Dan Munro

Writer

Blockchain Hype Comes To Healthcare

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As to be expected with any “new” and “breakthrough” technology, headlines abound on the promise and enormous potential of this “disruptive” innovation called blockchain. Outside of healthcare, the accolades are breezy, often breathless – if not breathtaking. A great example is this quote from Alex Tapscott.

We’re seeing a big problem where the world economy is growing unabated, but fewer and fewer people are benefiting, and we think blockchain could hold solutions to that.

Or this quote from “What the Internet was for your parents, the blockchain will be for you.”

If allowed to flourish, this technology has the potential to benefit consumers and enterprise on the scale [of] other transformative inventions like railroads, automobiles, telephones, computers, and the Internet itself. The promise behind the blockchain is clear, and its future relies on the collaboration between government agencies, lawmakers and industry leaders.

That “if allowed to flourish” is a little ominous and I’m always a little suspect of “futures” that rely “on the collaboration between government agencies, lawmakers, and industry leaders,” but we get the gist.

Just over two years ago, Marc Andreessen concluded a 3,000 word opus – Why Bitcoin Matters – with this grand vision.

Far from a mere libertarian fairy tale or a simple Silicon Valley exercise in hype, Bitcoin offers a sweeping vista of opportunity to reimagine how the financial system can and should work in the Internet era, and a catalyst to reshape that system in ways that are more powerful for individuals and businesses alike.

Given this level of general hype, it was only a matter of time before healthcare saw blockchain as a solution for many of its problems too. Here are just a few of the recent prescriptions I’ve seen for this new technology elixir.

Not surprisingly, the hype has also started to creep into the healthcare conference circuit. The first example I’m aware of was the Exponential Medicine conference in San Diego last November, but I’m sure there have been others and there will undoubtedly be more. Looking at all this hype, this blockchain is mighty powerful – able to leap tall buildings – solve world inequality stuff. There just has to be a fit in healthcare, right?

First a general definition from Wikipedia:

A blockchain is a distributed database that maintains a continuously-growing list of data records that each refer to previous items on this list and [that can be] hardened against tampering and revision

That’s really it. It’s a distributed database with some very powerful and innovative features. These innovative features are combined in a way to make a blockchain – any blockchain – comparable to a transaction ledger. Not surprisingly, that’s exactly how it acts. It’s a trustworthy distributed ledger.

This is critical because the hype is largely based on these innovative features – and this also goes a long way in understanding how blockchain instantly arrived at its first/best use case – the cryptocurrency called Bitcoin (summarized by its mysterious founder Satoshi Nakamoto’s in his 2008 whitepaper: Bitcoin: A Peer-to-Peer Electronic Cash System).

But much of the initial hype surrounding Bitcoin is officially ancient history. Earlier this year, a lead Bitcoin developer named Mike Hearn announced Bitcoin itself is a failure.

From the start, I’ve always said the same thing: Bitcoin is an experiment and like all experiments, it can fail. So don’t invest what you can’t afford to lose. I’ve said this in interviews, on stage at conferences, and over email. So have other well known developers like Gavin Andresen and Jeff Garzik. But despite knowing that Bitcoin could fail all along, the now inescapable conclusion that it has failed still saddens me greatly. The fundamentals are broken and whatever happens to the price in the short term, the long term trend should probably be downwards. I will no longer be taking part in Bitcoin development and have sold all my coins.

We’ll get to the why of the failure in a minute because it’s also a harbinger of things to come, but for now, let’s review the blockchain technology and why it was perfectly suited for use as a cryptocurrency.

General blockchain features:

  • Decentralized (distributed) database
  • Cyptographic signatures (using OpenPGP compliant programs)
  • Trusted timestamping (used to create irreversible transactions)

These features, stitched together in software, can create a unique “blockchain” that solves a very big, nasty problem for any and all digital currencies. The software engineering challenge is known as double spending.

Double-spending is a failure mode of digital cash schemes, when it is possible to spend a single digital token twice. Since, unlike physical token money such as coins, electronic files can be duplicated, and hence the act of spending a digital coin does not remove its data from the ownership of the original holder, some other means are needed to prevent double-spending.

