区块链：医疗行业的机遇.pdf

I. BlockchainA New Model for Health Information Exchanges A blockchain powered health information exchange could unlock the true value of interoperability. Blockchain-based systems have the potential to reduce or eliminate the friction and costs of current intermediaries. Particularly compelling use cases for blockchain technology include the Precision Medicine Initiative, Patient Care and Outcomes Research (PCOR), and the Nationwide Interoperability Roadmap. For these and other high-potential areas, determining the viability of the business case for blockchain is paramount to realize the benefits of improved data integrity, decentralization and disintermediation of trust, and reduced transaction costs. The exchange of Personal Health Records and Health Information Exchange (HIE) data via the Integrating the Health care Enterprise (IHE) protocol is an important part of addressing the challenges of system interoperability and accessibility of medical records. The strategy outlined to date provides the technical requirements and specific incentives for health systems to meet the Meaningful Use interoperability standards necessary to support the envisioned National Health Information Network, buttressed by a network of HIEs operating on a broad scale. That unrealized scale, driven in large part by insufficient incentives outside of compliance, threatens the viability of HIEs and merits exploration of new models. It may be possible that new value based models embedded in MACRA will be sufficient to make the market model work, but HIEs have been seeking alternative business models. Meanwhile the health systems that see true benefits from establishing a clinically integrated network in order to engage in risk-based contracts focus on private exchanges and are looking for low cost solutions that enable secure integration and support the assembly of virtual health systems that move beyond organizational boundaries. While blockchain technology is not a panacea for data standardization or system integration challenges, it does offer a promising new distributed framework to amplify and support integration of health care information across a range of uses and stakeholders. It addresses several existing pain points and enables a system that is more efficient, disintermediated, and secure. HIE Pain Points Blockchain Opportunities Establishing a Trust Network depends on the HIE as an intermediary to establish point-to-point sharing and “book-keeping” of what data was exchanged. Disintermediation of Trust likely would not require an HIE operator because all participants would have access to the distributed ledger to maintain a secure exchange without complex brokered trust. Cost Per Transaction, given low transaction volumes, reduces the business case for central systems or new edge networks for participating groups. Reduced Transaction Costs due to disintermediation, as well as near-real time processing, would make the system more efficient. Master Patient Index (MPI) challenges arise from the need to synchronize multiple patient identifiers between systems while securing patient privacy. Distributed framework for patient digital identities, which uses private and public identifiers secured through cryptography, creates a singular, more secure method of protecting patient identity. Varying Data Standards reduce interoperability because records are not compatible between systems. Shared data enables near real-time updates across the network to all parties. Limited Access to Population Health Data, as HIE is one of the few sources of integrated records. Distributed, secure access to patient longitudinal health data across the distributed ledger. Inconsistent Rules and Permissions inhibit the right health organization from accessing the right patient data at the right time. Smart Contracts create a consistent, rule-based method for accessing patient data that can be permissioned to selected health organizations. Blockchain: Opportunities for Health Care August 2016 2 II. What is Blockchain? At its core, blockchain is a distributed system recording and storing transaction records. More specifically, blockchain is a shared, immutable record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger. Blockchain relies on established cryptographic techniques to allow each participant in a network to interact (e.g. store, exchange, and view information), without preexisting trust between the parties. In a blockchain system, there is no central authority; instead, transaction records are stored and distributed across all network participants. Interactions with the blockchain become known to all participants and require verification by the network before information is added, enabling trustless collaboration between network participants while recording an immutable audit trail of all interactions. Deloittes blockchain framework1 serves as a simple guide for organizations interested in utilizing blockchain technology. It can help guide decision making by answering four key questions: When should organizations initiate blockchain pilots? How should they design the use cases? When should they strengthen the system through smart contracts? Should they implement a permissioned, permissionless, or consortium blockchains? For organizations new to the technology, the guided, four-step process simplifies a complex, rapidly evolving field into a series of discrete decisions. 1 Deloitte Consulting LLP analysis. Figure 1: Deloitte Blockchain Decision Framework 3 Before leaders INITIATE blockchain projects, they should consider whether the technology is suitable to the organizations needs. Not all problems require a blockchain solution. Blockchain truly shines when four conditions have been met: (1) multiple parties generate transactions that change information in a shared repository, (2) parties need to trust that the transactions are valid2, (3) intermediaries are inefficient or not trusted as arbiters of truth, and (4) enhanced security is needed to ensure integrity of the system. For health care organizations that have decided to initiate blockchain projects, the next step is to DESIGN THE USE CASES. There are two primary use cases to consider: (1) verify and authenticate information, or (2) transfer value. In the first use, organizations may consider blockchain technology to verify a patients digital identity, genetics data, or prescriptions history. Prescrypt, a proof-of-concept developed by Deloitte Netherlands, in collaboration with SNS Bank and Radboud,3 gives patients complete ownership of their medical records, allowing them to grant and revoke provider access to their data. Providers, in turn, can issue prescriptions on the blockchain. In the second application, organizations can use the technology to transfer value, such as cryptocurrencies or intellectual property rights. Deloitte, in collaboration with Loyyal, developed a prototype that incentivizes desired behaviors using gamification and behavioral economics principles. In the future, health ecosystems may emerge where providers, plans, or fitness centers co-develop programs to incentivize and reward patients for healthy behaviors. In the third stage of the blockchain framework decision making process, organizations have an opportunity to STRENGTHEN the system through smart contracts that automatically execute when conditions are met. This application is increasingly sophisticated, using algorithms to