Medical records on the blockchain – the history of a bad idea
davidgerard.co.uk
davidgerard.co.uk
There are a lot of use cases, most even, where it's not a great fit, and there are other, better, approaches.
Disclosure, I work for an election services company...
(But of course.)
The Byzantine fault tolerance, public consensus, and mining aspects that we associate with "true" blockchains are the parts that people can't find a way to justify and can typically be ignored.
I was talking about this a few months ago with a well-meaning non-techie, who suggested that Uber - the money-burning minicab firm with an app - was an example of a "decentralised system." More than that - it was a model for how blockchain could succeed.
I think they'd never thought about the concept of distributed systems of any sort ever before in their lives.
"It's like blockchain, because anyone can sign up to be an Uber driver!"
"Uh ... anyone can sign up to be a minicab driver."
or the very concept of "open source" only being possible with "blockchain".
When I bought my first screwdriver, a lot of problems seemed like they should be solved by tightening, loosening or adding screws to things. Because I had a screwdriver and damn it, I was going to use it. But often even when we have a fantastic idea, it isn't broadly applicable. Lots of problems I had couldn't be solved with a screwdriver, many more shouldn't be.
This came up for Certificate Transparency. CT uses Merkle hash trees to provide an immutable, cryptographically-verified Log of things it has been shown - in the original application those are X.509 certificates from the Web PKI ("SSL Certificates"). None of the component parts are even modern let alone unprecedented, although arguably it would be less practical without elliptic curve crypto, but nothing like CT itself had ever been done before, and its designers deserve significant praise.
And in the subsequent years as CT was successful we saw not only uptake of CT itself which was good, but also when there was some other problem people would propose solving it with this new magic toy - let's have Whatever Transparency. None of those went anywhere, because the unique recipe for CT is not a universal multi-tool, it solves one very specific problem very well indeed and that's fine.
I don't need global PoW or PoS consensus for my health records.
I need something my health providers and I can agree is authoritative and as accurate as the data entry makes possible. The parent comment's "immutable, distributed, cryptographically-verified database". Something like a shared git repo. Not like a crypto currency.
You can still work with those people if you revise the definition for "blockchain" in your mind into something that isn't really a blockchain.
* reconciling all the data in one place
* having a tamper-evident ledger of transactions
The second just puts logs in a 1979-style Merkle tree, and the first is 100% getting organisations working together and doing the hard tech-debt slog of cleaning up your data and formats.
If you have both problems, your problem is enough of a human/business mess that applying a blockchain won't fix any aspect, but may well make it worse.
Occasionally "blockchain" will be useful as a buzzword to get funding.
>Byzantine fault tolerance, public consensus, and mining
Why would I want ANY of these things associated with the system that manages my medical records?
I don't want them to be immutable, if there's an error I want it corrected. Clearly there should be security to control who (my provider) can update them, and perhaps turn on the database transaction log to track what updates were made by whom and when.
I don't want my medical records to be distributed for obvious reasons.
Encrypted, sure, but "cryptologically verified" seems to be overkill as there's little incentive for third parties to try and forge medical records.
Byzantine fault tolerance? Lol. My medical records get updated maybe once per year, by my provider, and no one has an incentive to insert false data.
Public consensus? See above.
Mining? Come on.
99.9% of the time when someone says we should use blockchain, they really just need a database, this is one of those cases.
Immutable here means no in-place update, you have to update using an "errata" record. This is the requirement for many type of official documents, even before computers were used.
>> I don't want my medical records to be distributed for obvious reasons.
Distributed here means no single point of failure.
>> Encrypted, sure, but "cryptographically-verified" seems to be overkill as there's little incentive for third parties to try and forge medical records.
Encryption without authentication opens up many types of attack. You almost always want authenticated encryption
Yes, and people have been building financial systems with relational databases using this journaling principle (updates and deletes handled by inserting new records and timestamping) for decades.
>>>Distributed here means no single point of failure.
Which can be done with most standard RDBMS or NoSQL databases and clustering/sharding. Not that the scale of medical records is anywhere near requiring any of this. Do you really want multiple copies of your personal medical records on some public blockchain?