This problem of double-spending really only exists in the world of cryptocurrencies and creating a unique “blockchain” that solves this problem is what led to the creation of Bitcoin. If that sounds circular – it is. The two are forever linked because the “double spending” problem only exists in digital currencies and the Bitcoin blockchain does solve this – elegantly. Even if Bitcoin itself is a complete failure, the Bitcoin blockchain is proof positive that the double-spending problem in the digital realm has been solved.

In fact, the rise of other cryptocurrency blockchain’s is a sure bet and already under way. Ethereum is a good example of a 2nd generation cryptocurrency that’s capturing Bitcoin-like interest – and hype. This New York Times/Dealbook headline appeared just yesterday. Ethereum, a Virtual Currency, Enables Transactions That Rival Bitcoin’s

Like Bitcoin, the Ethereum system is built on a blockchain in which every transaction is recorded publicly. The promise of such a system is that it allows the exchange of money and assets more quickly and more cheaply than relying on a long chain of middlemen.

The reference to Bitcoin certainly helps to frame the solution, but then there’s even more complexity.

The system is complicated enough that even people who know it well have trouble describing it in plain English.

The article concluded with this assessment by Joseph Bonneau – a cryptocurrency researcher at Stanford University.

Bitcoin is still probably the safest bet, but Ethereum is certainly No. 2, and some folks will say it is more likely to be around in 10 years, It will depend if any real markets develop around it. If there is some actual application.

Those are some mighty big ‘ifs.’

Just like Bitcoin, Ethereum is basically a cryptocurrency blockchain in search of other problems. Bitcoin and Ethereum are both non-trivial technical solutions, but what about building blockchain’s for purposes other than cryptocurrencies? Sure – but then we really have to look for similar business problems around “double spending” and that becomes the larger challenge.

The technical reality is that all of the features of a blockchain – except double spending – can easily be created with other tools that are readily available – and cheap – without technically being a “blockchain.”

  • Distributed databases (free, open-source or commercial)
  • Cryptographic signatures (OpenPGP – various flavors)
  • Trusted timestamping

The point is simply this. We don’t need a unique cryptocurrency in healthcare. Absent that need, there are other robust and mature technology tools that can easily (and elegantly) solve many of our existing problems that are often key features of the hype around “blockchain” (distributed, trusted, ledger, secure, etc…). In fact, this is also true for problems outside of healthcare as well.

A blockchain can certainly be used for many things, but is the resulting solution only available using a blockchain? Hardly.

But there’s also a larger, more general risk of blockchain that Mike Hearn referenced explicitly – and it goes to the heart of why Bitcoin failed.

[Bitcoin] failed because the community has failed. What was meant to be a new, decentralized form of money that lacked “systemically important institutions” and “too big to fail” has become something even worse: a system completely controlled by just a handful of people. Worse still, the network is on the brink of technical collapse. The mechanisms that should have prevented this outcome have broken down, and as a result there’s no longer much reason to think Bitcoin can actually be better than the existing financial system.

Mike’s credentials as a lead Bitcoin developer are beyond reproach and include more than 7 years (2006 – 2014) as a Senior Software Engineer at Google. He also worked closely with Bitcoin chief scientist Gavin Andresen (thought to be the successor influencer of Bitcoin’s development after the mysterious founder Satoshi Nakamoto). Mike’s assessment is also mirrored in other publications as well. This one from Bloomberg Gadfly just last week goes to the heart of the larger dilemma – evident not just in financial services (where “blockchain” is – or at least should be – a perfect fit), but healthcare as well.

But there are potentially unbridgeable gaps to cross before theory becomes reality. How do you get clearing-houses, exchanges and brokers to agree to a new system that would sweep away the one that is currently generating their profits? Wall Street is Blockchain’s Weak Link 

The question isn’t whether a blockchain can be used in any industry (including healthcare) but what’s the use case that a blockchain can solve exclusively? As a new technology consideration for healthcare, blockchain fails on two major fronts.

