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The dott. Stewart Southey weighs the potential benefits of blockchain and ledger technology distributed in the national health system
The last few years have seen a real frenzy wherever the term blockchain has been used. To be the silver bullet that will save every sector, billions of euros of venture capital and crowdfunding funds have been poured into new projects. Although there are many new and exciting start-ups that promise to revolutionize healthcare, there are significant challenges before knowing exactly how useful a distributed ledger can be. This article explores these issues in the context of the National Health Service (NHS) of the United Kingdom.
An overview of the national health service
It is a little inappropriate to think of the NHS as a national organization. Although funded centrally (almost exclusively through tax contributions), health care coordination is performed by a myriad of semi-autonomous and partially competing entities.
One of the largest employers in the world, the NHS treats 1.4 million patients every 24 hours. 207 clinical commissioning groups (GCCs) help channel funds to more than 7,400 general practitioners, 135 non-specialist trusts and other organizations in England. There are 853 independent, non-profit, non-profit sector organizations providing patient care from 7,331 locations.1 It is therefore fair to say that the flow of money and data is at best complicated but most probably indecipherable for each individual.
An attempt to centralize IT services (Connecting for Health, the National Program for IT) has notoriously failed after an excessive spending of around 440-770%.2 There have been many reasons for this failure that are not relevant to the purpose of this article. The message to take home is clear, however. Centralized projects of this magnitude can not function without complete autocracy.
Despite this colossal flop, the need for integrated service registries, prescription systems and performance management solutions persists. Poor communications and data integrity issues account for a significant percentage of medical errors and deaths each year. The privacy and accessibility of medical information continue to be of great interest to many patients and physicians. Financial transparency is almost impossible and the perceived extent of wasteful practices is often on the front page.
It would be unfair to paint such a dingy picture of the NHS without balancing it with some positive truths. Compared to the health systems of ten other countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United States), the SSN was the most impressive overall from the Commonwealth Fund in 2017. success despite the fact that in 2016 the health expenditure in the United Kingdom was equal to 9.75% of GDP, while others have significantly higher percentages and expenses per capita.
Unfortunately the clinical outcomes were not as stellar, although measuring the quality of health care is a complex task.
The "fourfold objective" of health care3 is to improve patient experience, improve population health, reduce per capita costs and reduce staff burnout. The addition of this ultimate goal is important. Although there are many reasons for this disturbing trend, a widely held view is that the administrative burden imposed on doctors is partly due to the fault:
"It is no coincidence that the peak of burnout rates has come at the same time as the broad adoption of [electronic health records (EHRs)]. One day, the EHRs could revolutionize health care by significantly increasing our ability to share and review patient information. But today, the EHRs are turning many doctors into employees. "4
Improvements to the quadruple bottom line require multiple approaches. Managing the relationship between health care demand and supply is complex, as well as balancing the conflict between quality and choice with respect to cost and efficiency. One thing remains true even if decisions should not be based on imperfect data. We can only fix what we can identify.
The case for blockchains
No single technology will transform any healthcare system, and it would be naive to believe that blockchain is the exception. Also combined with artificial intelligence, big data analytics and other newly generated promises, distributed registries are not entirely able to address the political and economic nuances that affect the way in which they are delivered. # 39; service.
That said, there is something quite unique in what is promised. It's not so much technology in itself, because it is the fundamental philosophy that underlies it to be so intriguing.
When Bitcoin was launched in 2009, people were able to send peer-to-peer cash all over the world for the first time without the permission of the central authority. This uncensored exchange of values, guaranteed through mechanisms of algorithmic consensus and crypto-economic incentives, has made dishonest activity economically unprofitable.
The network effect means that more participants share a common fiduciary brokerage infrastructure, the more valuable the platform becomes.
Translating this to health care is a bit of an act of faith, and the technology is nothing short of nascent. But knowing that we can create a virtually indestructible transaction log and a common channel of communication that allows the exchange of values without third party intermediation is certainly exciting.
Whenever the blockchain is added, the new "state of being" is replicated across the network. All participants can trust the integrity of the register and the data are recorded permanently, completely controllable and unalterable.
Although this does not guarantee the quality of the data entered, it is transparent and there is a clear responsibility through public-key cryptographic signatures. Leaving the importance of oracles and ensuring the veracity of inputs for another time, it seems that the use of distributed accounting technologies can significantly reduce trust and communication gaps in the health sector.
The NHS evidence base
As we have seen, the NHS is a monolithic tangle of disparate entities: some managed privately, others public, but almost always isolated from one another. The communication cracks between these parties contribute significantly to the observed inefficiencies.
The annual report of NHS England 2017/20185 identify ten areas of interest for improvement:
- Freeing the capacity of the hospital bed
- Improve staff productivity, including further actions on temporary labor costs
- Take advantage of the supply opportunities of the NHS
- Guarantee the best value from drugs and pharmacy
- Reduce the avoidable demand and satisfy the demand more appropriately
- Reduction of unjustified variations in clinical quality and efficiency
- Action on real estate, infrastructure, capital and clinical support services
- Reduction of the cost of business services and administration
- Improved cost recovery from non-UK residents
- Ensure financial responsibility and discipline in all NHS organizations
A more in-depth examination of these areas could provide the basis for testing the use of generalized accounting technology for those who aspire to take action.
