Get used to it. Blockchain is invading health IT. And it’s moving fast.
Sure, while blockchain’s encrypted distributed ledger technology has already made big inroads in the finance sector, in healthcare blockchain still is in its infancy.
But it’s one big infant.
Here’s a partial list of corporate, healthcare and academic heavyweights that have already made investments in or publicly signaled they are making a commitment to blockchain for healthcare:
- Accenture LLP
- Deloitte Consulting LLP
- Philips Healthcare
- Humana, Inc.
- Mayo Clinic
- MIT Media Lab=Beth Israel Deaconess Medical Center
- National Quality Forum
Some of these players’ conceptualizations were among the 15 finalists that the Office of the National Coordinator of Health Information Technology (ONC) picked in a contest over the summer.
There were also at least 62 other proposals submitted.
I witnessed the ferment in this early stage era of blockchain in healthcare earlier this week at a workshop put on by ONC and the National Institute of Standards and Technology at NIST headquarters in Gaithersburg, Md., about a half-hour from Washington, D.C.
By the way, the federal government’s interest in the technology is clear.
The potential for the technology is particularly promising for the Department of Health and Human Services, which oversees ONC and the Centers for Medicare and Medicaid Services. Blockchain’s auditing capabilities, in the form of an immutable ledger system that can’t be altered without everyone else on the blockchain seeing it happen, could dramatically reduce Medicare fraud, some proponents say.
Among the 200 or so attendees at the NIST-ONC event were also quite a few critics, skeptics and purveyors of alternatives to blockchain that do some of the same things blockchain does, such as use distributed ledgers.
The blockchain-questioning crowd included developers, analysts and fledgling vendors of blockchain-like systems.
Interestingly, though, it was physicians and representatives of big companies who expressed the most optimism about blockchain’s prospects in healthcare.
“We as a manufacturer are very interested in this,” Dominique Hurley, senior director for global commercial excellence and operations for Biogen, the Cambridge, Mass.-based life sciences giant, said after IBM’s blockchain presentation.
Some observers think blockchain in healthcare will take off once major vendors and healthcare provider and payers start to cooperate, as banks and other financial institutions are doing now with blockchain.
Even the perennially warring EHR mega-vendors Epic Systems Corp. and Cerner Corp. may agree to embrace the technology, Bryant Joseph Gilot, M.D., a Philadelphia area surgeon and blockchain aficionado, told me.
“I think they will be enthusiastic at some point when they realize the benefits and efficiencies to be gained,” Gilot said.
Yet as of today, it appears no real world applications of blockchain have materialized, at least in the U.S.
However, Estonia, the Baltic country known for its adoption of “e-government” in which some 1,000 government services are available online, has embarked on a project with blockchain vendor Guardtime to secure 1 million citizen’s health records with a form of blockchain technology linked to an Oracle database.
Efforts to make health information available to patients are paying off, according to the Office of the National Coordinator for Health Information Technology.
The data show that as of 2015 95% of the hospitals in the United States have enabled patients to view their health information electronically, 87% made it possible for patients to download their health information and 69% provided patients with the ability to view, download, and transmit their health information, according to a blog post by ONC.
Beginning in 2011, healthcare providers under the meaningful use program were required to enable patients to electronically view, download, and transmit their health information wherever they needed that information to go. The provision was included in the Centers for Medicare and Medicaid’s and ONC’s Electronic Health Record (EHR) Incentive Programs.
ONC asserts in the blog post that these are dramatic increases in a short period of time.
The agency found that the ability to view and download health information increased 70% compared to 2012 and hospitals that enable patients to view, download and transmit their health data increased seven-fold compared to 2013.
Furthermore, in 2015 all states had at least 40% of their hospitals providing patients with the capability to view, download and transmit their health data. In 2013, no states had that many hospitals providing patients with these capabilities.
Letting patients view, download, and transmit their health information is an important piece of enabling individuals to get and use their health information. Enabling patients to engage with healthcare providers electronically can lead to better communication, care, and outcomes for patients, according to ONC’s data brief.
ONC added that the ability of patients to digitally control their health data can lower costs as well. Furthermore, the Office for Civil Rights has emphasized that under HIPAA patients have the right to freely access their own health information.
The Department of Health and Human Services is awarding over $87 million in funding to more than 1,300 health centers in all 50 U.S. states and the District of Columbia, as well as Puerto Rico and the U.S. Virgin Islands, to support health IT enhancements. Ultimately, the purpose of this funding is to accelerate health centers’ transition from fee-for-service to value-based care .
