With a better understanding of the fundamentals of blockchain technology, we will now examine some of the current state-of-the-art uses of blockchain in healthcare, as well as some proof of concepts (PoCs).
Blockchain technology and cryptocurrencies are being touted as the “solution” to problems in many different, disparate sectors throughout multiple industries. Public perception of this technology seems to be largely divided, with one group praising its abilities and implementation and another claiming that it is all hype and empty promises [10]. When viewing blockchain technology in light of the Gartner Hype Cycle [11, 12], it likely resides (as of mid-2018) between the ‘peak of inflated expectations’ and the ‘trough of disillusionment’ depending on perspective.
In the healthcare sector, “the core tenets of blockchain technology—a decentralised and encrypted way of distributing, sharing, and storing information—seem appealing for health data…. Yet blockchain technology raises its own security and privacy concerns just as it offers a new paradigm for distributing information” [10]. Blockchain technology also has the ability to act on clinical data sharing, either through storing the data itself or instructions on who can access that data (potentially through smart contracts), securing patient and provider identities and credentials, optimising management of the health supply chain, data sharing and consent for research and clinical trials (including data monetisation), and insurance and claims processing and detection/reduction of fraudulent activities.
As with any emerging technology in healthcare, the benefits of blockchain implementation are accompanied by its own set of challenges. Difficulties arise due to maintaining truly distributed patient data, the overwhelming amount of generated clinical data, and changes in consensus causing blockchains to fork. Many blockchain applications for storing patient data actually take a hybrid approach and store rules and references to data stored in a protected, centrally owned system or by utilising a private blockchain [13, 14]. This can appear to defeat the purpose of distribution altogether, as it is only one-step away from centralised ownership; however, implementation is key.
Securing patient information and provider identities
Securing patient data for storage, patient access, and health system interoperability is a challenge for blockchain implementation due to its largely open nature. As said earlier, one solution to this is using a hybrid approach, but the issue of interoperability is still present using these models [14]. OmniPHR is a model focused on personal health record (PHR) distribution and interoperability [15]. The OmniPHR model stores PHR in encrypted datablocks that are distributed across nodes in their network. Each block is signed by the entity inserting the information into the datablock, which could be a healthcare professional, the patient, a caretaker, or a medical device [15]. Security is still a challenge—especially around ensuring only “authentic informants” have access to PHR data—but is a first step to completely decentralising patient information.
Securing provider identities and credentials is another area of focus. Piper Jaffray, a US investment bank and asset-managing firm, noted in a 2018 research report they published on blockchain in healthcare (28 pages; available by purchase from [16]), that data including education, licenses, and other credentials can be stored and updated in an immutable, verifiable way. The state of Illinois launched a blockchain initiative and partnered with Hashed Health [17], a blockchain healthcare company, to “explore opportunities to improve the efficiency and accuracy of the medical credentialing process in Illinois” [18]. By utilising a blockchain-based ledger to store medical credentials and licensures, sharing and verification of these licensures will become more efficient. The ledger can be viewed as the sole source of truth for existing credentials, allowing multiple parties to interact with this data in a much more streamlined manor [18]. Additional efforts for healthcare providers’ degree and credentialing have emerged including those by companies (e.g., Professional Credentials Exchange [19, 20]), educational institutions (e.g., Lipscomb University College of Pharmacy and Health Sciences [21]), and consortia collaborating on Decentralised Identity Hubs [22, 23].
Health supply chain management
Supply chain management is necessary in any industry moving materials and goods in any way; however, pharmaceutical supply chain management is especially important to track the materials sourced for manufacturing, the manufacturing process itself, and distribution of the manufactured goods. Delivering substandard or counterfeit medications can have incredibly adverse effects on the people the medications were meant to help. In 2016, “the global market for fake, substandard, counterfeit, and grey market medicines [accounted] for up to $200 billion per year” [24]. Ensuring medication authenticity is vital for patient health and outcomes.
Substandard, falsified, and counterfeit medications are often seen in developing countries, or those with low-income markets. The amount of medication importation also plays a role in the verifiable authenticity of the product, especially with a weak or nonexistent supply chain management system. However, the United States has also been on the receiving end of fraudulent medications. In response to the threat of obtaining more fake medications, the US has started to implement the Drug Supply Chain Security Act (DSCSA). Key requirements for supply chain management technologies compliant to DSCSA are product identification, product tracing, product verification, detection and response to non-standard medications, notification upon identifying a non-standard medication, and the ability to store relevant information including licensures, verification, and product information [24]. Blockchain technology is applicable and compatible with each key requirement of DSCSA.
While pharmaceutical supply chain management and integrity are incredibly important, safety and security of medical devices and supplies can also be improved through blockchain implementation. Devices including implanted cardiac pacemakers and medication pumps can be compromised and controlled. Blockchain technology can be implemented in this field by holding unique device identifiers for each medical device (a requirement by the US FDA (Food and Drug Administration) and the EU) and by keeping track and issuing firmware updates by utilising smart contracts. A partnership between Edinburgh Napier University, NHS (National Health Service) Scotland, and Spiritus Development is leading an effort to use blockchain technology to track medical devices through their lifecycle [24, 25]. This device tracking has the potential to improve safety and efficiency of medical devices through more responsive device recalls and issued notices [24, 25]. Blockchain-based medical device tracking also can utilise immutability to prevent device loss, theft, or any other sort of malicious tampering.
