Superb!
Thanks Edward -I've put this in my back pocket.
We should workshop this to find out everything that can go right and
wrong for all stakeholders - from the patient to the politicians.
It would be nerdy bliss.
On 30/10/16 19:24, Edward Picot wrote:
I've now made so many unsuccessful and partially-successful attempts
to get my head round the Blockchain concept that I'm starting to think
I might have some form of early dementia.
However, there's one field in which I dimly understand what the
implications might be: namely, the health service, where I work. Since
the Labour government introduced the 'Payment by Results' system into
the NHS about fifteen years ago, and then the Conservative government
put groups of GPs (clinical commissioning groups, or CCGs) in charge
of local health budgets, there's been no end of muddle about how to
get good reliable statistics out of the system as regards which
patients are being treated where, what they're having done, how much
it's costing, and which health authorities they belong to. The
blockchain is probably an answer to this problem.
Let's say a patient rings 999 one weekend because he's having a
heart-attack. The ambulance takes him to the local A&E department at
the Tunbridge Wells Hospital. He gets investigated, and after
investigation he gets transferred to St Thomas's Hospital in London
for a triple bypass. Then he's discharged to a Cottage Hospital in
Hawkhurst, and eventually back home.
At each stage of the journey he has incurred costs. First of all the
ambulance trust charges for transporting him (once to the Tunbridge
Wells Hospital, then from Tunbridge Wells to the St Thomas' Hospital,
then back to the Cottage Hospital). Then his A&E attendance and
investigations in Tunbridge Wells will all incur costs (via the
Maidstone and Tunbridge Wells Hospital Trust); then his treatment and
stay in St Thomas's (via the Guys and St Thomas' Hospital Trust); and
finally his stay in the Cottage Hospital (which comes under the
Maidstone and Tunbridge Wells Hospital Trust again).
Now, all of these costs and data about what treatments were carried
out, length of stay, drugs dispensed to the patient while in hospital,
etc, are supposed to find their way into our local health informatics
system, which is a big 'data silo', so that if we want to (or, more to
the point, if the CCG wants to) it's possible to 'drill down', as they
call it, and find, under the Cardiology costs for a particular
financial year, the treatment and costs for that particular patient as
a result of that particular health episode. The difficulty is that the
information has to be pulled in from various different trusts - our
local hospital, the hospital in London, and the local ambulance
service - and compliance varies from trust to trust. So the
information from our local hospital trust will probably be available
more or less straight away, the information from the ambulance trust a
bit more slowly, and the information from London a bit more slowly
again. Things can get even more complicated if our patient has his
heart attack while he's on holiday in Dorset - because all the costs
he incurs should still come back to the area in which he is a
registered patient, but of course a hospital in Dorset feeds back
information much more slowly to Kent than it would to its own health
authority. And things can also get more confusing if parts of the
patient journey, while still chargeable to the NHS, are carried out by
one of the private hospitals - let's say the patient, instead of
having a heart attack, has a cataract operation at a private hospital,
which is doing cataract operations on an NHS contract as part of the
Any Qualified Provider arrangements. The private hospital may not have
good arrangements in place for feeding back data into the NHS system.
A big part of the problem is that you've got all these different
organisations operating within the NHS - hospital trusts, ambulance
trusts, CCGs, individual surgeries, private hospitals etc. - and
they've all got their own bespoke computer systems with their own
bespoke ways of recording patient data, and it's a constant struggle
to get them to talk to one another. A blockchain distributed ledger
would surely be an improvement on the existing system. You'd just have
to enter a transaction onto the blockchain every time you performed
some kind of service for a patient - anything from a prescription for
paracetamol to a hip replacement - and as soon as the transaction was
recorded the information would be available from one end of the system
to the other, with the costs correctly allocated both to that
particular patient and to the patient's own health authority. Of
course you'd also have to record the same event on the patient's
clinical records, in order to keep an accurate clinical history, so
you'd either have to enter it twice, once on the clinical record and
once on the blockchain, or (much better) you'd have to get every
clinical system in the country to communicate with the blockchain,
which would probably be a lot easier than trying to get them all to
talk to each other.
So far so good. However, what do you do in the case of a patient where
you can't discover the NHS number, so you can't accurately say who the
patient is, where he's registered and where the costs ought to be
allocated? Let's say somebody's been run over in the street and is
taken to hospital unconscious, with no identification. Or let's say
it's somebody from abroad, or a refugee or illegal immigrant who has
never registered with a GP in this country. One option is to issue a
dummy NHS number and have some kind of 'miscellaneous' budget against
which the costs can be allocated. But the other option is to use the
system as a means of identifying people for whom the NHS doesn't have
to accept responsibility, and thus excluding or rejecting them. The
refugee, the illegal immigrant or the person from overseas, who
couldn't produce any evidence of valid NHS registration, wouldn't be
refused emergency treatment - not unless there was a really dramatic
change of philosophy - but if it was anything less than
life-threatening they might be turned away, or told that they could
only have treatment if they paid for it. And that's one of the
potential effects of the blockchain, as I understand it: it's so
efficient, that if you set the rules up in a certain way at the
outset, you'll end up disenfranchising people who are misfits of one
type or another. If you don't build some leeway into the system, you
can simply make it impossible for certain types of people to get
anything out of it. Presumably the same thing could happen to the
benefits system. And this, in turn, is likely to encourage a black
market. If you haven't got an NHS number, and therefore you can't get
treatment, the way round the problem is to steal somebody else's
identity.
- Edward
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