EMRs — Rushing to the ER

 |  July 9, 2018

It’s as routine as a blood pressure check at the doctor’s office: Your doctor is engrossed in his computer or tablet, toggling between various charts, data sets, and what appear to be (maybe) lab results. You can’t quite tell because most of the scanned notations are illegible, the stereotypes aptly confirmed by your firsthand account. What exactly is your doctor doing besides making you antsy?

Your physician is perusing various electronic medical records, or EMRs. These EMRs contain detailed information about your medical history: your scans, lab values, current and past medications, treatments, or any pertinent medical information that a health care provider has on you. EMRs are a digitized version of those thick paper charts physicians used to scribble on when asking about your last tetanus shot or if you’ve ever had chickenpox.

As impatient as we might be with our doctor’s head glued to a computer screen, navigating between EMRs can be a difficult, sometimes impossible feat that is an unfortunate reality of the current U.S. health care system.

The Promise of EMRs

EMR technology came about with the goal of eventually being part of a universal health records system where different providers could see the same data. This would mean having a standardized (but still customizable) template for collecting and recording patient data, the ability to access and share relevant data with other physicians taking care of the same patient, and direct access for patients to their medical charts. This would include physician addenda that would elaborate on data — for example, explanations for a lab value or results of a CT scan. This all sounds wonderful, but EMRs are still decentralized and a pain for your doc to navigate.

In theory, a centralized EMR system could revolutionize the way medicine is practiced. It would reduce medical errors and decrease, if not eliminate, duplicate testing. This in turn would spare patients from unnecessary and sometimes invasive procedures, significantly curtailing health care costs by removing redundancy. This would also empower patients with a more comprehensive knowledge of their own health and bodies, creating an open dialogue between patients and their physicians. And it would allow physicians to efficiently practice a craft that took years of schooling and real-world experience to hone — the quintessential craft of medicine, the art of caring for people.

Unfortunately, the current applications of EMRs fall short. Despite having more than 1,000 various EMRs in the U.S. alone, very few of these systems communicate with one another. Patient data collected on one system stays within the confines of that system. So while your cardiologist might be within walking distance of your primary care physician, if they don’t use the same EMR, important information like a newly prescribed heart failure medication that could interact with your cholesterol-lowering pill could get lost in translation.

Different Providers, Different Data

Are we any closer to a reliable centralized system for EMRs? Even if technology hasn’t recently experienced disruption (game-changing evolution), at least its adoption rate has increased. Less than a decade ago, 90 percent of physicians in the U.S. were still carrying around folders with stacks of printed papers with information not nearly as robust as the contents of today’s EMRs. According to a November 2017 article published on Medium’s Crypt Bytes Tech blog, “Medicalchain — A Blockchain for Electronic Health Records,” as of 2015, 65 percent of hospitals globally had adapted the use of EMRs, compared to 54 percent in 2014. Although their use is on the rise, their universal efficacy is still flawed; they’re still an unconsolidated mess.

Different practices, hospitals, and health care systems use various EMR databases with no centralization. Imagine a system of mobile phone carriers where AT&T users could not talk to Verizon users, and neither of those users could talk to Sprint nor T-Mobile nor MetroPCS nor Boost Mobile users. The only people you could directly talk with on your phone would be the ones using the same carrier. Finding out what your friends using other mobile carriers are up to for the weekend would require looking at text message transcripts from those other carriers. Maybe a friend could email those to you.

Of course, it would be idiotic for a mobile carrier to adopt such an isolated system. And it would be self-defeating for the telecom industry to create an infrastructure where different networks could not communicate with one another. Unfortunately, the industry that allows you to text your bestie cat memes has this reality better sorted out than the industry that’s supposed to keep you alive.

Why haven’t EMRs been centralized, pulling and pooling medical records from different providers? Wouldn’t it make sense for them to have access to all of your medical history and information, regardless of how many different doctors, hospitals, clinics, and labs you’ve visited? Sure! But instituting such a system would require the free flow of some of the most invaluable, sensitive personal information digitally prescribed to an individual. Health care providers have immense responsibilities for protecting patients’ medical info and face massive penalties if they fail to do so. Naturally, this makes providers wary of sharing. Fortunately, new technologies have improved the prospects of securely sharing medical data. One is called blockchain.

