Two months. That’s how long Dr. Adriana Raus waited to get a patient’s MRI results sent from another hospital to the hospital where she worked. Due in part to the American Recovery and Reinvestment Act of 2009, the medical records were in digital form, yet getting them emailed was impossible.
The hospital on the other end of the transaction had to print, scan, then fax the MRI results to Dr. Raus’s office. And this arduous process could begin only after the patient sent written permission allowing it.
“It’s become so complicated, and we’ve lost sight that technology is supposed to make the physician and patients’ life easier,” says Dr. Raus, a Michigan-based physician.
Raus finally got her patient’s MRI results. But she eventually left the hospital to start her own direct primary care practice, in part because she was tired of dealing with the logistical headaches of electronic health records.
Led by massive U.S.-based firms Cerner and Epic, the Electronic Health Records industry has become a global business that’s projected to swell in value to $33.4 billion by 2025, according to business consultancy firm Grand View Research.
Yet the market is rife with dysfunction, much of it stemming from the fact that electronic health records exist in numerous, different and decentralized data systems. Depending on where they’ve received treatment, and how much they’ve moved around, patients’ medical histories are typically scattered between several data centers, and even a few old-school filing cabinets.
“If you’re in the same system it’s easier to use, but when you’re trying to go outside of your hospital, outside of your EHR system, its very hard to share the information, especially because you’re sending everything as a fax or a pdf, and you can’t sort through it,” says Raus.
Failing medical records system
The fractured nature of EHR is a global problem. But the situation is particularly dire in the United States, where hundreds of private companies, and several government agencies, maintain their own silos of patient data.
The challenge is that these data systems are often incompatible with one another – a problem referred to as a lack of “interoperability” by industry insiders (Healthcare IT News).
Despite the U.S. federal government allocating $27 billion to digitize medical records in 2009, only 38 percent of hospitals were able to share EHRs with another hospital in 2015 (HealthIT.gov). Nearly $6 billion a year is lost on misidentifying patients because of poor record-keeping (Fierce Healthcare).
In a 2017 interview with Vox, Barack Obama said the clumsy shift to digitize medical records was his biggest healthcare regret while in the White House.
How blockchain technology might help
To the EHR rescue (maybe), comes the blockchain community, a group of engineers and advocates who’ve gained commercial credibility since the rise of the cryptocurrency Bitcoin, which runs on the nascent blockchain technology. After reducing inefficiencies in major financial firms, these ambitious technologists believe they can reduce the massive administrative costs in the healthcare sector (Coindesk).
A seemingly countless array of “blockchain in healthcare” companies have many individual ideas of how to disrupt the industry. Approaches may be different, but each has the same broad goal: give patients more control of their electronic health records.
“We believe that people should be at the center of their own data, full stop,” says Amber Hartley, spokesperson for BurstIQ, a blockchain company based in Denver.
Patients having ownership of their own medical data is a relatively new idea, legally speaking. Hospitals or physician’s offices that create electronic health records have traditionally wielded significant control over the data.
Since the December 2016 passage the 21st Century Cures Act, however, hospitals have been required to give patients their EHR when requested. Seeing opportunity, tech companies quickly began competing to develop better platforms for sharing this information.
With the distinct advantage of being nearly impervious to hacking – the healthcare industry is projected to spend $65 billion on protecting sensitive healthcare information by 2020, according to CyberSecurity Ventures – blockchain solutions have gained traction. By distributing information over several servers, blockchain makes pieces of data unreadable unless hackers have access to the entire chain. Bitcoin, notably, has yet to fall victim to the honeypot and ransomware cyber attacks that plague the healthcare industry, according to an industry audit conducted by Verizon (Wirexapp).
BurstIQ says it’s capitalizing on the cybersecurity of blockchain to develop a master ledger of patients’ medical history. Unlike traditional EHR systems, BurstIQ’s service is attempting to aggregate patients’ total medical history on a decentralized platform, instead of having it spread across a confederacy of EHR corporations – a concept supported by 94 percent of Americans in a 2016 survey that asked if health data should be concentrated (Surescripts).
‘Blockchain in healthcare’ means data is off-chain
With big promises to reshape the concept of money, the blockchain community can resemble something close to a parish of tech missionaries. Within the world of healthcare, however, many blockchain entrepreneurs have toned down the futurist gospel. Electronic health records are incredibly complex.
