain healthcare IT architecture principles relating to access, storage, audit etc. that are already well-defined and developed. They are actually similar in healthcare to what exists in finance. The art comes in the ability to think about data in a whole new way – in the context of relationships or what we call ‘entity pairs’ and how to manage all the data related to that pair effectively. So, what are the conditions for sharing data, what are the conditions under which access to data can be delegated and who has liability at each stage? These conditions and needs will be different for different entity pairs – say patient-doctor or doctor-doctor or doctor-insurer or patient-insurer. Blockchain technology is actually perfect for enforcing and managing the variety of bi-lateral relationships that exist in healthcare.
What should blockchain developers working on healthcare applications be careful about?
Different types of blockchains have different properties so we need to define what type of data we are working with and what is the transactional use case. Equally, don’t just pick on one blockchain that you like the look of and try to jam every use case into that framework – it just won’t work. In healthcare, for example, data is not homogenous so what works for managing clinical data might not work for managing clinical events – we need to marry the right type of blockchain to the right use case.
What advice would you give to someone trying to put Electronic Medical Records on a blockchain?
There are 3 major dimensions to healthcare data – clinical data (medical conditions, prescriptions, test results, quality of care), financial data (payments and billing) and administrative data (historical record of events that took place). Although many of the current blockchain healthcare startups are focused on clinical data and providing Electronic Medical Records using blockchain, 80% of healthcare data is actually financial and administrative. It may seem ‘boring’ but administrative functions are actually what users of healthcare systems struggle with the most and where most of the frustration sits with patients or their carers, doctors and nurses. EMRs are important but they are only a fraction of the problem and most current solutions are not being integrated with the care administration process. So entrepreneurs are focused on solving ownership of the results of our care but not on revolutionising how patients can actually access care in the first place and then manage their care. If we compare the healthcare system to booking flights before the Internet era, we can make an interesting comparison. Think of the time and expense taken just to do something like a flight booking, which we can now do at the click of a mouse – in the past you had to call the travel agent, pay them a large fee, wait while they discovered and compared prices for you, deal with all the admin. Processes of paying, receiving tickets in the mail and so on. Now we have online sites like Booking.com or Expedia where all these process are combined in very few steps – we have price discovery and comparison, plenty of information and choice, fairly frictionless payment and instant receipt of an e-ticket to our inbox. We can perhaps compare the future of healthcare using blockchain to this transformation. Being a patient will become more like being your own online healthcare travel agent. It will be a tremendously more efficient and fair way to transact on healthcare decision-making and will allow us to have a much more grown-up, transparent conversation about healthcare costs as well.
How will blockchain-based healthcare solutions deal with compliance issues like data security, privacy rules and so on?
Healthcare data security and privacy is very important but, when it comes to the application of blockchain technology to healthcare data, the debate has become over-simplified. We already have plenty of ability to encrypt and secure healthcare data. Of course the biggest risk in any system is the risk of data breaches – that applies whether the data is stored on a traditional server, in the Cloud or in a system using blockchain. Blockchain may actually even be helpful in allowing us to track down who was able to fraudulently access that data and how. The only solution to breaches in any system is proper diligence. But the real issue in managing healthcare data on blockchains is how to access that data with the proper consent. We need to look at consent management in a totally new way. This is why Solve.Care’s platform approaches consent management so carefully – by need, by person and by time. We need a robust consent module and – under certain conditions – a robust consent delegation module giving conditional access, such as access to data for next of kin if triggered by a care emergency. These layers of agreed access put me or only the people I trust firmly in charge of my care.
You have spent a quarter of a century building healthcare IT systems – what are the key dos and don’ts that others building the systems of the future need to know?
One key thing I have come to understand is that we need greater clarity of roles – no one has yet clearly articulated a plan for ownership of healthcare data, custodianship of that data and how we define the roles and liabilities of other users of that data. The flow of information and funds in most current healthcare token sales/Initial Coin Offerings is not addressing these points. The contractual terms involved in the new healthcare arrangements we are talking about may be more complex for consumers to understand so there is perhaps going to be a greater role for healthcare advocates and educators to guide patients on what types of terms and conditions they are willing to sign up to. But we also need to think about this provision of information in news ways. So this guidance, for example, can also be provided within an online care community. Just as your smartphone knows when you are driving by sensing your speed of movement and offers to turn off your message alerts to prevent dangerous distractions, so an online care community could use aspects of healthcare data transparency to the patient’s advantage. Occurrence of a particular care event could trigger certain care cards to pop up automatically inside your healthcare wallet. So let’s say you have an accident which affects your mobility, a healthcare transportation card might appear in your wallet giving you various options to travel to a doctor’s appointment. Once we have the right healthcare IT architecture in place, a wealth of innovative possibilities will come from a kind of ‘healthcare app store’ created by the community itself solving and responding to its own problems. Community volunteers could offer a rota for car sharing rides to local patients who can’t drive but need to go and collect their medication, for example. Once we build a sharing economy for healthcare, the potential for redefining healthcare and harnessing human ingenuity and goodwill in these new types of way is almost unimaginable.
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