使用区块链技术来实现责任制医疗的扩展及采用.pdf
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Paper Submitted for Call for Paper in August by ONC
1
Abstract—The recent trends in Accountable Care based
payment models have necessitated the adoption of new process
for care delivery that requires the co-ordination of a “network”
of care providers who can engage in shared risk contracts. In
addition, the need for sharing in the savings generated equitably
is key to encourage the network providers to invest in improved
care paradigms. Current approaches to digitize healthcare focus
on improvement of operational efficiency, like electronic records
as well as care collaboration software. However, these
approaches are still based on the classical centralized
authorization model, that results in significant expense in
implementation. These approaches are fundamentally limited in
their ability to fully capitalize on the peer-to-peer digital work-
flow revolution that is sweeping other segments of industry like
media, e-retail etc. In this paper we formulate a new digital
health care delivery model that uses block chain as the
foundation to enable peer-to-peer authorization and
authentication. We will also discuss how this foundation would
transform the scalability of the care delivery network as well as
enable payment process via smart contracts, resulting in
significant reduction in operational cost and improvement in care
delivery. In addition, this block-chain based framework can be
applied to enable a new class of accountable tele-monitoring and
tele-medication devices that would dramatically improve patient
care adherence and wellness. Finally, the adoption of block chain
based digital-health would enable the creation of varifiable
“personalized longitudinal care” record that can form the basis
of personalized medicine.
Index Terms—BlockChain; Telemonitoring; Telemedication;
Healthcare Asset; Authentication and Authorization; Deep Data
Creation; Personalized Data Control; Healthcare Marketplace;
Healthcare Security & Reliability; Personalized Healthcare;
Two-way Data Authentication; Comprehensive Data Repository.
I. THE HEALTHCARE LANDSCAPE
HE last decade has seen a significant change in health care
ranging from a dramatic shift in the payment method from
a “pay-for-service” model to “outcome based” model to a
focus on population “wellness” from a focus on “specialized”
procedures. This new payment model based on effective care
along with a focus on healthy living, called the “Accountable
Care” paradigm, outlines the “new” goal for delivery of
healthcare in the US [1]. This realignment from a “procedure”
based focus to “holistic care of the individual” necessitates
that Care Providers form “networks” that work together
towards a common goal of improving the care outcome of
patients under care, for post-Acute Care episodes or between
Acute Care episode. The need for cooperation between care
providers ranging from specialist to primary care physician,
post-acute care providers to wellness providers (like
nutritionist and rehabilitation nurses) has resulted in increasing
digitization of patient care data in order to seamlessly
communicate patient data. Over the last decade this has led to
increased adoption of Electronic Health Records (EHRs)
systems as well as development of care collaboration software
that enables the co-ordination of care across the various care
providers. Though these solutions have significantly improved
the tracking and efficiency for delivering care, they have
resulted in creating islands of information. Hence, co-
ordination of information between these systems has presented
a significant challenge causing the delay of both the adoption
of this new healthcare paradigm as well as posed serious
challenges for health systems in developing scalable
“networks” of providers.
The tsunami of data captured in Electronic Medical Record
(EMR) systems in hospitals and doctor’s offices as well as
information from labs, pharmacies, home care and nursing
systems plus the general growth in awareness of taking care of
one’s wellness has resulted in individuals capturing personal
wellness data ranging from biometric vitals like blood sugar,
blood pressure as well as keeping track of the exercise and
food intake via Personal Health Records (PHRs). This
behavior is not limited to individuals that have chronic
condition but also, extends to individuals who are interested in
pursuing a continued high functioning lifestyle.[2][3]
Though, there has been an increasing sense of
“individualized” information both on the clinical as well as
wellness front from the accumulation of data by care providers
and individuals, including their hereditary profiles, these have
not translated into “personalized” plans of care. Furthermore,
even though there is a plethora of data, the overall healthcare
payors and systems seem to be incapable of “assigning” a
value or risk to this information to help better predict future
cost of care for the individual or credit him for his focus on
actively managing his health. [4]
The key elements that prevent the lingering delay in dramatic
transformation of the healthcare landscape are discussed
below.
A. Data Silos & Accountability/ Authorization
There has been a lot of health and wellness related data that
has been collected by care providers and individuals but it has
not been converted in consumable formats that enable a
comprehensive individualized care plan that contributes to
effective long term patient wellness. This stems from the key
issue that most of these data are in individual silos of a given
Adoption of block-chain to enable the
scalability and adoption of Accountable Care
(August 2016 draft) submission)
Ramkrishna Prakash
T
Paper Submitted for Call for Paper in August by ONC
2
care provider and is not readily accessible by their “network”
partners engaged in the care of their patient.[5]
Furthermore, the accountability and authorization for
accessing and modifying of a given patient’s data is limited to
these individual silos. This results in each organization
“modifying” its copy of patient data on their interaction with
the patient. This has led to the “network” of care providers to
be in the constant task of “updating” the patient profile and
always trying to catch up the illusive “latest valid profile” of
the individual. This has further been exacerbated by minimal
authorization from the individual whose data is being
modified, leading to erroneous information being introduced
into his/her records resulting is both clinical and economic
woes.
