Blockchain is existing technology. The first work on a cryptographically secured chain of blocks was described in 1991 by Stuart Haber and W. Scott Stornetta. In 1992, Bayer, Haber and Stornetta incorporated Merkle trees to the blockchain as an efficiency improvement to be able to collect several documents into one block. So 25 years old, which is quite old in IT history There a re a lot more applications of blockchain in healthcare ICT, also described in the document I linked to, in very simple examples. Most important are transparent and provable tracking order of events, independent from sending/receiving computers, tracking of messages, it will be impossible to send a secret message, for example. It is very convenient for the all stakeholders to be able to be sure messages are only send to what they approved too at a moment they approved too, containing what they approved too. This will become very important in the future when exchanging medical data will explode in volume.
It is not about hacking why blockchain is interesting, although, that can happen too. But it is about having trustworthy computing without a trusted third party. Not only protecting against bad intentions but also against errors, for example, system which not run synchronous or have date/time(zone) not well configured. Not a trusted party ensures delivery and time of delivery and contents of delivery, but blockchain as a mechanism does.
I have given already a few examples.
Remember, computers make no errors, but people do, and it are people which configure computers and use them, and their responsibility must be able to transparently replayed afterwards.
Bert
There may be applications such as 'digital notary' that blockchain might be useful for, which is a trusted third party notary that accumulates signed hashes of content transactions to the main EHR; if it is thought that the EHR was hacked or integrity was in question, the digital notary can be used to check. There was even a gNotary project in gnu health years ago. But as Grahame says, protecting against transaction errors / hacking isn't a burning problem to date. However, if you want to accumulate the whole contents of transactions, blockchain is unlikely to be be scalable.
Maybe this will change and blockchain will find use there.
- thomas
I understand, I take that as an authoritative answer to my question why it hasn't been discussed in OpenEhr context.
The answer is also supported by Grahame. So what can I say 
Thank you both for that.
I think that both of you will discuss within two years if and maybe how to implement blockchain in OpenEhr and in FHIR.
In FHIR I think that discussion will come very sooner, because, it is about messaging, and also, it describes technical layers.
In OpenEhr maybe in that discussion it will be rejected as something because it will be regarded as not belonging to the non-technical character of the Openehr-specification.
Best regards and thanks for the considerations
Bert
It never got any traction so we discontinued that project.
Karsten
In FHIR I think that discussion will come very sooner, because, it is
about messaging, and also, it describes technical layers.
yes it did. I'm sceptical there for the same reasons. You can track the
discussion if you are interested:
https://chat.fhir.org/#narrow/stream/blockchain
Grahame
Thomas, one more remark, I remember the task-planning-specification where you have been working on, and on which you planning to give a presentation in London soon.
It is there where I thought there could be an excellent example of implementation of blockchain. Because it is about a processing model, state-machine, decisions, how good would it be for a performer to be able to prove: a decision taken on information or having taken a step, or other cicrumstances, by implementing the blockchain mechanism?
That would just be a classical use case for which blockchain was invented.
Bert
Bert, in particular, might find the collection of technologies around OpenBazaar[1][2] interesting.
It relies on DHT for it’s P2P marketplace framework and implementation, Ricardian contracts[3] for agreements, 2-of-3 multi-sig for escrow, BTC for remittance and IPFS for distributed file storage.
[1] https://www.openbazaar.org/
[2] https://en.wikipedia.org/wiki/OpenBazaar
[3] https://en.wikipedia.org/wiki/Ricardian_contract
thanks
Thanks William, but that is just the association I want to avoid. OpenBazaar is about Bitcoin, which I find a not so welcome implementation of blockchain, although there are situations where it can help people for the good.
OpenBazaar seems to be inspired by a hackathon project called DarkMarket, and the association with illegal trade is too obvious, and not what I want to associate this discussion with.
However, there maybe elements in that which are usable in this discussion-context, but there are many documents on the Internet which describe research-results for blockchain in health-ICT and filtered out unwanted associations.
Bert
I agree, that's an interesting idea. I have not put any thought into it, but it's worth investigating. But we need to be clear on what problem is being solved here. Is it improvements in medico-legal standard of proof, or something else? What is the economic driver, and why are the current mechanisms (signing and versioning) not good enough?
- thomas
I agree, that's an interesting idea. I have not put any thought into it, but it's worth investigating. But we need to be clear on what problem is being solved here. Is it improvements in medico-legal standard of proof, or something else? What is the economic driver, and why are the current mechanisms (signing and versioning) not good enough?
The advantage in legal context is that independent of machines can be proven what has happened. A nurse writes down in her app that a patient is doing bad, a doctor sees the messages, having it on the screen is also an action, and then going to visit the patient, action...
It gets more interesting when more systems are involved because they together register a chain of events, and because of the blockchain they can relate to each other.
Following up on the interesting exchange wrt blockchain what I can see is confusion. When to use blockchain technology? when to go for a distributed database? when is provenance and time stamping critical but blockchain does not make sense?
We want to hear about vision of technology, work in progress, critical views of technology in specific areas and much more. Our Call for Papers is clearly on topic for this discussion.