Blockchain technology can improve supply chain management in a number of ways including: “… reducing or eliminating fraud and errors, reducing delays from paperwork, improving inventory management, identifying issues more rapidly, minimising courier costs, and increasing consumer and partner trust” [24, 26].
Clinical research and data monetisation: giving patients the choice to share
A major benefit of blockchain technology is moving data ownership from institutions and corporations into the hands of the people who generated said data. This gives them control over who can see or interact with their data in any way. Not only does blockchain protect their data ownership, it also makes it easier to share data in a secure way while receiving benefits or payouts [27]. Health data can be used for clinical trial recruiting, can be monetised for research purposes, and shared with other healthcare professionals and EHRs (Electronic Health records) as needed for appropriate levels of care [28,29,30]. MedRec is an EHR implementation project started by the MIT (Massachusetts Institute of Technology) Media Lab and Beth Israel Deaconess Medical Center that takes a “decentralised approach to manage permissions, authorisation, and data sharing between healthcare systems” [13, 25].
Professor Andrew Lippman, associate director of the MIT Media Lab, recently spoke about MedRec at MIT Technology Review Conference. As he explained, full nodes act as the MedRec data server and maintain the blockchain. These nodes are themselves maintained by the entities generating data (medical professionals and institutions). Smart contracts define access and rights to data and is the “language” upon which the blockchain is defined. Patient wallets are how individuals interface with the blockchain. The wallets contain keys that provide access to the appropriate data [13, 14, 25]. MedRec does not put any actual health data onto the blockchain; Health data stays with the organisation that generated the data. This institution or organisation now acts as a data holder or repository when running the full node. When running the node, the organisation agrees to (1) be the repository of the smart contracts stored on the blockchain and the generated data, and (2) that they will obey instructions in the smart contracts to make the data available where needed and permissioned [13, 14, 25].
The MedRec blockchain sits somewhere in between the Bitcoin blockchain and a tradition database. In the Bitcoin blockchain, anyone can join and take part, which greatly increases complexity and expense to keep the chain running. MedRec restricts who can join the blockchain to medical providers and organisations. They run the full nodes, they maintain the data, and they keep the blockchain secure in a more efficient way than the Bitcoin blockchain could. The MedRec blockchain used to be maintained by medical researchers. As payment for maintaining the blockchain, they would gain access to random, anonymised health data for epidemiological research purposes. At the time of writing, MedRec has moved further to a proof of stake model. There are no transaction fees to move data around or use contracts. There is no coin that needs to be mined for transactions. It is maintained by the group of stakeholders made up by the healthcare organisations that take part in the MedRec blockchain.
Claims processing and fraud detection
Claims processing has been identified as a target for blockchain disruption or enhancement, inclusive of streamlining preauthorisation submissions, health insurance claims adjudication, and eligibility management [30, 31]. One blockchain framework has explored doing so via a ‘decentralised infrastructure for healthcare service marketplaces’ using non-fungible tokens which would enable participants to negotiate and discover value [32]. Claims processing and related components tied to abbreviating payment cycles are also particularly fertile areas for integration of smart contract functionality to automate and accelerate. Recent legislative decisions in some regions are allowing enforcement of DLT smart contracts through their classification as legally binding [20, 33]. However, concerns have been expressed that what is evolving as a “patchwork” legislative approach to regulating these aspects of blockchain and DLT could complicate rather than clarify, especially if lawmakers and their advisors do not fully understand the scope of these emerging technologies [34]. Alternately, it is hoped that some of the same underlying features of blockchain that solved the “double spend” problem [1] along with the immutability of some ledgers will similarly help address the medical fraud, corruption, and abuse that is rampant in some health care systems [35, 36].
Other emerging uses of blockchain in healthcare
In addition to the above-mentioned four major categories of blockchain use cases for healthcare, new categories are coalescing and individual use cases continue to emerge (see also the section below entitled ‘Geospatial blockchain use cases for smart healthy cities and regions’). These include, but are not limited to, public health surveillance [37], enhancing compliance in human subject regulations for IRBs (Institutional Review Boards) [29], improving medical records management [30], and leveraging genomic data in a broader way [38, 39]. Medication prescribing is another potential healthcare use case that could illustrate benefit from the transparency and share-ability of blockchains. A blockchain for prescriptions could be used as a ‘shared source of truth’, combating incorrect, outdated, and siloed data [10]. A blockchain for management of prescription data might also have the potential to enable new ways to interact with patients and their prescriptions, including writing a valid prescription to the blockchain without needing to specify a pharmacy and to allow partial filling of prescriptions across multiple pharmacies [10].