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PaperSubmittedforCallforPaperinAugustbyONC1Abstract—TherecenttrendsinAccountableCarebasedpaymentmodelshavenecessitatedtheadoptionofnewprocessforcaredeliverythatrequirestheco-ordinationofa“network”ofcareproviderswhocanengageinsharedriskcontracts.Inaddition,theneedforsharinginthesavingsgeneratedequitablyiskeytoencouragethenetworkproviderstoinvestinimprovedcareparadigms.Currentapproachestodigitizehealthcarefocusonimprovementofoperationalefficiency,likeelectronicrecordsaswellascarecollaborationsoftware.However,theseapproachesarestillbasedontheclassicalcentralizedauthorizationmodel,thatresultsinsignificantexpenseinimplementation.Theseapproachesarefundamentallylimitedintheirabilitytofullycapitalizeonthepeer-to-peerdigitalwork-flowrevolutionthatissweepingothersegmentsofindustrylikemedia,e-retailetc.Inthispaperweformulateanewdigitalhealthcaredeliverymodelthatusesblockchainasthefoundationtoenablepeer-to-peerauthorizationandauthentication.Wewillalsodiscusshowthisfoundationwouldtransformthescalabilityofthecaredeliverynetworkaswellasenablepaymentprocessviasmartcontracts,resultinginsignificantreductioninoperationalcostandimprovementincaredelivery.Inaddition,thisblock-chainbasedframeworkcanbeappliedtoenableanewclassofaccountabletele-monitoringandtele-medicationdevicesthatwoulddramaticallyimprovepatientcareadherenceandwellness.Finally,theadoptionofblockchainbaseddigital-healthwouldenablethecreationofvarifiable“personalizedlongitudinalcare”recordthatcanformthebasisofpersonalizedmedicine.IndexTerms—BlockChain;Telemonitoring;Telemedication;HealthcareAsset;AuthenticationandAuthorization;DeepDataCreation;PersonalizedDataControl;HealthcareMarketplace;HealthcareSecurity&Reliability;PersonalizedHealthcare;Two-wayDataAuthentication;ComprehensiveDataRepository.I.THEHEALTHCARELANDSCAPEHElastdecadehasseenasignificantchangeinhealthcarerangingfromadramaticshiftinthepaymentmethodfroma“pay-for-service”modelto“outcomebased”modeltoafocusonpopulation“wellness”fromafocuson“specialized”procedures.Thisnewpaymentmodelbasedoneffectivecarealongwithafocusonhealthyliving,calledthe“AccountableCare”paradigm,outlinesthe“new”goalfordeliveryofhealthcareintheUS[1].Thisrealignmentfroma“procedure”basedfocusto“holisticcareoftheindividual”necessitatesthatCareProvidersform“networks”thatworktogethertowardsacommongoalofimprovingthecareoutcomeofpatientsundercare,forpost-AcuteCareepisodesorbetweenAcuteCareepisode.Theneedforcooperationbetweencareprovidersrangingfromspecialisttoprimarycarephysician,post-acutecareproviderstowellnessproviders(likenutritionistandrehabilitationnurses)hasresultedinincreasingdigitizationofpatientcaredatainordertoseamlesslycommunicatepatientdata.OverthelastdecadethishasledtoincreasedadoptionofElectronicHealthRecords(EHRs)systemsaswellasdevelopmentofcarecollaborationsoftwarethatenablestheco-ordinationofcareacrossthevariouscareproviders.Thoughthesesolutionshavesignificantlyimprovedthetrackingandefficiencyfordeliveringcare,theyhaveresultedincreatingislandsofinformation.Hence,co-ordinationofinformationbetweenthesesystemshaspresentedasignificantchallengecausingthedelayofboththeadoptionofthisnewhealthcareparadigmaswellasposedseriouschallengesforhealthsystemsindevelopingscalable“networks”ofproviders.ThetsunamiofdatacapturedinElectronicMedicalRecord(EMR)systemsinhospitalsanddoctor’sofficesaswellasinformationfromlabs,pharmacies,homecareandnursingsystemsplusthegeneralgrowthinawarenessoftakingcareofone’swellnesshasresultedinindividualscapturingpersonalwellnessdatarangingfrombiometricvitalslikebloodsugar,bloodpressureaswellaskeepingtrackoftheexerciseandfoodintakeviaPersonalHealthRecords(PHRs).Thisbehaviorisnotlimitedtoindividualsthathavechronicconditionbutalso,extendstoindividualswhoareinterestedinpursuingacontinuedhighfunctioninglifestyle.[2][3]Though,therehasbeenanincreasingsenseof“individualized”informationbothontheclinicalaswellaswellnessfrontfromtheaccumulationofdatabycareprovidersandindividuals,includingtheirhereditaryprofiles,thesehavenottranslatedinto“personalized”plansofcare.Furthermore,eventhoughthereisaplethoraofdata,theoverallhealthcarepayorsandsystemsseemtobeincapableof“assigning”avalueorrisktothisinformationtohelpbetterpredictfuturecostofcarefortheindividualorcredithimforhisfocusonactivelymanaginghishealth.[4]Thekeyelementsthatpreventthelingeringdelayindramatictransformationofthehealthcarelandscapearediscussedbelow.A.DataSilos&Accountability/AuthorizationTherehasbeenalotofhealthandwellnessrelateddatathathasbeencollectedbycareprovidersandindividualsbutithasnotbeenconvertedinconsumableformatsthatenableacomprehensiveindividualizedcareplanthatcontributestoeffectivelongtermpatientwellness.ThisstemsfromthekeyissuethatmostofthesedataareinindividualsilosofagivenAdoptionofblock-chaintoenablethescalabilityandadoptionofAccountableCare(August2016draft)submission)RamkrishnaPrakashTPaperSubmittedforCallforPaperinAugustbyONC2careproviderandisnotreadilyaccessiblebytheir“network”partnersengagedinthecareoftheirpatient.[5]Furthermore,theaccountabilityandauthorizationforaccessingandmodifyingofagivenpatient’sdataislimitedtotheseindividualsilos.Thisresultsineachorganization“modifying”itscopyofpatientdataontheirinteractionwiththepatient.Thishasledtothe“network”ofcareproviderstobeintheconstanttaskof“updating”thepatientprofileandalwaystryingtocatchuptheillusive“latestvalidprofile”oftheindividual.Thishasfurtherbeenexacerbatedbyminimalauthorizationfromtheindividualwhosedataisbeingmodified,leadingtoerroneousinformationbeingintroducedintohis/herrecordsresultingisbothclinicalandeconomicwoes.Anotherkeyfactorinensuringsustainedwellness,istheactiveinvolvementbytheindividualintheircareregime.Thishasbeenproventobechallenging,aspatientsfeelthattheydon’thaveanappropriateaccessandincentivestoengageincaremanagement,leadingtoafrustratingexperienceforbothprovidersandpatients.Hence,thishasledtoacompletebreakdownintheoverallaccountabilityofallinvolvedinyieldingoptimalcareoutcomes.B.Liability&SharedCompensationTheprovidersinthehealthcareindustryareverywearyofwhetherthatdatabeingusedforclinicalprescriptionis“accurate”astheyexposethemselvestosignificantliabilitiesunlikeotherindustriesiftheyarefoundtohavemadeanerror.Therefore,theyareinsistenton“appropriatevalidation”ofthegenerationofdatatoensurethattheyarenotexposedtoanyliabilitiesstemmingfromerroneousinformation.Hencethereisaversenesstowardsusinginformationthathasnotbeencollectedbyanentitythatisdeemedreliableandisa“liable”participantintheirnetwork.Thishasresultedin“forcedaggregation”ofhealthcaredatawhichinturnhasledtoincreasedcostsanddelaysincaredelivery,whilestillnotilluminatingdataerrors.Thestandardapproach,adoptedisbythedominantprovidermandatingthathisnetworkpartnersentertheinformationintohissystemwhichisthenthe“goldenrecord”forthepatientandcanonlybeusedbyothers.Though,thisavoidstheliabilityissueitstilldoesnotaddressthefactthatthenetworkprovider,needsinformationinatimelymanner.Thisproblemisfurtherexacerbatedinchronicpatientswithtwoormoreissuesandthishasledtoacrisisindeliveringcoordinatedcareforthesepatients.Anadditionalissueinensuringeffectivehealthcaredeliveryistheaccountabilityassociatedwithwhohasreviewedthedata,accessedandauthorizedtherecommendedchangesandfinallyexecutedcaredelivery.AsmostofthehealthcareEHRsystemswerebuilttoaddressasingledomainofcareprovidersitwasonlydesignedforone“key”individualtoaccessandauthorizechanges.Thiswasadequatewhenmostofhealthcareprovidersdeliveredcomprehensivecareforanindividualwithinasingleprovidersystemwhichgatheredalldatafromtheir“client”thepatient.However,withtheemergingtrendwhereinmanyacasethisdataiscollectedandprocessedbyanumberofprovidersandintermediarieslikelabs,technicians,homehealthcareworkerorevenafamilymember,thisapproachislimiting.Furthermore,withtheformationofAccountableCarenetworks,whereinthepenaltiesarehighforbadoutcomesresultinginnon-collaborativebehavior,itisimperativethateffectiveautomationofthesecarecoordinationcapabilitiesisvital[6].Finally,intheemergingAccountableCarelandscapeofhealthcare,compensationwillbebasedonhoweffectivelythenetworkofproviders’worktogethertoensureimprovementinthequalityofcareandwellnessoutcomewhileatthesametimereducingassociatedcarecost.Hence,totrulyincentivizedifferentparticipantsinthenetworktopro-activelycreatebettercareregimesthereneedstoameritbasedcompensationofsharedsavings.Toeffectivelyallocateaproportionatesharetotheproviderinthenetworkthatcontributedthemosttowardstheoverallsavingsacleartrackingoftheircontributionisvital.Else,itwouldleadto“leasteffort”approachbyallprovidersinthenetworkresultinginoveralllossofincomeforcareprovidersandanadverseeffectincarequalityofpatients.C.Portability&PrivacyAstheCareDeliveryModelisshiftingto“outcomebased”accountablecare,thereisanincreasingneedforthepatientdatatomove“fluidly”acrossvariousapprovedcareprovidersinthecarenetworkwithoutsacrificingtheprivacyofthepatientdata.However,thesingledomainnatureofEHRsystems,whichlimitstheportabilityofhealthdatahasresultedinsignificantchallenges.Hence,providershavemandatedthatpatientssignaHIPPAwaivertoensuretimelycareisbeingdeliveredtopatients.ThishasledtotheleakageofpatientHealthinformationresultinginunscrupulousproviderstargetingpatientsattheirmostvulnerabletimeduringneedformedicalcare.[7]Thisproblemisexacerbatedduetothefactthatuponreceivingthiswavierinformationhasbeentransferredviapapercopiesleadingtothisinformationtendingtolingeralongtimeinthecaregivercommunity.Thishasledtopersistentfraudpracticesthateffectpayorandpatientsadverselyforalongperiodoftime.ThoughtherehavebeenmanyeffortsviatheHealthInformationExchanges(HIE)toaddresstheportabilityofthisinformationacrossprovidersinasecureandtimelymannerithasfallenflatbecauseoftheincredibleamountofupfrontcostandeffortandtheneedforallvendorstoparticipatetoprovideanymeaningfulimpact.HencethecurrentsolutionspursuedbytheHealthCaretechnologyindustryhasresultedinadifficultchoicebetweencareandprivacy/economicfraudforpatient.Weseethisissuegreatlyexpandingasmoreandmorementalhealthservicesarebeingdeliveredtoindividuals.II.BACKGROUNDAnumberofapproacheshavebeenproposedtodealwiththeissuesidentifiedintheprevioussectionassociatedwiththeCentralizedDataModel.Though,thesesolutionsaretemporaryfixestoleveragetheexistingcaredeliverymodelandHealthCareITinfrastructuretheyarefundamentallylimitedinaddressingthesignificantchangethatissweepinghealthcareatanationalandgloballevel.Figure1,illustratesthecorearchitectureofcurrentElectronicPaperSubmittedforCallforPaperinAugustbyONC3HealthRecord(EHR)systemsandtheassociatedchallengeswiththeexistingarchitecturaldesign.Asillustrated,byFigure1(a),EHRsystemsarebasedonanisolatedcredentialvalidationarchitectureinwhichpatientdataiskeptineachoftheseparatesystems.Thishasresultedinone-to-onecareco-ordinationsoftware“add-ons”solutionstothesesystemstoenabletheco-ordinationofcareacrossotherprovidersandancillaryhealthorganizationsasillustratedinFigures1(b).Figure1(a)Figure1(b)Figure1:TheCentralizedHealthSystemModelHowever,asisillustratedbythefiguretheaccessoftheinformationfromthePrincipalProviderorganizationtotheotherorganizationsisonlyvialimitedcapabilityliketoRead,toSubmit,toSendortoNotify.Furthermore,thePatient/Consumerhasverylimitedinteractionorinvolvementinthisexchangeofinformation.Inaddition,anyerrorrelatedtothemiss-communicationorerrorisveryhardtorectify.InthesectionsbelowwediscusshowthelimitationpresentedbythesesystemshasbeenaugmentedtoaccommodateforCareServiceOptimizationorPaymentmanagementunderthenewParadigm.Wewilldiscusshowtheseaugmentationshaveimpactedcaredelivery.A.CareServiceOptimizationThenewhealthcareparadigmdemandstheneedforeffectiveandoptimalcaredeliveryforpatientstoyieldbettercareoutcomes.ThisrequiresthatPrincipalCareprovidersareabletoactivelyco-ordinateandcollaboratewithothercareprovidersinvolvedandancillaryhealthorganizationslikeLabsandPharmacyincaredelivery.Thisrequiresthatthepatientrecordsareupdatedandmodifiedinatimelymanner.Thoughtthereareanumberofadd-onsthathavebeenimplementedbasedonnewemerginghealthcaredatastandards,thisadd-oncollaborationsoftwarestillreliesonthePrincipalCareProvider“orchestrating”thecare.Furthermore,thissoftwareonlyprovidesalimitedcapabilityofexchangeofinformationfromonesystemtoanotherandusuallyrequiresadesignatedindividualwhoiscapableofsuchinformationtransfer.Thishasledtoanincreasingamountofdelaybetweenorganizationsindeliveringcareforthepatientandalsoresultedintheoveralldecreaseinqualityofdeliveryofcareservicestothepatient.Also,ascareprovidersarespendingmoreoftheirtimeinvolvedincoordinationofcaretheireffectivenessintreatmentofpatientsandworkloadhassignificantlyincreasedresultinginacounterintuitiveimpactincareoutcomesforpatients.Inaddition,giventhatmanydoctorsdon’twantpatientstoaccessEHRs,hasresultedinthepatientadoptingapassiveroleintrackingtheirhealth,andresultinginthemfeelingalackofcontrolandownershipoftheirhealthleadingtothepatientbecomingfrustratedandbeingdisengagedintheircare.ThoughtherehasbeenarecentincreaseinMobileHealthCareappshelpingindividualstracktheirvitalsandhealthparameters,thenoveltyhasnottranslatedtoimprovedpatientcareoradherenceandoutcomesasittoofacesthechallengesofgettingintegratedintoEHRs.B.PaymentManagementAnotherkeyimpactofthenewhealthcareparadigmisthecompensationmodelwhere-intheprovidersareeligibleforreceivingadditionalcompensationbeyondthecaredelivered.Thiscompensationistheresultofsavingsthataregeneratedbasedonhoweffectivelytheprovidersmanagethecareofthepatient’shealthoutcome.Anysavingsgeneratedthroughefficientmanagementofthepatient’scarecanberetainedbytheprovidersandtheirnetworkpartnersaspartofthesharedsavingsaspectofthenewhealthcareparadigm.Torealizethesesavings,aproviderhastoeffectivelytrackallthecostsassociatedwiththecareofthepatientandactivelyworkwithhispartnerstoensuretimelyhealthoutcome.However,thisrequiresthatalltheprovidersenterthecarecostsinnearreal-timewhiledeliveringcare,whichisverydifficulttoachievebasedonthecurrentEHRarchitecture.Inaddition,itisveryhardfortheprincipalcareprovidertodivvyupthesavingsacrossthe“key”providerpartnerstoappropriatelyincentthemtoexplorenewcareapproaches.Though,thenewhealthcarepoliciesprovidethepotentialtoincentivizeproviderstoworktogethertoimprovecarepathways,thecurrentEHRsarchitecturescomeshortofenablingthisability.C.CentralizedCareDeliveryTotakeadvantageofthenewhealthcareparadigmhealthcareprovidershaveadoptedtwoaggressiveapproachestoensurethattheycanfullytakeadvantageoftheopportunity.Thefirstapproachistotrytoconsolidateallofthecareprovidersaspartofacentralizedhealthcaresystem.This,ensuresthatallprovidersarewithintheircentralizedEHRthusenablingthemtoactivelymanagealltheaspectsofthecareofferingsforapatient.Thesecondapproachhasbeenfor“regionallydominant”providersto“persuade”otherprovidersandancillaryhealthproviderstoassimilatewithintheirhealthsystembyusingtheirEHR.ThoughthesetwoapproachesPaperSubmittedforCallforPaperinAugustbyONC4providethedesiredtrifectagoalsstipulatedbythenewhealthcareparadigm,ithoweverresultsinreducingthechoicesforbothpatientsandinnovationofhealthcare.Furthermore,tough“dominant”regionalhealthcareproviderscanconsolidatethedeliveryofhealthcare,butinthelongrunoverallimprovementinpatienthealthcanbeachievedonlybytheinclusionofconsumerwellnessserviceproviderslikenutritionist,exerciseprovidersandothersuchserviceproviders,whowouldbedifficulttoassimilate.Furthermore,thismodelwillnotbeapplicableatanationallevelastherearemanysecondandthirdtiercitiesandruralareaswherecareisdeliveredbyanumberofindependentcareproviders.Inaddition,therearespecialistcareprovidergroupswhovaluetheirdedicationtowardsimprovementofpatientcareandwouldresistassimilationintoasinglehealthsystem.Toconclude,inthissection,wehavedescribedthatthoughthecurrentCentralizedHealthCareDatamanagementapproachisapplicableintheshort-term,inthelong-termitresultsinsignificantimpedimentsfortheenablementofinnovationandmotivationforsustainedpatienthealthasintendedbytheAffordableCareAct.III.TENETSFORANEWAPPROACHInthissectionwediscussthetwofundamentaltenetstowardrealizingthefullpotentialoftheobjectivesofthenewhealthcareparadigmwhichare:(i)strengtheninghealthcaredelivery;(ii)advancescientificknowledgeandinnovation;(iii)advancedhealth,safetyandwellbeginofpatients;and(iv)improveefficiency,transparency,accountabilityandeffectiveness.ThefirstofthetwotenetsthatwewillbediscussingisPatientCenteredCarethatfocusesonprovidingindividualspecificcareneedsforoneandall,whileenablingtheirlongtermwell-being.Thesecondtenetisthecapabilityofaninfrastructurethatcantrulyenableadvancedinnovationanddeliverseamlesstransparencyandaccountabilityforallparticipatinginthedeliveryofcare.A.PersonCenteredCareToachieveeffectivesuperiorcare,apersoncentricapproachisimportant.Suchanapproachshouldtakeintoaccountnotonlytheclinicalaspectsbutthesocialandeconomicfactorsthatimpedeone’sabilitytosuccessfullyengageincarecomplianceandhealthylivingtoyieldsustainedwellness.OutcomeandWellnessOptimizationToyieldeffectivecareoutcomesrequiresclearlyidentifyingthebarriersofindividualhealthandlifesituations.Withthegrowingnumberofpatientshaving2+co-morbidities,the“siloed”one-typeofcarefits-allcaredeliveryapproachisnotconduciveinmotivatingandaddressingeffectivecareoutcomes.Henceamoreflexiblecaremodeltailoredtoincludepatients’multi-facetedhealthandwellnessneedshastobeconsidered.Thisrequiresthatacomprehensive,dynamicinteractivecareplaninwhichthepatientcanactivelytrack,manageandparticipateinhiscareisvital.DistributedandScalable“CareNetwork”TodeliverPersonCentricCarerequiresthatCaredeliverynetworkcanincludeawidevarietyofCareProvidersandnotjustapredefinedsetofselectproviders.Sucharestrictionwouldlimittheabilityofpatientstoseekcareviathemostoptimalpath.Forexample,mostofthefolksthataremostvulnerabletohealthcareissuestypicallyworkmultiplejobswithnostandardhours.Inaddition,manyofthemostvulnerablepatientseitherhavelimitedtransportoptionsorlivein“healthcaredeserts”.Henceitisnecessarytobeabletousealternatecaredeliverypartnerslikeparamedicsorvisitingnursetohelpaddressthesechallenges.Thatsaidthegeneralconcernthatisraisedistheaspectofensuringthatthese“non-traditional”careprovidersarewellvetted.Thislimitationisaresultofinadequateinfrastructureandnotaresourceissue,whichwewilladdressinsubsectionBofthissection.DataPortabilityandPrivacyThefinalaspecttoachieveeffectivePatientCentricCareistheneedtobeabletosenddatatoacareprovidejustintimesothathecandelivertheappropriatecare.Furthermore,whilewedesirethiscapabilityitisalsoimportantthatwemaintainthepatients’privacy.Ithasbeenrepeatedlystatedthatthesetwoaspectsaremutuallyorthogonal.However,thisseemstobeafallacylimitedonlytothehealthcareindustry.Otherindustrieslikee-retail,financeandevenmediahavetransformedtheirentireinfrastructuretoletconsumershavetheflexibilitytochoosetheirvendorofchoicewithminimalliability.Webelievethatbyleveragingsomeofthesimilarinfrastructureconceptsalreadybeingimplementedinotherindustrysectorsbutaddingahigherlevelofdataprotectionwecanachievebothdataprivacyandportability.B.AccountableCareNetworksInthissubsectionwewilldiscussthetenetsofanAccountableCareNetworkinfrastructurethatisneededtoensurethefourhealthcareobjectiveslistedearlier.Anyinfrastructurethatisbeingdeployedtoachievetheseobjectivesshouldhavebuilt-inabilitytoensureallthefacetsofacollaborativenatureofthenewcarerelationshipsareseamlesslyenabled.Inthesubsectionbelowwewilldiscusstheseaspects.LiabilityProtectionandAccountabilityInanyCarenetworkitisnecessarytoensurethatparticipantswhoarecollaboratingtogethercandependoneachothertodeliverthenecessaryservicesthatareexpectedofthem