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Advances in Healthcare Information Technology

Workshop Report

November 14, 2017       Dulles, Virginia, USA

 The NCOIC’s Technical Council hosted a workshop on 14 November 2017 that brought together experts in the fields of block chain applications and hyperconvergence infrastructure to discuss the feasibility of rapidly developing a solution for creating situational awareness of healthcare resources in disaster-recovery situations. This paper summarizes the information presented in the workshop.

Situational awareness involves the timely acquisition of knowledge about real-world events, distillation of those events into higher-level conceptual constructs, and their synthesis into a coherent context-sensitive view. Workshop speakers explored how convergent trends in video sensing, blockchain-secured communications and federated cloud standards can be leveraged to implement a solution for providing situational awareness to first responders.

The speakers had published their work in professional peer-reviewed journals, direct experience with implementing blockchain systems, or published work in hyperconvergence networks. Three speakers presented material related to blockchain applications and healthcare information systems. One speaker presented information on rapidly deployable federated networks for supporting data collection for situational awareness. Workshop participants discussed cybersecurity issues related to blockchain and federated networks. Technical problems related to interoperability of block chain systems, wide area networks and network standards were also addressed. The following sections summarize the five keynote presentations.

Workshop participants included both NCOIC members as well as non-member experts. The information below does not represent an official or consensus position of the NCOIC’s membership. The NCOIC is an industry led not-for-profit consortium established to promote secure interoperability and network centric operations. More information may be found at www.ncoic.org.

Block chain in Healthcare Information Systems

Dr. Prithviraj Mukherji, Mukherji Consulting Inc., Centreville, Virginia, USA

In 2016-2017, NCOIC researched the idea of using a challenge team for developing a software/hardware system that utilizes block chain software and rapidly deployable communication networks for situational awareness in disaster recovery situations. When Satoshi Nakamoto presented the simple idea for block chains, little did he/she realize it would be applied across domains from diamond certification to banking systems to disaster recovery.

We have focused on healthcare applications for situational awareness. This implies obtaining information on availability of hospitals, clinics, and that healthcare providers capable of dealing with emergency disaster recovery.

Over the past five years, block chain technology has been considered for healthcare information systems by a number of organizations in industry and government, such as the Office of the National Coordinator/ Health and Human Services and Phillips Healthcare. Philips has launched a lab specifically aimed at block chain research. The Hyperledger Healthcare Working Group features participants such as Accenture, Gem, Hashed Health, Kaiser Permanente and IBM. The MedRec platform developed by the Massachusetts Institute of Technology Media Lab and tested at Beth Israel Deaconess Medical Center is decentralized electronic medical records (EMR) management using block chain technology to manage authentication, accountability and data sharing.  Other instances include:

• Gem, a block chain company, announced a partnership with Philips to build a private Ethereum block chain for use in the development of enterprise healthcare applications.
• The American Enterprise Institute testified to Congress about the benefits of block chain to health plans.
• The Office of the National Coordinator for Health Information Technology announced a block chain challenge and received over 70 responses to its call for white papers on the technology and its potential use in health IT to address privacy, security and scalability challenges of managing electronic health records and resources.

Emphasis in all of these instances is on privacy, security and scalability. Block chain technology inherently provides these three attributes by way of increasing confidentiality, availability and integrity of its records. For example, the user’s choice of software applications, such as Epic, Evernote or Google Docs, is governed by third parties; Apple and Google maintain and curate (or in some cases, censor) the specific apps you’re able to download.

Using block chains, one entity will no longer have control over your medical records or notes; no one can modify or ban the app itself, temporarily taking all of your notebooks offline. Only the user can make changes, not any other entity. If all goes according to plan, Ethereum block chains return control of the data in these types of services to its owner and the creative rights to its author. In theory, it combines the control that people had over their information in the past with the easy-to-access information that we’re used to in the digital age. Each time you save edits, or add or delete content in notes, every node on the network makes the change.

Areas of potential application of blockchain technology in healthcare include: (see http://www.healthcareitnews.com/news/blockchains-potential-use-cases-healthcare-hype-or-reality)

• Master patient index. Blockchain could solve the challenge health systems have when their data sets get mismatched, or address the problem of duplicate records.
• Claims adjudication. Automated adjudication means being able to automatically take a claim and decide whether it’s going to be paid or denied without manual intervention; 80% of claims are handled this way.
• Interoperability. This is the ability of two or more systems to exchange information and be able to use the information that’s exchanged, working together across organizations to improve patient health.
• Longitudinal health records. Most of us go to our primary care provider roughly 54% of the time we engage with care. The other providers need to have a view of longitudinal records but don’t have a complete view of our health history. What’s needed is a clinical summary or view into what’s going on with a patient, including labs, treatments and diagnoses.

