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July 13, ; Accepted date: July 17, ; Published date: J Health Med Informat 8: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Blockchain technology and the associated crypto currencies have the ability to transform industries including healthcare. We suggest the decentralized and programmable nature of the blockchain applications can be used to change health information technology to gain greater efficiency in public and private health care systems.
Current public health information technology systems such as eligibility, enrolment and electronic health records have documented issues with interoperability and are slow to adapt to changing program and technology demands. We suggest that blockchain can potentially solve these issues. We argue that a public program such as the U.
We finally argue that a decentralized benefits administration system can provide greater efficiency to enrolment, eligibility, claims payment and adjudication processes thus driving efficiency and reducing systemic fraud. Blockchain technology applications have the potential to transform our current use of health information technology and the associated hardware and software infrastructure. The underlying technology and associated crypto currency with its decentralized architecture suggests a range of applications that can, we argue, bring cost savings and efficiencies versus traditional legacy systems currently in use in not only the public healthcare space but also in associated private market participants.
We suggest that there are numerous applications that can be implemented in public programs in the U. The decentralized and distributed database of a blockchain that contains data allows for an auditable and distributed ledger that allows all to see every transaction.
The open source attributes of the blockchain make the technology a natural fit for the requirements associated with the complexities of transaction laden systems associated with health information technology in the public and private sector. We suggest that there are specific applications in public programs that include both the U.
Medicaid and Medicare systems that could benefit from the deployment of blockchain applications by replacing expensive hardware and software IT systems with a blockchain infrastructure. In addition, we argue that the potential cost savings would be significant versus current costs and ongoing system maintenance of existing legacy IT systems. Blockchain is relatively easier to program and to implement system wide changes in comparison to changes made to legacy IT systems.
The advantages of blockchain are obvious, but with any new technology there are questions about efficacy and efficiency. In this paper we attempt to answer questions about the technology, issues of interoperability and specific applications related to the health care space and associated costs.
We also address some of the privacy and data security concerns associated with health care that are inherent in any health IT system. Finally, we also examine the policy implications of deploying blockchain technology and suggest further areas of research. The advent of blockchain technology can trace its beginnings to creation of Bitcoin as a digital crypto currency [ 3 ]. While the rise of digital only currencies in recent years has captured the attention of the financial industry, the public, and regulators it remains largely unknown to the general public.
Blockchain has potential to improve healthcare in a number of innovative ways. Some of those examples include a Master Patient Identifier MPI , autonomous automatic adjudication and interoperability [ 4 , 5 ].
Autonomous automatic adjudication would simplify and lead to significant efficiencies in how claims or other healthcare transactions are processed between parties. Essentially, blockchain could lead to elimination of the third party thus creating a more efficient process.
The process would use smart contracts across parties that would enable automatic adjudication of claims. Enhancing claim adjudication in health care has the benefit of reduction in the occurrence of claim fraud that is currently prevalent [ 5 ].
All players in healthcare, from providers to payers, would benefit from this reduction in fraud. Fraud detection and mitigation is increasingly becoming a policy issue for state Medicaid programs. Conservative estimates from the U. These findings suggest that the deployment of a blockchain application that utilizes a smart contract and verifiable ledger of all service and payment activities could reduce fraud and overpayment that is prevalent in the U.
Blockchain could also improve interoperability across systems and organizations. This is crucial for progress in our current health ecosystem which consists of a plethora of disparate IT legacy systems that have been amassed over the years and that do not communicate well with each other.
Blockchain would provide the ability to replace these disparate systems with a single system that offers interoperability. With the use of smart contracts and fully auditable history, Blockchain would enable peer-to-peer interoperability among participants within transactions. The patient would be able to designate by whom the data can be accessed and at what level of access by the use of keys that users would have access to either private or public [ 5 ].
The benefit of blockchain in healthcare would take place across the entire supply chain spectrum. Contractual agreements between payer and patient or provider and patient or between provider and payer would be implemented with the use of smart contracts within the blockchain [ 10 ]. Smart contracts lead to efficiencies as they enable a reduced number of intermediaries that exist today which lead to more streamlined transactions [ 11 ]. Beyond contractual transactions, clinical transactions based on electronic health records would also occur on the blockchain.
Improvements in the supply chain from blockchain would be extended to drug companies and manufacturers, as well as improvement to pharma clinical trials and longitudinal health research for the patient [ 5 , 16 ].
The federal government can also benefit from the improvement in blockchain with more streamlined transactions in the supply chain. For instance, one of the issues facing Medicaid recipients is high churn due to changing economic qualifications. This would be especially valuable if account based plans from the private sector are implemented as an option for Medicaid recipients with hope of reduction in costs and better outcomes [ 18 ].
Other government programs would similarly benefit from a more streamlined delivery of care across all players within the supply chain, including with private prescription plans [ 10 ]. Overall, Blockchain applications have been surging in a number of different industries. The industries implementing blockchain are numerous and are led by real estate, supply chain and others.
Within healthcare, a number of companies have begun implementations of Blockchain in various areas of applicationsincluding Gem in collaboration with Philips Healthcare Blockchain Lab , PokitDok, Healthcoin, HashedHealth and many others [ 4 ]. The Hyper ledger Healthcare Working Group is a consortium that provides an open source collaboration of member companies in healthcare with the goal to speed the development of commercial adoption of blockchain [ 16 , 20 ].
