Perhaps you’ve heard of ‘blockchain’, a buzzword for a technology propagating the internet and financial markets like wildfire. More likely, you’ve heard of ‘Bitcoin’ and its recent explosion in value as a tradable commodity. The more attentive of you may have heard of ‘Ethereum’ and ‘smart contracts’, as well as a slew of other cryptocurrencies (or alternative digital currencies, ‘alt-coins’) such as Litecoin, Cardano, Ripple, Monero, and IOTA. As of this writing, a single Bitcoin is worth well over $10,000 and the total market capitalization of all cryptocurrencies combined is well over 500 billion U.S. dollars. And while the financial side might be in a “hype cycle” that might be described as “peak of inflated expectations” – otherwise known as a “bubble” – there is no denying the potential of the underlying technology behind these cryptocurrencies. There’s no better time for pharmacy as a profession to understand how this technology can fundamentally change the way we track, exchange, authenticate, and store information.
I’ll preface by saying I’m by no means an expert in blockchain or distributed ledgers, but nor does it require one to plainly see the potential behind blockchain. The original purpose of blockchain was to solve a previously insurmountable barrier of digital currencies – preventing double spending. If you think of it from the perspective of a digital photo, how do you ensure there is only one copy of the photo in existence anywhere? And after you’ve transmitted that photo, how do you ensure the previous “owner” of that image no longer has access and they did not also transmit the same photo to another person? You can after all, currently have multiple recipients of any photo and you get to keep the photo too. Change “photo” to “dollar” in the previous sentences and you can see how this would be a major problem with digital currencies. Kuo and colleagues do and infinitely better job at explaining this than I do. The short of it is that by transmitting that image along with a history of all previous transactions of images while a group of people watches, everyone involved confirms the transaction to be authentic and there’s only a single valid copy in existence. If we know what was transferred, from whom it came, to whom it went, and when it happened, validated by all the people present, we can have high confidence in all transactions on the blockchain.
Perhaps now you’re looking at blockchain as a natural solution to the Drug Supply Chain Security Act (DSCSA) and the various transactions between manufacturers, wholesalers, and pharmacies – and you’d be right. However, that is under the assumption that blockchain can only be applied at the purely transactional level – a premise that would make blockchain a whole lot less exciting than it currently is. Imagine now your photo includes information about who took it, where it was taken, what time it was taken, what camera was used, and what exposure settings were used. The blockchain begins to look more like a database, but one with verified transactions of data that cannot be changed or corrupted but can easily be audited from now until the end of time. And because every transaction (or blocks… of transactions) builds upon the previous transaction (forming a chain…) all participating individuals have access to the view complete history of any given transaction and the data exchanged.
Perhaps now you’re thinking blockchain could have tremendous utility in the field of medication histories – and you’d be right. Why have disparate databases of medication histories siloed across a patient’s continuum of care (i.e. doctor’s office vs. outpatient pharmacy vs. hospital 1 vs. hospital 2 vs. patient reported OTCs) when such organizations (and individuals!) can contribute to a blockchain that has an immutable authenticated timestamped history of medication prescribing and fill? Add in a few progress notes, CT scans, and lab results and perhaps you’d have a blockchain that’s more of an electronic health record (EHR). And because blockchains by design are decentralized, there’s no middlemen like existing health information exchanges (HIE) yet the data remains accessible, secured, and authenticated. The folks at Harvard Business Review made this exact point. Google “blockchain healthcare” and you’ll find a variety of organizations such as Deloitte and IBM getting involved, in addition to numerous proof of concept projects such as MediLedger (for DSCSA compliance) or MIT Media Lab’s MedRec.
Before we get ahead of ourselves, let us also be very realistic. The above is an overly simplistic review of the technology. Blockchain and cryptocurrencies are all currently in states of infancy. Five years from now, I’d guesstimate the vast majority of the existing digital currencies will have crashed far below their all-time highs. More importantly, there are currently few real world success stories using blockchain technology. Significant expertise in this area is limited even in the technology industry and infinitely more so in the healthcare industry. There are all sorts of apparent and unapparent issues before blockchains can be implemented to any significant extent – from operational to technological and even regulatory or legal – all of which will take exceedingly daunting amounts of effort and capital to overcome. Certainly, there will be a need for new standardized terminologies – for example, how can a patient be consistently identified across their continuum of care without using their social security number and without some manual adjudication? So first step – a global patient identifier?[6,7] Moreover, what about legal and regulatory frameworks that exist today? Are they compatible with paperless transactions? Are the relevant regulatory bodies and lawmakers even aware of blockchain? How do they write laws and regulations on a technology they do not understand? How can advocates such as ASHP members advise on laws and regulations for a technology they do not understand? I am a firm believer that blockchain will change healthcare in some meaningful way – but until there is healthcare-oriented expertise guiding its development, I’m afraid we’ll vastly underutilize and undervalue the technology’s inherent interoperable nature and re-create the existing siloed landscape. It’s time to get smart on blockchain.
 Gordon W, Wright A, Landman A. Blockchain Technology in Health Care: Decoding the Hype. NEJM Catalyst. https://catalyst.nejm.org/decoding-blockchain-technology-health. Published February 9, 2017.
 Kuo TT, Kim HE, Ohno-Machado L. Blockchain distributed ledger technologies for biomedical and health care applications. J Am Med Inform Assoc. 2017 Nov 1;24(6):1211-1220.
 Halamka JD, Lippman A, Ekblaw A. The Potential for Blockchain to Transform Electronic Health Records. Harvard Business Review. https://hbr.org/2017/03/the-potential-for-blockchain-to-transform-electronic-health-records. Published May 18, 2017.
 MediLedger – Blockchain solutions for Pharma companies. MediLedger – Blockchain solutions for Pharma companies. https://www.mediledger.com.
 Ekblaw A, Azaria A, Halamka JD, Lippman A. A Case Study for Blockchain in Healthcare: “MedRec” prototype for electronic health records and medical research data. Proceedings of IEEE Open & Big Data Conference. 2016 Aug.
 Orcutt M. Blockchain technology will revolutionize medical records-just not anytime soon. MIT Technology Review. https://www.technologyreview.com/s/608821/who-will-build-the-health-care-blockchain. Published September 22, 2017.
 Mainelli M. Blockchain Could Help Us Reclaim Control of Our Personal Data. Harvard Business Review. https://hbr.org/2017/10/smart-ledgers-can-help-us-reclaim-control-of-our-personal-data. Published October 5, 2017.