The practice of providing health services is moving away from the traditional clinician centrist practice model. The prevailing line of thought revolves around the patient being placed firmly in the center of the process. The health system in New Zealand like most economies around the world is straining under resource constraints. Policy, Funding, Players, Technology, Customers and Accountability – These are the factors listed by Forbes as being the forces that either drive or kill innovation. Historically, healthcare silos have been poor adopters of horizontal innovation. The same can be expected with blockchain technology. The seemingly complex nature of the technology makes it a hard sell. The inescapable rhetoric behind the benefits of blockchain are however, easier to comprehend: data security, decentralization leading to cost reduction, provenance and putting the onus back into patient’s hands. So, how can blockchain help New Zealand’s healthcare system? Several questions arise when initiating a discussion about Distributed Ledger Technology (DLT):

Has the healthcare system in New Zealand moved from a proactive one, to a more reactive model?

It is the proverbial ambulance-at-the-bottom-of-the-cliff scenario. Healthcare is meandering towards a population health data science model. It is here that blockchain finds one of its many potentials. The government recently announced a review of New Zealand’s health and disability sector. The review is set to provide an interim report by 2019 and a final one by 2020. Political exercise or otherwise (one could argue both ways), affirmative action of this nature lends itself to a strong argument against the current health system in New Zealand. Through my readings, the one recurring point surrounds the ‘growing’ and ‘aging’ population. This coupled with rising proportions of obesity, cardiovascular disease, mental health poses a new age challenge to the healthcare system in the very imminent future. Is one solution, incentivising people to take care of their health? Using transferable tokenized reward systems provides people with realistic proactive rewards which might help influence unhealthy choices, thus reducing downstream reactive healthcare interventions.

Can blockchain technology provide cost reduction options to New Zealand’s healthcare system?

As per recent OECD data, the current expenditure on health in New Zealand is 9.2% of the GDP. The OECD average stands at 9.0%. The total number of hospital beds per 1000 population in New Zealand is 2.7, while the OECD average stands at 4.7. More than 30% of ordinary New Zealander’s find it difficult to access primary care. This has to change.

Having said that, New Zealand has had lower expenditure on its health care system than most comparable countries for many years (as a percentage of gross domestic product). In comparison, matching the Australian share of national income spent on healthcare would add $996M of extra funding to New Zealand’s system. While these numbers should not be examined in isolation, the truth is that we are overly reliant on hospital care and compounding this challenge is the fact that our hospitals are not very efficient. They are stretched thin, doing the very best they can, given the resources they have.

Every New Zealander must at some point wonder, “surely, there must be a better way to do this!”. This is where technology such as blockchain comes into play. Strategies often talk about people-powered care models but we need to fundamentally shift the emphasis towards technological solutions enabling access to primary care, and workforce development. Once again, put the patient back in the centre and change will come about.

Is a healthcare employer in New Zealand ethically bound to ensure the adoption of technologies such as blockchain, which exist and function to make work environments and the services provided safe?

The Digital Health Portfolio is a monthly report providing updates on key New Zealand digital health initiatives. According to the April 2018 portfolio, a business case relating to a National Electronic Health Record (EHR) platform is awaiting cabinet approval. The plan to build a national EHR was first announced in 2015, at which stage it was expected to take 3-5 years.  The existing National Health Index and the National Health Provider Index provide solid baseline data to kick start the process. Plus, the groundwork for shared care platforms has been in place for a few years now with agreements between DHBs and private entities.

There is much to be discussed in terms of privacy challenges and interoperability gaps between payers and providers. Use cases in Denmark, Ireland and the UK offer a wealth of information from experiences. For those inspired by the four P’s of healthcare (personalization, preventative, predictive and participation), pertinence is the 5th P. There is a sound case that the appropriate EHR model will add material value to New Zealand’s healthcare delivery system. The momentum surrounding it may however be lost if the business case is delayed. It is imperative that the first step towards this goal is finding a way to build a connection between the existing system with the new distributed ledger offering. A bridge of trust needs to be established. While no technology can be thought of as being a panacea for existing problems, time will reveal the true capabilities of blockchain technology within the healthcare framework.