>>>Encryption without authentication opens up many types of attack. You almost always want authenticated encryption
For financial transactions, sure, but for medical records? For what purpose? Other than me and my provider (and any specialist I select) why would anyone else even need to access my medical records? Who would be faking them?
None of this makes any sense for medical records.
>> Do you really want multiple copies of your personal medical records on some public blockchain? No I don't. This thread's starter and I never said that these properties can only provided by "blockchain", neither did we said that "blockchain" should be used. We only said that these properties were useful and people wanted them.
>> For financial transactions, sure, but for medical records? For what purpose? Other than me and my provider (and any specialist I select) why would anyone else even need to access my medical records? Who would be faking them?
For example, a fraudulent specialist with access to your data can modify your prescription so they can steal money from your insurance provider and also take these extra medicine to sell on the black market.
Technically, you do. If you go to see a different health care provider than usual, you want them to access your medical records.
I don't see how the blockchain is the best solution for this, but the distributed part isn't really the problematic part.
A lot of the pointless debate and highly opinionated grandstanding that takes place around blockchain is centred around misuse of the word. As far as data structures go, it’s a perfectly reasonable one, and has plenty of uses outside of cryptocurrency. Sure it’s a buzzword, but politicising the use of a particular data structure seems just as pointless as any other kind of dogmatic evangelism to me.
You might come up with a reasonable definition, like "append-only ledger with a consensus mechanism" - but in marketing terms, "blockchain" literally only means "whatever I'm trying to sell you today."
And then there's weasel terms like "blockchain technology", which means "I can't even claim this thing is actually even a blockchain, but it's got a few of the same parts."
You want a blockchain without mining? You could set one up in a couple of minutes.
https://aws.amazon.com/blockchain/
Do you want a real world example? It seems to be getting some use in supply chain management.
https://www.ibm.com/blockchain/industries/supply-chain
A blockchain is just a type of data structure. Cryptocurrencies use blockchains, but mining, trustless distributed consensus, fault tolerance, and all these other things are features of cryptocurrency implementations, not essential elements of blockchains.
That IBM page is just a puff piece and they have no clients using anything like that.
It’s not even clear if you know what a blockchain is, and your comments on its usefulness are just as extreme and misinformed as the evangelists who say it can be used to solve any problem under the sun.
Looks like they want to use it to lower traditional auditing costs in developing countries. Not sure how the blockchain tech is supposed to help tracking materials or establish trust in such an environment but that's not really my field - presumably it adds a component of different people creating a digital paper trail that's harder to manipulate. That's an application compliance people in a few sectors seem to like these days, guess we'll see if it actually makes sense over traditional efforts in N years.
https://www.coindesk.com/volkswagen-to-track-minerals-supply...
> Last I checked there was literally no reason to use blockchain outside of cryptocurrencies since you get the same benefits just using GIT.
How does the data structure of a git repo differ from a blockchain? The only difference I can see is in how it’s used. A blockchain wouldn’t have more than one permanent branch.
There is a reason why the topic is brought up so often and its because among all that garbage there is genuine potential. It requires education, and R & D to unlock most of it. But at some point we'll have straight-forward tools that can be applied to solve a variety of common problems.
I predict the end result won't look any where near as exciting as it is today. It's likely going to end up being a flexible and boring set of auditing tools. But that's still going to improve the transparency and efficiency of many organizations. And give how archaic some of the processes around businesses are today -- those changes are still going to look revolutionary in their context.
We’ve been hearing this for a decade – it’ll change the world, if you don’t agree it’s because you don’t understand it well enough – and yet we don’t have a single example of it being competitive, much less compelling.
One of the common comparisons is the internet or, more specifically the web, but those really just highlight how inappropriate those comparisons are. In both cases, within a few years there were multiple examples of real problems being solved and businesses seeing profits from adoption (not just speculation) — and that despite far greater barriers to adoption.
It allows you to store and transfer value in situations where you either cannot obtain, or do not trust your available banking relationships. You also have much, much lower fees for international remittance.
> What risks does it have - for example, do users take on responsibility for fraud risk?
It has two primary risks:
- Transaction finality. This is a positive and a negative, of course.