Value-based care rewards healthcare providers with incentive payments for the quality of care they give patients with Medicare. Fee-for-service pays providers for the number of visits and tests they order.
Health centers that use the funding to purchase or upgrade EHR systems must use technology that has been certified by the ONC (Office of the National Health Coordinator for Health Information Technology).
HHS Secretary Sylvia M. Burwell said in a statement that the investment will “help unlock health care data and put it to work, improving health outcomes and building a better health care system for the American people.”
The funding will also help improve efforts to share and use health information to support better healthcare decision, as well as increase engagement in delivery system transformation.
Funding for the health centers comes from the 2010 Affordable Care Act’s Community Health Center (CHC) fund, which was extended by MACRA in 2015. The CHC fund provided $11 billion over a 5-year period for the operation, expansion and construction of health centers throughout the U.S. and its territories.
HHS had previously announced over $36 million in funding to 50 health center controlled networks (HCCNs) in 41 states and Puerto Rico. HCCNs promote enhanced health information sharing and support health centers in achieving the requirements for Medicare and Medicaid EHR incentive programs .
A complete list of grant recipients can be found on the Health Resources and Services Administration website.
When the government mandated that healthcare organizations adopt EHRs seven years ago via meaningful use, the promise was that EHRs would transform healthcare, make processes more efficient, and improve patient care. Maybe the systems did those things but, according to a study by the Mayo Clinic, EHRs could also be causing physician burnout.
Indeed, nearly half of doctors in the United States are burned out, with EHRs partly to blame, according to an article by U.S. News and World Report.
Since 2008, the number of healthcare organizations using EHRs has soared from 15% to 80%.
However, the Mayo study found a link between the use of EHRs and physician burnout – with computer ordering likely to be the driving cause.
The study also showed that today’s EHR systems have failed to live up to their early expectations. Instead, they have triggered widespread exasperation among physicians with 44% of respondents who use EHRs responding that they were dissatisfied or very dissatisfied with EHRs and 41% of respondents said they disagreed or strongly disagreed that EHRs have improved patient care.
A majority of the surveyed doctors (63%) also reported that EHRs fail to improve efficiency. In fact, they said their work often ends up leaking into what should be their leisure and personal time. Nearly two-thirds of the physicians said they work at least 50 hours a week and about one in five said they work nearly 70 hours a week.
The study also found that EHRs and computerized orders actually make documentation and other clerical chores more burdensome for physicians.
Anti-EHR sentiment among doctors is fairly widespread. Charles Krauthammer, M.D., a Pulitzer Prize-winning columnist, wrote an opinion piece in the Washington Post asserting that EHRs are a major reason why doctors quit.
Telemedicine can be a viable alternative to in-person visits for children with asthma, according to a new study published in Annals of Allergy, Asthma and Immunology. The study found that telemedicine visits were “noninferior” to in-person visits and children who chose a telemedicine session achieved comparable degrees of asthma control as those who were seen in person.
Children with asthma who resided in two remote locations were offered the choice of keeping an in-person appointment at the allergy clinic at Children’s Mercy Hospital (CMH) in Kansas City, Mo., or changing it to a telemedicine visit. The telemedicine option included a visit to a local clinic where a registered nurse or respiratory therapist operated the telemedicine equipment.
Of 169 children, 100 were seen in-person and 69 were seen via telemedicine. The children in both groups were assessed initially, after 30 days and at six months. Both groups showed an improvement in asthma control over six months, said study author Dr. Chitra Dinakar, an allergist at CMH.
“We were encouraged because sometimes those with the greatest need for an asthma specialist live in underserved areas such as rural or inner-city communities where allergists aren’t always available,” Dinakar was quoted as saying in a report accompanying the study. “The study shows these kids can get effective care from a specialist, even if they don’t happen to live close to where an allergist practices.”
Most of the patients who were seen via telemedicine were satisfied with the experience.
Telemedicine allows young patients to receive care when and where they need it. Telemedicine can provide effective and cost-efficient care for children with asthma who live in rural areas or far away from an allergy clinic, the study concluded.
Eight high-ranking congressmen are calling on federal healthcare officials to consider “flexibilities” in administering the new MACRA healthcare law, particularly as it applies to small physician practices.
However, in a Sept. 6 letter to Sylvia Burwell, secretary of the Department of Health and Human Services, the congressmen, who include members of both parties, did not go as far as calling for a delay in the Medicare Access and CHIP Reauthorization Act.