The applications of blockchain technology are numerous as well the potential to transform legacy health information technology. We focus our discussion on public health information technology because of not only its impact on the U. Recent industry and government reports suggest that adoption of electronic health record standards outlined by the law that has funded much of the industry growth is lagging behind with a good deal of variation in provider adoption rates.
Given these coming milestones and varying degrees of implementation success, serious questions remain about the future of wide-spread adoption of electronic health records systems and how the U. As implementation has progressed, there are numerous milestones established by both the authorizing statute, but also under CMS guidelines and regulations. Stage 2 of the program intended to advance clinical processes for all eligible healthcare professionals and hospitals and to report to CMS by the end of The final Stage 3 of the program was slated to be fully implemented by with goal of improved clinical outcomes as result of Electronic Health Records EHR use by providers, but has been delayed [ 23 ].
Each stage of the implementation process has had varying degrees of success with both hospitals and provider professionals as evidenced by both published research and various industry reports.
The variation in adoption rates of EHR standards raises the greatest levels of concern among health IT professionals, policy makers and academics about the prospects for wide adoption of uniform electronic standards.
Adoption rates and the progress toward Stage 3 EHR standards continue to be of concern to not only providers, but policymakers as well. Rural hospitals have generally lagged their peers and older physicians greater than age 55 have lower adoption rates [ 24 ]. Given these lower than expected adoption rates, many health IT firms have struggled to achieve CMS guidelines with their clients as many small providers struggle to implement Stage 2 standards, which leaves serious questions about how the majority of professional providers can achieve Stage 3 attestation and meaningful use standards.
Federal government agencies are not immune to the challenges of implementing EHR standards. Government records management in general and EHR specifically suggest that the deployment of a blockchain solution could potentially alleviate the issues discussed. Most notably the issues surrounding interoperability and secure data access can be achieved through APIs in a blockchain environment. Central to the architecture of the ACA is the coordination of diverse set of disparate programs including Medicaid and various social programs and accompanying legacy technology systems that are needed to verify eligibility, enrolment and ongoing programmatic support.
Inherent in the implementation of these ACA programs are the varied nature of state policy choices and associated complexity [ 26 ]. In anticipation of the passage of the Affordable Care Act, CMS developed and codified a policy and financing structure designed to provide states with tools needed to achieve the immediate and substantial investment in information technology systemsv. In order to achieve this goal, federal funding is provided through a variety of venues to help states improve their eligibility and enrolment systems.
MITA is a national framework to support improved systems development and health care management for the Medicaid enterprise. MITA has a number of goals, including development of seamless and integrated systems that communicate effectively through interoperability and common standardsvii. The MMIS is an integrated group of procedures and computer processing operations subsystems developed at the general design level to meet principal objectives. The objectives of this system and its enhancements include the Title XIX program control and administrative costs; service to recipients, providers and inquiries; operations of claims control and computer capabilities; and management reporting for planning and control.
Often, there are integration and interoperability issues that cause significant cost overruns and additional maintenance costs to both the state and federal government. The promise of blockchain can potentially solve these issues at a reduced cost due to relative ease of deployment versus traditional hardware and software infrastructure. We argue that the MMIS program is a candidate for the deployment of blockchain to only reduce costs but gain additional efficiency to deal with the inevitable changes in the program and technology.
Blockchain technology has the ability to simplify and reduce the cost of benefits administration. As benefits design, enrolment, beneficiary engagement and provider payment systems have evolved overtime there are the inevitable and predictable issues associated with the myriad of health information technology systems designed to work together.
Interoperability has become a key concern and challenge in the development and deployment of the health IT infrastructure. We suggest that the use of blockchain application can assist in dealing with the challenges and allow for potentially infinite modularity and allow multiple systems to work in greater efficiency. Benefits administration involves the use of disparate systems that are designed to gather and process data from numerous sources.
This fact is especially true in public health care systems, including Medicaid and Medicare as well as Health Insurance Exchanges administered by the states and the U.
Integration complexity is a hallmark of these systems as previously discussed. The challenges associated with blockchain deployment with any complex health care system not only include interoperability, but also issues associated with data access and privacy [ 14 ]. Data privacy and the ability to access sensitive patient specific information is one of the key challenges in the design of a healthcare blockchain application.
Numerous researchers and software engineers suggest that addressing authentication of users can be achieved through design of systems that utilize a Proxy pattern to facilitate the transfer of data [ 15 ]. The promise of using blockchain applications are readily apparent when considering how the deployment of the technology can be flexible and address key issues of interoperability and data privacy.
There are numerous processes and systems that potentially meet the criteria and challenges with the new technology; this includes the use of benefit incentive systems such as wellness programs, enrolment and eligibility systems and the previously discussed records management systems surrounding EHR deployment. Current benefits administration systems suffer from several key limitations that we argue are a direct result of the centralized nature of health information technology today. We also suggest that existing large scale health IT infrastructure are inflexible and costly to maintain and update to deal with programmatic technology changes.
As an example, we argue that current eligibility and enrolment systems have rigid logic rules that often cannot deal with the inevitable issue with beneficiaries and their needs. This fact is largely a result of centralized networks that are often inflexible. We suggest that the documented issues of duplication, fraud, and overutilization of service are traceable to the need for data security and data availability.
The centralized nature of current systems lead to a limited and narrowly defined views of what data needs to be shared by whom to whom and who owns the data. We argue that the data belongs to the individual, not the system nor the corporate entities that build the system. We believe that a blockchain application environment utilizing smart contracts can remove many of the barriers and limitations inherent with centralized technology systems.