David Chou, CIO at Children’s Mercy Hospital Kansas City, and I wrote a paper “How Healthy is Blockchain Technology?” for the HIMSS Asia Pacific 17 conference in Singapore last week. The paper is a critical analysis of the strategic potential for current blockchains in healthcare applications, with a pretty clear conclusion that the technology is largely misunderstood, and on close inspection, not yet a good fit for e-health.
And we were awarded Best Paper at the conference!
The paper is archived here (PDF) and my conference slide deck is here.
Abstract
Blockchain captured the imagination with a basket of compelling and topical security promises. Many of its properties – decentralization, security and the oft-claimed “trust” – are highly prized in healthcare, and as a result, interest in this technology is building in the sector. But on close inspection, first generation blockchain technology is not a solid fit for e-health. Born out of the anti-establishment cryptocurrency movement, public blockchains remove ‘people’ and ‘process’ from certain types of transactions, but their properties degrade or become questionable in regulated settings where people and process are realities. Having inspired a new wave of innovation, blockchain technology needs significant work before it addresses the broad needs of the health sector. This paper recaps what blockchain was for, what it does, and how it is evolving to suit non-payments use cases. We critically review a number of recent blockchain healthcare proposals, selected by a US Department of Health and Human Services innovation competition, and dissect the problems they are trying to solve.
Discussion
When considering whether first generation blockchain algorithms have a place in e-health, we should bear in mind what they were designed for and why. Bitcoin and Ethereum are intrinsically political and libertarian; their outright rejection of central authority is a luxury only possible in the rarefied world of cryptocurrency but is simply not rational in real world healthcare, where accountability, credentialing and oversight are essentials.
Despite its ability to transact and protect pure “math-based money”, it is a mistake to think public blockchains create trust, much less that they might disrupt existing trust relationships and authority structures in healthcare. Blockchain was designed on an assumption that participants in a digital currency would not trust each other, nor want to know anything about each other (except for a wallet address). On its own, blockchain does not support any other real world data management.
The newer Synchronous Ledger Technologies – including R3 Corda, Microsoft’s Blockchain as a Service, Hyperledger Fabric and IBM’s High Security Blockchain Network – are driven by deep analysis of the strengths and weaknesses of blockchain, and then re-engineering architectures to deliver similar benefits in use cases more complex and more nuanced than lawless e-cash. The newer applications involve orchestration of data streams being contributed by multiple parties (often in “coopetition”) with no one leader or umpire. Like the original blockchain, these ledgers are much more than storage media; their main benefit is that they create agreement about certain states of the data. In healthcare, this consensus might be around the order of events in a clinical trial, the consent granted by patients to various data users, or the legitimacy of serial numbers in the pharmaceuticals supply chain.
Conclusion
We hope healthcare architects, strategic planners and CISOs will carefully evaluate how blockchain technologies across what is now a spectrum of solutions apply in their organizations, and understand the work entailed to bring solutions into production.
Blockchain is no silver bullet for the challenges in e-health. We find that current blockchain solutions will not dramatically change the way patient information is stored, because most people agree that personal information does not belong on blockchains. And it won’t dispel the semantic interoperability problems of e-health systems; these are outside the scope of what blockchain was designed to do.
However newer blockchain-inspired Synchronous Ledger Technologies show great potential to address nuanced security requirements in complex networks of cooperating/competing actors. The excitement around the first blockchain has been inspirational, and is giving way to earnest sector-specific R&D with benefits yet to come.