This article is a part of the ‘Technology, transformation and health care” series created in partnership with AMS Healthcare. These solutions-focused articles will focus on emerging technologies and their potential for transformational change in our health-care system.
For many, the word “blockchain” either conjures images of Bitcoin or is a cause for confusion. But the seemingly abstract technology typically reserved for cryptocurrency aficionados is on the verge of improving efficiency, transparency and trust in health-care settings.
“There’s tons of novel approaches [using blockchain], especially when it comes to managing data,” says Pedro Miranda, a PhD candidate and researcher with Ubiquitous Health Technology Lab at the University of Waterloo whose work has focused on harnessing the technology for use in health care and health research. However, Miranda cautions that there are still a number of limitations to the technology.
To imagine how to integrate blockchain into our health systems, we first need to understand how this technology works and where it excels.
What exactly is blockchain?
It’s easy to get lost in the weeds when entering the world of blockchain technology.
In its most basic terms, blockchain is an electronic database or ledger. It keeps a record of different types of information, mostly transactions, that are then shared among different actors, or “nodes,” within a computer network, each of which can enter data into the block.
Unlike typical databases that use tables, blockchain stores and organizes data into groups, known as “blocks.” The first block is called the Genesis block, also known as Block 0 or Block 1, which is generally hardcoded into the software. Blocks only have a certain amount of storage space. Once a block is full, it is “closed” and linked to a previously filled block, connecting all the blocks in the chain in chronological order. Each of these blocks are identified by long numbers that include encrypted transaction information from previous blocks as well as a sort of “mathematical puzzle” that must be completed for the block to be added to the chain.
Plinio Morita, a researcher and director of the Ubiquitous Health Technology Lab, explains that the data housed within a block is shared across all nodes in a network, each of which plays a part in verifying the information. Blocks must be verified by the network before they can be “closed,” and new blocks can then be created to log new data. The blockchain distributed within a network can be added to but never deleted or modified without common consensus.
The immutable nature of blockchain is particularly valuable from a security standpoint. Since the information in a given block is nearly impossible to change and requires consensus among the nodes in the network to update, blockchain creates essentially tamper-proof records.
Private vs. public networks
There are several different types of blockchain technology, defined in part by the type of network it operates within: public or private.
Public networks are where blockchain first got its start with cryptocurrencies. Anyone can join a public blockchain and the contents of the blocks are visible to all. Thousands of people race against one another to complete and “sign” the blocks by solving complex mathematical problems. In cryptocurrencies, this is called “mining” and generates a cryptocurrency that is entered into circulation and can be used instead of government-issued currency.
Although a central feature of cryptocurrencies, Miranda says mining doesn’t have a role to play in health care.
“In public networks like Bitcoin, the more people using and mining it, the better it is for the network. In private networks, you close it down and say only authorized people will be able to go here,” Miranda says.
A private blockchain is generally controlled by a single entity (say, a business or a health authority) that authorizes specific people to join the network. The network’s creator knows exactly who all the participants are from the start and the information contained within the blocks is restricted to approved actors.
Consent and data management
The blockchain that we’d use for health care wouldn’t involve the excitement of thousands of miners racing to complete math problems for monetary gains. But the principles that make blockchain technology secure, efficient and transparent make it an appealing option for numerous health-care solutions.
One possible application is in health-research studies, specifically managing the data and consent of study participants, something very near to Miranda’s heart. He’s been designing a platform for his doctoral thesis that would use blockchain technology to assist health researchers.
“Now, especially with the pandemic, what researchers want is a massive amount of health information,” says Miranda. “But when we collect that data, we’re talking about hundreds of thousands of people.”
“Now, especially with the pandemic, what researchers want is a massive amount of health information.”
Miranda notes that since a lot of research is still highly paper-based, there’s an administrative burden that comes from managing data and consent efficiently and ethically.
“Managing that volume of information with a spreadsheet or requiring participants to come to your clinic to explain the consent form and get a signature doesn’t work at a national scale or when we’re talking about public-health surveillance,” he says. “It’s very susceptible to error.”
On Miranda’s platform, participants would be able to read about the study and decide whether to participate. If they consent, that information gets stored on the blockchain and relayed to relevant parties in the network (researchers, stakeholders, the institutional review board, etc.).
If the protocol to a study change or a form has to be updated, retrieving updated consent from thousands of participants through conventional means can be a painstaking process, Miranda says. “We want to provide tools to lower the amount of human error in conducting studies and improve transparency. Blockchain is the backbone that can provide that transparency.”
Another near-term use for blockchain technology is the creation of “digital identities,” says Miranda.
