Paul de Raeve, of the European Federation of Nurses Associations, discusses the potential of blockchain technology to assist in the continuity of care.
Patients’ empowerment has become a central priority in the health and social care ecosystems, and nurses’ advanced roles are essential to respond to patients and citizens’ unmet needs within a people-centred care approach. In a context of growing numbers of people living with co-morbidities, non-communicable diseases, and in need of complex care interventions, a nursing co-designed blockchain technology value-based healthcare system has the potential to strengthen continuity of care and nurses’ advanced roles in care pathway co-ordination.
Blockchain technology can go beyond the solutions offered by paper files or electronic health record (EHR) and offer a seamless and secure way to capture, track and share a citizens/patient entire health experience. Combining personal data on multiple chronic conditions with primary care and public health data facilitates and enables the transition from fee-for-service payments, prioritising volume of medical actions over effective and efficient people-centred care, towards value-based reimbursement models, that prioritise quality outcomes of continuity of care.
The European Commission stimulus
The European Commission has recognised the huge potential of blockchain-inspired technologies for administrations, businesses and society in general.1 In this context, the EU has already allocated millions to blockchain related projects, and potentially more to be committed from 2018 to 2020. However, some stakeholders believe it is just a hype although the European Innovation Council2 (EIC) and Horizon Prize on ‘Blockchains for Social Good’3 provide incentives to attract developers and end-users to blockchain developments.
Following the Council conclusions of 19 October 2017,4 that highlighted blockchain, along with artificial intelligence, as ‘key emerging trends’, the Commission recently launched the EU Blockchain Observatory and Forum,5 mapping existing initiatives on blockchain, monitor related trends and developments, informing policy debates and inspiring common actions based on specific use-cases. Other EU initiatives as CEN-CENELEC Focus Group on Blockchain and Distributed Ledger Technologies6 (DLT) are focusing on boosting the blockchain potential to provide an infrastructure for trusted, decentralised and disintermediated services way beyond the financial sector.
Meanwhile, many EU member states have announced their engagement to projects with blockchain technology, joining the European Blockchain Partnership.7 With this tool, the Commission aims to ensure those ideas can work across borders, consolidate expertise and address challenges such as disintermediation, trust, security and traceability by design, read end-user co-design.
Blockchain pilot projects in the health and social care sector, ambitious for upscaling, need to be mapped and assessed with regard to their impact on inputs, processes and outcomes. Use cases in the health and social care ecosystem, engaging the frontline end-users as co-creators, needs to be empowered at EU level aiming at eventually developing a working prototype for systematic upscaling, making sure continuity of care, as set out in article 4 & 5 of Directive 2011/24/EU, becomes a daily practice, not just a conference topic.
However, there are concerns regarding the many initiatives from banks, insurance companies, stock exchanges and other business sectors leading to diverse systems that cannot work together, something the health and social sector should urgently move away from, so we finally get interoperability that works out for frontline.
The impact of blockchain on health and social care
Blockchain has a great potential in health and social care, as it modifies the way health and social data are traditionally collected, interpreted and connected, shifting from disparate bits of information held by a single ‘owner’, to the lifetime history supporting efficient and effective continuity of care. In this way, capturing long-term data becomes available to frontline with important implications for clinical trial records, regulatory compliance, and personalised health and social records, making the clinical pathways fit for purpose for the clinicians and researchers.
Blockchain in health and social care needs to offer a longitudinal view of a citizen’s history that incorporates information drawn from hospital stays, outpatient visits, wearable device data and preferably indicators guiding the prevention of diseases, including the social determinants impacting on the health status of citizens. Among its uses, it allows to verify the patient’s digital identity, keep track of prescriptions, drug delivery and the relative assumption of treatment and care.
Blockchain is particularly important for boosting patients’ empowerment in the management of their own health and social data, as within the people-centred care approach it is essential to ensure citizens in the chain know exactly how and where their data is being used. In this sense, blockchain has a significant potential in addressing urgent health and social challenges such as vaccination hesitancy, where it can facilitate keeping record of vaccination, with an increased control by the citizen/patient on his/her own information.
By providing a synchronised record, including the electronic vaccination history, without compromising data security and integrity, blockchain can offers a more secure, standardised method of sharing and validating a citizen’s entire health and social record, facilitating the exchange of information among health and social care providers, to smooth continuity of care. Such better data sharing can turn in a higher probability of accurate diagnoses, more effective treatments, and the overall increased ability of healthcare providers to deliver cost-effective care.
