Office of National Coordinator, can we get a blockchain?

In 2008, 9% of US Hospitals had some form of an electronic health record system (EHR, EMR), today over 96% of US Hospitals have an EHR system. The arms race in healthcare information technology adoption since The HITECH Act has created a patch work quilt of systems to communicate our nation’s healthcare data. The double edge sword of a free-market system. This is not much ado about nothing, it’s critical that patient’s and providers can effectively communicate and access their health information. To be sure, we’ve come further with clinical data capture and exchange in the past 10 years than anytime since the days of Hippocrates. Our pre-eminent challenge in 2019 is the extensibility and backward compatibility of the software technologies underpinning our current healthcare systems. The frameworks some of these programs were built on are literally from the 1960’s. Blockchain technology as a concept (decentralization) only makes sense given the time sensitivities of emergent healthcare events alone; however, second and third order thinking is critical to executing the implementation of this concept into healthcare.

EHR software in healthcare today operate more like North Korea than they do Switzerland. So, is it even realistic to begin incorporating a decentralized model into ever-expanding workflows dependent upon centralized models? To centralize or decentralize, that is the question. Cerner and Epic dominate the large health system EHR space with Epic specifically starting to sink its teeth into the lion’s share of new adoptions. The interesting part of this is our nation’s defense systems (VA and DOD) will be working on their $16B adoption of Cerner’s health records over the next decade or more while the rest of the major free world hospitals seem to be looking towards Epic. There are others that operate in the smaller hospital marketplace, but most hospital beds in the future will be covered by Cerner and Epic. Given those centralized databases are not going anywhere for the foreseeable future, the interplay here has to be the middleware systems (Redox, Crimson, Mirth, etc.) that are the plumbing for these disparate systems interactions across the U.S. healthcare ecosystem.

Another feather in the blockchain cap, innovating for usability is not the only place that healthcare research dollars are required to be spent. Vendors not only have to develop towards the most productive workflows for end-users but also adhere to the ONC/CMS standards (MACRA, HIPAA, LOINC, ICD, etc.) for privacy that are imposed upon them, and for good reason. Unfortunately, the certification criteria alone for EHR and complimentary systems have taken immeasurable human capital (Google Physician burn-out coinciding with onerous EHR workflows). Talk about unintended consequences! Blockchain as a technology offers significant benefit to managing the integrity of our healthcare information. Having instantaneous access to an immutable account of your longitudinal history through a token or the like is akin to how our banking system operates today. What’s a guy got to do to get a stateful piece of end user software around here?

Here is the uptick, the FAANG gang and the like are looking towards this massive part of our nations GDP as an opportunity, as they should. While it’s certainly been tested before, the HITECH Act has finally created the opportunity for some of the most effective business operators in human history to start accessing, aggregating, and stratifying personal health information across the United States and other developed nations.

Several EMR vendors are creating marketplaces to open their software packages up to third-party developers to create tools for patients and providers to gain better access to information. It’s a start. Think of these marketplaces like you would your iTunes or App Stores. To be sure though, like the limitations that any oligopoly imposes on consumer marketplaces (think Microsoft, Android, and iOS restrictions), these organizations filter third-party app developers access accordingly.

Salesforce is highly touted as the world’s #1 CRM, which it is. Amazon is the world’s #1 e-commerce retailer, which it is. These same organizations though are quietly starting to build enterprise healthcare software systems and infrastructures for managing vast amounts of healthcare operator’s business processes. There is no reason to think that these organizations cannot continue to innovate and impose their will on the healthcare ecosystem. Apple in its own right is making access to that information easier than ever before for end-users and will only continue to drive the socialization of personal health information through its applications. Today, there is no mint.com for our health and wellness data. Who is going to be the first organization that begins to think outside the box and deliver an aggregated longitudinal history to our mobile devices?

Blockchain technology provides a host of pros and cons. We will dive into those aspects in part II of this series on the current and future states of technologies that are enabling healthcare information exchange. From data availability, Patient-Generated Health Data (PGHD), and immutability to voluminous clinical data, verification of new transactions, and privacy. Thank you, General-Data Protection Regulation.

The concepts that define block-chain are nowhere more critical than in our nation’s healthcare system and it’s going to take the likes of the FAANG gang to revolutionize how we manage and exchange our personal healthcare information. Let me leave you with this, there is a high degree of probability that my most personal information was one of the 80 million or so records that Blue Cross decided to dump into the stratosphere in 2015. Throw some credit monitoring and credit freezes into the mix and we’re back in business though. So, at this point, why can’t we just allow consumers to use the tools that we use for all other aspects of our lives to more effectively manage our personal health information?

Published by Miers Q.

This website is a testament to the importance of our healthcare system and the importance our choices have on that system. I have worked in the health information technology software space since hanging up my baseball cleats. Hopefully this information can offer some unique perspective in a notoriously ambiguous industry.

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