2017 is in the rear-view mirror and 2018 is fast upon us. Two emerging technologies are likely to help drag healthcare into the modern age—blockchain and artificial intelligence. And my third area of focus continues to be interoperability, enabling seamless health data exchange.
We will see some significant progress in 2018 on adoption of blockchain and AI, and hopefully at least some baby steps on achieving nationwide interoperability.
Healthcare must make a shift to Interoperability 2.0—that’s because health data are essentially useless if systems aren't integrated. A platform for interoperability is essential to thrive in a transformed health system. 2018 is going to see interoperability come even more to the forefront as regulatory action, pressure from value-based payment and delivery models, and deeper partnerships between physicians and payers bring the needs for sharing health data into sharp focus.
HIMSS defines interoperability as the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. In the 21st Century Cures Act, Congress specifically defines interoperability in that it:
- Enables the secure exchange of electronic health information with, and use of electronic health information from, other health information technology without special effort on the part of the user.
- Allows for complete access, exchange and use of all electronically accessible health information for authorized use under applicable state or federal law.
- Does not constitute information blocking.
The law defines information blocking (and assigns some potential stiff penalties for violation) as a “practice that ... is likely to interfere with, prevent or materially discourage access, exchange or use of electronic health information” if that practice is known by a developer, exchange, network or provider as being likely to “interfere with, prevent, or materially discourage the access, exchange or use of electronic health information.”
HHS has a big pile of work to do on interoperability issues in the next few years. A year after the Cures Act being signed into law, ONC is expected to provide rulemaking on implementation of the relevant sections in the near future. The Office of the Inspector General at HHS, which will be the enforcement arm investigating possible information blocking violations, is waiting for such rulemaking to work through process and become final—hopefully early in 2018 to provide some stability to the market.
The law also created the EHR Reporting Program, which consists of reporting criteria on the product security, user-centered design, interoperability and conformance to certification testing. Regulations will need to be promulgated for the implementation of this program.
And finally, a draft of the Trusted Exchange Framework and Common Agreement (TEFCA) mandated by the law is expected to be released. The law actually calls for ONC and the National Institute of Standards and Technology (NIST) to collaborate on a set of policies that will establish a trusted and voluntary framework capable of sharing health information across networks while still protecting proprietary information.
The process will go like this, first taking stakeholder engagement (ONC held a series of listening sessions and meetings) and then publishing a draft of TEFCA, to be followed by a 45-day public comment period. The final version of the rules is expected later this year.
As a next step, on Friday morning, ONC released it draft of TEFCA, which can be found here.
I do not expect 2018 to be year that the federal government solves healthcare interoperability—as a matter of fact, the solutions lie in the private market with a light regulatory touch from the government. ONC acts best in the role of convening and collaborating with the private market to solve the pressing issues facing our nation as we attempt to transform the system to one that pays for quality of care, not quantity.
Organizations like the Sequoia Project and DirectTrust have successful trust frameworks in place that are industry led and standards based. ONC would do well to remember that Congress warned that TEFCA should not disrupt the exchange that is already in place. I do not expect this administration to start throwing out all kinds of new regulations. However, interoperability will continue to be front and center in 2018, and it is not simply a technology problem.
Blockchain is getting a lot of attention lately. HIMSS recently established a work group to examine blockchain distributed ledger technology and its potential implications for the healthcare information and technology community. Everyone seems to be talking about blockchain technology, and sometimes it is difficult to separate the hype from reality. Blockchain technology is very nascent in healthcare; however, I do expect to see progress in 2018.
Blockchain is a distributed ledger technology implemented in a decentralized manner used to record transactions. The records are kept across many computers such that data cannot be altered retroactively without the alteration of all subsequent blocks and collusion with the entire network.
Most often, when people hear blockchain, they think of Bitcoin, which is a cryptocurrency and digital payment system based on blockchain technology. However, blockchain is so much more than Bitcoin or any other flavor of cryptocurrency. While the primary use cases being developed today are in financial services, blockchain will have a profound transformative impact on every industry. Distributed ledger technology will have significant implications for the global economy and society at large.
Blockchain technology is like the Internet in that it has a kind of robustness built in. By storing blocks of information across the network, a blockchain isn't controlled by a central authority and has no single point of failure (redundancy is a part of the framework).
Undoubtedly, blockchain will have an important role in the Internet of Things. The centralized security models in common use today will find it very difficult to keep up with the billions of connected devices we will see soon. This will ultimately have implications in healthcare, especially in areas like telemedicine and remote patient monitoring.
Blockchain technology is an emerging technology that is subject to the law of accelerating returns. We will see exponential growth in the advance of this technology over the coming years. In “Practical Blockchain: A Gartner Trend Insight Report” Gartner predicts that:
- By 2022, at least one innovative business built on blockchain technology will be worth $10 billion.
