NumbERs

technology, autonomy, privacy, medical credentials: Physicians on HPEC by SpecialtyFigureThe concept of identity cannot be taken for granted in an increasingly digital world. Our digital identities, more than our real-world identities, are complex, sprawling, mutable, inconsistent, and vulnerable to attacks. Defining what exactly constitutes a digital identity—and who owns those data—is critical to our ability to use digital information to exchange money and information. Individuals must also be aware that these data are valuable and that privacy and autonomy are frequently eroded to capitalize on their value. Emergency physicians often worry about a parallel process occurring within our specialty: an erosion of autonomy (and privacy) due to an increasingly complex professional structure overseen by companies paid to navigate the business complexities on our behalf. This parallel is even closer than it may initially appear: The disparate systems (educational bodies, employers, hospitals, credentialing bodies, insurance companies, etc.) that comprise our professional identities are just as sprawling, mutable, inconsistent, and vulnerable to attacks as our online accounts. Our lack of autonomy over our professional identities leaves us vulnerable to professional exploitation. I discussed this problem with Leah Houston, MD, the founder of Humanitarian Physicians Empowerment Community (HPEC), a company that aims to protect a doctor's professional identity using blockchain technology. “HPEC uses decentralized identity to make the individual the owner and single point of control over their credentialing and identity information,” she said. “You paid for medical school, your degrees, and your medical license. All of these credentials are actually owned by you, but because there has never been a way to authenticate your ownership, physicians have had to use third-party systems for verification. HPEC is an automated primary source verification tool.” ‘Truth Machine’ The solution proposed by HPEC is already being used to address other issues surrounding digital identity; it is called decentralized identity (DID) based on distributed ledger technologies such as blockchain. “Blockchain” is a buzzword that conjures images of bubble markets, fraud, and Bitcoin bros, but it is really best thought of by a nontechnical person as a system of trusted recordkeeping. Anytime a user adds a new piece of information to the record (logging events into the system as transactions or additions), that new record is permanently linked to the old record. Every user can track and verify each of these transactions as they occur; the security comes from there being no single “owner” of the transaction record, which is why it is called decentralized. DID solutions are already being explored by several large companies, including IBM and Microsoft. “Blockchain creates a truth machine because you cannot delete or erase any of the blocks on the chain,” Dr. Houston said. “Once we get our medical degree, that should be documented permanently and not controlled by an entity that could delete or erase it. We hash-proof that your degree was issued onto the blockchain, so when you want to show your degree, it comes along with a provenance log that points to a place on the chain that proves the credential is authentic.” Participants in DID solutions are given an encrypted digital wallet that holds their credentials. Verified information (such as a diploma) can be placed by another verified user (such as a medical school) into the wallet, and this information, controlled by the user, can later be shared to communicate and verify credentials immediately and securely. “The average cost to credential a physician is around $1500 every year,” Dr. Houston said. “Rather than third-party systems making lots of money off of selling our data, we are providing a mechanism for you as a physician to truly own your data.” HPEC's goal is to provide a more streamlined, secure tool for traditional credentialing services at a substantially reduced cost. It costs nothing to join or to use its services, Dr. Houston said, and the app is also free to download and use. The company may add services in the future that physicians could purchase, but the current version will always be free, she said. Liberating Physicians “We want to create a network that allows us to collaborate towards common goals with regards to advocacy, legislative issues, or things that affect our practices right now,” she said. “Our medical societies are conflicted; they have failed us. HPEC allows physicians to find each other and be found. With proper architecture, we can design consensus mechanisms for discussing problems, delegating, and voting on major issues.” It was clear from my discussion with Dr. Houston that HPEC's ambitious goal is to liberate physicians. Allowing us to own the credentialing process permits us to move ourselves more easily to other states and medical practices, potentially increasing our own leverage. Having a secure way to associate freely lets us gain the ability to form ad hoc unions, advocate for important issues, and collectively compete in other ways. Extrapolated even further, decentralized health data could revolutionize what it means to be a patient seeking medical care. I have to say that I pursued this interview with great skepticism, a characteristic that is often advantageous in emergency medicine. We are apt to mistrust things we don't understand; blockchain is a concept that emergency physicians will likely encounter as novices rather than with our typical expertise. This startup company, while attempting to apply a new technology to the famously rigid business of medicine, is also navigating the difficult business of simply being a startup. A skeptical mindset is a valid starting point; novel, conceptually difficult technology pushed by a startup comes with real risks. Even so, it would be foolish to dismiss ideas because they are new or employ technological advances. Every good idea was new at some point; this one has significant potential and certainly deserves open-minded consideration. Dr. Belangeris the secretary of the American College of Emergency Physicians Locum Tenens section and an emergency physician in McKinney, TX. Read his past articles athttp://bit.ly/EMN-numbERs.