Blockchain is a distributed and decentralized network which is crypto-secured and has immutable records of transactions made in peer to peer network. Blockchain transforms the way trust is built between multiple parties (actors) involved in the system (network) which otherwise do not trust each other or require a separate authority to work together. While the concept is a decade old, it is now finding real-world application across various industries and use cases. In fact, Blockchain remains at the ‘peak of inflated expectations’ on Gartner’s hype-cycle.
Given the attention, it goes without saying that Blockchain needs to be assessed for healthcare use cases. Does it really address a lot of problems in healthcare? Or are there too many myths floating around that prevent Blockchain from becoming a reality in the healthcare industry. In spite of the hype, Blockchain is not necessarily relevant to all healthcare use cases. A Blockchain does not provide any significant value if:
- Blockchain is treated as a replacement to a database.
- Blockchain is simply understood as a system that allows data to be present with multiple actors or is considered as a shared database.
- Only one writer exists. For a single writer system, a traditional database application approach is well suited
- Something of value or the entity being transacted does not change its state post the transaction.
- There is no need for multiple parties to reach to a consensus or verify the state or ownership with every transaction
- Data being transacted consists of large data sets.
- Multiple parties or writers involved in the system trust each other.
Key Factors When Selecting a Blockchain
Fundamentally, all Blockchains constitute a mechanism for public verification and consensus among actors. Understanding these attributes is essential to identify the right type of Blockchain for a specific use case.
Verifiability
In terms of verifiability, Blockchains can be public, permissioned or private.
- Public: The network does not identify the writers or nodes. Anyone can be part of the network. All the nodes in the network can read the state and participate in the consensus to verify the transaction and commit the block in the chain. Public verifiability is a must for all Blockchains.
- Permissioned: In this type of Blockchain, the network knows who its writers are. The decision on who joins the network is made by a trusted party. Public verifiability is also a requirement in this type of Blockchain.
- Private: Verifiability is selective in way that the central authority decides who can write / commit in the network. Private Blockchain is similar to a shared database.
In the healthcare context, BFT is a better choice of consensus building as compared to PoW or PoS, since it does not involve resource extensive computation, fuel / token or any other incentive-based approach, which means there is minimal to no cost of participation by patient.
Consensus Mechanisms
Blockchains may use different consensus mechanisms such as Proof of Work (PoW), Proof of Stake (PoS) or Byzantine Fault Tolerance (BFT).
- Proof of Work (PoW): This is an incentive-based mechanism to create consensus using cryptographic puzzles. Proof of Work is used by cryptocurrency players such as Bitcoin and Ethereum. Transactions on the Blockchain can only be performed by ‘miners’ who need to solve these puzzles (Proof of Work). The first miner to show Proof of Work gets rewarded with cryptocurrency.
- Proof of Stake (PoS): Participants need to have a stake in the system, and those with a larger stake have a higher chance of getting selected to create the next block in the Blockchain. Typically, stake is in the form of cryptocurrency.
- Byzantine Fault Tolerance (BFT): The system overcomes malicious or malfunctioning Blockchain nodes through distributed consensus. The BFT method can achieve consensus even if there are faults such as collusion between nodes, or deliberate non-participation.
In the healthcare context, BFT is a better choice of consensus building as compared to PoW or PoS, since it does not involve resource extensive computation, fuel / token or any other incentive-based approach, which means there is minimal to no cost of participation by patient.
The table below compares public and permissioned Blockchains based on regulatory overview, consent and type of consensus mechanism. We have not included private Blockchains here since they have limited applicability.
Identifying the Need for Blockchain
In many cases, we can identify the need for Blockchain through a few questions such as:
- Are multiple writers involved?
- Does the state need to be stored?
- What is the type and volume of data that needs to be managed / stored
Let's evaluate a few examples to see if they can be potential Blockchain use-cases:
Patient Health Data Sharing and Access Control
Where patient owns the data and can share the control to a physician, provider, payer or a clinical research 3rd party; sharing and access control can be part of a smart contract.
Since there is no need to store the state, this use case can be managed without Blockchain. It is also important to answer a few other questions like:
- Would a trust-based system be feasible in case of an emergency? For example, the patient is unconscious / immobilized but the physician needs access to patient data.
- How do we handle false entries made by patients?
Claim Tracking and Management
Various stages of a claim can be verified by various actors across the network.
Patient Health Check with Rewards and Incentives
The objective is to incentivize patients with rewards and points on every health check of a patient.
Interoperability Issues
Resolving Interoperability issues requires all participants to work together and follow a common set of processes. It is more of an agreement to have universal standards than a technical initiative. Without having standard processes, technology will just be an overhead and make the process more complex.
Pre-authorized Payment Infrastructure
Based on the patient’s insurance plan and cost of treatment, a decision is taken by the payer before the treatment starts on whether the claim would be approved or rejected.
Avoid Falsification of Clinical Trial Results
To make sure that the pharma company does not tamper with a new drug trial results on various patients.
Counterfeit Drug Prevention
To track the drug right from its origin / source to the patient who consumes.
Tracking of Blood, Blood Components, Ortho/ Synthetic Implants
To get a verifiable record of current state of a component / implant whose origin can be a donor or synthesized in lab, along with the information of its receiver.
Patient Visit Monitoring
Monitoring patient visits to identify the fraudulent claims.
Conclusion
The above approach can be used to evaluate if a business problem can be solved without Blockchain. As mentioned earlier, Blockchain cannot be a solution to all the problems in healthcare. To make the most of Blockchain investments, technology and security teams must carefully weigh the pros and cons of each use case and have a transparent, roadmap-driven approach to Blockchain implementation.