- By 2030, 30 percent of the global customer base will be made up of things, and those things will use blockchain as a foundational technology with which to conduct commercial activity.
- By 2025, the business value added by blockchain will grow to slightly over $176 billion, then surge to exceed $3.1 trillion by 2030
Gartner analysts further state that blockchain technologies:
- Offer a radical departure from the current transaction and record-keeping mechanisms and can serve as a foundation of disruptive digital businesses, for both established enterprises and startups.
- Enable a standard trust architecture that allows untrusted entities (both human and nonhuman) to undertake commercial transactions and exchange value with a diverse range of assets.
- Foundational concepts are immature, poorly understood and unproven in mission-critical, scaled business operations.
- Have operated outside traditional legal, accounting and institutional governance frameworks, threatening long-standing working practices.
Since blockchain is an alternate computing model that uses distributed and decentralized computing networks to potentially offer greater levels of security and lower costs than traditional methods, this would seem to be tailor made for healthcare uses cases. There is still the outstanding issue of power consumption to be dealt with for blockchain technology to be able to effectively scale across the healthcare sector. The Allied Control white paper estimates Bitcoin mining alone consumes 250-500 megawatts
Blockchain offers a new way to manage trust between untrusted parties by supporting an immutable record of transactions and other types of value exchange; and the vendor ecosystem is not yet cohesive. Various consortia are working with startups and professional services firms requiring a careful, multilayered evaluation of the market.
The most important consortia at this time is the Hyperledger Project, an umbrella project of open source blockchains and related tools, started in December 2015 by the Linux Foundation, to support the collaborative development of blockchain-based distributed ledgers. The executive director is Brian Behlendorf, and they have a health working group that is very active.
According to an article in Harvard Business Review by John Halamka, MD, and others, there are five basic principles underlying blockchain technology: a distributed database, peer-to-peer transmission, transparency with pseudonymity, irreversibility of records and computational logic.
However, clinical record applications for blockchain technology, while compelling, are still further along the adoption curve than some other healthcare use cases. Areas such as automated claims adjudication, revenue cycle management, provider licensure and credentialing, pharma supply chain management and medication monitoring, along with possibilities in clinical trials, are likely to be adopted within the next three to five years. Some solutions are in the market today and 2018 will begin to see implementation of these solutions throughout the healthcare system.
Examples of current blockchain efforts in the healthcare space include:
- The CDC is exploring a proof-of-concept using blockchain technology to assist public health workers in responding more quickly to a crisis.
- IBM Watson Health has partnered with the CDC to explore possible benefits of a blockchain-powered solution for collecting, sharing and managing healthcare data.
- Hashed Health is developing a system to verify graduation credentials using blockchain technology for partner Lipscomb University College of Pharmacy & Health Sciences.
- ScriptDrop is a blockchain-based healthcare startup that seeks to reward patients that adhere to their medication with cryptocurrency tokens they can use toward their healthcare costs.
- MintHealth has launched a blockchain-powered personal health record.
- The startup HealthHeart is developing a decentralized EHR based on Ethereum.
I’ve theorized over the last five years that we have been moving through three waves in digital health: data collection, data sharing and data analytics. With the explosion of health data being gathered and stored, we are now edging into the fourth wave, machine learning. This is being enabled by big data—the more data we have to train algorithms, the more powerful AI will become.
The development of AI tools in healthcare is rapidly maturing and is expected to have a profound impact in 2018. AI in healthcare uses algorithms and software to approximate human cognition in the analysis of complex medical data. A primary goal of healthcare AI applications is analysis of the relationships between prevention/treatment techniques and patient outcomes. AI solutions have been developed and applied to treatment protocols, diagnostic recommendations, drug development, personalized medicine and patient monitoring and chronic care, among others.
But what role will AI play in the future? Richard Susskind, chairman of the advisory board of the Oxford Internet Institute, and his son Daniel, an economics fellow at the University of Oxford’s Balliol College, argue in Harvard Business Review that AI will not only support physicians in their work, but also ultimately replace them. We have seen a big impact from machine learning tools on the practice of radiology, and pathology is moving in that direction as well.
2017 was AI’s coming out party in healthcare. In 2018 we will see further advances. AI will aid human clinicians in diagnostics, particularly in radiology and oncology. Predictive analytics will be used to reduce bottlenecks, thus improving patient flow.
AI-based solutions currently used in the industry have been created by medical institutions such as Mayo Clinic, Memorial Sloan Kettering Cancer Center and England’s National Health Service, along with multinational technology corporations such as IBM, Microsoft and Google, as well as startups like Welltok and Ayasdi. Healthcare remains the top area of investment in AI as measured by venture capital deals. 2018 will see AI begin to have a very serious impact on the entire healthcare industry.
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