  • Healthcare has no “double spending” problem – and the larger question is – are there any industries outside of cryptocurrencies that do?
  • Existing, robust and mature technologies can easily replicate all of the other functions of a “blockchain” without fitting the purely technical definition of being a “blockchain.”

Beyond any of these technical challenges, however, looms the ever-present – and much larger business conflict. That conflict – mirrored so clearly by data interoperability – is using any technology that requires voluntary industry consensus and agreement among competitors to eliminate revenue and profits. On what healthcare (or financial) planet is this likely to happen without a government incentive (or mandate)? Certainly none that I’m aware of – especially for heavily regulated industries like healthcare.

The Bitcoin blockchain works technically and elegantly, but even the best use case to date – Bitcoin – is a global and resounding failure. Not because of the technology – a brilliant software engineering feat – but because of larger issues around voluntary industry consensus among competitors for the reduction of revenue and profits.

The even larger challenge in healthcare IT isn’t technology – we’re swimming in it. Adding a new buzzword to the IT word salad won’t save us. The fact that we don’t use existing technologies – that are robust, mature and low-cost – to solve some of the enormous challenges that we do have is tantamount to criminal negligence and won’t be solved with the breathless hype of any blockchain. Interoperability is a prime example – and has the exact same challenge that felled Bitcoin – voluntary industry consensus among competitors that result in lost revenue – and that’s before you get to any technical discussion.

As we have known for centuries, government mandates for national standards actually do work – even if they’re pedestrian and completely devoid of hype – and they continue to work long after we’ve come to take them entirely for granted. A great example is one of the most basic of all called fiat currency and I’ll bet there’s some of it in your possession right now. Healthcare IT needs more stuff that just works – not the glitter of more technology complexity that can’t be described – even by the people who know it. If there’s a banner definition of technology hype, that’s the best one I’ve seen.

This article first appeared in Health Standards (April 2016)

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Epic Hate

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This article was originally written in 2015 and links were updated in 2021

The headline couldn’t have been more focused and directed against a single EHR software vendor. It screamed in bold, capital letters ‒ EPIC FAIL ‒ but then for some reason, backpedaled with the subheading.

Digitizing America’s medical records was supposed to help patients and save money. Why hasn’t that happened?

Since it’s original publication date (October 2015), the headline has been changed and now reads:

We’ve Spent Billions to Fix Our Medical Records, and They’re Still a Mess. Here’s Why.

It’s a reasonable question for the industry, of course, which is the way the subheading phrases it, but that’s not the responsibility of a single commercial software vendor, regardless of their size or corporate structure.

To date, the MotherJones article by Patrick Caldwell has generated over 260 comments, 1,100 tweets and 3,400 shares on Facebook. Most of the comments are supportive of the Epic Fail premise, but the primary argument ‒ as stated in the 4th paragraph of the 2,300+ word essay ‒ is technically wrong.

But instead of ushering in a new age of secure and easily accessible medical files, Epic has helped create a fragmented system that leaves doctors unable to trade information across practices or hospitals.

Epic has certainly contributed to the challenges of sharing patient data ‒ but to blame them for lack of interop is about the same as blaming Apple for fragmenting the mobile world with iOS. In a nutshell, software is only designed, marketed and successfully sold when it does what customers want. Nowhere is that more true than on the expensive enterprise side of software manufacturing. It only sells to people willing (and able) to buy it ‒ often by the billions of dollars.

To be clear ‒ I’m not an Epic fan anymore than I’m an Apple fan ‒ but there are parallels. The biggest, easiest distinction, of course, is that Apple creates the whole consumers experience (hardware and software), and Epic is exclusive to enterprise software only.

By about paragraph 11 we finally get to the argument that’s at the heart of the whole HITECH Act ‒ which includes Epic and about 400 other software vendors that manufacture and sell electronic health record software.

