A Link to a Better Marketplace?
By Kathy Hardy
Radiology Today
Vol. 20 No. 1 P. 16

Blockchain has the potential to connect digital imaging players more efficiently and securely than ever before, but can it overcome its limitations?

"A chain is no stronger than its weakest link."

This quote, by American philosopher William James, could be applied to the type of network necessary to successfully navigate the diagnostic imaging process. From referring physicians placing exam orders to radiology reporting, each step is a vital part of the process. What's driving the introduction of a relatively new technology called blockchain to radiology is the need to connect all participants in the diagnostic digital imaging process. In addition to more expedited processes, blockchain brings with it expectations that this technology will build new business opportunities for radiologists, as well as streamline access to imaging providers.

Blockchain, famous for its use with Bitcoin, is a technology that developers say could irreversibly link the data and information that connects radiologists with referring physicians. Described as a tool in creating a marketplace—or an ecosystem—for radiology, blockchain supports the development of an image management network that allows secure access by referring physicians, radiologists, treatment team members, and, eventually, even patients and their families. Blockchain, and its recorded attributes, incorporates a verification aspect that ensures stability of the network. Radiologists and radiology practices are credentialed and all transactions are validated and cannot be changed.

"The ultimate goal of the platform is to build a marketplace for radiology," says Michael Averbach, CEO and cofounder of Medical Diagnostic Web (MDW). "Using a blockchain platform makes the process transparent and fair to everyone involved. There's no taking advantage of any imaging facility or radiologist in the process. It's a marketplace for the people, by the people."

MDW introduced the first decentralized blockchain platform connecting health care facilities, radiologists, and AI companies. The platform is currently in a "closed beta" status, but Averbach says results so far are positive.

"This isn't just a concept," he says. "This is a working platform today. We have enough users on the platform now to be able to see a fast turnaround time from when the exam is done to when the radiologist provides a report and subsequently receives payment for services rendered."

Building Blocks
Blockchain consists of blocks of digital data linked together in an immutable chain in a manner that prevents any block from being altered. As each transaction occurs and the parties involved agree to the details of that transaction, it is encoded into a block of digital data and uniquely signed or identified. There's no opportunity for new data to cut in line—it's impossible to insert one block in between two existing blocks.

Blockchain allows for the secure sharing of records among network members, eliminating the need to reconcile disparate ledgers that can contain different types of shared data such as transaction records, attributes of transactions, and credentials. Each member of the network must have access privileges; information is shared only on a need-to-know basis.

Averbach says that the MDW blockchain platform addresses common problems within the digital imaging process, including service access, delivery, communicating results, speed of payment for services, and integration across the continuum of care. From a business perspective, MDW also enables transparency, allowing users to see an open record of transactions.

"Participants can see what's going on in the platform and, with that, can trust that the process is working in a fair and equitable manner," he says.

MDW utilizes an open, decentralized communications infrastructure, encrypted data transmission, and inalterable audit trails. MDW's blockchain marketplace enables individual radiologists and radiology groups to create new business relationships, Averbach says. He refers to the process as a "smart contract" for diagnostic imaging. Smart contracts automatically execute transactions and record information onto the ledger without human intervention. Smart contract conditions are mutually agreed upon by network members and are a key component for establishing trust and efficiency between parties.

"Radiology is a high-transaction operation," he says. "There are lots of data and lots of parts to the process. It starts with an order for the imaging. Then the image is taken, and the radiologist reviews the image and provides a report. That report needs to go back to the referring physician, and that information might eventually be shared with the patient. A blockchain platform enables there to be an immutable record of the process, from imaging through to payment transactions."

Opening Up the Marketplace
Averbach says blockchain could be applicable to other areas of health care; however, the practice of radiology lends itself well to the multifaceted discipline.

"In radiology, the workflow is a series of transactions," he says. "The more transactions there are in a process, the more blockchain-friendly that process is."

All transactions are maintained on the blockchain platform, which is like a database in that regard. Once a case is in the database, it cannot be removed. Images, however, are stored securely in the cloud, in keeping with HIPAA compliance.