Programmable Scarcity

A blockchain is a digital ledger in which transactions are recorded chronologically and publicly. It starts with separate entities transacting digitally. They could be exchanging currency, information, identification — essentially any digital asset. When one party transmits an encrypted ledger, that transaction’s information is encrypted into “blocks.” Those blocks are then made to be transparent and documented by all parties involved in the transaction. Every party involved must not only review the transaction but validate it as well. This happens for every block of data. When the block is approved, it is added to a “chain” of transmitted data. And then that transmission is fully sent over to the receiving party. Any changes, edits, or interceptions of data that are not authorized break the chain, and the changes and transmission are not validated.

Imagine ordering a pizza. You confirm the order with the pizzeria and pay. But before the pie arrives to your house, your annoying neighbor intercepts the delivery guy on the sidewalk. “Yep, that’s me who ordered the margherita with extra basil,” he says, scarfing down a couple of slices and leaving the rest on your doorstep, with a ring-and-run. That jerk. Now imagine if at every step of the delivery the pizza box was transmitting electronic signals to both the pizzeria and you, letting you know there is still a full, untouched pie. If someone even cracks open the box, the entire delivery is voided, and the van has to return to base to get you a new one, with all events recorded and transmitted to you, the pizzeria, and the delivery guy. That is basically blockchain, if you’re thinking with your stomach.

Blockchain is “the most consequential technology since the internet,” Balaji Srinivasan, CEO of cryptocurrency firm 21 Inc., told The Wall Street Journal last September. “The internet is programmable information,” Srinivasan said. “The blockchain is programmable scarcity.” Srinivasan explains scarcity in a very simple example: If Person A takes his or her own dollar bill and gives it to Person B, then Person A no longer has a dollar bill, whereas Person B does. Scarcity of a dollar bill has transferred from B to A. Conversely, if Person A simply could email the serial number of the dollar bill to Person B, and that could allow for use of the currency, we would have a problem of duplication, where we would need to introduce scarcity. Let’s apply this to information in the form of our own question. How would we ensure that data can be exchanged between multiple parties and that the exchange of data can be viewed by all parties while still ensuring the data at hand is being edited by only the party currently in possession of it?

The same technology that began as a means of providing encryption protection on cryptocurrency transactions and ordering/invoicing for logistics and retail companies is now making its way into health care, where there is considerable potential for its application to EMR networks. An electronic ledger that tracks sets of data and all modifications to that data while keeping out unapproved editors is practically the definition of an effective EMR network.

Imagine creating a blockchain network able to receive data from all existing EMRs, track and notify all relevant parties of changes and appends to records, and safely and securely transmit this data efficiently to the necessary recipients. This could save a patient’s life. Blockchain is unique in that it it relies solely on “peer-to-peer” validation for any data transacted within a given ledger or instance of a blockchain data transaction. This means that all participating contributors to that particular ledger can view any and all changes as well as those who made them. Such collaborative transparency would allow for data validation by all and aid in the accurate reconciliation of data. A patient’s medical records could be verified by any of his or her providers, who would have a much clearer understanding of the patient’s medical history.

Blockchain Limitations

Many complain about the data limitations of blockchain, specifically, where to better encrypt transactions. Originally, blockchain could handle only two transactions per second (on average). Today, however, it can do about six to seven (a few gigabytes per transaction, maybe). In reality, patient medical history, including charts, graphs, and notations, won’t be all that much in terms of size load. So long as all data is readily available to participants, whether it’s decentralized or centralized, these transactions’ size limitations actually would not slow down or hinder the health care industry’s data flow as much as it would, say, financial services. Health care would be a poster child for applying this technology.

In a March 2017 article in Harvard Business Review, “The Potential for Blockchain to Transform Electronic Health Records,” Dr. John D. Halamka, Andrew Lippman, and Ariel Ekblaw advocated for the use of blockchain technology in electronic medical records. They postulated that manual reconciliation of records by humans is ineffective because there is no single reference of all EMRs that contain all medical records along with their proper history. “We may know every medication ever prescribed, but it can be unclear which medications the patient is actually taking now,” they wrote. “Further, although data standards are better than ever, each electronic health record stores data using different workflows, so it is not obvious who recorded what, and when.”