As such, blockchain technology creates unique opportunities to reduce complexity, enable trusty collaboration, and create secure and immutable information. Indeed, trust among care participants is a key issue as the blockchain transactions require the consensus of the entire network with issues related to ‘who decides on what’. Multiple stakeholders need to connect to a cohesive, shared-write repository, and it becomes crucial to align all ecosystems actors on problem insights, possible interventions and parameters that are impactful for improving outcomes.
In community care, faster blockchain transactions are possible where a smaller number of participants and an explicit trust model is in place. It is within this context that nurses can prove the added-value of blockchain in boosting continuity of care, facilitating the communication between the different actors involved to deliver the best outcomes for patients and citizens.
To unlock the potential of blockchain in the health and social care sector, a common, shared and systematic approach is needed leading to deployment facilitating high quality continuity of care outcomes with the huge amount of health and social data and the use of Artificial Intelligence, predictive and assistance tools for frontline nurses to use in their daily practice, making continuity of care a reality.
Accessibility to health and social care – one pillar of the EU Social Rights
As advised in the chapter three of the European Pillar of Social Rights, social protection and inclusion, the digitalisation of health and care should improve access to health and social care. To this purpose, EU and national governments should focus on implementing blockchain policies that make the health and social care ecosystems communicate more efficiently.
The right of citizens to timely access, affordable, preventive and curative health care of good quality is a key societal challenge in the EU, to be addressed with an urgent re-focus on ‘moving care back to the community’8 by designing, in partnership with frontline nurses, a more holistic approach to value based health and social care.
The close relationship three million EU nurses instill with citizens/patients greatly contributes to implement a people-centred approach, therefore a nursing co-designed blockchain is the only way forward to ensure that its outcomes really benefit citizens and patients. In particular, with co-designed blockchain technology, nurses that are responsible for accessing, recording, and processing health and social care data can be more confident that such data will be accurate and consistent, which can lead to improved patient care pathways and its outcomes.
In this sense, blockchain should support nurses in leading the transition towards an integrated care model through measures that acknowledge and emphasise the frontline responsibility in ensuring continuity of care. Nurses working in primary care centres, schools, in the community and, not least as informal carers in their own families, are in a unique position to increase the access to health and social care.
Plus, their contribution is fundamental in combatting the main challenges that European health and social ecosystems are facing, i.e. the increase of people living with multi-morbidity and chronic diseases, antibiotic resistance (AMR) and lack of trust in vaccinations, all conditions that require support from a blockchain co-ordinated approach and investment in an efficient primary and community care system.
In this context, the Advanced Nurse Practitioner (ANP) is central to improve access and outcomes in a people-centred approach, ensuring continuity of care across primary and secondary health and social care sectors. In leading continuity of care, nursing practices hold potential to enable patients and citizens to become active contributors and partners in the decision making process, and as the recording the history of data is key in continuity of care, blockchain becomes a technology supporting frontline.
A good example of this is represented by nurse prescribing focusing on empowering patients to have access to quality and safe prescriptions, while at the same time enabling cost efficiency and saving physicians’ time. Nurse prescribing, supported through ICT solutions, shows clear benefits for professionals and patients alike: reporting through blockchain, it enables transparency, and boosts patient/citizens confidence.
However, this model of care delivery requires a deep change of mind set of those co-designing value-based ecosystems. Only co-created, fit for purpose technology solutions will facilitate the deployment of the digitalisation of health and care.9 In this sense, nurses and blockchain processes are becoming joint leaders in reforming health and social ecosystems.
Lowering nurses’ workloads
One of the main potentials the nursing profession sees in blockchain is the development of a network that will allow patients/citizens having access to synchronised databases, visible to anyone with validated access to the patient/citizen continuity of care pathway, giving unprecedented benefits for frontline care provision. By having a distributed database for health and social care-related information, providers can benefit from increased accessibility, accuracy, and safety, resulting in better outcomes for all. The regular and updated exchange of the patient’s health and social history will allow nurses to improve the process of discharging patients and data sharing in continuity of care.
A reduced bureaucratic red-tape and increased speed of nurse interventions are central to decrease the growing unmet needs of patients/citizens and to boost continuity of care. Nurses are overwhelmed with data collection, often ‘outsourced’ by the doctors, as nurses often complete the medical ICD codes for the DRG systems. This system of data entry is exacerbating the risk of pulling nurses further away from the citizen/patient, now risking spending more time typing than talking to patients, causing a real barrier to deliver health and social care and, at the same time, staying in the profession. In this sense, blockchain needs to show the evidence of its potential to decrease the burden of data collection pending on nurses, allowing them to spend more time in patients’ direct care.
