February 19, 2020

Learning about blockchain in healthcare

By Conor McKechnie and Dodi Axelson

Learning about blockchain in healthcare

Blockchain is everywhere. But what is it, really? And what can the blockchain technology bring to healthcare? Dodi and Conor unravel these questions together with Dr. Cathy Mulligan at Imperial College London in this week’s podcast episode.

DODI: I'm always looking for the next technology that starts in industry and that eventually is gonna change our everyday lives.

CONOR: Right. And then moves into the public sphere and blows things away. Well, like the world wide web when Tim Burners-Lee invented it at CERN and it's just kind of change the universe.

DODI: Exactly. So, in the middle of last year, I just, I felt like blockchain was everywhere.

RECORDING: It's known as block…As a founder and CEO of a technology company, which focuses on blockchain…And most of the system of transacting money that was actually fraud proof. It exists. It's called blockchain…

CONOR: Oh, blockchain, it’s everything. It's everywhere.

DODI: It is. And there's an application for blockchain in the healthcare and life sciences environment. So that's what matters on this episode…

CONOR: …of Discovery Matters.

CONOR: Okay. So why don't we start with a simple definition of blockchain?

CATHY MULLIGAN: Well I think the best way to conceptualize a blockchain is that it's a way to have an irrefutable, immutable record of transactions between a number of parties. We do that through creating radical transparency. So, the big innovation actually in blockchain is the fact that you don't need an intermediary or a third party to provide trust in the system. The most common example is of course Bitcoin, where we remove the need for a central bank. And we create a trust in a currency, Bitcoin, through radical transparency, which we do by saying that every single person or every single node on the network stores a copy of every single transaction. You're only allowed to record a transaction when it's, you know, in accordance to a particular type of consensus protocol. And that means that every single transaction is seen by everybody and therefore verifiable. So that's how you create trust through showing everybody everything basically, which is a bit of a difference to the previous way. Where we usually set up technical systems where we build barriers. We tried to hide information from other people as much as possible and say: it's trusted because it's in a closed environment.

CONOR: Okay. So, I asked for simple and it started simple.

DODI: There's some detail there.

CONOR: It very quickly got complicated.

DODI: Yeah.

CONOR: And at one point all the words were English and I knew the meaning of each individual word, but when we put them all together, I was honestly struggling.

DODI: So, we're going to parse them out. But first let's understand who we were talking to though.

CONOR: Yeah. We haven't introduced her.

CM: I'm Cathy Mulligan and I'm a Visiting Researcher at Imperial College. I was the co-director for the Center for Cryptocurrency Research Engineering for four years. And I'm also a researcher at University College London, where I'm the CTO of the GovTech Labs. And the GovTech Labs, what we're looking at is how you apply AI, blockchain, 5G, all of the advanced communications technologies to create national infrastructure, for example, healthcare or banking or finance or any of those kinds of things. My broad area of research is looking at how digital technology affects economy, environment, and society.

DODI: We're going to focus entirely on Cathy in this episode. Usually we talk to a few people in Discovery Matters, but Cathy really is gonna walk us through a lot of detail in blockchain. So, we're just going to focus on her. And our challenge in this episode was the cleaning guy who kept following us around with a vacuum.

CONOR: That's true.

DODI: We had to go into different, different cellar rooms.

DODI: And hold on for just a second while the cleaner finishes the vacuuming.

CM: He's coming closer and closer. Should we move room?

DODI: Let's go down the hall. We go down the hall where the vacuum…so, I think let's go to another room. Again, we go deeper and deeper into the caverns. Okay. This is better. All right. So…

CONOR: Well that's what happens when you go and you do your interviews live in the real environment. It's not like we have a studio, so, well done for your perseverance. Let's concentrate on part of blockchain that everybody has really heard of: Bitcoin. Can you tell us more about Bitcoin?

DODI: Yeah, it's been around since 2009, but it's only accepted in certain closed circles. So, I wondered if you could really count that as a success story for blockchain.