In addition to this, Lord Holmes published a report in 2017 that examined the potential benefits of distributed ledger technology to improve health care in the UK.6 Some of the results include opportunities lost due to duplication and fragmentation of data. Access to medical records, the integrity of the pharmaceutical supply chain, and patient and employee identification mechanisms were also lacking.
Significantly, the report suggests that the use of distributed ledger technology can improve health data and patient life if used in these areas.
It is not a straight line linking improvement goals with the opportunities promised by blockchain. But with verifiable data integrity, a reliable register and almost at the same time real-time status replication, distributed register technology could make agile and informed decisions a viable reality.
There is obviously the problem of interoperability and the fact that blockchains are not good for data archiving. Nobody believes that legacy systems will be replaced overnight. However, if reliable and traceable access to these systems can be guaranteed, under which operational decisions can be made, efficiency could be greatly improved.
The road ahead
Of course there is a lot of work to do. Testing of the concept (PoC) with the quadruple objectives will have to be conducted before the benefits can be claimed. What kind of blockchain (public, authorized or consortium), whether or not a cryptocurrency is required in a semi-trusted environment and the need to comply with regulations (GDPR and many others) influence future choices.
The burning questions that remain, however, are these:
- Who will finance these trials and how do we get potentially conflicting stakeholders to engage in a sharing economy?
- Much more difficult than technological barriers are the political and economic paradigms that need to be challenged. How can we convince individual hospitals with limited budgets to build a shared infrastructure with a private provider, a group of local pharmacies and surrounding GP practices?
- Do co-option models work where historical private sector competitors are fighting for public purse contracts?
- Who (not what!) Will block the path of data sharing and how can it be mitigated?
Future perspectives of distributed registers
Reorganizing the national health service for 66.57 million people is a gigantic task. But we should not be deterred – the appetite for change and improvement is high. The overall benefits for patients and doctors can far outweigh the costs. Indeed, the potential revenue for the UK economy could be significant.
Imagine these scenarios:
- Several major UK pharmaceutical companies collaborate with research institutions, GCCs and major university hospitals across the UK. Each of them is a shareholder of the new joint venture, whose purpose is to extract health data at national level to deepen the treatment of cancer. Any derived intellectual property is shared, as are financial gains from the development of new products. All parties win, patient health improves and the NHS has additional revenue for reinvestment
- All NHS hospitals share data on the doctor's credentials (authorizations granted by the doctor, of course). The dissemination and blocking service, the general medical council, the royal universities and the universities also share these common communication channels. Now a doctor can move freely within the system nationally if his CV meets the requirements for the job. It does not take months of compliance checks or the costs associated with duplicating these tasks. The correspondence between supply and demand reduces the need for expensive agency intermediaries. Savings are used to improve the doctor's salary and improve patient care
- NHS is committed to joining forces with contracting entities, supply chain stakeholders (including equipment companies) and GCCs. Real-time business resource planning with comprehensive tracking facilities creates a responsive and efficient ecosystem. The savings are once again shared, with patients and listed companies sharing the spoils.
While all this seems dreamlike, unrealistic and perhaps threatening to some, it represents a paradigm shift in business models in which profit and the sharing economy can coexist.
Data silos emerge when information sharing costs society. The collaboration of data on the other hand brings economies of scale and scope, a shared cost basis and a potentially larger percentage of a premium.
Naturally, there are no guarantees. But perhaps, with all the other emerging technologies and combined resources of the public and private sectors, there could be an opportunity to achieve this quadruple goal.
And if the PoC tests show positive returns, the burning question will be: who will block the path or make it happen?
About the author
Dr Stewart Southey MBBCh FRCA MBA MSc (Digital Currencies, in progress) is a senior consultant to NHS, a health strategist, founder of Catena Consulting and chief medical officer of Biohax International. He is passionate about any medtech and health innovation that promises to improve delivery of care.
References
- http://www.nhsconfed.org/resources/key-statistics-on-the-nhs
- https://www.telegraph.co.uk/news/uknews/1473927/Bill-for-hi-tech-NHS-soars-to20-billion.html
- https://qualitysafety.bmj.com/content/24/10/608
- https://labblog.uofmhealth.org/industry-dx/opinion-its-time-to-treat-physicianburnouts-root-causes
- https://www.england.nhs.uk/wp-content/uploads/2018/07/Annual-Report-Full-201718.pdf
- http://chrisholmes.co.uk/wp-content/uploads/2017/11/Distributed-Ledger-Technologies-for-Public-Good_leadership-collaboration-and-innovation.pdf
Dr Stewart Southey
Founder
Chain Consulting
Tweet @docsouthey
https://catena.mba/
This article will appear in Health Europe Quarterly issue 8, to be published in February 2019.
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