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PoweringthePhysicianPatientRelationshipwithHIEofOneBlockchainHealthIT

AdrianGropper,MD

August7,2016



● AddresswhetherthereisaplaceinhealthITand/orhealthcarerelatedresearchfor

thetechnology[1];



Physicianssteertreatmenttogetherwithpatientsandareresponsibleforthevast

majorityofdecisions,andthereforeexpenditures,inhealthcare.Yetthetechnologythat

mediatesthephysicianpatientrelationshiptodayisnotdirectlypurchasedorcontrolled

byeitherthephysiciansorthepatients.Electronichealthrecordsandhealthinformation

exchangetechnologyaresoldasstrategicassetstoinstitutions,typicallyverylarge

businesses,thatcurrentlyhaveincentivestomaximizeinstitutionalgrowth.Weseeka

betterbalanceofinstitutionalneedswiththeneedsofphysiciansandpatients.



Itiswidelyacceptedthatreducinghealthcarecostgrowthrequiresgenuinepractice

reform.Fewinstitutions,however,areplanningtoreducetheirownsize.Byfocusing

healthinformationtechnologyandinteroperabilityonthephysicianpatientrelationship

webypasstheinertiaofinstitutions,fertilizetheenvironmentforvaluebasedpayment,

andoptimizecareoptionsamonghospitals,thecommunity,andhome,asappropriate.



Blockchainiswidelyrecognizedforitsabilitytoempowerinnovatorsandindividualson

alargescaleinanenvironmentthatincludesthenecessityofinstitutions.The

appropriateapplicationofblockchaintechnologytohealthITcanshiftthebalancetothe

physicianpatientrelationship.It’shardtoimagineamoreeffectivelubricantfor

innovationinourcomplexprivatizedhealthcaresystem.



● DescribethevalueofBlockchaintothehealthcaresystem;



Blockchainhasprovenvalueatreducingtransactioncostsintradingsystemsand

expandingtheaccessiblemarketforinnovators.Itdoesthisbyshiftingpowertothe

edgesofthenetworktheconsumers.Thispaperdescribesastandardsbasedwayfor

blockchaintoshiftdecisionmakingandpurchasingpowertophysiciansandpatients.



ShiftingcontrolofhealthITawayfromthehospitalnotonlyopensthemarketmakingit

accessibletophysiciansandpatientsbutitalsoopensthemarketfordecisionsupport

atthepointofcare.Forexample,hospitalsarereluctanttoshowphysiciansthecostof

amedicationorprocedurewhenthey’reabouttoorderit.Theyareevenlesslikelyto

presentthephysicianwithalistofalternatives.Onthepatientside,there’snowayto

CCBY2.0Pleasefindthisdocumentathttp://bit.ly/BlockchainHealth1



independentlyadvisethepatientofoutofpocketcosts,alternativesources,andtypical

riskswhilethepatientandphysicianareengagedinmakingverycostlydecisions.

Mobiledevicesinthephysicianpatientencounterandsecureblockchaininfrastructure

enablethenextgenerationofdecisionsupportappsatthepointofcare.



Ourproject,HIEofOne,(HealthInformationExchangeofOne)shiftsthetrusted

intermediaryroleawayfromthehospitalandintotheblockchain.Theblockchain

canalsoprovidethelinkbetweenphysiciancredentialsandpatientidentity.



InthecurrenthealthITarchitecture,thehospitalisresponsibleforbothcredentialingthe

individualsandsecuringtheprotectedhealthinformation(PHI).IntheHIEofOne

architecture,credentialingisdonebyinstitutionssuchasmedicalsocietiesorstate

agenciesthatdonothaveorwantaccesstoPHI.Identityofphysiciansandofpatients

ismanagedontheblockchainwithoutplacinganyPHIontheblockchain.(N.B.Identity

isawriteseldomreadmostlyapplicationthat’sideallysuitedforthewriteseldomread

mostlycharacteroftheblockchainwhereproofofworkisonlyrequiredtocreateor

updateanidentitywhileuseoftheidentitycostsessentiallynothing.)Finally,intheHIE

ofOnemodel,thePHIstaysinplacewhereveritwasgeneratedorismostconvenient.

HIEofOneworkswithPHIininstitutionalEHRs,PHRs,regionalhealthinformation

databases,cloudwellnessservices,orthePrecisionMedicineInitiative.