How can automation of manual process through the use of technology be corroborated?

The positive influence of technology in improving the healthcare service model in recent times is best demonstrated by the melding of robotic assisted surgery into the system. One of New Zealand’s Ministry of Health’s targets for 2017-2018 and beyond is to provide better access to elective surgical care. In August 2017, the country’s first robot assisted knee surgery was carried out at Auckland’s North Shore Hospital. With a 92% rate of patient satisfaction, 36% lower 30-day complication and 66% lower readmission costs, this is the cutting edge of surgery. The prudent leadership demonstrated by the District Health Boards and the brave surgeons who chose to embrace the future, is a seminal example of change for good.

Despite the successes of the healthcare system in New Zealand, the system falls short of achieving substantial health outcome. Not targets, outcomes. Healthcare is in principal risk-averse as an industry. It also involves significant investments and long terms strategies.

What role will blockchain hope to play in terms of enabling secure healthcare data transactions?

The Office of the Privacy Commissioner in New Zealand reported a steady rise in privacy breaches over the past 10 years. At the end of 2008, 16 data breaches were officially reported. By the end of 2015, this number had risen to 121. A bill recently introduced to Parliament hopes to overhaul the 25-year-old privacy legislation currently in place. Submissions on the bill have since been closed and report is due back in Parliament in October 2018. Significant among the recommendations in the bill is mandatory reporting of data breaches.

A noteworthy issue thrown up amidst the kerfuffle surrounding the privacy bill, is the lack of transparency within the system. The outcome is an absolute lack of trust. The healthcare sector operating in New Zealand has over the years, unwittingly relatively restriction free access to personal health information. A downstream effect of such an open-gate approach is the very real threat of privacy breaches. Through the use of self-executing computer programs (smart contracts) and a decentralized blockchain platform, in the future patients will become data vendors, choosing who they divulge their personal information out to.

In early 2000, a discussion document titled “The New Zealand Health Strategy” was published the Ministry of Health. The document, published for consultation with the sector and the wider public outlined the direction of action on health. In relation to the use of technology, the document stated “The ability to exchange high-quality information between partners in health care processes will be vital for a health system focused on achieving better health outcomes. Privacy and confidentiality of personal information must be maintained at all times”.  18 years on, this call to action has never had a louder voice than the present moment. A survey published in June involving 1600 Kiwis revealed that 67% were concerned about their individual privacy, albeit not medical data privacy in particular.

So, what happens now?

Healthcare organizations in New Zealand, much like most healthcare systems around the world consider patient data as being invaluable. That being said, large volumes of data of this nature lends itself to being used inappropriately. Blockchain has the potential to offer long term solutions. Critics argue that the technology is too cumbersome and complicated for large populations, high computational expenses and government regulations will stifle growth, there aren’t enough incentives in place to attract talent, large health record silos might potentially be difficult to govern and it’s only a matter of time before hackers find their way into the immutable system. These arguments aside, the first step is the creation of a trust-bridge between the incumbent system and the DLT offering. Working in conjunction with the District Health Boards, Private healthcare providers and EHR vendors will allow the best solution generating alternative. Interoperability is critical to prevent the fragmentation of the current system from being replicated. Federated blockchain wherein interoperable systems which run sub-critical transactions (emphasis on speed over security) on the centralized chain system while critical transactions (emphasis on security over speed) are diverted towards the decentralized chains might well be a viable option. Such an arrangement would blend into the existing array of sensors and the IoT landscape to track and measure health parameters, whilst using DLTs to enable healthcare practitioner make actionable decisions. It is time to get back to the drawing board and set change in motion. Sine qua non, or is it just me?