As it stands, she [Julia Adler-Milstein, a University of Michigan researcher who studies health care IT] says, using Epic is easier than trying to piece together better options from various software vendors. On top of that, Epic will tailor each installation on-site to a customer’s specific needs. What it doesn’t have—and ditto systems created by competitors Cerner and Meditech, the other bigwigs in EHR—is a framework to connect to other facilities using competing EHR systems.

It’s perfect staging for the appearance in the next paragraph of healthcare’s word of the year ‒ interoperability. For such a lengthy article ‒ it’s surprising that the interop word only appears about 5 times, but  that’s really the point of the whole piece ‒ and the biggest charge against Epic.

Without defending Epic, here are some “interop” statistics that Epic President Car Dvorak gave to ONC’s Health IT Policy Committee last year ‒ under oath.  

Epic has strong support for “standard HL7 traditional interfaces,” as well as other transaction types such as NCPDP and ANSI X12, enabling “about 20 billion data transactions per year, over 12,000 different interfaces across our 320 customers, to about 600 other vendor systems ‒ including 88 public health agencies, 18 research societies, 51 immunization registries across 46 states and 17 research registries. As for meaningful use, specifically we support the Direct protocol, which is reasonable for planned transitions of care. That “is clearly better than nothing,” he said, but it’s just as clearly inadequate for unplanned transitions such as ED visits. For those, “we support Healtheway exchange standards ‒ the Connect or NwHIN standards; we think both are vital for solving interoperability in the country,” said Dvorak. More generally, he pointed out that Epic’s Care Everywhere technology enables the exchange of 480,000 consolidated clinical document architecture, or C-CDA, documents each month with products built by other vendors – and that number is on the rise: more than double the amount that changed hands as of January 2014. That exchange ecosystem “includes about 900 hospitals, 20,000 clinics, with another 85 hospitals and 3,000 clinics coming online in the coming year,” said Dvorak.

We connect to 26 other vendors systems, 21 HIEs, 29 HISPs and 28 eHealth Exchange members,” with 20 more coming online soon” he said.

Epic Defends Interoperability Bona Fides by Mike Miliard / Editor, Healthcare IT News

We should demand this type of interop accountability from all the EHR vendors. To date, I’ve only seen it from one ‒ Epic.

Also lost in any discussion is the cost by software manufacturers to actually build the gateways into competing software systems. They can do that and they often do ‒ for a fee ‒ but like every other industry, software engineers expect to be paid for their work. Sorry, but just because it’s healthcare, doesn’t entitle industry observers to “free software.”

“We have what I would call a ‘loosely-defined’ standard that’s subject to interpretation. At the end of the day, for two systems to figure out how to convert and communicate, there’s some level of manpower, hours and efforts that are required. If you’re a for-profit organization, this results in having to charge somebody for their time. There’s a cost for interoperability, and that’s where we get a lot of talk.” Mark Janiszewski ‒ EVP of Product Management for Greenway in The Vendor’s View of Interoperability ‒ Becker’s Health IT and CIO Review

A survey in 2014 suggested that Epic owns about 20% of the inpatient market and about 20% of the ambulatory market. That’s an important distinction because the fragmented market often referenced is really the ambulatory one ‒ where there are newer entrants that tend to have relatively small percentages of the market but are among the most vocal when it comes to screaming about “interoperability.” It’s also easy to make that noise and attract free publicity, but it doesn’t solve any problems.  

Here are two charts highlighting that exact point from a firm called Software Advice. They published their EHR Meaningful Use Market Share for 2014 last year and included two helpful charts. There are other studies, of course, but most of the really current ones are by firms that charge big bucks and then heavily restrict public disclosure.

For our purposes, however, it doesn’t matter that much because the market just isn’t that volatile ‒ especially at the top. Here’s the Software Advice chart for the ambulatory market.

Software Advice was quick to highlight the visibly obvious here.

What’s surprising is how fragmented the market continues to be: five of the market’s top 10 vendors boast a market share of less than 3 percent each, and nearly 40 percent of the market uses an EHR from a vendor that falls outside of the top 10. 

Here’s the Software Advice chart for the inpatient market (Hospitals) that MotherJones could also have included ‒ but elected not to. 