“When you go to a walk-in clinic or hospital, after they take your blood pressure or other information from a monitor, that information is connected to your health card. But ultimately, that information is not yours. It stays with the hospital or provincial government,” Miranda explains. “With digital identities, the hospital would still have a copy of your records, but that data actually belongs to you and would be binded to your digital identity.”
Digital identities, or electronic medical records (EMRs), puts patient data into their own hands and allows them to travel to different health-care providers without having to rely on health records to be transferred among them. With patients in control of their own health data, we would no longer have to worry about delays or interoperability issues, like waiting for one clinic to fax a patient’s records before seeing a new doctor.
Blockchain technology could also improve issues of redundancy; keeping data with the patient could help prevent different clinicians from doubling up on tests, for example.
But there are a number of kinks left to iron out before digital identities can become a reality. Blockchain is by design a high-stakes host for sensitive health information. To put it in cryptocurrency terms: If someone forgets their “key,” a digital password for their Bitcoin wallet, whatever was in that wallet is lost forever. With health records, patients losing their “keys” would mean losing their medical history.
Another issue is accessibility – not everyone is comfortable using this technology. But Miranda says he’s confident that platforms will become easier to use.
“Ten years ago, only nerds were using blockchain,” says Miranda. “But now, if [you want to buy cryptocurrency] there’s an easy-to-use website, like online banking. You don’t have to be a computer programmer to use it. In a few years, I believe it will be the same with digital identities.”
Who would be responsible for managing these platforms is yet to be determined, though Miranda says provincial governments would be the most likely to want a stake.
“I feel like digital identities are one of the main players. Eventually we will probably also see [the use of Blockchain] applied to digital identities together with consent management.”
Managing drug-supply chains
Blockchain is also a fast and secure way to manage drug-supply chains since it can keep a log of each shipment as it’s received at each stop along a given route, Miranda says.
It is already being used in the pharmaceutical industry to track certain shipments and help crack down on the production and sale of counterfeit drugs, a growing industry in recent years that has resulted in an estimated 100,000 to 1,000,000 deaths world-wide each year.
One study cited that “blockchains can be used to trace the origin of pharmaceuticals, the transport of drugs, and the procurement of raw materials,” that also “reduces the number of intermediaries involved in the pharmaceutical process, thereby reducing costs and improving safety.”
What blockchain can’t be used for
The very same features in blockchain that make it incredibly secure also render it too cumbersome for certain tasks – for the time being.
“Blockchain never deletes data, it just updates the data on the ledger on that record and then it adds another row to that ledger,” Morita explains.
The immutability of blockchain presents distinct obstacles with regards to health information. The Personal Information Protection and Electronic Documents Act (PIPEDA) states that patients have the right to amend and delete their health information, which is currently impossible with blockchain.
“With every modification that you make on the system, you create a new record essentially stating ‘That other record is not valid anymore, this new one is the valid record,’” says Morita. “So, the volume of the data grows exponentially.”
Miranda says that what blockchain can do is help provide transparency within the process of sharing data.
Blockchain technology isn’t ideal for housing data itself, rather it logs the connections between the data readers and the data repositories. For example, if a doctor wants to access a patient’s data, the blockchain network would log the patient’s consent to share that information. That would then redirect the doctor to the (non-blockchain) database that stores that patient information and authorize access.
What blockchain has in store
As well as patient autonomy, transparent and accurate consent management and drug-supply tracking, also in the works is creating immutable records to organize fair organ transplant recipient lists. Researchers have highlighted how a blockchain-backed system of organ donation could allow for a more equitable, safe and efficient transplantation network. The immutability of blockchain could help prevent people from “jumping the queue,” as well as better synchronize databases and allow for more efficient donations. Expanding a transplant waitlist on a larger scale, say internationally, could also dramatically improve chances of finding a viable donor with whom patients could easily exchange and verify health records.
Once researchers solve the problem of scale, another significant benefit is that “blockchain offers a good structure to collect information on genomics data, pandemic data and other public health data,” Miranda adds.
Improving the issue of scale could allow anonymized genomic data to be shared securely around the world. This kind of widespread data could be hugely valuable for researchers developing therapies and diagnostics. Blockchain also has been used to support COVID-19 contact tracing in countries like South Korea due its ability to efficiently and securely relay data across the network, a use for the technology we’re likely to see refined for future pandemics.
Miranda says that once certain issues are addressed, there are myriad possible applications for blockchain technology in health care. “Anything you want to keep immutable, transparent and anonymous, blockchain is great for doing that.”