Hopefully OpenEHR may share some interesting light in the use, or the when not to use, blockchain tech in health care.
Following up on the interesting exchange wrt blockchain what I can see is confusion. When to use blockchain technology? when to go for a distributed database? when is provenance and time stamping critical but blockchain does not make sense?
We want to hear about vision of technology, work in progress, critical views of technology in specific areas and much more. Our Call for Papers is clearly on topic for this discussion.
Hopefully OpenEHR may share some interesting light in the use, or the when not to use, blockchain tech in health care.
Hi to all,
A Blockchain is a public (or at least shared) digital notary.
The easiest (hence probably the more meaningful) use case is to disrupt
existing notary systems (disrupt in its accurate definition: deliver
something that is initially less powerful, but evolves greatly faster).
A Blockchain can come with or without a trusted third party. It seems to
me (in such a domain, I know very few people with a firm opinion) that
transactions are more expensive without a third party, because you need
to make the process of adding a new block "expensive enough" in order to
make sure that the one doing it can not deploy enough computing power to
hack the existing blocks during the process.
However, in real estate, for example, the price of a Blockchain
transaction, even if we take the cost of a Bitcoin transaction as a
reference, remains far below what we have to pay to register our ownership.
In health, I am always amazed by the level of ingenuity of some actors
(do you know of any innovation that has not been qualified as
"applicable in health"?) and, in contrast, the global archaism of the
domain at large.
I recently read a paper about a FIHR conference that said that all this
is fantastic, but that, in current times, it could be nice not to only
exchange information "about the patient"
So... yes, the Blockchain is super trendy... yes there are probably many
smart ways to use it in health... but maybe, before considering the use
of such marvelous pieces of technology, it could be wondered if the
medical domain is not fully missing its inclusion in the information
society.
Best,
Philippe
A Blockchain is a public (or at least shared) digital notary.
...
transactions are more expensive without a third party, because you need
to make the process of adding a new block "expensive enough" in order to
make sure that the one doing it can not deploy enough computing power to
hack the existing blocks during the process.
And, one needs to remind oneself, "expensive enough" can only ever mean "today".
Karsten Hilbert
I think we are heading an era where it can be impossible to tell where from and/or when data are received /created and which event created the data or made the data cause to interchange when the data do not tell us themselves on an accountable way. For that we need an open notary-system which does not rely on third parties (which would make it to expensive).
There are not many kinds of personal data which will be interchanged so much or are created in chains of events (context) as medical data.
I see that is quite a challenge to arrange such a system, but we will need it to guarantee professional and medical safety and also privacy.
Maybe I am wrong, but I think blockchain may be a way to help us with that.
I have not seen in this discussion many people acknowledging these near future problems which can effect clinicians (in accountability) and patients (in health-safety).
How about a clinician taking a fatal decision on base of an event described on another system and that other system changed its contents afterwards?
How about a patient who discovers its employer has knowledge of private medical data? People often think about psychiatric circumstances, but it can be other things in this time of revival of religions, f.e. a woman who hides the fact she has had an abortion and is now teaching on a christian school.
Also interesting in this discussion is how to handle deletion of medical data (the patients right to be forgotten).
Can it be that data refer to data on other systems, or may they only refer to data on the same system, copies of data from other systems?
Do these copies need some accountable reference to where they come from?
These are problems which will not be solved easy. But they need to be solved by system builders which will advise the lawmakers.
Bert
Hi Karsten,
This is the reason why, at least in the Bitcoin universe, adding a block
is organized as a competition between miners.
Hence a bad guy who intends to use the addition of a new block as an
opportunity to modify some already existing blocks would need to process
this much more complex task quicker than the other miners who simply
concentrate on adding a block.
It can currently been argued that this competition led to concentrating
miners in China... but what could possibly go wrong?
Philippe
In the Netherlands we have a national system called the LSP, which makes medical data available to other clinicians. They can look into medical data from other institutions (of course, in the right legal context, however that is also a problem, but apart from that)
Data which a clinician has seen, but not copied in a *accountable way* to his own system, may disappear from another system, by system error, or by an other clinician trying to hide an error
Remember this quote from Leslie Lamport (from DEC, was it in 1988?)
"A distributed system is one in which the failure of a computer you didn't even know existed can render your own computer unusable."
Replace the last "computer" by "data" and you have the current context. In the Netherlands people will discover the meaning of this quote when they do not handle information carefully
It must be clear that Blockchain is not a complete solution and should be seen as a piece within the gear.
Who we have approached blockchain, we see it as an opportunity for innovation, which needs “some surgery” to be used in the health area, and that its current implementation is not to make “CTRL + C - CTRL + V” in the health area.
It seems to me totally valid to make a map in what blockchain has won and all the weaknesses that the current implementations have, even applying standards, since, the possibility of implementing standards is not in the hands, nor in the pockets of Third World countries.
Businesses like SAP and Deloitte do see a great opportunity to eliminate certain gaps in the health area. As an implementer, I hope that the organizations that manage the standards consider objectively and seriously if a technology such as blockchain would give us a great leap in the management and empowerment of health … my two cents
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