- Risk that you improperly handle your private key and have your funds stolen.This is already a small percentage of people but it’s smaller still when you realize that it requires full access to the blockchain network and a solid local network of people who accept it and/or convert into local currency at low rates, not to mention that since the model is so well-suited to support oppressive regimes you’re really only talking about people who live in countries which have collapsed into disfunction but not authoritarianism.
> You also have much, much lower fees for international remittance.
From whom? What are the actual rates?
> Risk that you improperly handle your private key and have your funds stolen.
This is a big caveat for most people since “handle improperly” actually means “never use buggy or untrustworthy software, get mugged, etc. The benefits listed above don’t apply to most people enough to be worth that big of a risk transfer.
The rates are the cost of buying/selling bitcoin on both ends, let's call that 20 bps on each side, and then the cost of a single bitcoin network transaction, which is about 66 cents at the moment, if you're willing to wait 6 blocks [1]. So, to send $1000 it'll cost you 40 bps + 66 cents = $4.66. By comparison, international wires at your local bank will run you around $50 all in [2]. That's quite a savings.
1. https://bitcoinfees.info/ 2. https://smartasset.com/checking-account/average-wire-transfe...
> This is a big caveat for most people since “handle improperly” actually means “never use buggy or untrustworthy software, get mugged, etc. The benefits listed above don’t apply to most people enough to be worth that big of a risk transfer.
Sure, and those are real challenges of using cryptocurrencies right now. However, they're also extremely solvable problems and people are working on them.
Don’t forget to add in the currency conversion fees on either side since most people transfer money to use it.
Walmart charges $8 for the same service. There is some potential savings here but it seems unlikely to argue that Bitcoin’s enormous costs can be justified by the number of people who need to regularly do international transfers and, if everything is lucky, save a dollar or two on the transfers.
> Sure, and those are real challenges of using cryptocurrencies right now. However, they're also extremely solvable problems and people are working on them.
“Extremely solvable” but unsolved a decade later suggests that they are not in fact that easy and will end up making the cost even less competitive. People have been preaching that Bitcoin will take over for years but even most advocates don’t use it for a non-token percentage of their transactions because it’s simply not financially sensible to do so.
Hm? That would be factored in already. If I wanted to send money to say, India, I would buy Bitcoin with US dollars and then send it to someone's account on an Indian exchange, where they'd sell it for Rupees. The conversion is already baked in.
> Walmart charges $8 for the same service. There is some potential savings here but it seems unlikely to argue that Bitcoin’s enormous costs can be justified by the number of people who need to regularly do international transfers and, if everything is lucky, save a dollar or two on the transfers.
I'm not arguing that international wires are the only useful thing it can do. It's simply a counter-example to the idea that there are none.
> “Extremely solvable” but unsolved a decade later suggests that they are not in fact that easy and will end up making the cost even less competitive. People have been preaching that Bitcoin will take over for years but even most advocates don’t use it for a non-token percentage of their transactions because it’s simply not financially sensible to do so.
It's already solved if you keep your money on an exchange.
Right, but if you're comparing apples to apples, you need to compare the cost of, say, going to Walmart.com (or a bunch of other places) with $1,000 and sending it to someone in India vs. starting with the same $1,000 and shipping it. Unless the conversion rates for gating in and out Bitcoin are always exactly the same you need to measure the whole cost.
> I'm not arguing that international wires are the only useful thing it can do. It's simply a counter-example to the idea that there are none.
Note that I wasn't saying that there no things which were technically possible, only that very few people have a situation where it's advantageous to use Bitcoin. A possible modest savings on international transfers does not seem like a viable foundation for a decade of big world-changing rhetoric.
> > “Extremely solvable” but unsolved a decade later suggests that they are > not in fact that easy and will end up making the cost even less competitive. People have been preaching that Bitcoin will take over for years but even most advocates don’t use it for a non-token percentage of their transactions because it’s simply not financially sensible to do so. > > It's already solved if you keep your money on an exchange.
… so, you get rid of banks by creating a new bank, putting a “not a bank” sign on it, and hoping nobody will notice a) how many people have lost money by trusting Bitcoin exchanges and b) how quick the community was to blame them for the loss and saying that they were fools to trust an exchange?
Ya, but that only argues for even more cost to the traditional method, no?
