Blockchain and Interoperable Standards for Ehr - a Comprehensive Review
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Turkish Journal of Physiotherapy and Rehabilitation; 32(2) ISSN 2651-4451 | e-ISSN 2651-446X BLOCKCHAIN AND INTEROPERABLE STANDARDS FOR EHR - A COMPREHENSIVE REVIEW Faheem Reegu1, Salwani Mohd Daud2, Shadab Alam3* 1, 2 Razak faculty of technology and Informatics, Universiti Teknologi Malaysia, Malaysia 3College of Computer Science & IT, Jazan University, Jazan, KSA Email: [email protected], [email protected], [email protected] ABSTRACT The focus has remained on determining and reviewing the interoperable standards in electronic health records (EHR) while determining which standard is best for interoperability. For this purpose, the research identified that the current state of interoperability is not up to the required standard, so numerous issues are experienced in managing electronic health records. In addition, the research identified numerous standards being used for interoperability, including OpenEHR, OpenEMR, OpenMRS, GNU Health and OSHERA VistA. It can be argued that the use of HL7 and its different versions can play an instrumental role in the integration of the healthcare environment. It can be further advanced by harmonizing different standards in reference to Information Communication Technology and advanced technologies like Blockchain to ensure integration between healthcare systems and their respective applications. It will prove to be beneficial in the transparent exchange of healthcare information. Keywords-EHR; electronic health records; HL7; Interoperability I. INTRODUCTION Approximately $30 billion was earmarked in funds owing to the 2009 Health Information Technology for Economic and Clinical Act (HITECH) to stimulateElectronic Health Records (EHR), which has primarily been embraced by the healthcareservice providers in the USA[1]. In this context, it has been suggested about it is done through the 'Meaningful Use' program, and this effort led to aconsiderable increase in the use of EHR in healthcare and by the providers. Only 9 per cent of the acute care hospitals were found to have basic EHR, compared to the forecast of 96 per cent by 2015 [2]. However, it has been recognized that even with the increase in the health records being digitized, the sharing and dissemination of the electronic health data among the providers and different hospitals have lagged behind in reference to EHR adoption, which [3] and[4]attributed to multiple reasons ranging from privacy-related concerns to the technical and operational issues. Irrespective of this aspect, the healthcare system has grown exponentially during the past decade. The hospitals or the primary care organizations have moved from the use of isolated software systems to more complex and advanced systems that have supported and facilitated the continuous medical processes. In particular, it has been argued that these solutions have resulted in the inclusion of multiple healthcare institutions and professionals and has allowed them to utilize the ubiquitous computing healthcare environments[5]. In this interactive environment, the need of looking at the information sharing among the healthcare software systems have gained significant momentum, which is quite evident in the findings of [6]and [7]that reflected the availability of the relevant patient clinical data that has helped in improving the healthcare's delivery and quality of care. On the other hand, it was recognized about interoperability with respect to healthcarefocused on the exchange of data between different business entities; for instance, the Healthcare Information Exchange (HIE) has enabled the hospitals and their systems to engage in sharing the information statewide[8]. However, the technologically advanced era has pushed topatient-driven interoperability, where the health data exchange is patient-driven as well as patient-mediated. However, this has also led to some significant challenges and requirements surrounding privacy and security and the incentives and governance, which [9]argued to be still prevalent because they are unsolved for the traditional interoperability. In this context, [10]suggested Bitcoin is a novel technology that can help improve interoperability because of its appeal to the healthcare data due to its emphasis upon not just www.turkjphysiotherrehabil.org 3651 Turkish Journal of Physiotherapy and Rehabilitation; 32(2) ISSN 2651-4451 | e-ISSN 2651-446X sharing, but also the distribution and encryption of the data so that the potential breaches can be reduced. In this work, the focus has remained on determining and reviewing the interoperable standards in electronic health records (EHR) while determining which of the standard is best for interoperability. II. CURRENT STATE OF INTEROPERABILITY AND EHR According to the Health Information and Management Systems Society, interoperability has been defined as the capability of the software and systems to converse and exchange the data while using the exchanged information for a greater purpose[11]. In the case of healthcare, this interoperability has been argued to have numerous benefits; for instance, [12]suggested the improvement in operational efficiency and the amount of time spent on administrative tasks because of the well-communicating system. It can reduce the need to manually enter the data within the system due to the information being faxed, whereas [13] and [14]suggestedreduced duplication in the clinical interventions, which can significantly reduce the overall health system cost. In fact, the study further elaborated that interoperability can help significantly reduce waste while exponentially improving the quality of care and patient safety that can be achieved by decreasing the exposure of the patients to radiations or invasive procedures. However, if these results are taken into account, it can be identified that mixed results have been shared by the empirical studies that have specifically focused on the interoperability implementation; for instance, [8]identified the interoperability's overall goal at state-level HIEs was to improve the cost-effectiveness while ensuring inclusive clinical care. The interoperability setting in healthcare is centred around businesses like pharmacies, private clinics, and hospitals. The data is generated in silos within the information system responsible for creating it. A prominent example of it is embedded in the electronic health records within the hospital, which [15]suggested is the result of the motivation of financial incentives or the regulatory pressures that are generally to encourage to work on improved and better health data liquidity. In this context, [16]reflected on 21CCA that has placed a strong emphasis on sharing data, and [1]suggested that the groundwork for the statewide exchange of health information has been laid by the HITECH, but this requires significant funding. Given this situation, the health data of the individual patient has become scattered across numerous system, and no particular institution has shown interest in having a complete picture. Even with higher interoperability between different system, it can be argued that there would still be some missing data like lifestyle behaviour, the personal device monitoring data and even the social determinants of the health, as the patient generates these. In [17]and [18][19], in this context, elaborated about the EHR representing the patient because of the close approximation that may offer a complete picture in one place. It might be the reason that significant interest has been given to gaining additional data in reference to EHRs. It implies that the limitations of the EHR can be particularly resolved by including data like the behavioural and social determinants of health. However, the most concerning aspect is regarding the challenges associated with interoperability, which persists due to the operationally challenging exchange between different institutions as it requires an optimal level of collaboration between the involved entities. Further,[20][21]elaborated on the operational and strategies issues in data sharing agreements and the matching algorithms for the complex patients and the government rules, which the researchers argued must be agreed upon to ensure the data exchange. The challenges are not just operational in nature, but many technical hurdles are also there; for instance, the entity and transactional authentication has been suggested to be robust and should be a repeater for every entity-to-entity relationship. There is also a need for threshold monitoring and anomaly detection requirements; meanwhile,[22]suggested the data exchange security presented to be of vital information while ensuring that the data exchange standards are optimally met like CDA or FHIR. On the contrary, recent studies have indicated the burst of energy towards bringing improvement in the patients' abilities to access their own health data, but there has been ambiguity about whether or not the patients must be able to access their health data and records. The article [23]presented the case of HIPAA under which the covered entities are responsible for providing accessibility to the individuals, but this only occurs upon the requests generated by the individual. However, there isa particular exception, like the psychotherapy notes are excluded from the information[24]. Though organizational Health Information Management offices have generally handled this, the accessibility to the electronic data has now been heavily regulated inMeaningful Use. According to [25], the patients can view, download