CM: You know, if we compare it, for example, to the smartphone, we saw the first smartphone around about the same time, the proper first smartphone. And really that didn't take off in the you know, in the same way for, for, you know, another what, 15 years. Right? And so we've seen the mass adoption that we see for smart phones. I think the same will happen for Bitcoin.

I think Bitcoin is an example of what you can do with a blockchain in certain situations. But what we're going to see as an evolution of this technology. It will get faster. It will get more scalable. It will get more usable. And once we have some of those attributes in blockchains, then we will see a different type, I think, of application. In terms of Bitcoin, I think the reason it's so interesting and controversial is that it's a currency, right? It's not just an application built on top of you know, a database technology. It's actually, you know, it was set up as a threat in inverted commerce to the established banking system. So that's what's so interesting about it because it brings together technology and economics in a way that's never been done before.

DODI: So, sure, like Cathy says, but every change is a threat and applications on top of blockchain are coming out right now. As I said earlier in insurance and social media. But Cathy and I started to talk about: where is blockchain useful and where is it not?

CM: If we leave the cryptocurrency aspect aside and think about blockchain as a way to record transactions, we can see that where there are connections between parties that don't necessarily always, a hundred percent, trust each other, then a blockchain might be useful, right? It could be useful in some of those scenarios. So, what does that look like in the real world? We're seen some interesting examples in supply chains. Because, obviously, supply chains are very large. They're networked organizations in today's world, and many people don't necessarily a hundred percent trust one another. So, if you can put things like bills of lading and all of these kinds of things, take them off paper systems and put them into a digitized system and an irrefutable record of transactions on that supply chain, then you can actually have some real of use and some, some very interesting applications. We’re seeing that in the shipping industry for example. So MESK and IBM have put out one example.

CONOR: Okay. So, I'm starting to get this, but just then Cathy used IBM as an example and I'm pretty sure I read that they have their own closed blockchain. So, in its essence, that's not quite exactly blockchain is it?

CM: Yeah, I mean, it depends who you talk to, right? So, for from my perspective, we talk about blockchain as being one type of what we call a distributed ledger technology. And there's three main sorts of archetypes of distributed ledger. There are the Bitcoin ones, which are public permission-less shared systems and there are ones like Hyperledger, which is actually a Linux Foundation initiative, which is private and permissioned. So, what does private and permissioned mean? In contrast to Bitcoin, you know, not anyone can join that network. So essentially you have to create a consortia before you're able to create the blockchain itself.

So, in the example of shipping, you have to get a number of shipping companies together in order to create that particular blockchain. And to agree what type of information they're going to share on the blockchain and how it's going to be shared, et cetera, et cetera. And that change is actually fundamentally the way you build some of your IT systems, but it also changes the way that you have to deal with business processes. Because suddenly you're starting to work more closely with possible competitors in a new way. So, there's an interesting business challenge. The other place that we see, you know, probably more relevant to your industry is there's a lot of work that's been done around understanding how you could use it for pharmaceuticals. So, track and trace on the pharmaceutical supply chain to make sure there's no tampering, reduce fraud, reduce theft in that supply chain.

DODI: Yeah, that's a highly regulated industry. So, I wanted to know: how can blockchain threaten or improve this highly regulated environment?

CM: So I think there's a number of interesting examples. Just because an industry is not, sorry, is highly regulated doesn't necessarily mean that you're not having fraud in it and not having problems in the supply chain. And actually in some cases blockchain can help, you know, in terms of data integrity, prove compliance to regulation in a way that currently costs a lot of money to do. So, there's a lot of paper involved in a lot of the processes. We, in the college we've also been looking at how you would use it for, for example, clinical trials. Because a lot of the transmission of data between, for example, the CRO's, the government labs, the research centers and the companies that needs to have a very strong level of attribution and proof that this is the correct data and correlation of that data.

