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Team: alexanderjsingleton

Open-Source Healthcare via Blockchain


By:
Alexander J. Singleton
with contributing scholars
The George Washington University - School of Business
Department of Information Systems Technology Management
ISTM 6222 | Dr. Elias Carayannis
June 28, 2016

Introduction

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What is Blockchain?
First application based on Blockchain:
Application of Blockchain in Healthcare:
Organizational use of Blockchain:
Electronic Health Records
HIPAA Guidelines
Interoperability
Go-to-Market Strategy
Sources

Introduction
During the 2012 Elections, President Barack Obama courted opponents
of the Affordable Care Act with the promise of delivering a healthcare
exchange to clear the froth peddled by insurance brokers and companies
selling group-policies to Corporate America; ironically however,
ObamaCare merely interrupted free-market efficiency and increased the
cost of insurance specifically for those who found it unaffordable in the first
place- the unintended consequence of government policy: injury instead of
assistance, which is why an American dog probably receives better healthcare today, cash-only, without ObamaCare insurance. American healthcare
insurance is nothing more than a glorified payment-processing system. A
true free-market exchange indexed with real-time data and pricing would
ultimately benefit the patient. More data, means more transparency, means
better pricing and better health. Technology is exponentially displacing
yesterdays middlemen - so why should healthcare data remain exclusively in
the hands of corporations and governments but out of the patients reach in
the age of the iPhone and electronic-medical record (EMR) software? At the
end of the day, a transaction occurs between the patient and physician: an
exchange of data, vital stats, which is ever-accessible by the entire

healthcare complex except for the greatest beneficiary of all: the patient. If
transparency promotes democratization, then hopefully data promotes
health- so EMR companies should pivot strategy and approach in which
healthcare information may be shared via open-source exchanges modeled
after a blockchain framework facilitating anonymous but secure
cryptocurrency transactions, like Bitcoin. Although medical records are
personal, life-saving data could be aggregated from a healthcare blockchain
ledger, advancing wellness for the greater good with an open-source
healthcare exchange conceivably akin to ARPAnet, a precursory Internet
championed by DARPA. Like the human-genome, medical data belongs to
humanity, to the individual- not a corporation or government; arguably,
healthcare data is a basic human-right (Cook-deegan, Robert, and
Christopher Heaney). An examination of an industry leader in EMR, Cerner,
reveals an outline of the current healthcare exchange environment threatmap and how a blockchain framework indicates the direction to better
health, so America can live long and prosper.
Cerner was founded in 1979 by Neal Patterson, Paul Gorup and Cliff Illig
to create a software-solution platform for hospital administrators sharing
mission-critical information historically isolated by siloed hospital
administration ("Cerner Company Fact Sheet." ). In the 1980s, the Cerner

solution continued to grow and eventually evolved into patient-centric


healthcare solutions architecting and engineering data-integrity solutions for
the physician. Cerner, and the entire EMR industry, invisibly stand in the
examination room between the doctor and the patient; they know more
about many than those who care to know, but for those who would like to
access the data, in the age of the iPhone, the patient still waits in the waiting
room for answers. The following SWOT analysis of Cerner, an industry-leader
in EMR, outlines the current market landscape.
1. Strengths: Cerner has a strong focus on research and &
development (R&D), deploying significant resources into new
health and information systems solutions and services; as of FY
2014 approximately 4,300 associates were engaged in R&D
activities, reporting total expenditures on R&D and enhancement
of software solutions i/a/o $467.22 MM, $418.7 MM and $319.8
MM during FY2012, FY2013, FY2014, respectively ("Cerner
Corporation SWOT Analysis."). Cerners solutions were licensed
by approximately 18,000 facilities globally, including hospitals,
physician practices, laboratories, ambulatory care centers,
behavioral health centers, cardiac facilities, radiology clinics,
surgery centers but the company expects to drive growth in

ancillary markets outside the core healthcare information


technology (HCIT) market ("Cerner Corporation SWOT Analysis.").
2. Weaknesses: Although free cash flow increased from
$524.9 MM in FY2012 to $570.4 MM in FY2014, Cerner remains
heavily dependent on third-parties for certain technology,
hardware, and software which are integrated into its offerings
and processes supporting operations, including its flagship
production Millennium Solutions ("Cerner Corporation SWOT
Analysis."). According to software engineering consensus
advanced via Reddit, Millennium is in dire need of overhaul if not
categorical replacement, due to antiquated architecture
presumably incompatible with robust application program
interfaces (API)s or internet of things (IoT) connectivity.
Moreover, the company cloud services businesses rely on a
limited number of suppliers- namely Oracle, Citrix and Cisco; if
the cost of licensing, purchasing or maintaining third-party
solutions continues to increase in order to fulfill delivery,
Cerners operating earnings will significantly decreaseinefficiently brokering parsed solutions instead innovating inhouse ( ("Cerner Corporation SWOT Analysis.")).