> Note that I wasn't saying that there no things which were technically possible, only that very few people have a situation where it's advantageous to use Bitcoin. A possible modest savings on international transfers does not seem like a viable foundation for a decade of big world-changing rhetoric.
Let's take a look at what you said:
> We’ve been hearing this for a decade – it’ll change the world, if you don’t agree it’s because you don’t understand it well enough – and yet we don’t have a single example of it being competitive, much less compelling.
I'd say I provided a single example of it being competitive. And I think there's a lot more value there that isn't being properly realized yet, but the international wire use case is concrete and immediately available.
I think part of the reason people don't see the value (yet) is that they are so entrenched in the existing system they don't even realize what it's costing them. You see people on this site complaining about companies like Facebook violating their privacy rights all the time by aggregating their behavioral data. Do you know who's been doing that for decades? Credit card companies and banks. Nobody bats an eyelash when they do it, simply because they've been grandfathered in, and we had no reasonable alternative to them. Cryptocurrencies are a reasonable alternative to the banking / credit card system. And they're one that allows their users to maintain genuine autonomy and privacy. It's fine if you don't personally find that valuable, but the chorus of people here whining about corporate privacy violations ought to if they're concerns are more than performative.
> … so, you get rid of banks by creating a new bank, putting a “not a bank” sign on it, and hoping nobody will notice a) how many people have lost money by trusting Bitcoin exchanges and b) how quick the community was to blame them for the loss and saying that they were fools to trust an exchange?
This is a common criticism, but there is a very important difference. You cannot practically remove your money from the banking system. You can practically remove your crypto from an exchange. This gives you a degree of leverage and autonomy you simply don't have when your money is at say, Wells Fargo. You have a meaningful choice about where to keep your funds when you're dealing in crypto. You can keep them on an exchange and incur that risk, or you can hold them yourself and incur the risk that you'll lose them in some way. But you get to choose.
This is patently false. My bank, Fidelity, lets me send domestic wires (which are virtually instantaneous) for free. (Fedwires actually cost most customers virtually nothing.) International wires aren't that much more expensive, with the majority of the cost for small transactions being antifraud. In that respect, every cryptocurrency is orders of magnitude more expensive than the status quo.
Perhaps your bank is different, but googling "international wire cost" brings up links like these:
- https://smartasset.com/checking-account/average-wire-transfer-fee
- https://www.nerdwallet.com/blog/banking/wire-transfers-what-banks-charge/
Just google it though. It's the most common way to send moderate sums of money in the world. And yes, pretty much any retail bank or credit union will offer wiring, probably for a fee.
That is, something that blockchain is clearly and obviously the use case for.
"Potential" goes only so far. Eventually you need kinetic.
I suspect not too many drug dealers or gun runners want to wait around 20 mins staring at their phone (with a traceable internet connection) for 2 confirmations before declaring the deal "done"...
The seller still needs to make sure the buyer can't get a transaction transferring the coins back into a wallet under their control confirmed before the seller can move them out.
(I'm now vaguely curious about how the financial transactions on shipping container sized sales of guns/drugs work. But I'm not about to Google _that_...)
* Decentralized digital Asset ownership verification. Again, imagine facebook without a facebook. Or imagine purchase a music or software token that you could use on any provider, and never expired. Sign up for a new streaming service and take all your songs/videos/games with you from the old one.
* All the legal structures of a company, purchased off the shelf, handling all the vagaries of human resources and accounting, but without managers or payroll accountants. Just remote teammates, who may never have worked before, but know they will get paid a salary, receive evaluations and promotions from their peers.
These are just toy examples, I'm sure if I took more than a few seconds, I could give you much better ones. The problem with blockchain isn't finding applications - it's finding monetizable ones.
All the examples above would make amazing open source projects, but IMHO would be very difficult to generate revenue without compromising their decentralized nature, by inserting oneself into the transactions to take a cut. Centralized control of an application is almost a requirement for monetization, and, blockchains, are, by definition, intended to circumvent centralization.
Moreover, trust and verification aren't new problems, and we already have plenty of centralized solutions for these problems. So, blockchain applications both have to be better than what was there before, and work around the decentralized nature of the system.