So, that's some examples. But you can see, for example, in the insurance, we did a little bit of a project for one, in one country where we were working with insurers to connect their sort of anti-fraud mechanisms together. And the first thing we had to do obviously was invite the regulator in. Because the one thing that the regulator wants to ensure in that particular scenario is customer protection, make sure there's no price collusion, right? So, and I think that, so solutions where you have blockchain actually the regulator can see every transaction that actually happens. So, it might end up being that it makes regulators life a bit easier. So, if we think about, you know, in today's world, they do dawn raids, right? They still doing dawn raids and you could actually remove the need to do all those dawn raids. You'd be able to just grab all of the transactions if you think something has been going on. You could just grab them off the blockchain.

CONOR: Okay. So, this is the part of the show that I like to call the Devil's advocate round.

DODI: What's on your mind?

CONOR: Well, I'm thinking specifically about provenance, right? Cathy mentioned supply chains earlier. I wonder how resistant to the idea of using something like blockchain in securing provenance of multiple different raw materials or the production of pharmaceuticals in the pharmaceutical industry.

DODI: Data.

CONOR: Exactly. And it's a conservative industry for very good reason, because people's lives are at risk. So, is Cathy finding open doors in the pharma industry to the use of blockchain to address these problems?

CM: What we're finding is there's a huge amount of interest in it and then a little bit of wariness about putting it into the real world. So, I think what we're at with blockchain, in a lot of industries actually not just pharmaceuticals, is proof of concept, right? So, proving that it can actually work. I would say that, you know, the other issue of course is that if you are going to do track and trace with blockchain it actually takes an incredible level of organization and it takes a new way of organizing both internally in your company and externally. So if you want to track and trace every single source product that's going into a drug, for example, you're going to have to work with source suppliers and that requires, you know, a different type of interaction with that supplier and a different way of transacting information between one another. And I think often people love the idea, but they struggle a little bit with saying: how am I going to get all of these suppliers to agree to do this?

DODI: When it comes to clinical trials, it seems there are people doing work with the concept of each patient owning their own data. And then that data becomes available for trials and research. So, then I started to wonder: is that okay as an approach? Because that starts to feel like organizational resistance to that would be far too much to overcome.

CM: Yeah. I mean, I think if we, if we leave blockchain to one slide for a second, I think there was some really interesting advances that are going to start challenging that mindset. So we're seeing, for example, with the use of AI, we're seeing that if you run a pattern matching across large data sets around disease and drugs, you know, some, some AI has actually already identified that a drug that's already on the market could be suitable for another disease. Once you start to say, well actually that's a new revenue stream, not just a great, you know, benefit for the people suffering from the disease, but also it's a possibly a new way to sell a drug that you've already developed. Which is expensive obviously. I think people will start to have a different approach to how they digitize.

I think there are of course issues around the use of people's data. You know, there's all of the privacy and security issues that need to be addressed. What we're seeing actually is the, you know, for example, Israel are actually making a big play in this area, saying that because of the very diverse genetic makeup of their population and the fact that they have an exceptionally good, sort of digitized, sort of healthcare system, using blockchain to anonymize exactly like you're saying, you know, people's data and put it into a, you know, basically countrywide research sort of mechanism that they'll be able to, you know, improve disease identification, but also you know, exactly as you're saying, create a research based upon which the nation can benefit. And I think what we're talking about there is, I don't think that's necessarily so much to do with blockchain. I think that's about the fact that we're moving to a new form of economic structure.

So, I think, you know, blockchain is one of a series of technologies that is indicating we're moving to a different type of economy. We're moving out of the industrial economy and into a new type of economy. I don't necessarily agree with the industry 4.0, you know, name for it, but something new is definitely emerging. Do I think that's going to happen in the more broader medical, sort of, medical research industry? I think your right in the sense that I think there's going to be a lot of resistance to it in other countries. So, giving up my data, it's not necessarily something you would want to do in every single case. Right?

CONOR: Yeah, this is absolutely fascinating. And I have learned an absolute ton today.

DODI: Every day is a school day, Conor.

CONOR: Totally is. I just schooled myself, I just got schooled in blockchain. Brilliant.

DODI: Well, but we're not done yet.