3. Opportunities: Cerner is headquartered in Kansas City,


MO. Growing firms in the area have expressed difficulty
recruiting local talent but according to a recent study conducted
by the Kauffman Foundation, citing Heike Mayers research,
concludes that firms in the area are disconnected-and indeed
Cerner qualifies; however, Kansas City is home to a substantial
pool of talent in the region tapped by growing firms with a
strategy to hire Millennials for hands-on training (Motoyama,
Yasuyuki, Brian Danley, Kate Maxwell, and Arnobio Morelix).
Furthermore, Kansas City remains as a very competitive, low-cost
center next to more progressive markets located in Boston, New
York and San Francisco (Motoyama, Yasuyuki, Brian Danley, Kate
Maxwell, and Arnobio Morelix). Since Cerner is essentially a
parser, not a manufacturer, of technologies, strategic alignment
with innovative start-ups is advisable; obviously Cerner is not
lacking invention but innovation.
4. Threats: Intense competition- HCIT solutions, devices,
services and wearables is increasingly encroaching upon
Cerners dominance of EMR; principal competitors include the
following: Allscripts Healthcare Solutions, Epic Systems, GE

Healthcare Technologies, Dell, Deloitte, IBM, Xerox-and more


recently, Apple and Google ("Cerner Corporation SWOT
Analysis."). Population health start-ups also threaten Cerners
position in the market-place, aiming to simplify Cerner software
applications and systems that are highly complex and
sophisticated, as reported by internal engineers and verified by
market-research ("Cerner Corporation SWOT Analysis.")
(Signalthree). Population health start-ups also threaten Cerners
position in the market-place; Cerner pioneered EMR in 1996, and
over a decade later, the company is still unable to roll-out any
solution that can connect the patient to their own health-care
data. The Blue Button initiative has been championed by the
Departments of Defense, Health and Human Services, Healthcare
Information and Management Systems Solutions and Veterans
Affairs (HealthIT.gov. (n.d.)). Northrop Grumman was one of the
first private contracts awarded to enable EMR access to
veterans, suggesting API functionality for public access ("Mobile
Health Technology & Solutions.")- evidently, a viable tactic to
couple with an open-source strategy.

Proponents of radical transparency, notably Facebooks Mark Zuckerberg


among other Silicon Valley elites, believe the future will become increasingly
transparent; omni-directional camera feeds could be recorded and linked
with the Global Positioning System (GPS), so that each frame of video could
time-stamped with a location, all accessible over the Internet- a radical
notion, yes, but entirely possible, which means healthcare data collection is
also achievable on the same scale. ("Digitally Empowered Development").
Inevitably, electronic medical records will be transacted over a universal
healthcare exchange platform; thus, it may be reasonable to consider
blockchain as a framework to facilitate the exchange of personal healthcare
data anonymously, but securely, for the ultimate advancement of population
health.

What is Blockchain?
Blockchain is essentially a distributed database, or a ledger, similar to
Excel spreadsheets that warehouse a growing list of continuous transactions
from numerous parties within a distributed network. It uses advanced
security mechanisms such as cryptography and digital signatures to allow
each participant on the network to manipulate the ledger in a secure way
requiring a consensus among the group which, at the same time, eliminates
the need for a central authority to approve transactions. Basically, once a

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block of data is recorded on the blockchain ledger, it is not so easy to


modify or remove. Prior to the addition of a new data block, participants in
the network that have access to the existing blockchain assess and verify the
proposed transaction through executing complex algorithms. Once all the
participating entities (aka nodes/computer servers) ensure the validity of the
transaction and reach consensus for the approval of the new transaction, the
new block gets added to the chain. According to Guardtime, a cyber-security
provider of blockchain-based products and services, the process works as
follows:
Assume an organization has 10 transactions per second. Each of those
transactions receives its own digital signature. Using a tree structure,
those signatures are combined and given a single digital fingerprint
a unique representation of those transactions at a specific time. That
fingerprint is sent up the tree to the next layer of infrastructure, such
as a service provider or telecom company. This process happens for
every organization in the network until there is a single digital
fingerprint that encompasses all the transactions as they existed
during that particular second. Once validated, that fingerprint is stored
in a blockchain that all the participants can see. A copy of that ledger
is also sent back to each organization to store locally. Those signatures
can be continuously verified against what is in the blockchain, giving
companies a way to monitor the state and integrity of a particular
asset or transaction. Anytime a change to data or an asset is proposed,
a new, unique digital fingerprint is created, Guardtime said. That
fingerprint is sent to each client node for validation. If the fingerprints
dont match, or if the change to the data doesnt fit with the networks
agreed-upon rules, the transaction may not be validated. This setup
means the entire network, rather than a central authority, is
responsible for ensuring the validity of each transaction (Norton,
Steven).
Blockchains distributed ledger structure and consensus process varies
depending on the type and size of the network and the use case of a
particular company. While some firms continue to develop on the

