Epic needs to make sure that any editing of a specific CHR record (or ledger, using the above example) is completed throughout the network to maintain source-of-truth. Then there’s a concern about keeping that source centrally, in a single place. Even with secondary and tertiary backups, would you be comfortable with three locations holding your company’s entire reason for being? Decentralization would almost be a requirement for something of this gravity.

HIMSS18 hosted Epic Systems to no one’s surprise. Whatever your opinion. you can’t speak about the current state of healthcare information technology without at least a cursory nod to what Epic has accomplished in the last couple decades or so.

Founder Judy Faulkner has a strong belief that the days of the “E” in Electronic Health Records have come and gone. In a recent article written on heathitanalytics.com,* she explains the need for removing the “E” and replacing it with a “C” for Comprehensive. Effectively, Epic is trying to implement a new way of handling patient data by which there is a single source of record for a patient’s health records; a CHR.


The Comprehensive Health Record

The goal of having a single system using a single record is a more informed physician making decisions with more complete information. In addition to the pertinent data regarding a specific procedure, Faulkner envisions a patient’s CHR as a place where socioeconomics, genomics, family history, and environmental data are all included. These data points would be introduced from multiple systems with which Epic would have interoperability to varying degrees.

I read this and considered the direction and evolution of this idea. While the thought of CHRs being a patient’s health-omnibus are attractive, my first concern is they’re slightly pointless if they’re old. Any time you have a single source of truth feeding to multiple endpoints, the challenge is making sure it’s as up-to-date as possible, as quickly as possible. The goal is to approach as close to real-time as possible while minimizing source corruption. It just so happens that this is the core tenant of everyone’s favorite buzzword right now: Blockchain.


The Latest Tech: Blockchain

The next great thing is all technology is purported to be Blockchain. Blockchain is everywhere doing everything for everyone all the time. It will raise your kids, do your taxes, and supply the world with potable water while composing the most beautiful music you’ve ever heard. All hail the Blockchain!** The problem is that probably 2 people out of 10 know how it works. For my CHR thoughts to make sense, I will explain Blockchain to you the way I would explain it to my parents… with whom I spent fifteen minutes of my Easter instructing how to forward an email.


“What is Blockchain?”

 Blockchain is basically a universal running ledger, or record. There are multiple entries (a chain) all kept historically, but the current value (a block) is what is referenced.


“Why is this different than a bank?”

 Banks keep a central ledger. Here, the ledger is shared by everyone who has a copy. That said, no one copy of the ledger is the master copy. They all work in unison.


“How is anything ‘owned’?”

Keep in mind that ownership of a ledger, and control of a ledger are two different things. You can have an entry in the ledger that attributes ownership of something to you, but that entry must be validated by other copies of that ledger. Because copies are all looking at each other for validation, this control is decentralized.


“If there’s no controlling copy, how does anything get written and validated as truth?”

In the case of Bitcoin, transferring ownership of a coin is done using unique ID’s. For example: Ann has a bitcoin in her wallet. Her wallet is a unique ID that can never change (the ID is stored in every ledger). Ryan wants that bitcoin, so he sends her his wallet’s ID. The transfer of ownership takes place, but before it’s written to the ledger, Ann’s ID and Ryan’s ID are both confirmed by other copies of the ledger. If the majority of the ledgers confirm the ID’s are valid, the new entry is written and disseminated to the other ledgers. This creates a new block in the chain.***

Got all that? Did I lose you? There’s plenty more to it, but my parents were tentatively ok with this explanation (read: I left before they could ask more questions). Banking is the most synonymous application; thus, spawning Bitcoin, Etherium, or one of the other hundreds of ICO’s.****

It is important to keep in mind that banking is not the only use. The prediction from many IT professionals is that the next brass ring is healthcare. Remember that Blockchain is cutting edge technology and while there’s a variant of Moore’s Law in play here, no one really has a concrete example of how this application makes sense, or what it looks like. Epic may have fired the opening salvo at HIMSS18. If a CHR is to stand as a single point of reference in a networked system as large as Epic, even if Epic is bringing in data from other systems, it would make sense that as the CHR base is built, that a Blockchain-type system is implemented.

What it all adds up to is the next step in the evolutionary process of health record keeping. One by which you have an immutable record-keeping system wherein the latest entry is always considered the true record and can be edited or maintained from any location.

Obviously easier said than done. Once this gets worked out though, we can solve more pressing problems. My hope is that by 2020, Blockchain will be mowing my lawn… or least come up with less awkward blog titles.


* – Link to the article HERE.

** – I desperately hope that in ten years, that’s still a joke and not a thought of as an unfortunate Quatrain.

*** – Bonus question, because I figured that was getting tedious:


“Why is it considered so secure? What makes this ‘un-hackable’?”

– Nothing is un-hackable, but to trick a ledger into allowing an illegal transaction, the unique ID’s would have to be re-written in multiple places. This would employ hacking multiple servers and changing the IDs almost simultaneously on multiple copies of the decentralized ledger. When the majority of other ledgers see a discrepancy, it’s overwritten to reconcile the change; a sort of self-healing correction. Making a change on a scale to affect the majority of ledgers is nearly impossible to do with Blockchain… nearly.


**** – List of other ICO’s HERE… it’s ridiculous.