CONOR: I know.

DODI: Cathy mentioned Israel just then. If I were to ask you, Conor, which nation is at the forefront of using blockchain? What would you say?

CONOR: I would go like Sweden or the US. It's gotta be the Bay area or something like that.

DODI: Well, go back to Europe, close to Sweden, across the Baltic.

DODI: Germany?

DODI: Estonia.

CONOR: Oh, little Estonia.

CM: Estonia uses, it's blockchain adjacent, I call it, it's not exactly pure, it's not what I call a pure blockchain. But what they have done exceptionally well is create, you know, the X road infrastructure. Which is based on a form of blockchain, or distributed ledger shall we say. They actually worked extremely hard to break down the silos between the government departments. And that's one thing that you sort of realize when you use blockchain, right? You must break down the silos between existing barriers, right? So, yeah.

DODI: Alright. So that is today's exploration of the use of blockchain in healthcare. Thanks to Cathy for the great interview. Even if we were almost chased down by that vacuum man.

CONOR: Yeah. No. So go on, give me one more example. Estonia is rocking the blockchain. What else is going on?

DODI: All right. Well, let's look at DNA.

CM: There are certain types of information you just never really wants to be irrefutable, immutable, and stored forever. The reason for that is one day people will break that cryptography, which means anyone will have access to it. Now, I know that everybody says: Oh, but don't worry, once we break that cryptography, we'll create new cryptography and protect it all. Again, the point is there will be a period of time where that information will be available. And if we look more broadly, so outside of the healthcare industry, we can see that there's a move towards these things called digital identities.

Now in some scenarios, digital identities could be very useful. But we're seeing some scenarios, for example, in Kenya and India, where in order to get a digital ID you have to give your biometric data. So that starts with the fingerprints, for example, Aadhaar in India. But in Kenya they've been asking for, you know, sort of DNA tests. So, if you think about what DNA can tell you other than just your health information you know, there are some really quite deep philosophical and problems, right? So, there's a problem with the social contract. And I think a lot of these technologies demand that we rethink the social contract. What does it mean to be a citizen, an employee? What does it mean to be a patient in an era where my data might be used for something else?

So, you know, as a very simple example, I, when I, when I was living in Sweden, I ended up in the hospital. And I was in the Karolinska and they were like: This is really unusual. We've never seen this before. Can we do research on it? And I had to sign like six forms and I was like, this is crazy. Can I just say yes? It's like: No, we need all of this consent before we can do any kind of research, right. And you know, and I think that when you have data, so let's say I put all of my healthcare data on the blockchain and I say, in principle, I'm happy for research to be done on this. The question will be, how often do I have to give my consent? What do you need to ask consent for? How would you give that consent? Because you would get frustrated if every 10 minutes a researcher is saying, can I, can I do something on your data and dah, dah, dah. You know? So, there's a question of what that actually implies. But that's a much broader social question, rather than specifically for one industry, I think.

CONOR: So, the irony of this is we're in Annecy, which is where Jean Jacques Rousseau met the love of his life. And he was the philosopher who came up with the idea of the social contract. But I think that's a little bit deeper...

DODI: So, at the end of this conversation about blockchain, what we do is we opened this whole new can of worms. Yeah, exactly. Who are we on this planet?

CONOR: Well, isn't that, isn't that what's amazing about the whole technological spaces that you can start with something that's designed to solve a particular problem.

DODI: Right.

CONOR: …it's application in a much wider environment has the potential to completely change society, our relationship with society, our relationship with each other. And if you think that's hyperbole, just think about how the internet and the world wide web has just fundamentally changed what it means to be a person in society in a very, very short time. So blockchain could be, could be one of those.

DODI: I think so. So, with that, thank you for listening to this episode of Discovery Matters. Please rate us on the app from which you listen to this podcast.

CONOR: Rate us. Say things. Thank you very much.

DODI: Our executive producer is Andrea Kilin. Discovery Matters is produced in collaboration with Soundtelling. Production and music by Thomas Henley.

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