Blockchain Technology: A Data Framework to Improve Validity, Trust, and Accountability of Information Exchange in Health Professions Education

Abstract

Health professions educators face multiple challenges, among them the need to adapt educational methods to new technologies. In the last decades, multiple new digital platforms have appeared in the learning arena, including massive open online courses and social-media-based education. The major critique of these novel methods is the lack of the ability to ascertain the origin, validity, and accountability of the knowledge that is created, shared, and acquired. Recently, a novel technology based on secured data storage and transmission, called blockchain, has emerged as a way to generate networks where validity, trust, and accountability can be created. Conceptually, blockchain is an open, public, distributed, and secure digital registry where information transactions are secured and have a clear origin, explicit pathways, and concrete value. Health professions education based on blockchain will potentially allow improved tracking of content and the individuals who create it, quantify educational impact on multiple generations of learners, and build a relative value of educational interventions. Furthermore, institutions adopting blockchain technology would be able to provide certification and credentialing of health care professionals with no intermediaries. There is potential for blockchain to significantly change the future of health professions education and radically transform how patients, professionals, educators, and learners interact around safe, valid, and accountable information.

Health professions education (HPE) is in constant change and must adapt to address advances in biomedical sciences, improvements in learning theory, new regulatory policy, technological innovation,¹ and efforts to have health care professionals perform at the highest level of competency.² Recently, digital platforms,³ online learning,⁴ massive open online courses,⁵ and social-media-based education⁶ have become powerful forces shaping medical curricula. These innovations are built over the World Wide Web,⁷ a distributed network designed to allow reliable creation and rapid transfer of digital content.

This network is extremely efficient for sharing information,⁷ but its structure does not intrinsically allow for source and validity verification.⁸ As such, it is often difficult to judge the accuracy and legitimacy of the content found on the Internet,⁹ which can make it difficult to trust¹⁰ the information contained therein.¹¹ A new framework called blockchain¹² has been recently developed that allows for the creation of trust and value in networks.

The implementation of blockchain in HPE has the potential to help solve many of the challenges currently facing academic administrators, faculty, learners, and institutions. By generating trust and value in informational transactions, blockchain can help improve HPE.

In this article, we will first provide a basic explanation of what blockchain is and how it works, including a brief explanation of Bitcoin, the most easily recognized implementation of blockchain. We then offer three examples of how the novel network attributes of blockchain might be applied to HPE.

Blockchain Technology

Blockchain is a novel framework that provides a new architecture for storage and exchange of information among members of a network. Like any network, blockchain consists of users exchanging data between each other.¹³ The difference between existing networks and blockchain lies in how data transactions occur, and how the data are then stored and secured. Although these differences initially seem obscure and irrelevant, they have profound effects on the applications available to users, from economists to educators.

To illustrate the basic concepts of blockchain, imagine two users who are transferring data from one user to the other (Figure 1). At the moment of a blockchain network creation, an original or initial block is created (known as the genesis block), which will serve as anchoring block and will also define the type of data and transactions in the network. Data are recorded when User A initiates a transaction to send a piece of information to User B by broadcasting their intent to make the transaction to the entire network. A different subset of users, called miners, are network members who listen for these requests and record the transactions into blocks. The role of the miner can be understood as a freelance registrar who gets compensated by their work. A block is a list of all the transactions, grouped and recorded together by miners, that the users make during a set amount of time. The miners then add the current block (list of transactions) on to the growing list of blocks that have been recorded previously. The term “blockchain” is derived from this data architecture, whereby each subsequent block is chronologically linked (chained) to the previous blocks. The recording of transactions into blocks, and the addition of new blocks onto the blockchain, is secured using high-level mathematical instruments that are beyond the scope of this article and, moreover, are not necessary to understand the overall concept.¹⁴ After the addition of the most recent block, the miners broadcast to all members the recent change, and all of the data in the blockchain are publicly available to every single user in the blockchain network.

Figure 1: Blockchain technology: mechanism for transaction.

Simply stated, blockchain is a software solution protocol for reaching consensus within a decentralized group of peers, that events have occurred and that each event is recorded in an indisputable historical ledger, of which each peer has a copy.^14,15 It may be helpful to think of blockchain as akin to a group of children engaged in a playground football game. There is no referee, yet the game is played successfully because all of the children know the rules and generally play according to them. There is no scorekeeper, yet they all agree on the score, keep it in their heads, and often call it out loud. When a foul is committed or a touchdown disputed, they quickly reach consensus and continue the game. No single child can change the rules or the score by him- or herself, and any child can leave or join the game at any time, as long as she or he accepts the current score.¹⁵ Although the analogy eventually breaks down, playground football—like blockchain—is a simplified example of a peer-to-peer network achieving an indisputable decentralized consensus via a distributed ledger.

Several aspects of blockchain are unique compared with previous network systems such as the World Wide Web. These characteristics provide the substrate for new applications and explain the potential of blockchain. First, blockchain is a decentralized system. Rather than having to obtain the permission of a central authority (e.g., bank, government, credentialing board) to make a transaction, users can collaborate primarily. Information does not need to be passed from one user to a central node and then out to another user, as is the case with previous centralized network systems. Rather, it can be passed directly from user to user,¹⁶ increasing speed and usability.