NCOIC’s approach is to develop a working prototype or proof of concept (POC) for demonstration purposes. Specifically, we will develop three types of user stories into demonstrable features. They are:

• Disaster recovery: provide situational awareness to providers and first responders.
• Sharing of patient information across secure, private or public networks on a global scale
• Healthcare payment systems

We will also develop non-user stories and provide hyperconvergence infrastructure (HCI) to support demonstration of POCs for private networks, public networks and “spikes,” including research on the initial coin offering for mining, bill payment and transfer of funds in “neuros” and “hdollars” across block chain networks.

Such POCs will aid NCOIC’s role to provide government agencies with technical input on the interoperability of network and blockchain components during the initial planning and high-level design phases of a project’s lifecycle. The idea is to minimize risks associated with interoperability failures.

 What is a block chain?

Personal data, passwords and financial information are often stored on third-party computers, in clouds and servers owned by companies like Amazon, Facebook or Google. This provides a number of advantages; companies deploy teams of specialists to help store and secure this data, minimizing the costs that come with hosting and uptime. But there is also vulnerability. As we’ve learned in the case of Equifax, OPM and a number of other high-profile cases, a hacker or government can gain unwelcome access to your files without your knowledge by influencing or attacking a third-party service – i.e. they can steal, leak or change important information.

The internet was always meant to be decentralized. A movement has sprung up around using new tools, including blockchain technology, to help achieve this goal. Ethereum is one of the newest technologies to join this movement. A disruptor technology such as Bitcoin is aimed at PayPal and online banking.  Ethereum’s goal is to use a blockchain to replace internet third parties that store data, transfer mortgages and keep track of complex financial instruments. Ethereum wants to be a “world computer”that would decentralize – and some would argue, democratize – the existing client-server model. In Ethereum, servers and clouds are replaced by thousands of so-called “nodes” run by volunteers from across the globe (thus forming a “world computer”). The vision is that Ethereum would enable this same functionality to people anywhere around the world, enabling them to compete to offer services on top of this infrastructure.

Implementation hurdles to adoption and use of block chain technology include:

• Setting up network infrastructure for testing in development lab, test environment and production environment (need stubs and drivers, network infrastructure and software tools)
• Testing for scalability using increasing loads on CPU and network
• Obtaining buy-in from sponsor(s)
• Culture change within institutions requires overcoming inertia
• Dependencies exist on other software systems needed to support blockchain implementations, such as identity and access control systems, and security systems
• A lack of standards for block chain systems interoperability

For over a year, we have designed and are developing a software application using blockchain software for situational awareness in disaster recovery situations. In addition to software, this application requires a communication network that can send and receive secure messages impermeable to hacking during transmission and subsequent storage in a database.

 Sharing medical information globally in a secure and immutable manner can be implemented using local storage, a virtual communications network and distributed ledger technology (block chains). A high-level operational view is presented in the following illustration for conceptualizing such a system of systems.

It shows three types of medical information that can be shared across a global communications network by hypothetical users, Bob and Alice, who are geographically separated but connected by a virtual public (internet) or private (organization-dependent) communication network. They are:

• Clinical information related to conclusions from tests, images and diagnoses
• Laboratory tests, radiological imaging and pharmacy information related to a patient
• Provider-generated encounter notes after a patient visit with a provider

This illustration also shows the storage-related activities that must be considered after transmission has occurred. These include creating, reading and updating data. The delete operation in block chain is forbidden so as to make block chain records immutable. We call such a system of systems a Next Generation Enterprise Information System (NGEIS).

NGEIS can be useful for collecting and sharing situational awareness information. Block chain technology assures that transmission and storage systems are secure and safe from hacking. Appropriate users within a pre-registered network of users can access the information on a need-to-know basis. For example, first responders can access critical information on safety and operations of buildings, such as hospitals, high rises, roadways, communication cell towers, etc.

In the event of a safety critical natural disaster, such as a hurricane or earthquake, cell towers are frequently damaged and communication networks are often rendered useless or are below acceptable performance criteria. In such situations, rapidly deployable virtual networks and cloud systems become imperative for rendering assistance to stricken people and systems.