fully customize conditions that determine when to exchange value, transfer information, or trigger events. This serves as the foundation for more sophisticated applications of blockchain technology in health care, including prior-authorizations and auto-claims processing. Finally, to IMPLEMENT a blockchain solution, organizations may choose to use a permissionless blockchain, such as the Bitcoin blockchain, or a permissioned blockchain that restricts access to a pre-determined group. Consortia such as R3 in the financial services industry are experimenting with permissioned blockchains, and R3 has recently completed a successful transfer of commercial paper between banks.4 Implementation also requires selection of a blockchain protocol the underlying blockchain technology and framework that guides the structure of the blockchain and development of applications. Platforms such as Ethereum provide the ability to create decentralized applications built on top of blockchain architecture; it is a leading blockchain protocol for both permissioned and permissionless blockchain development.5 Additionally, Hyperledger is an open source project created by the Linux Foundation seeking to create a platform for corporate based blockchain platforms and other standards.6 The choice of blockchain protocol is important, because it will influence the range of possible applications and the number of users participating on the network. While blockchain may have significant potential to improve data interoperability, security, and privacy, it is important to note the boundaries of the technology. Blockchain is not a substitute for an enterprise database. Blockchain powered solutions are not optimized for high volume data that needs absolute privacy and instantaneous access within a single organization. Blockchain solutions are designed to record specific 2 If this condition is not met, a shared database may be a more appropriate solution. 3 Redman, Jamie. (2016, May 28). Prescrypt Brings Medical Prescriptions to the Blockchain. Retrieved August 3, 2016, from https:/ 4 Higgins, S. (2016, March 3). 40 Banks Trial Commercial Paper Trading in Latest R3 Blockchain Test. Retrieved August 3, 2016, from http:/ 5 Ethereum. Retrieved August 3, 2016, from https:/www.ethereum.org/ 6 Linux Foundation. What is the Hyperledger Project? Retrieved August 3, 2016, from https:/hyperledger.org 4 transactional data events that are meant to be shared across a network of parties where transparency and collaboration are mission critical. The Blockchain Framework highlights these preconditions. In the health care landscape where the United States Department of Health and Human Services (HHS) operates, blockchain technology has transformative potential. Nationwide health information interoperability could be realized through a consortium blockchain, which can leverage a leading protocol and create a standardized transaction layer for all organizations. Blockchain technology has the potential to advance HHSs strategic goals7 and investments to standardize health care information by establishing a transaction layer on which all stakeholders can securely collaborate. Organizations considering blockchain technology may find the aforementioned framework useful as a guidepost and a part of an iterative decision process; however, it is not intended to be an exhaustive, prescriptive list. The four steps outlined above are intended as a forcing mechanism to apply disciplined consideration of requirements, limitations, and alternatives before launching costly and time consuming experiments. III. Blockchain as an Enabler of Nationwide Interoperability The Office of the National Coordinator for Health Information Technology issued a Shared Nationwide Interoperability Roadmap, which defines critical Policy and Technical Components needed for nationwide interoperability, including (1) Ubiquitous, Secure Network Infrastructure, (2) Verifiable Identity and Authentication of All Participants, (3) Consistent Representation of Authorization to Access Electronic Health Information, and several other requirements. However, current technologies do not fully address these requirements, because they face limitations related to security, privacy, and full ecosystem interoperability. The current state of health care records is disjointed and stovepiped due to a lack of common architectures and standards that would allow the safe transfer of sensitive information among stakeholders in the system. Health care providers track and update a patients common clinical data set each time a medical service is provided. This information includes standard data, such as the patients gender and date of birth, as well as unique information pursuant to the specific service provided, such as 7 HHS Strategic Plan: FY 2014 - 2018. (n.d.). Retrieved August 03, 2016, from /about/strategic-plan/ Figure 2: Illustrative Healthcare Blockchain Ecosystem 5 the procedure performed, care plan, and other notes. Traditionally, this information is tracked in a database within a singular organization or within a defined network of health care stakeholders. This flow of information originating from the patient through the health care organization each time a service is performed does not need to stop at the individual organizational level. Instead, health care organizations could take one more step and direct a standardized set of information present in each patient interaction to a nationwide blockchain transaction layer. The surface information on this transaction layer would contain information that is not Protected Health Information (PHI) or Personally Identifiable Information (PII); rather, select and non-personally identifiable demographics and services rendered information could enable health care organizations and research institutions access to an expansive and data-rich information set. Information stored on the blockchain could be universally available to a specific individual through the blockchain private key mechanisms, enabling patients to share their information with health care organizations much more seamlessly. This deployment of a transaction layer on the blockchain can help accomplish ONC HITs interoperability goals while creating a trustless, and collaborative ecosystem of information sharing to enable new insights to improve the efficiency of the nations health care system and health of its citizens. Toward Blockchain Interoperability As a transaction layer, the blockchain can store two types of information: (1) “On-chain” data that is directly stored on the blockchain or (2) “Off-chain” data with links stored on the blockchain that act as pointers to information stored in separate, traditional databases. Storing medical information directly on the blockchain ensures that the information is fully secured by the blockchains properties and is immediately viewable to those permissioned to access the chain; at the same time, storing large data files slows block processing speeds and presents potential challenges to scaling the system. In contrast, encrypted links are minimal in size and are activated once a user with the correct private key accesses the block and follows the encrypted link to a separate location containing the information. As an example, the blockchain cannot directly store abstract data types such as x-ray or MRI images: this type of data would require links to a separate location. Organizations considering how da