One benefit is that radiology organizations can see immediate compensation for services rendered. In addition, they gain access to resources on an as-needed basis to transact with new clients, increase reading volume, and decrease turnaround times from imaging to reporting.

Averbach adds that global data sharing helps to eliminate major issues such as IT interoperability, scan duplication, access to current and prior exams, and continuity of patient records.

To contract for imaging reading services through the MDW blockchain platform, users purchase blocks of exam interpretation credits, creating a "cabinet" on the system through which they interact. They can select any willing provider who is a part of the system.

"Through the cabinet, radiologists choose the work they want to take, post reports, and conduct other services related to the work they take on," Averbach says.

Radiologists need to be credentialed to join the platform, he says. In addition, they will only be able to take assignments for which they are licensed.

There is also no fee to join the platform, he says.

Once imaging specialists submit their report, payment credits are immediately applied to their account through a secure blockchain transaction. The system also allows imaging specialists to withdraw credits as cash immediately following the deposit.

"The MDW blockchain platform has the ability to revolutionize health care delivery because of its innate ability to support communications, workflow, transparency, and accountability to form an open, fair, and decentralized marketplace," Averbach says. "The possibility of new and creative partnerships to bring a full range of medical skill sets wherever needed is limitless, when organizational structure and geography become irrelevant. It's a win-win for everyone involved."

Strategic Decision
Another company linking its efforts to blockchain is teleradiology service and technology provider NucleusHealth, which uses Ethereum, an open-source, public, blockchain-based distributed computing platform. According to Chris Hafey, chief technology officer of NucleusHealth, Ethereum serves as a common point, bridging processes between users.

Hafey says there are a number of different blockchain technologies, some proprietary and some open source. There are similarities among them but enough differences that interoperability could be a problem. Since beginning to implement blockchain approximately one year ago, Hafey says NucleusHealth is optimistic but has seen mixed results.

"We've made more progress than expected and less progress than expected," he says. "On the positive side, we've experienced fast movement and innovation, more tooling, robust infrastructure, and increased number of choices for how to initiate blockchain projects. There has also been more understanding in the industry regarding how blockchain is different and why it's important to use."

A factor that has hindered blockchain's progress for NucleusHealth, Hafey says, is the speed with which the technology is evolving. Enhancements are good for productivity but make it difficult for implementation and could be slowing adoption.

"By the time you can get the technology implemented, it's almost outdated," he says. "We've implemented Ethereum twice but haven't productized it, due to changes with the technology. The technology is moving so quickly that it's creating a more conservative mindset among decision makers. They want to implement blockchain but hate to do so and then find that there's a newer version."

Also, because blockchain is a permanent storage device, Hafey says there is some caution involved in making the decision to implement.

"As compared to other technologies, blockchain can't be changed once it's been implemented," he says. "If you switch blockchain technologies after implementation, you won't have an immutable record anymore. The big question is, 'What is the right blockchain technology and when will it be ready?'"

Another factor to consider is how well the selected blockchain technology handles the high transaction rates experienced with radiology. A standard EHR system can handle 1,000 transactions per second, while Ethereum can currently handle only five transactions per second.

"Who wants to invest in a technology that won't allow the business to scale?" Hafey says. "And to improve scalability, will you have to make compromises in other areas, such as security? Scalability is a concern within the industry. Blockchain would become more of a niche product if this issue can't be fixed."

When making the decision to implement blockchain technology, Hafey recommends coming up with a comprehensive strategy.

"Implementing blockchain isn't just a one-off decision," he says. "You want a regionwide view. You want to consider how it will work with your image-sharing methods and your PACS. If this is the blockchain technology you want to adopt now, will it still be the blockchain technology you want to be using 10 years from now?"

Increased market awareness, through speaking at conferences and other educational efforts, will help bring attention to the potential value in using blockchain to create a marketplace for efficient and cost-effective radiology transactions, Averbach says. It could just be a matter of tightening up the weaker links in the chain.

— Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania. She is a frequent contributor to Radiology Today.