Consequently, people trying to make a living on the blockchain mostly resort to monetizing the networks themselves - in other words, developing cryptocurrency-like products of some form. Is this decentralized? Not entirely, but it's less centralized than what came before. If people disagree with the behaviour oof the ethereum foundation, they can fork the currency. However, this still a long cry from actual decentralization. It is certainly an open question what value 'kindof-sortof' decentralized networks provide.
* Digital assets ownership ultimately only require external sources of truth for storage of whatever digital asset they intend to provide. I concur that this would be impossibly expensive to provide via an existing blockchain implementations, without an external point of truth, but still a technically possible feat.
* An entire company on the blockchain? Sure, it's not reasonable at the moment. It was just an attempt to paint a bigger picture. The fact that it's 'not yet reasonable' is why many people are starting to try. By the time it's 'reasonable', someone will have done it.
There are about 500 articles every week about China's "social credit score" dystopia, and you want to put that on the block chain?
An decentralized credit score would have you scored by your peers. An anonymized one would only be evaluable when you chose to use it.
Could it present some heretofore unimagined dystopian situation? Sure, but the question was whether there was an application, not whether it was a good idea to build it :)
Moreover, reputation systems aren't inherently dystopian (or all encompassing like a social credit score, ftm), or we wouldn't have the long standing real-world ones.
This reputation system is one application I'd really like to see in the future. It's silly that we have sepearte silos of reputation (eBay, Amazon, credit scores, etc.) that are each controlled by a company. In our increasingly global world, who would we trust to govern this system? Seems like a legitimate application for a blockchain (including consensus).
Don't really see what's hand-wavy about your parent comment tbh, the link you posted doesn't seem to address common scenarios like 51% attacks or even why our current system is flawed. The only tangible thing I can find in there is that they don't like trusting verisign - which is fine but really a weird narrative to demonstrate why the world needs that particular implementation.
In the link that was posted, a pollution of a distributed root zone will vitiate the entire Internet's DNS. That is the vulnerability, and there are many attacks that will achieve that for the link that was posted.
Beyond that, some games are using public blockchains to track ownership of game items.
For example, property records. Right now there are considerable checks and balances needed to ensure there aren't funny things going on with the books when they are locked away at night.
This isn't as pressing an issue in the US, but it is a massive problem worldwide. Central governments in some countries want to be able to track property without the record keepers stealing it.
I don't think we'll see this widespread for the next 20-30 years. But imagine when existing power structures have absorbed this tech and they can then sell it - like VISA selling a block chain property registry to countries where the money is auto transferred in local currency from one end user to another while communicating to the countries central bank... maybe with tie in to bio metrics for ID and transaction verification and automatic tax payments.
Hardly a disruption from existing nation state and corporate power structures, but definitively a disruption in the possibilities of what can be offered.
The biggest problem is that decentralized systems tend over time toward recentralization. That pressure will not go away, and it can only be fought against if there is no friction in the decentralized system.
(finding actual convincing use cases in the medical space for this tech is hard)
But seriously, isn't this putting the cart before the horse? The usual order is "find a problem, build a solution", not "find a technology, build a solution, work out who has a problem it can solve". How's that working out for you?
Sadly, I feel like this could be used to describe most applications of "blockchain technology".
Well, there is a whole industry of universities of finding a technology and then licensing it out or spinning a company off to do something with it. It may be that it's very hard to do if you don't have all the things a university does going for it, but it does work in some cases.
Another way to look at it is to consider that if a technology excels at offering capabilities in a certain domain, and a certain industry is known to require capabilities in a certain domain, if there is a good fit for it, it will probably eventually be deployed there. But if you can be first, there's likely money to be made. In that respect, I imagine a "CEO of a medical blockchain startup which is trying to find actual meaningful use cases" is really just someone (or a small group of people) doing intensive research to try to locate the match if it exists and be the first to provide it. A gamble, but one okay odds given the potential payoff.
Kinda sorta, but that's a difference in kind.
Most university research tends to be "basic research", meaning that it tends to be focused on understanding how things work rather than developing anything that is immediately useful.
In the course of doing that, sometimes something immediately useful is developed -- but that's not the most common case.