As study findings10 show, a worrying situation for primary care physicians is spending more than half of their workday in front of computer screens, reducing the time of patients’ direct care, spending an average of 5.9 hours on data entry and other tasks with electronic health records (EHR) systems during and after clinical hours. It is time to turn this trend urgently around. Blockchain should turn this do this, and we need first the evidence that it can.
The nursing figures are even worse, despite the industry promises about tools that would free up time for the nurses’ bedside care. This situation leads inevitably to work-life imbalance, dissatisfaction, high rates of attrition, and burnout rates. A co-designed blockchain can become a solution in the value-based health and social care ecosystems as now the gatekeeper becomes the patient/citizen, that will directly access his/her continuity of care pathway. As such, blockchain offers a new supporting infrastructure to reduce the increasing administrative nursing and medical workload.
From DRG towards value-based reimbursements
Furthermore, blockchain-related innovations will have an impact on the management of insurance and billing practices and health records. In both cases the protocol would be fundamental to guarantee the integrity and correctness of citizens/patient data, which can be consulted – and possibly modified – only by health professionals, family members of patients, informal carers who are allowed by the patient/citizen, the owner of the record. In parallel, its functioning will impact on changing the health and social care payment model, by providing a safe, interoperable sharing of real-time data between providers, payers and patients.
The traditional and still widely embraced fee-for-service system cannot be deployed in value-based ecosystems, which should integrate preventive care services. As fee-for-service prioritises volume of care over effective and efficient people-centred care, it is key for nurses to acknowledge outcome-oriented designs, refocusing, even giving up, traditional data collection.
Value-based reimbursement models such as capitation (a fixed payment per beneficiary across a defined population) and bundled (pay for an episode of care or condition during a defined period of time) payments should link continuity of care and blockchain. The bundled payments model has demonstrated the most potential, even described by renowned American academic Michael Porter as “the only true value-based payment model for health care”.11
Unfortunately, alternative payment models have struggled to be effective largely because of issues related to risk, trust and operational efficiency. The promise of blockchain is to provide new supporting infrastructure to solve these problems, by creating a common platform to administer payments and adjudicate claims.
In this sense, the blockchain potential lies in redesigning the payments process from one that is system-centric to one where the needs of the patient take the lead in determining the services delivered across a condition or episode.
Conclusion: make blockchain work for three million nurses
The development of blockchain in healthcare still counts some challenges to overcome related to the early start of investment, patients and healthcare professionals that need to be educated and trained on its deployment, and the need of technology providers to work to create trust among the stakeholders and towards supporting the interest of the patients.
Nonetheless, blockchain is a great opportunity for increasing the delivery of health and social care in a trusting, secure and transparent way, as it offers a new distributed context that promises to expand and support the integration of healthcare information related to a wide range of uses and stakeholders, through its main strengths, i.e. better system effectiveness, disintermediation and security.
Evaluating the many opportunities to apply blockchain to data-processing needs in healthcare is urgently required. That’s where nurses come in: building trust!
Blockchain can greatly contribute to enable nurses to deliver on access to health and social care through the digitalisation of health and care. To promote this mission, blockchain needs to foster the nursing workforce policies encouraging integrated and continuity of care, with advanced nurse practitioners and nurse prescribing deployed throughout the EU.
Engaging end-users and local frontline nurses in co-designing ‘fit for purpose’ health and social care systems is the first step forward to this path.
1 Digital Single Market mid-term review. Available in: https://ec.europa.eu/digital-single-market/en/content/mid-term-review-digital-single-market-dsm-good-moment-take-stock
2 European Innovation Council (EIC)
4 See page 7 http://data.consilium.europa.eu/doc/document/ST-14-2017-INIT/en/pdf
6 CEN-CENELEC Focus Group on Blockchain and Distributed Ledger Technologies (DTL). Available in: https://www.cencenelec.eu/news/articles/Pages/AR-2017-012.aspx
7 See the European Blockchain Partnership. Available in: https://ec.europa.eu/digital-single-market/en/news/european-countries-join-blockchain-partnership
8 EFN Position statement on Moving Care back to the Community –http://www.efnweb.eu/wp-content/uploads/EFN-Position-Paper-on-Moving-Care-to-the-Community-Final042015.pdf
9 ENS4care – Prevention guideline http://www.ens4care.eu/wp-content/uploads/2015/07/D2-2-Final-ENS4Care-Guideline-Prevention-19-06-2015.pdf
10 Providers spend more time in front of computers than patients, University of Wisconsin and the American Medical Association – http://www.annfammed.org/content/15/5/419.full
Paul De Raeve
EFN Secretary General
European Federation of Nurses Associations (EFN)
+32 2 512 74 19
This article will appear in issue 5 of Health Europa Quarterly, which will be published in May.