HIEofOnelinkspatientPHItoblockchainidentitiesandblockchainidentitiestoverified

credentialproviderinstitutionsthatdon’thavePHIanddon’twanttheliabilityofPHI.

Thisnotonlylowerstransactioncostsbutitimprovessecurityforallparticipants.Data

movesunderthecontrolofblockchainmediatedidentityandtrust.



● Identifypotentialgapsinstandardscreatedand/orresolvedbyBlockchain;



Practicesthatprotectpatientprivacyhavenotkeptupwiththescaleoftoday’shospital

andHIEnetworks.When5or10Millionpatientsand50,000staffhaveaccesstoa

singleEHRsystemordeliverynetwork,standardsforconsent,authorization,

singlesignon,andaccountingofdisclosureshaveprovedelusive.Atanationalscale

likethePrecisionMedicineInitiative,today’spracticesareinsufficient.



HighlevelpanelsincludingPCASTandJASONconcludedthatseparatingaccess

controlfromPHIstewardshipwillbenecessarytoachieveinteroperabilityatscale.But

thisgoesagainstthecurrentroleofhospitalsascombinedholdersandcontrollersof

PHI.Thegapsincurrentstandardsarenotincidental.Theyaretheresultofan

imbalanceofITpurchasingpowerinfavorofhospitalsandtheirEHRvendors.

CCBY2.0Pleasefindthisdocumentathttp://bit.ly/BlockchainHealth2



Anotherobviousgapisthelackofidentitystandardsinhealthcare.Thereisessentially

zeroadoptionofidentityfederation(singlesignon)foreitherphysiciansorpatients.In

addition,identitymatchingseemstobeaproblemuniquetohealthcareandhas

spawnedexpensiveandunreliableprobabilisticmethodsthatharmprivacyandwillnot

scaletotheneedsofanation.



Blockchainhassomeestablishedidentitystandardstotheextentthatitisableto

reliablymaintaintheintegrityandaccessibilityofindividual“wallets”buttherearegaps

inlinkingthecryptographicidentityofblockchainstosinglesignonstandardslike

OpenIDConnect[2]andtoverifiedclaims[3].



HIEofOneisworkingwithmultipleblockchainsundertheauspicesoftheWorldWide

WebConsortium(W3C)toadvanceblockchainIDstandards[4]andtoalignthemwith

theOpenIDConnectcapabilityalreadyinHIEofOne[5]andourFHIRstandardEHRs

[6].TheinitialdemoofHIEofOnebasedonHL7FHIROpenIDConnectKantara

UMAstandardswasmadetotheOpenIDHEARTworkgroupinFebruary2016[7].



TofilltheblockchainidentitystandardsgapwearenowworkingwiththeW3CWeb

Authentication[8,9]andW3CVerifiableClaims[3]standardsworkgroupsalongwith

theW3CBlockchainCommunity[10]groupandcontributingtotheHL7FHIR[11]

standardsandUMA[12]developmentaswell.Thisworkwillbepresentedatthe

RebootingtheWebofTrustmeetingattheendofOctober2016[13].



● DiscusstheeffectivenessofBlockchaintofunctioninthe“realworld.”



Theeffectivenessofmanagingblockchainprivatekeyshashadagreatdealof“real

world”experiencebecauseitisthecoreofblockchainwalletfunctionality.Theuseof

privatekeysforidentityauthenticationhasbeenshownatscalebytheFIDOAlliance

productsandisbeingadoptedasWebAuthn/FIDO2.0bytheW3C[8,9].



Theeffectivenessofmanagingblockchainidentityinthe“realworld”hasnotbeen

establishedbutsecondgenerationsystemsalreadyexistandtwovendors(oneBitcoin

andtheotherEthereumbased)havebeenselectedforintegrationwiththeMicrosoft

Azurecloudplatform[14].BlockchainIDhasbeenbroadlyavailableforoverayear.[15]



TheHIEofOnesystem[16]doesnotstoreormanagePHIontheblockchain.Thus,it

avoidsseriousprivacyandscalabilityissueswithblockchaintechnology.TheHIEof

OnesystemusesFHIR[11],OAuth2[17],andUMA[12]togetherasinHEART[18]to

CCBY2.0Pleasefindthisdocumentathttp://bit.ly/BlockchainHealth3



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