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permission-less public Bitcoin blockchain that allows anyone to participate


and contribute to the ledger, many are also exploring ways to deploy
private blockchains on smaller permissioned networks consisting of only
known participants.

First application based on Blockchain:


Bitcoin has gained popularity as the first decentralized cryptocurrency
in the financial services sector primarily due to its underlying blockchain
technology. It is basically a peer-to-peer electronic payment system, which
allows online payments to be sent directly from one party to another without
having to go through a middleman/third-party financial institution such as a
bank or a clearinghouse, thus reducing or completely eliminating transaction
fees and accelerating transaction-times. The Bitcoin network is completely
transparent as it stores details of every single transaction ever recorded in
the network on the blockchain ledger and records all of the transactions
collected during a period into something called a block. This block can be
used to explore any transaction made between any Bitcoin addresses at any
point on the network. Whenever a new block of transactions is created, it is
added to the blockchain creating an increasingly voluminous list of all the
transactions that ever transacted on the Bitcoin network. A constantly
updated copy of the blockchain is given to all the participants. When a block
of transactions is created, miners take the information in the block and apply
a mathematical algorithm yielding a random sequence of letters and

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numbers known as a message hash, which is used in creating a digital


signature. This hash is stored along with the block at the end of the
blockchain at that date-time-stamp. This approach is highly secure as it is
quite simple to generate a hash from a collection of data, however the
reverse process of decrypting the hash to examine the underlying data is
virtually impossible. In order to produce each blocks hash, miners not just
use transactions in a block but the hash of the preceding block as well, which
as a result authenticates the legitimacy of this block and every subsequent
block. Any attempts to alter a block that had already been stored in the
blockchain for the purpose of counterfeiting a transaction would corrupt the
blocks hash thereby conflicting with the hashing function to verify that
blocks authenticity, so a different hash would be revealed from the one
already stored, instantly exposing the counterfeit block. This highly effective
proof of work scheme protects against tampering and other hacking attacks
on the Bitcoin network. The underlying technology driving Bitcoin is clearly
compelling as Gems CEO Micah Winkelspecht states, It took about a year
and a half for the financial industry to go from looking at Bitcoin and saying,
'This will never work,' to where it is now, where essentially every major
financial institution in the world is either exploring blockchain or has active
teams devoted to building projects using it (Green, Max).

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Application of Blockchain in Healthcare:


Aside from the financial sector, healthcare is poised to transform with a paradigm-shifting
blockchain model. It has the potential to revolutionize healthcare by addressing the biggest
concerns of access, privacy, security and scalability as it pertains to population health, medical
records, and patient-generated data around the globe. In the context of healthcare, patient data
can be stored on the Bitcoin-like blockchain by creating a multi-signature (multi-sig) address
associated with each patient record. The patient would be provided with a code (private key or
hash) and a multi-sig address in order to unlock their data. Additionally, a separate universal
signature (hashes or multi-sigs) would be assigned to healthcare providers as a way to
authenticate their identity by decrypting the patients hash, which would result in unlocking the
patients data. Concordantly, the patient profile would consist of access rules defined by the
patient to further unlock their medical records. The M-of-N multi-sig basically means that N
computers would be required to decrypt the code. For instance, defining a 2-of-3 multi-sig
indicates that not only would two separate codes be required to compromise three separate
machines but the fact that data could still be unlocked with the availability of just two of the three
keys. Using the multi-sig principle, patients will have full control of their medical information and
can select the information shared and viewed by providers or doctors by using their signature
along with that of the hospital. This new method of decentralizing healthcare data would be
extremely beneficial and cost-effective for hospitals by preventing huge costs associated with
outsourcing the task of setting up and maintaining patients electronic records. As stated by the
founder and CEO of blockchain startup, GEM, the ultimate goal is to combine the various
services of the healthcare industry to create a patient-centric healthcare system where were
essentially tracking the entire lifecycle of a patient for their entire journey through the healthcare
system and are able to give more control to patients over how their data is used and how its
shared, to actually give them access to their own data (Bryant, Meg).

