By Deborah Borfitz

January 22, 2019 | A trio of blockchain-enabled applications that debuted at the recent Distributed: Health conference in Nashville, Tennessee, could start giving patients more control over their personal health data as early as next year. The pilot-phase initiatives include an electronic medical record (EMR) platform with built-in incentives for diabetics to meet their treatment goals, a smart prescription app that makes a script more than a promissory note, and software that transfers ownership of electronic health records (EHRs) from providers to patients.

AMCHART, an initiative of the healthcare division of Houston-based IT services provider AMSYS, launched inside a clinic in Mumbai, India, in early November with the goal of improving diabetes outcomes by better engaging patients in their own care and providing a feedback loop with their physician. For many clinic physicians, AMCHART is their first-ever experience with an EMR and it could bring welcome relief to some patients who currently ferry their own paper files from one visit to the next, says CEO Aman Quadri.

An associated app serves as a care management platform that issues points patients can turn into tokens, redeemable for gift cards, if they comply with their monthly treatment plan. A key feature of the care model includes more frequent blood sugar testing than the once-a-month standard of care in India, a point that could be challenging in India, where many patients have a strong aversion to finger pricks . Points can also be earned by filling out their initial intake form at the clinic.

The threat of lost points quickly proved to be a huge driver of treatment compliance, says Quadri, noting that the model takes a stepwise approach to behavior modification. Clinic staff assist patients in downloading the app and inputting their goals, which might include taking their blood sugar three times per week, walking 2,000 steps per day, and taking their medications as prescribed. In most cases, the app gets integrated with an IoT-based continuous glucose monitoring system (patients otherwise manually enter their readings) and the clinic is automatically alerted of a concerning blood sugar level. The app can similarly be integrated with a wearable fitness device that tracks steps walked.

Patients are asked to come to the clinic once a week, at least initially, rather than wait out the typical 30 to 45 days between checkups, says Quadri, so issues can be quickly addressed. Patients having problems can communicate with their physician any time through the app. If goals aren’t being met, an alert can also be sent to the patient’s accountability group, which might be a family member, nurse, or the treating physician. The broader objective is to reduce use of unnecessary and costlier hospital-based care.

The baseline against which success will be measured are 100 patients seen at the clinic and treated via the standard of care—monthly visits and glucose checks, plus verbal instructions regarding medications, says Quadri. A second set of 100 patients will be enrolled into the AMCHART initiative by the end of 2018 and use the mobile app and points-based incentive system. Results are expected by mid-2019, and the metrics are still being defined, but will likely look at symptom control, disease self-management, dietary habits, need for intervention, speed of recovery, and patient engagement.

It has yet to be decided if certain point-earning behaviors are more critical to behavior change and improved health status and therefore need to be weighted more heavily. AMCHART expects to forge partnerships to create a multi-token model that can be tailored for different cultures and people, says Quadri. The platform will eventually include curated educational content that patients can watch or read to earn digital tokens.

Within the next six months, natural language processing will make the EMR fully voice-controlled with fields for capturing information from exam room conversations, reducing the time providers spend on documentation during patient visits. The backlog of preexisting paper files won’t immediately be digitized, but once they are, machine learning can be applied to the large, longitudinal dataset to create a clinical decision support tool providing insights back to physicians, says Quadri.

All that data will get aggregated over time—including genomic tests done on patients coming through the clinic—with AMCHART helping to monetize it on patients’ behalf. The output is expected to be of interest to pharmaceutical, research, and life science companies focused on the interrelated areas of diabetes, hypertension, and obesity, Quadri says.

Blockchain sits in the background of the AMCHART platform, providing an audit trail of when and by whom medical records were accessed, says Quadri. The technology also creates hash references to verified data, yielding a clean dataset that can make any clinical decision support tool more reliable.

The platform has the interest of more than two dozen, mostly U.S.-based organizations that would modify the AMCHART platform, or adopt pieces of it, to meet their needs, says Quadri. One large health information exchange may use the patient engagement and personal record components to create its own clinical decision support tool for member providers. Another company is looking at how the patient data could be used in the development of an EMR-based medication reconciliation tool to prevent prescribing errors and drug-drug interactions. A diabetes and obesity management organization is assessing AMCHART for the ongoing monitoring of 7,000 patients in its clinic system. And a few mid-tier EMR providers have recently inquired about having AMCHART integrate with their product to improve its chronic disease management capabilities.

Improving Medication Adherence

Sydney, Australia-based ScalaMed—the winner of the “investor pitch” competition at the Distributed: Health event—will be launching its blockchain-enabled smart prescription app in the Houston market before the close of 2018. The technology encrypts patient prescription data, which then gets transported to an e-prescription blockchain service through an application programming interface with the patient’s electronic health record, says CEO Tal Rapke, M.D.