This sort of research is not "finding a solution, then looking for a problem to solve". It's simply trying to figure out how our world works.
That depends on who you mean by "they". The researchers themselves generally don't give this any thought. The university administration, however, is always hoping for additional revenue streams.
We should consider the following:
A startup can have a product offering and also be the product itself.
I struggle to think of a use case for this in healthcare.
It's a slow process, for exactly the reasons you describe- in fact, I've quoted that exact same line of reasoning many times myself.
The reason to work in this area regardless is because there are definitely large opportunities long term.
If you don't mind me being more nosy, are the long-term opportunities in this exact line of business? (i.e. do you think that one day medical records will be routinely stored on a blockchain?) or is it more than developing skills and capability with both blockchain and health tech will be valuable in the future?
I find the private blockchain technologies (Hyperledger Fabric, Hyperledger Sawtooth) superior for these types of applications especially since Fabric implemented private data.
Also is good for supply chain tracking.
But I understand why people avoid the blockchain space altogether. There was so many bad projects that were not suitable for the tech when all the hype was going on. Not to mention all the cryptocurrency scams. Fortunately a lot of the private blockchain tech has nothing to do with cryptocurrencies.
I hope he doesn’t read hacker news. The vague talks, exaggerated claims, and unfinished research projects here would give him an aneurism!
One problem is blockchain is good for identity but not so much access/authentication.
If it's the access/authentication layer activity, I don't see what blockchain really brings to the table.
To the content - there is only one way to place data on the cloud that is impervious to all global state, corporate and nefarious actors. That is with a robust blockchain. Whether or not you think that is useful in medical records is another story.
I've been a medical doctor for 10 years and think that it is.
All medical records are encoded as transactions between doctors and patients - that is, if person A is diagnosed with medical issue A by Doctor A, a public transaction is sent from a patient, via anonymized address, with a few bits of information:
- Amount (public due to nature of transaction on blockchain)
- Doctor (public due to complexity of anonymized destination addresses on blockchain, lets not solve impossible problems)
- Encrypted with the public key of the Doctor, the medical record
- Encrypted with the public key of the Patient, the medical record again
- Public, well-known "code" for some medical transaction, for example "code 1" could be a checkup, "code 2" could be a heart-transplant - I'm completely unfamiliar with the medical world so I suspect this system most likely already exists
- Encrypted with the public key of the Doctor, a random UUID identification code
This would allow Doctors offices to collect all their records by reading thru all transactions. Offices could validate that the patient correctly filed the transaction before accepting the transaction, and one can imagine software such that patients could easily file the transaction without having to copy the medical records, etc.
Additionally, using the public key of a doctor, one could verify that similar medical procedures were priced fairly compared to their own (ie: you could see the average cost of checkups, etc). This is most likely a naive assumption about pricing in healthcare, but maybe a good feature thanks to blockchain?
It would be particularly neat if it was powered by a contract, via something like Ethereum - You'd still need a bit of government help, but:
- Retrieval of medical data by the Doctors office is signed by a secret key contained in a contract oracle. When data is retrieved, it's signed with a timestamp indicating when the data was obtained.
- Laws requiring that valid signatures for valid timestamps from the contract oracle accompany _any and all_ use of medical records.
- Assuming the fines were steep and enforced, medical records could not be used for longer than a certain date, could be invalidated, and could be "observed being observed" by the patient.
In other words, assuming minor changes in the legal/medical system, the blockchain could actually be used to create immutable records of medical transactions, protect patient privacy, etc.
But if to accomplish this blockchain _also needs_ a trusted 3rd party and law enforcement... Then i'm not sure how it's better than any other application, except that it comes with a free globally available API, which is not actually a bad feature. Just not world-changing is all.
Can you explain how blockchain is useful for this in a more nuts-and-bolts way?
I say this having also been a medical doctor for 10 years.
I already did, because it looked like a clear invocation of the "appeal to authority" fallacy.
While being an MD can provide insight (depending on the nature of the doctor's practice) in terms of how things impact the practice of medicine, being an expert in a field only really matters when discussing topics that are in that field. Outside of their field, an expert's evaluation carries no more weight than anybody else's.
hey, it's me, your blockchain developer