Interestingly, it was Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid, Services (CMS), who – during a July Senate Finance Committee hearing – raised the prospect of delaying the Jan. 1, 2017 official start date of MACRA’s first quality reporting year.
As it stands now, physicians (though not hospitals, because MACRA does not apply to hospitals), would record and report quality measures under MACRA’s MIPS (merit-based payment system) program. Reimbursement and penalties under the new system are now scheduled to start to be applied in 2018.
In Slavitt’s public remarks, he did not specify how long a delay might be, but just suggested “alternative start dates,” shorter reporting periods and other help for physicians.
In the meantime, groups representing doctors and payers have pressed for a delay and easier reporting requirements, arguing that as is MACRA would be onerous for many doctors and physician practices.
In their letter, the congressmen asked CMS officials to consider “flexibilities” including:
- Simplified requirements
- “Clear pathways” to succeed in MIPS or alternative payment model (APM) tracks
- Opportunities for doctors to move to APM tracks and more flexible ways to be reimbursed for “meaningful delivery system reform activities” in MIPS and APMs.
Nonetheless, the congressmen, who include two powerful committee chairmen, two ranking committee members and four subcommittee chairmen, affirmed their support for MACRA, which Congress overwhelmingly passed last year.
“While MACRA requires significant changes in physician payment to move to value over volume, we believe that many of our nation’s physicians are ready for these changes as they incorporate the physician payment and quality predecessor programs which have been in existence for many years,” the letter said.
A wide range of possible use cases for blockchain in healthcare are revealed in 15 papers chosen by the Office of the National Coordinator for Health Information Technology as the top proposals among more than 70 that were submitted to the “Blockchain Challenge” sponsored by ONC and the National Institute of Standards and Technology.
Some of the ideas will be presented at a workshop at NIST headquarters in Gaithersburg, Md. Sept. 26-27.
“We are thrilled by the incredible amount of interest in this challenge,” Vindell Washington, M.D., national coordinator for health IT, said in a release. “While many know about blockchain technology’s uses for digital currency purposes, the challenge submissions show its exciting potential for new, innovative uses in health care.”
The topics and applications for blockchain technology in healthcare in the 15 winning proposals (whose authors were awarded grants of $1,500 to $5,000) are:
- Establishing a peer-to-peer network to store and analyze health data with 100% privacy to use the data for precision medicine clinical trials and research
- Improving interoperability for information exchange, patient tracking and identity assurance and validation
- Improving healthcare claims processing, including using “smart contracts“
- Opportunities for using blockchain in health information exchange to satisfy national healthcare objectives
- A prototype decentralized record management system for electronic health records
- Using Internet of Things and blockchain technology for patient-recorded outcome measures
- Linking protected health information (PHI) to blockchain identities to verify credential providers to lower healthcare transaction costs and improve PHI security
- Using blockchain in the pre-authorization payment process and in clinical trials, and to prevent counterfeit drug production
- Storing patient health data securely
- Predictive modeling and improving health data interoperability between institutions
- A blockchain-based access control access control management system for health records
- Sharing patient data with network consensus instead of a single centralized source
- Enabling scalability and adoption of accountable care with peer-to-peer authorization and authentication
- Using blockchain and artificial intelligence to develop new ways of delivering healthcare in Medicaid programs
- Blockchain-based alternative payment models linking quality and value
All the submissions will be posted on ONC’s web site, healthIT.gov, on Sept. 26, the start of National Health IT Week.
As medical devices become increasingly connected to the internet and, therefore, the Internet of Things (IoT), Forrester Research, said in a report that there are four types of attacks healthcare organizations need to aware of, especially after coming off the worst year for data breaches in healthcare:
- Denial-of-Service or ransomware attacks. Ranked by Forrester as a high risk attack with a high likelihood of occurrence that often involves demands for ransom payment
- Therapy manipulation attacks. At medium risk of happening, this type of attack is when an attacker gains access to a connected medical device and can manipulate a patient’s treatment
- Patient data theft attacks. Using malware or a software exploit an attacker can gain access to an EHR and steal patient data
- Asset damage attacks. When an attacker sets out to destroy or damage a medical device
Four healthcare IoT security action steps
Step 1: Categorize existing devices based on risk.
According to the Cambridge, Mass. research firm, there are five key factors that contribute to a connected medical devices’ risk rating:
- Potential impact on patient safety
- Network connectivity
- Data sensitivity
- Likelihood of attack
- Vendor security service level agreement
Forrester recommends using healthcare industry assessment guidelines, standards and expertise.