BurstIQ has made a name for itself in the “blockchain in healthcare” community in part because of a distinctly ambitious business model. As one of the few (if not the only) companies attempting to put electronic health records on blockchain, the startup venture is an outlier.
The vast majority of “blockchain in healthcare” companies have no plans of putting actual medical data on a decentralized platform. One reason is that EHR has a massive digital footprint, especially with X-rays, MRIs, and other image-based tests taking up large amounts of data. Kaiser Permanente, a major hospital network, has 30 petabytes in medical data (1 petabyte equals 1,000 terabytes), according to The New York Times. Meanwhile, a typical Bitcoin transaction is 200 bytes (Mashable).
“The data itself is too large, in too many places, in too many formats, it’s just not feasible in the blockchain environment,” Professor of Healthcare Information at the University of Louisville Judah Thornewill told WikiTribune.
For blockchain to store that level of data, multiple servers would need to store it, making a system cost-prohibitive. Instead, most blockchain entrepreneurs are limiting their scope to utilizing blockchain, similar to how Bitcoin tracks an individual’s balance as a ledger of transactions.
“Blockchain is excellent at doing certain things,” says Thornewill. “Like keeping track of permissions: who is allowed to access data. Audit trails: who actually did access data. And providing authorization transactions: who’s allowed to access this data.”
Thornewill has started his own blockchain company, YouRiz, with the goals of fulfilling the spirit of the 21st Century Cures Act, and empowering patients to control their own healthcare data. Like most of his colleagues, his approach is to use the technology as an entry into a patient’s medical data, rather than making it the home of EHR. He hopes patients will soon charge companies and researchers to access copies from EHR servers. This model of keeping track of transactions is commonly referred to as a “pointer system“(Digital Trends). Blockchain may not store the coveted data, but will be used to point to where such data resides.
Even Thornewill’s pointer system is too complicated for many blockchain companies. Hashed Health, a major blockchain in healthcare developer network, has no plans to work with EHR anytime soon.
“I think it is a noble effort, but think that it’s equivalent to launching Uber in 1996,” Hashed Health COO Giles Ward told WikiTribune.
Hashed Health is focusing on using blockchain to share physician credentials. Currently, these must be manually sent to government offices and insurance companies any time a doctor applies for licensing in a new state or hospital network. The process of credentialing physicians causes delays that cost hospitals up to $7,500 a day, according to Business Wire. That’s a small piece of administrative dysfunction Ward says blockchain can quickly alleviate.
Ward sees interoperability woes with EHR as more of a political and business problem than a technology one.
“I think that EHR companies could be interoperable by the end of the year if they wanted to be, but they don’t,” he said. “We live in a competitive mostly for-profit healthcare world – [interoperability] is not part of the business model.”
Estonia says keep data off-chain
The first country to integrate blockchain with the national EHR system was, unsurprisingly, Estonia (Gemalto). Estonia’s commitment to “e-residency,” an initiative making all government services accessible online, has put the small Baltic nation at the forefront of the blockchain movement.
Despite being a pioneer in blockchain, and having a universal healthcare system, Estonia opted for pointer system over the ambitious on-chain model of BurstIQ. Guardtime, the software security company tasked with implementing blockchain in the Estonia system, uses what’s known as KSI, a platform designed on the assumption that data will be kept off-chain.
Guardtime General Manager Glen Ogden says Estonia saves 2 percent of its GDP every year thanks to use of blockchain technology across the board. After being contracted by other departments of the U.S. government, he says Guardtime plans to help integrate blockchain solutions in the American healthcare system in the near future.
WikiTribune asked Ogden whether the United States should pursue placing EHR on-chain or accept an off-chain approach, such as those employed by a majority of blockchain companies. He strongly supported the off-chain approach. In addition to heavy data-capacity storage needs on blockchain, he says the prospect of competing with traditional EHR companies is daunting.
“If you’re going to do something like this, you can’t go to the EHR companies like Epic and Cerner and tell them ‘we’re in competition with you,” Ogden says. “You’ll be destined for failure.”
Cerner and Epic have not responded to requests for comment for this story.