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In a blockchain world, health information exchanges (HIE), all-payer


claims databases (APCD), and electronic health records (EHR) will be
rendered obsolete. There no longer stands a need to trust and deal with a
middleman/third party system when blockchain provides direct continuous
access to patient records, which results in increasing data security while
eliminating cost, time, and resources required for compliance. EMR
repositories do not always represent accurate up-to-date data of a patients
history, which is routinely subject to unauthorized modification by hackers, or
the less nefarious data-entry error, creating discrepancies or redundancies,
which could be life-threatening for the wrong-patient. This could pose a
huge risk to patient health data source-control shared between hospitals,
specialists, or care-facilities. A blockchain healthcare exchange may provide
the validation and assurance that the healthcare industry needs by
synchronized delivery of trusted service and support. An interoperable,
healthcare blockchain exchange would inherently afford data-integrity and
information-security without risk of compromises between health-care
service-providers. If one party is unable to manipulate the blockchain ledger
without signaling other counterparties transacting within the blockchain
ledger, or in this case exchange, data-integrity and information-security
safeguards are essentially crowd-sourced. According to the CEO of
Guardtime, whenever someones health records are accessed, that event
is recorded on the blockchain, alongside what information was changed or
added. That way, the information remains both secure and tamper-proof;

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nobody can change it without leaving traces (Kar, Ian). Quality of care may
finally benefit from a notion of transparency, or truth, that is readily
available and accessible not only health-care exchange providers but most
importantly, the patients.

Organizational use of Blockchain:


Blockchain technology is a booming in healthcare: corporations,
governments, and NGOs the world-over are experimenting with the
possibilities of such a groundbreaking framework. Tierion, a company
specializing in collecting and ingesting data into the blockchain, recently
launched their first project with the Philips Healthcare group in effort to
transform patient healthcare by making it more accessible and affordable
but most of all achievable via blockchain

Tierion achieved

first-mover

advantage offering a blockchain-based healthcare solution. Other leaders


pioneering in healthcare blockchain infrastructure include Gem, Guardtime,
and Factom. Guardtime is another preeminent solution already implementing
its blockchain approach in Estonia that secures the countrys one million
records. According to the CEO of Guardtime, Mike Gault, adopting
Guardtimes technology for healthcare records would allow Estonia to
effectively eliminate lies. Every update to healthcare records and every
access to healthcare records is registered in the blockchain. That makes it
impossible for the government or doctors or anyone to cover up any changes
to

healthcare

records

and

thats

really

powerful

(Williams,

Oscar).

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Furthermore, Gem, another leader in blockchain technology providers,


initiated a collaborative project with Philips Healthcare to create the new
Philips Blockchain lab as a way to offer blockchain technology solutions to
companies who can identify use-cases in their businesses. As per Gem CEO
Micah Winkelspecht, one of the most interesting groups that reached out to
us when we started talking about the blockchain and healthcare were
physicians themselves. Many of them see the problems with todays
technology and are fed up with the current system. Physicians want to help.
And so we want to create platform for all the different stakeholders to
collaborate (Prisco, Giulio).

Electronic Health Records


Cerner s offerings strive for compliance with HIPAA and Health
Information Technology Certification Criteria. Cerner offers 965 products that
currently meet the Health Information Technology Certification Criteria. The
guidelines within HIPAA and the Health IT are exactly that, just guidelines.
HIPAA list the following technical guidelines:

HIPAA Guidelines
164.312 Technical safeguards. A covered entity or business associate
must, in accordance with 164.306...[68 FR 8376, Feb. 20, 2003, as
amended at 78 FR 5694, Jan. 25, 2013]:
1. Standard: Access control. Implement technical policies and procedures for
electronic information systems that maintain electronic protected health

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a.
i.
ii.
iii.
iv.
b.
c.
2.

a.
b.
c.
i.
ii.

