Intro: Melanie Swan is one of the newest members of healthbank’s Advisory Board and she has a fascinating bio that spans finance, genomics and philosophy. She has recently written a book about blockchain technology entitled, “Blockchain: Blueprint for a New Economy”. Blockchain technology is a decentralized ledger that Bitcoins are built upon, but it has the potential to play a major role in many other sectors of the economy including health. Melanie is at the forefront in envisioning the potential applications of blockchain technology and at healthbank we are very interested in exploring the potential for blockchains in both storing health data but also enabling more possibilities for applications of health data to beyond the clinic. In the exchange below we have asked her to speak about some of these possibilities and how they could relate back to healthbank in the future.
Can you tell us a bit more about your background and how you became interested in blockchain technology?
Melanie SwanHello, thank you for this interview opportunity. I am excited to be participating with healthbank, which I find to be a novel and useful venue for empowering us as individuals with our personal data. As you mention, I have a varied background, and have always had an interest in creating new solutions for improving the ways we do things in the world. Initially, I became interested in Bitcoin in a general way, noticing it as a new technology, as a form of digital payment system. I started to understand it more in March 2013, when a hackathon team member wanted to transfer our winning payment to me in Bitcoin. A few months later, when another colleague was excited about Ethereum, I started to investigate more closely and then I became extremely interested in blockchain technology. I saw that whereas Bitcoin has the potential to reinvent all money, finance, and economic transactions, Ethereum, and more broadly smart contracts, have the potential to reinvent everything we are doing in society: all agreements, contracts, documents, IP registrations, legal systems, and governance models.
The progression is that first, Bitcoin and cryptocurrencies could reinvent economics, and smart contracts could reinvent politics and legal systems. Second, this level of pervasive reinvention exposes blockchains as a foundational information technology with the potential to completely reconfigure the way we do everything as human societies. Blockchain technology is a revolution on par with the Internet. Third, from reinventing the current world, it can be seen beyond this to the notion of blockchains and decentralization as a crucial infrastructural technology and organizational paradigm to allow us to scale human endeavor to the next tiers of progress, for example the establishment of million-member health databanks.
What is blockchain technology in a nutshell?
A blockchain is a record (ledger) of cryptographic transactions. It is the software upon which Bitcoin and other cryptocurrencies operate. Similar to the way that TCP/IP is a technology protocol layer upon which applications like email run, so too blockchain technology is the technology layer upon which applications like cryptocurrencies run. A blockchain is a decentralized database or ledger, like a giant ‘interactive Google doc spreadsheet’ that anyone can view and administrators (miners) continually verify and update to confirm that each transaction is valid.
The novel and revolutionary benefit of blockchains is that they establish a secure network where any transaction can be independently confirmed as unique and valid without a centralized intermediary like a bank or government. It is called a blockchain because blocks (batches) of transactions are posted sequentially to a ledger in an ongoing chain. The ledger can be viewed online on the Internet anytime from anywhere in the world with a browser by going to a block explorer site like blockchain.info.
One way the nascent blockchain industry is bifurcating is into enterprise applications and individual applications. Enterprise blockchains are permissioned private ledgers where identity is known and confirmed. They are compliant with current legal and regulatory regimes. Enterprise blockchains are simply more efficient ways of conducting existing business operations, like better VPNs or EDIs, conceptually like decentralized SaaS. Blockchains are a long-overdue means of improving the current way of doing things, updating the standard processes of transacting, with bank transfers and securities buying and selling perhaps being immediate (t=0) instead of taking three days (t+3). The other side is individual blockchains, for applications that offer new functionality and could completely reinvent the current way of doing things, first by eliminating transaction intermediaries. Individual blockchains are permissionless censorship-resistant pseudonymous ledgers where the user name is not fully traceable back to the person executing the transaction. Enterprise blockchains are a faster horse, a legally-compliant improvement to existing methods, whereas individual blockchains are a car, a completely new mode of innovation that may be a-compliant with existing structures.
In your book you talk about the role that blockchain technology could play in genomics and healthcare. What are some of the most interesting applications that you think could be realistically implemented with health and genomic data in the next three years or so and what advantages to you see in utilizing blockchains over existing technologies currently used in biotech and healthcare?
I think that there could be many different interesting potential applications in blockchain health. At the most practical, blockchains could be the basis for universal EMR (electronic medical record) systems. Many medical records are now digitized, however they are stored in different data siloes, and are not interoperable (e.g.; one EMR cannot be easily read or transferred into another EMR system). Instead, with blockchain-based EMRs, there could be one universal worldwide standard. Blockchain-based (e.g.; on the Internet) EMRs could mean that any EMR could be accessible worldwide on-demand 24/7.