Another key factor in ensuring sustained wellness, is the
active involvement by the individual in their care regime. This
has been proven to be challenging, as patients feel that they
don’t have an appropriate access and incentives to engage in
care management, leading to a frustrating experience for both
providers and patients. Hence, this has led to a complete
breakdown in the overall accountability of all involved in
yielding optimal care outcomes.
B. Liability & Shared Compensation
The providers in the healthcare industry are very weary of
whether that data being used for clinical prescription is
“accurate” as they expose themselves to significant liabilities
unlike other industries if they are found to have made an error.
Therefore, they are insistent on “appropriate validation” of the
generation of data to ensure that they are not exposed to any
liabilities stemming from erroneous information. Hence there
is averseness towards using information that has not been
collected by an entity that is deemed reliable and is a “liable”
participant in their network. This has resulted in “forced
aggregation” of health care data which in turn has led to
increased costs and delays in care delivery, while still not
illuminating data errors. The standard approach, adopted is by
the dominant provider mandating that his network partners
enter the information into his system which is then the “golden
record” for the patient and can only be used by others.
Though, this avoids the liability issue it still does not address
the fact that the network provider, needs information in a
timely manner. This problem is further exacerbated in chronic
patients with two or more issues and this has led to a crisis in
delivering coordinated care for these patients.
An additional issue in ensuring effective health care delivery
is the accountability associated with who has reviewed the
data, accessed and authorized the recommended changes and
finally executed care delivery. As most of the healthcare EHR
systems were built to address a single domain of care
providers it was only designed for one “key” individual to
access and authorize changes. This was adequate when most
of health care providers delivered comprehensive care for an
individual with in a single provider system which gathered all
data from their “client” the patient. However, with the
emerging trend where in many a case this data is collected and
processed by a number of providers and intermediaries like
labs, technicians, home health care worker or even a family
member, this approach is limiting. Furthermore, with the
formation of Accountable Care networks, wherein the
penalties are high for bad outcomes resulting in non-
collaborative behavior, it is imperative that effective
automation of these care coordination capabilities is vital [6].
Finally, in the emerging Accountable Care landscape of
healthcare, compensation will be based on how effectively the
network of providers’ work together to ensure improvement in
the quality of care and wellness outcome while at the same
time reducing associated care cost. Hence, to truly incentivize
different participants in the network to pro-actively create
better care regimes there needs to a merit based compensation
of shared savings. To effectively allocate a proportionate share
to the provider in the network that contributed the most
towards the overall savings a clear tracking of their
contribution is vital. Else, it would lead to “least effort”
approach by all providers in the network resulting in overall
loss of income for care providers and an adverse effect in care
quality of patients.
C. Portability & Privacy
As the Care Delivery Model is shifting to “outcome based”
accountable care, there is an increasing need for the patient
data to move “fluidly” across various approved care providers
in the care network without sacrificing the privacy of the
patient data. However, the single domain nature of EHR
systems, which limits the portability of health data has
resulted in significant challenges. Hence, providers have
mandated that patients sign a HIPPA waiver to ensure timely
care is being delivered to patients. This has led to the leakage
of patient Health information resulting in unscrupulous
providers targeting patients at their most vulnerable time
during need for medical care. [7]
This problem is exacerbated due to the fact that upon
receiving this wavier information has been transferred via
paper copies leading to this information tending to linger a
long time in the care giver community. This has led to
persistent fraud practices that effect payor and patients
adversely for a long period of time.
Though there have been many efforts via the Health
Information Exchanges (HIE) to address the portability of this
information across providers in a secure and timely manner it
has fallen flat because of the incredible amount of upfront cost
and effort and the need for all vendors to participate to provide
any meaningful impact.
Hence the current solutions pursued by the Health Care
technology industry has resulted in a difficult choice between
care and privacy/economic fraud for patient. We see this issue
greatly expanding as more and more mental health services are
being delivered to individuals.
II. BACKGROUND
A number of approaches have been proposed to deal with the
issues identified in the previous section associated with the
Centralized Data Model. Though, these solutions are
temporary fixes to leverage the existing care delivery model
and Health Care IT infrastructure they are fundamentally
limited in addressing the significant change that is sweeping
health care at a national and global level.
Figure 1, illustrates the core architecture of current Electronic
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