information to allow access only to those persons or software programs that


have been granted access rights as specified in 164.308(a)(4).
Implementation Specifications:
Unique user identification (Required). Assign a unique name and/or
number for identifying and tracking user identity.
Emergency access procedure (Required). Establish (and implement as
needed) procedures for obtaining necessary electronic protected health
information during an emergency.
Automatic logoff (Addressable). Implement electronic procedures that
terminate an electronic session after a predetermined time of inactivity.
Encryption and decryption (Addressable). Implement a mechanism to
encrypt and decrypt electronic protected health information.
Standard: Audit controls. Implement hardware, software, and/or procedural
mechanisms that record and examine activity in information systems that
contain or use electronic protected health information.
Standard: Integrity. Implement policies and procedures to protect electronic
protected health information from improper alteration or destruction.
Implementation specification: Mechanism to authenticate electronic
protected health information (Addressable). Implement electronic
mechanisms to corroborate that electronic protected health information has
not been altered or destroyed in an unauthorized manner.
Standard: Person or entity authentication. Implement procedures to verify
that a person or entity seeking access to electronic protected health
information is the one claimed.
Standard: Transmission security. Implement technical security measures to
guard against unauthorized access to electronic protected health information
that is being transmitted over an electronic communications network.
Implementation specifications:
Integrity controls (Addressable). Implement security measures to ensure that
electronically transmitted electronic protected health information is not
improperly modified without detection until disposed of.
Encryption (Addressable). Implement a mechanism to encrypt electronic
protected health information whenever deemed appropriate.
These guidelines are very specific on how to manage data, how to
access data, how to store data, how to track data, and so forth; however,
HIPAA guidelines are just that-guidelines but do not exactly dictate the best
way to execute requirements.
Architecting systems in accordance with EHR guidelines can be costly.
Health care systems require redundancies, which in turn have massive

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memory and load requirements. Specialized, application program interfaces


(APIs) and services can accomplish interoperability, albeit at significant
costs. Data-integrity and information security standards vary from renowned
hospitals, like the Mayo Clinic, to the rural doctors clinic located in Dodge
City, KS; which begs the question: if all standards are universal, but are they
universally executed? Information-security is generally robust on the backend but bottlenecks are exposed downstream in front of the user. There are
two types of organizations: those that have been hacked and those that will
be- although HIPAA compliance is standard, there is no standardized
network of exchange; health-care data is transmitted along the same data
carrying financial transactions and Netflix- obviously, sensitive health-care
data deserves more security and encryption than the last Netflix episode. A
universal blockchain standard would ensure a universal information-security
standard.
EHRs are ready for blockchain technology. Blockchain is a new
technology altering the upside of information-security at its fundamental
core. This would be orders of magnitude groundbreaking than the existing
paradigm haphazardly cobbled by the healthcare status-quo. The regulatory
climate may be nebulous but navigable for blockchain-believers in
healthcare.

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Interoperability
Cerner currently participates in an interoperability network called
CommonWell Health Alliance. This alliance provides Cerner clients with an
opportunity to exchange healthcare data as a patient or medical
professional. The benefit is that a patient can receive better health services
because their record is accessible to any member within the alliance. An
alliance like this is powerful for providing health services because it reduces
physical records and limits required for record delivery via e-mail, fax, or
mail. The member-alliance is relatively secure for patients and healthcare
professionals because there are established security guidelines governed by
encryption protocols for transmission within the member-alliance network.
There are also downsides to this alliance. CommonWell Health Alliance
is simply a portal for healthcare records. CommonWell Health Alliance does
not store any the information and does not manage any of the integrity of
the records that can be accessed via their portal. Devoid of data-integrity
quality assurance and procedure, a healthcare professional is not guaranteed
updated records for their patient, let alone information security. This means
that each member within the alliance accepts blind-faith and confidence in
fastidious participation among CommonWell members. Although Cerner
technology ensures that data-records are accurately documentated and
exchanged, that is far from data-integrity and information security between
end-points among CommonWell alliance-members (even though this is a
HIPAA requirement). Accessing data through an alliance yields network

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vulnerabilities. If a file is accessed on one date, it does not mean that it is


the most up-to-date file after the hypothetical time accessed. Audit trails for
how data is managed is only maintained to within the alliance system, so
Cerner users may not be able to understand how data is handled in another's
system.
How can Cerner ultimately improve interoperability? Enter the
blockchain: if Cerner implements blockchain technology as a core-offering,
its already scalable. The first, lowest level that blockchain technology can
help improve its product is within a single institution. If an institution adopts
the blockchain ledger it can ensure that a patient's record within that
institution is accurate and continuously updated on a separate but
interoperable platform. Another obvious benefit is transaction-history within
the ledger, allowing complete examination of patient history upon recorded
entry into the platform-ledger. The most viable option is a Cerner-led
concerted effort among not just the CommonWell Health Alliance and its
members but to implement blockchain technology across all healthcare
providers throughout the country.

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Washington, D.C. 14 June 2016. Lecture. Slides: 96-99.

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Norton, Steven. CIO Explainer: What is Blockchain? The Wall Street Journal
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