Digital Health Wallet
Related to universal EMRs on the blockchain, another practical tool could be the digital health wallet. The digital health wallet would be like any contemporary software wallet or application-based cryptocurrency wallet (for example there could be a Health Counter Wallet), and would include a suite of functionality related to personal health management. The wallet could contain secure pointers to the user’s identity, EMR, insurance, and payment information all in one location. The benefit would be that this coordinated information could be automatically read into the incoming hospital emergency room or doctor’s office when a new individual arrives for medical treatment or health services. Emerging blockchain-based services like health insurance billing chains (for example, the Factom HealthNautica billing and insurance claims system) could be linked to user digital health wallets. In fact, many health-related services could be tied to the digital health wallet, including new forms of insurance. Individuals might choose to participate in decentralized peer-to-peer insurance services out of preference or supplementation over Medicare in the US for example, and there could be an implementation with Dynamis, BitSilk, or other vendor. Consumers could opt to pay into a p2p personalized long-term care health insurance contract with blockchain-guaranteed payouts. The benefit of blockchain-based insurance is the ability to specify and agree to the specific time and amount of payouts, unlike what is available in current insurance arrangements. Data from quantified self-tracking wearables could be logged into IoT chains (Internet-of-Things blockchains) and fed into the digital health wallet with remunerative micro-payment programs like Fitcoins.
Are there any ethical issues that you see that need to be addressed from a policy or practitioner perspective?
Certainly in the health context all of the usual ethical issues that have been articulated continue to be important. All of these issues can, and would have to be, addressed in the blockchain context in order for health service providers to migrate to blockchain-based models. In the ‘blockchains as modernizing software’ argument, blockchains may make the orchestration of ethical health practices easier and more automated. For example, a digital health wallet feature could reconfirm and update HIPAA (or other national health service) user privacy agreements. New services such as third-party blockchain-based smart contract dapps, DAOs, and DACs could serve as independent health advocates in cases of elder care, incapacitation, and general support. There could be smart contracts as third-party advocates for long-term care, and also blockchain-based medical directives (no need to have to hunt around for them and confirm them, they are attested legal documents that are part of any individual’s digital health wallet), along with medication and allergy records. A potential future headline indicative of the adoption of these tools could be “Digital Health Wallet saves another person from anaphylactic shock.”
The vision you have of blockchain technology in healthcare really has some novel uses of data and ways of thinking about the body, data and perhaps even ethics itself. Could you speak to these issues a bit and how they connect?
Blockchains and their related concepts suggest a potential rethinking of all areas of life, including data, the self, and ethics as a discipline. Many new ethical issues could arise at both a practical and theoretical level. At the theoretical level, one interesting moral, ethical, and more broadly philosophical issue could be articulated as the emergence of the cryptocitizen. The earlier position was the biocitizen, the new sensibility of rights and responsibilities engendered by having access to one’s own data and the ability to self-track, self-experiment, and self-manage one’s own health in new ways. An example of this kind of quantified-self crowdsourced health study and intervention is testing how homocysteine levels (potentially related to heart disease and other pathologies) can vary per taking different consumer-available Vitamin B formulations. healthbank contributes to developing and supporting the emerging sensibility of the biocryptocitizen, where part of that sensibility relates to the conscious use of the personal data I generate, directly through my online footprint and interactions, and per my body as a data-generation object producing health, biorhythms, and quantified self-related data. These data are valuable, and used in ways where individuals could be empowered and liberated by having more knowledge and control over them. As a biocryptocitizen, there may be new rights and responsibilities, and stewardship and collaboration principles to be developed regarding personal data, and these are exactly the questions in which healthbank is engaged. The biocryptocitizen then is one who is knowledgeable and savvy about personal health data, perhaps using healthbank as a venue and context for permissioning access to these data.
What do you think are some future opportunities for an organization like healthbank with a cooperative business model and interest in health data and the ability to incentivize sharing of health data?
A class of blockchain health applications particularly relevant to healthbank could be those related to big data; helping move big data to smart data. I think we are firmly in the big data era in the contemporary world, with health being one of the ‘biggest’ data sectors; imaging and genomics generate exabytes of data, much of which could be used, stored, and accessed more usefully. I believe we need a new computational era to fully process these data, and one first step is amassing very-large health data corpora.
The health data for any one individual could collectively comprise petabytes of data from various health data streams: genomic, proteomic, microbiomic, imaging, lab history, virtual patient modeling, quantified self-tracked behavioral and micro-health data, daily health check data per smarthome connected car IoT applications, etc. Blockchains have the key properties needed to make robust large-scale health data systems for the future of public health in both pathology resolution and ultimately preventive medicine and enhancement operations. Blockchains have the security, privacy, and scalability to handle the requisite needs of very large data health information systems. These features include identity protection, private-key permissioning to different data sets, accessibility, universality, and scalability. It is not that the large data files, like a genome file, would be stored on the blockchain, but that the blockchain-based transaction structure with private key access to data can point authorized users to off-chain stored data. An example project in this area is DNA.bits, a blockchain-coordinated genome file sharing service for research commons project.
In the health sector, we are still awaiting very-large data corpora, of the degree that has made the big difference in other familiar applications like search, news, translation (Google has provided many examples), and other pattern recognition and classification tasks. Having a large enough data corpus was the critical step, and then straightforward machine learning algorithms could be run over these data. The unreasonable effectiveness of data has not yet been applied in the health sector because very-large data corpora have not existed, but now decentralized technology models like blockchains have the ability to coordinate the assembly of these large data stores. One of the most interesting potential applications for healthbank then is serving as a tool for amassing very-large health data corpora that would be of the critical size over which to run machine-learning and deep-learning algorithms. This is perhaps one the most crucial potential blockchain health and healthbank applications, allowing information operations to scale to completely new tiers beyond what is possible now with centralized models.