Software Advice was equally quick to highlight the obvious here as well (bold emphasis mine).

When it comes to inpatient hospital attestations, the biggest vendors show greater market dominance: the top 10 account for over 90 percent of the market, while the top three alone account for over half of it.

While it may be popular, the case against any single vendor for the industries lack of interoperability is just technically wrong. The only real mistake here ‒ and it’s a big one ‒ was the original legislation called HITECH ‒ which paid for EHR adoption, but didn’t insist on standards for sharing information. Commercial software companies aren’t responsible for Government failures and by comparison, no one looks at the sizable lead that Android has in the mobile world and blames Google for failing to “interoperate” with Apple.

Commercial software in the healthcare industry isn’t automagically different than commercial software in other industries except that our Government did pay handsomely (to the tune of almost $30 billion) to accelerate the adoption of EHR software. If, as a part of the HITECH Act, the Government had wanted “interoperability,” it could have ‒ and should have mandated it. MotherJones finally acknowledges this deep in the article.

Epic is not the only barrier to a seamless medical records system. Thanks to legislative maneuvering by former Rep. Ron Paul (R-Texas) in 1999, the federal government can’t fund any sort of system with unique health care identification numbers. (Paul saw individual medical IDs as further creep of Big Brother). Social Security numbers aren’t a good fill-in; they’re not on insurance cards, and in April Obama signed a bill that will strike them from Medicare cards in order to reduce identity theft.

Large and influential healthcare IT organizations like CHIME and HIMSS have all recognized the enormous handicap of trying to build interoperability without this critical component. They are also joined by influential CIO’s like Michael Blum at UCSF who called the Congressional ban on establishing a universal patient identifier “the biggest single failure in the history of health IT legislation.” [page 189 of The Digital Doctor by Robert Wachter, MD]

Everyone’s entitled to an opinion of course and it’s certainly popular to blame Epic for all that ails in getting EHR software to share patient information, but almost all the reasons for the blame revolve around safety and quality. The healthcare system we have has been optimized for revenue and profits ‒ not safety and quality ‒ so neither the system or Epic is “broken.” It was actually designed this way and we need to change the design. Hating Epic Systems Corporation may be popular ‒ and it may even feel good ‒ but it’s totally misdirected and won’t change one byte of their software.

Targeting the ‘Superusers’ of Healthcare with Telehealth

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Peter Fine – CEO of Banner Health

The consumer version of “telehealth” is both easy to imagine and easy to use. Faced with a healthcare event or condition (that isn’t 911), a consumer uses a smartphone, tablet or desktop connection to engage clinical care in real‒time. The cost is relatively affordable (even outside of insurance) and it saves an annoying trip to either a walk‒in clinic or the local urgent care. It’s the video equivalent of “1‒800‒doctor” or the nursing call center.

It’s an important consumer category of primary care, of course, but what about the so‒called “superusers?” These are the 5% of patients ‒ often elderly ‒ that have multiple chronic conditions and account for up to 50% of all healthcare spending. For this group, healthcare needs and remote care management are vastly different. These solutions need to be industrial‒strength and much broader in scope. Not just from the technology side, but also from the business side of care delivery.

With facilities in 7 states, Banner Health employs over 46,000 people and is Arizona’s largest private employer. It’s also one of the largest secular, nonprofit healthcare systems in the U.S. with more than $5 billion in annual revenue.

While Banner’s formal commitment to remote care (often called “telehealth” or “telemedicine”) dates back to 2006, the results around a recent pilot with 135 “in home” patients is a strong endorsement for using technology as a strategic mechanism for the remote care of superusers. Banner and Philips announced the results of the pilot (started in 2013) earlier today at the opening of the 20th annual Telemedicine Meeting and Trade Show in Los Angeles.

  • 27% reduction in cost of care
  • 32% reduction in acute and long-term care costs
  • 45% reduction in hospitalizations

The only real doubt about the future of this type of remote care delivery is the moniker itself ‒ “telehealth.”