Step 2: Implement a clinical risk management framework.
Forrester said this will also help healthcare organizations determine the risk levels of medical devices, mitigate and control the risk, and bring the risk exposure of the hospital network to acceptable levels. Forrester warned that following this framework is a major undertaking and requires a thorough review of day-to-day processes. Even so, it’s worthwhile considering the serious implications of connected medical device risks.
Step 3: Follow basic security hygiene.
“Your first step toward reducing threats calls for a campaign to raise security awareness and change employee behavior,” the report said. “Use frequent, relevant, and engaging communication to ensure your workforce doesn’t miss security messages.”
Forrester added that another fundamental security control is reviewing and updating password policies.
Step 4: Apply a zero trust networking architecture.
- Acknowledge that your connected medical devices are vulnerable
- Monitor medical devices for infections
- Make sure manufacturers are aware of security risks
- Develop a detailed incident response and recovery plan
The Department of Veteran Affairs (VA) is partnering with the National Cancer Institute (NCI) and the Department of Defense (DoD) to form the nation’s first screening program intended to provide targeted and individualized therapies for cancer patients.
The tri-agency precision medicine partnership is called the Applied Proteogenomics Organizational Learning and Outcomes (APOLLO) and is part of the NCI’s Cancer Moonshot initiative. Proteogenomics is a combination of genomics, the study of the human genome, and proteomics, the study of a specific proteome (set of proteins).
Researchers in the APOLLO program will regularly screen tumors for protein and gene information in order to provide targeted and customized therapies for lung cancer patients in VA and DoD medical programs. Approximately 8,000 veterans in the VA system are diagnosed with lung cancer every year. The program will eventually include other types of cancer.
APOLLO clinicians and researchers will classify tumors in veterans’ lungs based on gene changes in the tumors, as well as the levels of proteins. The researchers will then use the findings to either recommend targeted therapies or refer patients to the appropriate clinical trials. The goal of the program is to share the information gathered with the global cancer community in order to provide precision medicine therapies to cancer patients.
“APOLLO will create a pipeline to move genetic discoveries from the lab to VA clinics where Veterans receive cutting-edge cancer care,” VA Secretary Robert A. McDonald said in a press release. “This is an example of how we are striving to be an exemplary learning health care system. We are proud to join our federal partners in this exciting initiative, and we expect it will lead to real improvements in the lives of those affected by cancer.”
The NCI hopes to use precision medicine to accelerate research that will help identify which treatments work best for which cancer patients. APOLLO will complement other Cancer Moonshot initiatives, including a partnership between the VA and IBM that uses the Watson supercomputer to interpret tumor sequencing results.
Vice President Joe Biden, whose son Beau passed away in 2015 after a battle with brain cancer, leads the Cancer Moonshot Initiative.
If you’re a patient of a hospital or physician that is using the technology of a CommonWell Health Alliance member—including Cerner Corp., athenahealth, Inc., and McKesson Corporation, to name a few—then you’ll be able to get your health data via the CommonWell network.
CommonWell is now allowing people to self-enroll in the interoperability organization and be able to view their health data on the network. MediPortal, a company that focuses on data exchange and patient engagement, and Integrated Data Services, Inc., a provider of technologies that allow patients to retrieve and control their medical data, both CommonWell members, say they will offer these new services through their patient portals by the end of the year.
Enabling patients to enroll and link their health records to the network means patients will be able to give their providers quick access to important health data and improve care coordination, according to the release.
“Far too often individuals and the people who care for them are stymied by the onerous task of accessing their health data,” Jitin Asnaani, executive director of CommonWell Health Alliance, said in the release. “By enabling these services, our CommonWell members will empower people to be more engaged in managing their health and the health of their loved ones.”
Although the importance of patient involvement in health data has been highlighted by the White House and the Office for Civil Rights at the Department of Health and Human Services, a survey from HealthMine found that 53% of patients surveyed can’t access their health data online. Furthermore, 74% of healthcare consumers surveyed said that easy electronic access to health data would improve both their knowledge of their health and communication with their doctors.
Among the CommonWell members participating in the initiative are Aprima Medical Software, Inc., athenahealth, Cerner, Evident, Modernizing Medicine, Inc., and RelayHealth, a subsidiary of McKesson that McKesson is selling to health IT vendor Change Healthcare.