The co-authors have been working with colleagues at the MIT Media Lab as well as Beth Israel Deaconess Medical Center (Harvard Medical School) on a potential blockchain-incorporated solution known as MedRec. MedRec does not consolidate medical records. Instead, it places the onus on patients to manage their medical records for submission and authentication. Similarly, another system, Medicalchain (mentioned in the Medium Crypt Bytes Tech article), allows patients to authorize or deny access to their records but also allows health care participants to contribute appended data, notifying the rest of the network when this occurs.

The concept sounds promising; however, there is still no way to centralize the data. This is because medical professionals still store data in whatever database or warehouse they or their organizations have a contract with. The medical world does not have a consolidated network. The current offerings of blockchain solutions, such as Medicalchain and MedRec, still rely on just providing the blockchain-like element of logging all activities and transactions. However, they still do not actually consolidate all the data. That means an inquiry into your physical health would be like an inquiry into your financial health if you were looking at a statement from only one of your many credit cards.

The other drawback is that Medicalchain plans to have digital tokens, or cryptocurrency, as payment for use of its network. Cryptocurrency’s value can be volatile on even a daily basis, and any system predicated on it would require of medical staffs an additional expertise in a nuanced and esoteric field of finance. The primary intended use of blockchain and other distributed ledger technologies was for cryptocurrency-based transactions, but cryptocurrencies failed to prove stable in value, leading to shutdowns and restrictions placed on some exchanges, trades, and originators of the currencies. A system that relies on cryptocurrency invites unnecessary additional risk and downside.

Once Bitten, Twice Shy

Despite pockets of the health care industry leveraging blockchain technology, overall adoption is slow. We spoke with professor David Shrier about the topic. Shrier leads the University of Oxford’s Blockchain Strategy program and advises the government of Dubai, which is heavily investing in the technology.

“Why is the medical industry so slow to embrace this technology, despite the obvious benefits?” we inquired.

“Blockchain’s slow adoption in health care is mirrored by the slow adoption of other technologies in health care,” Shrier said. “Providers and payors alike are very slow-moving and tend to be averse to new adjuvant technologies (outside of clinical products, which have their own process and which is also slow). The breakthrough for EMR companies was when they figured out how to optimize reporting for the hospital CFO, and that drove some adoption, unfortunately to the detriment of the clinics’ experience and with no demonstrable positive impact on clinical outcomes (see the long-term studies). Once bitten, twice shy — why would providers then rush to embrace blockchain?”

It’s not the first new technology health care professionals have been slow to embrace. Regardless, with experience and experimentation, innovation often prevails. Clearly, blockchain can enhance the current model of EMR networking and communication. But don’t just blame the bottleneck on C-suite executives. Health care IT managers might also have reservations about adopting the new skillsets necessary to make best use of blockchain. Eventually, the opportunity for competitive gains over other providers and fellow professionals will force the hands of those in both boardrooms and server rooms.

Improving technology and practices will make embracing blockchain an easier decision for health care leaders. We’re already seeing the progress unfurl. For example, Google’s artificial intelligence arm, DeepMind Technologies, has been using blockchain via a private network and employs its own “proof of peer review” algorithm, which essentially relies on contributors to a particular ledger to validate medical data. Professionals familiar with EMRs get an assist from AI, improving the efficacy of the data and mitigating the human costs necessary to compile it.

The future of the health care industry relies heavily on the talent of current and future generations, equipment, and research. Distributed ledger technology such as blockchain has the potential to save lives and resources. However, for the holistic solution to be successful, distributed ledger technologies for transactions and security must be paired with a massive effort to centralize all existing records, reconcile them, and chronologically order that historical data.

Blockchain and any future variants along a similar premise of encryption and centralization are an excellent way to ameliorate reservations about the centralization of EMRs attributed to the challenges of synchronizing, editing, and removing patient data and communicating changes to all parties involved. As for centralization, there are existing solutions that already offer that capability without forcing organizations to spend capital expanding their IT departments.

Could we necessarily trust the Googles, Amazons, and Facebooks of the world with our medical data, consolidated only by them? I don’t think so, in which case we need to encourage entrepreneurs and the medical industry to work together and fuse existing technologies with common sense. Put all of your data in one place, secure it, and make it accessible to all relevant parties.