In a conscious effort to drop the dated reference, Banner calls this version of their remote home care program Banner iCare™. It’s been so successful that they recently upped the dosage to 500 patients ‒ 90% of which are Medicare age.

A key requirement for patients in the iCare program is that they must have at least 5 chronic health conditions. The program also matches patients with health coaches, nurses, social workers, pharmacists and primary care “intensivist’s” in a way that delivers near‒instant access to patients by an entire care team. Combining team-based continuous care with remote delivery is a key part of the success. This isn’t consumer‒grade, episodic care by a single specialist working in isolation.

Telehealth has helped us move beyond the limitations of geography, access to specialists and constraints on time. First it was the technology which changed the paradigm and opened up new ways of serving patients. What has happened as a result is vastly improved patient care, not only because of increased access and efficiency, but also because of a new integrated team approach which came out of having a centralized hub of physicians, specialists, nurses and pharmacists. Telehealth, at its best, improves the physician/health care provider experience and improves not only the measurable care patients receive, but the care experience as well. Hargobind Khurana, MD ‒ Senior Medical Director of Health Management at Banner Health

The Philips supplied hardware includes an Android tablet, custom software and a range of biometric sensors for blood pressure, oxygen saturation, weight, and heart rate measurements. Also included is Philips Lifeline ‒ a personal emergency response device with automatic fall detection.

Banner pays directly for the home monitoring tools (no reimbursement through CMS) and patients like Marion Berg (turning 102 in July) are a great example of the “triple‒aim” benefits (better care, better health and lower cost).

While being around for a while, Telehealth has gotten a new lease on life with the advent of digital technologies, like wearables, two-way video and big data. We see a tremendous interest in telehealth models where people suffering from chronic conditions are monitored from their homes and cared for by multi-disciplinary teams of professionals. By taking a holistic, patient-centric approach and by leveraging digital technology, we foresee widespread clinical change to save lives, reduce costs and create a better patient experience. Our work with health systems, including our collaboration with Banner, demonstrates that telehealth can transform how care is delivered, while also helping organizations reduce costs and more effectively manage patient populations. Jeroen Tas, CEO ‒ Healthcare Informatics Solutions and Services, Philips

All of which is just one of three significant Banner commitments to remote care. The second is their TeleICU program for monitoring over 450 beds across 24 facilities in Arizona, Colorado, Nebraska, Nevada and Wyoming. While the primary TeleICU operations facility is tucked away in a fairly nondescript building located in Mesa Arizona, all of the equipment is state‒of‒the art ‒ including electronically controlled standing desks for round‒the‒clock clinical staff.

Telemedicine is becoming increasingly attractive to a health care industry that is re-inventing itself to provide better care at lower costs. At Banner we’ve experienced outstanding results in multiple settings where telemedicine is used – from ICUs to inside the home. Not only have we realized improved care outcomes, but we’ve seen cost reductions through reduced days in ICUs and a decrease in avoidable hospital readmissions. Peter S. Fine, President and CEO, Banner Health

A third program at Banner ‒ called TeleAcute ‒ is used by expert nurses in a separate Remote Operations Center for all adult medical/surgical patients associated with a select group of Arizona facilities. This program isn’t targeted at superusers per‒se, but at other patients that also benefit from watchful monitoring during their hospital stay.

There’s still a big disconnect between hospital systems like Banner that are able to lower their cost of care and consumers who don’t see this translate into lower premiums, but the results of the iCare pilot are impressive in terms of keeping patients healthy at home ‒ away from the high‒risk and high‒expense of the hospital itself. In combination, all three programs ‒ iCare, TeleICU and TeleAcute ‒ represent a significant commitment to enterprise-scale telehealth at the very heart of big healthcare delivery.

Now if we can just drop the antiquated prefix. The history dates back to 1837 and the French invention of the telegraph ‒ which pre-dated the telephone by almost 40 years. John Sculley is right ‒ the only future for anything “tele” is the “one ringy‒dingy” from Ernestine (Lily Tomlin) on Saturday Night Live reruns.

This article first appeared in Forbes (May – 2015)
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