Louisville Medicine Volume 65, Issue 6 - Page 7

From the PRESIDENT Robert A. Zaring, MD, MMM GLMS President | rob.zaring@glms.org A TRANSFORMATIVE Technology L ast year, IT and financial worlds were abuzz with Craig Steven Wright’s claims that he was the elusive Satoshi Nakamoto. It remains to be seen if Wright is or is not Nakamoto. How- ever, what I hope is that right now you are asking who Satoshi Nakamoto is and what does he have to do with health care. To answer those questions, we must take a quick jaunt back to the 1990s to the early days of the internet, and look at a group known as the “Cypherpunks.” The Cypherpunks were created in 1992 by Eric Hughes, Tim May and John Gilmore. Some of the other famous members of the group in- cluded Jacob App elbaum, Julian Assange and Hal Finney. The group were Libertarian-lean- ing activists who believed that only through cryptography could privacy and security be maintained in a digital world. They also were in search of a currency which would not be centrally controlled. The group feared central control of the currency by institutions such as the Federal Reserve, because they believed it allowed for too much manipulation and cor- ruption. Many ideas were brought up, such as BitGold, but none hit the mark. The search went on, but interest in the currency they en- visioned waned until 2008 with the collapse of the financial markets. Only two months after the failure of Lehman Brothers, a paper was released entitled “Bitcoin: A Peer-to-Peer Electronic Cash System” by Satoshi Nakamoto. A few months later, the first exchange of Bitcoin occurred. Although Bitcoin has weathered peaks and valleys, its val- ue continues to rise. Today, Satoshi Nakamoto, whoever he (or they) may be, is estimated to have well over a billion U.S. dollars worth of Bitcoin. You may be wondering what do Bitcoin and health care have to do with each other? The answer to that question is that the real beauty of the technology is not Bitcoin, but the underlying technology known as Blockchain. It is important to understand that Bitcoin does not equal Blockchain. One could say that Bitcoin and Blockchain are related to each other the way email and the internet are. As email is just one use or application of the internet, Bitcoin is just one application of Blockchain. So, what is Blockchain? Blockchain is a distributed digital ledger se- cured by cryptography. In accounting terms, a ledger is a detailed record of transactions. Blockchain is also an accounting of transactions but in a digitally distributed network. Multiple transactions are placed in a block and digitally linked to another block, which links to another block, and so on, hence the name Blockchain. No transaction or block can be changed with- out majority acceptance of all the individual computers in the distributed network. The computers must solve special algorithms to approve a change, and multiple copies of the correct ledger are on all computers and updat- ed immediately. If one copy is incorrect from being tampered with, it is easily identified in comparison to the others and corrected. To understand the use of this technology, consider a house that was built and had several additions and fixes. Each change would be a transaction and no change could be deleted or forgotten as everything that happened would be recorded and would be immutable. Therefore, the life of the house would be recorded and verifiable for any potential buyer, eliminating title fraud or potential problems about the house that may not have been disclosed. This distributed immutable digital ledger has many potential uses in health care. Some of those uses include: clinical trials where altering or creating data would not be possible; drug traceability from creation to patient ending the problem of counterfeit drugs; immediate insurance eligibility determination and claims processing, and an Electronic Health Record (EHR) that allows for interoperability, with patients able to determine with complete se- curity who sees their records. I cannot go into every scenario of how this would work, but for a brief example, consider the EHR. Every change or addition would create a new trans- action with a unique pointer created and sent to an outside depository, where the patient information is held. The patient could approve those asking to see their information by using smart contracts or computer logic built into the Blockchain. Every addition or change would be authenticated and marked in the Blockchain but, at the same time, held as completely secure with only those given authorization able to see the information. Given this cryptography, the Blockchain is essentially hacker-proof, elim- inating the problems with ransomware and other serious HIPAA violations. The financial industry is embracing Block- chain rapidly. It’s estimated that by 2021, Block- chain will grow to a 2.3 billion dollar market from its 339.5 million market today. Health care organizations are currently investing in the technology, and last year the Office of the National Coordinator for Health Information Technology offered a challenge for white papers on how to use it best. Furthermore, Estonia, one of the most tech savvy countries in Europe, has partnered with the Blockchain company, Guardtime, to protect all its medical records. Dubai is planning on doing the same and ad- vancing its use of Blockchain by securing all government records by 2021. Many have lamented health care’s slow adop- tion of horizontal technologies in the past. But, it appears with Blockchain, health care is keep- ing pace and may be on the verge of imple- menting a truly transformative technology. Dr. Zaring is an anatomic and clinical pathologist with Louisville Pathology Associates and practic- es at Jewish Hospital. NOVEMBER 2017 5