“Tender-handed stroke a nettle, And it stings you, for your pains: Grasp it like a man of mettle, And it soft as silk remains.” Aaron Hill’s Works circa 1760

There’s been a lot of talk about Blockchain, especially with the dot-com style explosion of crypto-currencies. So before I get into the stinging or grasping part of this article, I thought it would be worth giving a simplistic explanation as to what Blockchain is and how it works. As with previous blogs, I will focus on one industry vertical to illustrate my points, but the concepts will apply equally to all verticals. This time, it’s the turn of the healthcare sector and the use of Blockchain for Electronic Health Record (EHR) management.

But first, a simple explanation of Blockchain.

Last year, my 12 year old son’s class was set a project to investigate how connected New Zealanders are. Each student was given an envelope that contained a standard, templated letter. The letter was then addressed to the famous person of the student’s choice, started with an explanatory paragraph, a picture of the student and finished with a request to return to sender. The student wrote their own name in the first box on the front of the envelope and the name of a famous Kiwi in the last box. The idea was that the student would then pass the letter on to someone who might know, or know someone else who might know the famous Kiwi – you get the idea. The letter then passes from person to person, each signing the next available box until it finally reaches the famous person. They then open the letter, sign and return to the student, thus showing how many links it takes to connect a 12 year old student to a famous Kiwi. My son chose the then Prime Minister, Bill English (sigh). To our amazement, it took only four people (one of whom was me) for the letter to reach Mr English….

 

Now imagine that instead of being written in plain English (no pun intended), the letter was written in a secret code and the instructions needed to crack the code were only given to each recipient of the letter, so only those people could read the letter and understand its contents. This, in essence, is how Blockchain works; each of the participants (including my son and Bill) are blocks in the chain and each of the blocks adds a piece of information to the record. The letter is not copied or held separately by any of the participants and nobody else can see, change or delete the letter. If somebody else steals the letter, it’s of no use to them as they won’t have the code to decipher it. The letter is the Blockchain ledger, the participants are the blocks, my son is the record owner, the decipher code is the encryption. Simple.

Now on to healthcare…

For over a decade, the global healthcare industry has been grappling with the whole idea, implementation and uptake of shared electronic health records. Intuitively, it makes perfect sense that in today’s age of technology, patients shouldn’t need to take a scrawled-on piece of paper from the doctor to the pharmacist to get their medicine – but they still do. Likewise, it makes no sense for that same patient to have to give their contact details to the doctor, the pharmacist, the hospital and any number of other healthcare providers AND remember to notify them all of any changes – but they still do. Then when we look at the sharing (or lack of) of clinical data, we find enormous risks in vital information being missed or not being shared in time to be appropriately actioned. Incomplete or inaccurate records, out-of-date information and the potential for breaches of patient privacy are the dread of any healthcare provider and the scourge of software developers and vendors in the healthcare industry.

Of course, there are some good examples of electronic health records being shared across providers; Healthlink is used extensively here in NZ to electronically communicate, among other things, radiology and pathology results to healthcare providers. But there are also the horror stories. Take the NZ Electronic Prescription Services (NzePS) for example; a project commenced in 2013 with the creation of SimplHealth, a subsidiary of the Simpl Group, set up to be the data aggregator of electronic prescribing and dispensing information from GPs and pharmacies. According to the latest update on the Ministry of Health’s website; “As of June 2017, the NZePS was used by 66 GP practices, up from 47 in Dec 2016.” So in 6 months, only 19 additional practices were using the service. Given there are 1024 practices in New Zealand, that means if adoption of the service continues at the same rate, it will be another 25 years before the roll-out to GPs’ practices is complete!

So the big question is does Blockchain offer the technological path towards making shared EHR a reality? On the face of it, perhaps not; the ongoing failure of the NZePS is more to do with funding, cost and take-up by reluctant GPs who are concerned about patient privacy rather than anything to do with technology. However, on the other hand, Blockchain could be seen as a real game changer, creating a paradigm shift in the way all digital assets are ultimately stored, updated and consumed. If this is truly to be the case, then traditional obstacles like funding, cost and user take-up could all become irrelevant.

To test this theory out, I trawled back through all of the published blogs on Orion Health’s website, assuming that they would likely be at the forefront of this particular technological revolution, leading the charge toward a new era of database-less healthcare applications where health records are truly owned by the individual and access is distributed and controlled by the Blockchain ledger. To my surprise, I had to go all the way back to an article written in October 2016 by Drew Ivan, Orion’s Director of Business Technology entitled A Piece of the Puzzle? The Blockchain-Based Personal Health Record In this article, the author offers a proposal that existing systems that hold clinical data in their proprietary databases continue to do so, but that the data is replicated onto the Blockchain ledger so that it can then be used to provide the benefits of Blockchain already detailed. Interesting that there has been no further update on this since October 2016, but I can only assume that this is still the prevailing view of the author and Orion Health.

This is like brushing against the nettle. Adapting existing systems to work in this way will introduce complexity, confusion and unnecessary risk. Data replication, synchronisation and leakage will be rampant; patient confidence in privacy and security will be compromised and the performance of systems will nosedive. Healthcare professionals will become even more frustrated with their IT systems and the benefits of at least having shared data on the Blockchain ledger will be drowned out in a sea of problems.

It is time to grasp the nettle.

Clinical software applications must be re-written to incorporate and accommodate Blockchain. If end users desire (or demand) identical looking applications with exactly the same functions performed in exactly the same way, then so be it; software vendors can do this and still replace their behind-the-scenes databases and interfaces with Blockchain calls. However, if the nettle is grasped, this heralds the arrival of a new breed of applications based on a breaking-down of the traditional silos, which enable real-time collaboration of health providers having the patient truly at the centre of their interactions with each other and with the patient, not to mention of course, that the patient will own and retain control of who accesses any and every part of their personal and individualised data.

The upside of grasping this particular nettle is massive. Healthcare software providers around the world will finally be able to deliver on the promises that they have been making for over a decade; to create safe, secure systems that allow patient data to be truly owned by the patient, shared with their own network of health professionals and used in a collaboration that is focused on the patient.

Not to mention making NZePS redundant before it is even rolled out.