Once published to the blockchain, the transaction generates a digital prescription that gets dropped into a digital wallet on the patient’s mobile phone via the app along with education about potential allergies or other complications associated with the prescribed drug. Patients can fill their prescription at the pharmacy of their choice, using a price comparison feature that will soon be added to the app, notes Rapke. No new integrations are required of pharmacies. Patients can “self-curate” the content and tools they need to make medication management seamless and easy, which can improve medication adherence, Rapke adds. Among the many reasons for nonadherence is that consumers don’t understand the importance of taking prescribed medicines and the risks of stopping them. Most patients are “onboarded” with a medication in less than four minutes during a single doctor visit, which helps explain why 30% of them never pick up their first prescription, he says. Most physicians are also unaware of the true cost of a medication to a patient prior to prescribing, although the financial burden is a known cause of prescription abandonment. And that is to say nothing of the logistical issues, such as required travel and pharmacy operating hours, which can also negatively affect adherence.

Therapy summaries currently offered on the smart prescription app will expand to include “a selection of the best content” from manufacturers, the U.S. Food and Drug Administration, publicly available sources, partners, and sponsors, says Rapke. The menu will also include multimedia and crowdsourced content.

The app will be used at clinics, identified with the help of Texas Medical Center’s TMCx accelerator program, which serve 180,000 patients annually across 15 sites.

The population expected to gain immediate benefit from the smart prescription platform are consumers between the ages of 40 and 65 who are most likely to be on chronic medications—on average, three or more per day—and are also smart phone users, says Rapke. But it is applicable to people of all backgrounds and ages, which currently includes an 80-year-old man proficiently using ScalaMed to manage his multiple prescriptions.

In the future, Rapke says, “ScalaMed will offer a decentralized way for patients to store and integrate their genomic data to ensure a more personalized approach to medication advice.” The app will advise them if the drug or dose they’ve been prescribed is genetically appropriate, and to securely share this information with their physician to support that decision-making process.

ScalaMed will be rolled out nationwide in 2019, starting with clinics and doctors currently spending an inordinate amount of time and work managing the prescription process. “Anything that reduces the need for patients to call back and have their prescriptions redirected can be of immense value,” says Rapke. Patients can use the app to self-manage their prescriptions and make needed changes, including having a prescription forwarded to a more convenient pharmacy during a vacation or holiday.

Next year, ScalaMed will be taking steps to bring Schedule II medicines to the platform, says Rapke, and the security and fraud protection offered by blockchain technology should help the company make its case with the Drug Enforcement Administration. Ultimately, the plan is to market the app globally. “We see the opportunity for ScalaMed to be the seed of a fully consumer-centered health record … portable, owned by the patient, shareable, accessible and intelligent.”

Patient-Centric Health Records

Riverside, Iowa-based startup MedBlox wants to decentralize medical records storage to give patients status as stakeholders in their own healthcare, says Somchai Rice, founder and chief science officer. The patient interface will be a mobile phone app consumers can use to grant or revoke provider access to portions of their record via a secret cryptographic key.

MedBlox was originally slated to roll out in the second quarter of 2019, but Somchai says its recent initial coin offering—roughly equivalent to an initial public offering—ended without reaching its target so investor funds were returned. The digital coins up for sale were issued on top of the popular Ethereum and Bitcoin cryptocurrency platforms, while the MedBlox blockchain is based on Hyperledger Fabric.

The coins are redeemable for MDBLK tokens, which will facilitate data requests through the MedBlox API, says Somchai. Providers will be required to contribute a minimum of one compute node, plus connectivity to integrating systems and data storage, or the equivalent from a recommended software-as-a-service suite. Only a deficit of storage space would trigger per-use transaction fees.

The cost of participation for providers will easily be countered by the savings MedBlox will enable by eliminating breach fines, simplifying compliance programs, discouraging duplication of effort, and removing support expenses (licensing, implementation, and training) for legacy EHR technology, says Somchai. Active discussions are currently underway with several health systems in the Midwest, she adds, while MedBlox continues developing the data ingestion and pipeline capabilities of its algorithm.

Somchai says MedBlox is currently working with its lawyers and seeking patents. Among the details she is at liberty to disclose is that MedBlox intends to securely store medical data off-chain in S3 buckets. Third-party validation of transactions could be done by “anyone who wants to get a foot in the space” by contributing compute power. Genomic data is not an immediate focus and probably too big for most of today’s blockchain networks anyway, she adds, but “is on our radar.”

MedBlox is also having “important conversations with payers,” says Somchai, for whom EHRs can create “common standards for billing and quality reporting, streamline pre-authorization procedures, and result in greater reimbursement for preventive care services.”