Another important feature is the immutability of the blockchain. Once a transaction between two users has been made, that information is publicly available to every single member of the network. This allows each individual user to follow the trail of data between members of the blockchain network, stretching all the way back to the creation of the blockchain.¹⁴ All users in the network are witness to the fact that the first user is no longer in possession of the data, and that those data now belong to the receiving user. Therefore, if a user sends a unique piece of data to another user, then tries to cheat the system by sending it to a third party, their subterfuge will be immediately discovered. The entire network recognizes that it is no longer in possession of the data, and thus members are prevented from making the fraudulent transaction.

Finally, blockchain has a profound impact on the necessity of trust. With current networks, all users must trust that a central authority will store the data appropriately and allow users to control the data as they wish. Central authorities are very easy targets for outside attacks and can be easily compromised by internal sabotage. This contrasts with a distributed system like blockchain that gains its authority from the collaboration of users and completely transparent records. Rather than relying on trust in a central authority, no trust is needed to use a decentralized system because all users can verify the relevant aspects themselves.¹⁷

Bitcoin as an Example of Blockchain

The most easily recognized application of blockchain technology is cryptocurrency. Bitcoin was the very first example of blockchain technology, and its primary application is as a cryptocurrency.¹² The Bitcoin blockchain records the amount of currency each user owns, as well as a recording of all the transactions that have taken place between users. As with any blockchain, the data are stored in a decentralized manner, open to any individual, and secured by the distributed nature of the data and the cryptographic mathematics behind it. Any person can buy, own, and sell Bitcoin, and any person with an Internet connection and enough disposable computing power can download the appropriate software and become a miner, the incentive for mining blocks being an amount of new Bitcoin that is rewarded to the miner who creates each block.¹² The invention of blockchain technology with Bitcoin revealed the many advantages of blockchain networks over previous network archetypes. Blockchain has already had a large impact on the financial and economic fields from which it came, and will continue to expand into new areas.¹⁴

Blockchain Technology in HPE

Blockchain technology in HPE has the potential to help solve many of the challenges currently faced by academic administrators, faculty, learners, and institutions. An educational blockchain could contain information about learners, teachers, content, evaluations, outcomes, performance, and degrees conferred that encompass the totality of the learning process.

Educational blockchain allows for the creation of educational structures that have a clear origin, a responsible author, reviewable information, and a known publication time. This information framework, with measurable public exchanges between learners and teacher, allows for the transmission of content, feedback about the instructional designs, evaluation of learners, competency assessment, and certification. This flow of information can lead to rapid, efficient, transparent, and explicit management of the education instruments, which provides increased internal validity that generates trust in the products.^10,16 In the following paragraphs, we describe three potential applications of blockchain to HPE.

Educational Value Units: Value-Based Education Portfolios

Clinical educators face challenges achieving advancement and promotion in academia, which is often attributed to the difficulty of documenting, tracking, and assigning a value to educational activities, especially the impact of their bedside teaching in learners, systems, and institutions.¹⁸ Several initiatives have been implemented or proposed, such as educational portfolios^19–21 and educational value units,²² to overcome these challenges.

A blockchain-based structure for the recording, crediting, and appraisal of educational deliverables could be a robust way for educators to track the value that their academic and system achievements create. For example, a medical school’s blockchain-based curriculum could link blocks of curricula to the faculty responsible for their course or block. Curriculum evaluation then would take place in the blockchain system, where the most highly used, most validated, and better-evaluated deliverables could be easily identified and the authors rewarded accordingly. This framework can also be adapted to record the time faculty spend teaching, creating the learning material, and mentoring. The verification and legitimization of this would occur because these efforts and achievements are transparent for all users (students, teachers, institutions), leading to the stakeholders’ consensus about the merit of the work done.^16,23

The blockchain could also record the impact educators have on their learners. The effect of a teacher could be tracked down generations of learners, as all of them would remain connected in a chain. For example, a teacher could get nominal credit for the work of mentees and previous learners, or automatically get credit for an entire class performing above a certain threshold. Again, these transactions would be explicit and transparent and would allow for the creation of trust and value¹⁷ of educational activities as educators would have clear provenance, unambiguous work, and now a method to track and measure outcomes separated by large periods of time or geographical distance.²⁴

Competency-Based Medical Education and Entrustable Professional Activities

Integration of the blockchain into competency-based medical education (CBME) and entrustable professional activities (EPA) is possible and would be relatively easy to achieve.²⁵ As educational communities define the necessary competencies (e.g., the CanMEDS framework)^25–27 and associated EPAs representing the clinical behaviors to be achieved and observed,²⁸ blockchain would work as a digital ledger of observed behaviors, directly addressing many of the challenges of CBME.²⁹ It is open and public, where learners can have a better understanding of their performance relative to their colleagues and established standards. The system is flexible in time and space (asynchronous and not bounded to location), which would allow faculty to assess behaviors and skills in real time, independent of those constraints. Evaluations and instruments would have increased internal validity, increasing trustworthiness.¹⁰ Blockchain could help facilitate the complete paradigm of CBME, where the learner progresses through a scaffolding of knowledge, skills, and attitudes at their own pace and location. This architecture would provide a clear and accountable record with well-documented achievements and milestones consistent with EPAs and competencies.^26,29

Decentralized and Open Credentialing

Health professions boards currently serve as accreditation bodies to ensure that a given provider has the knowledge, skills, and behaviors consistent with certain professional roles and specialties.^30,31 This system exists because of information asymmetry between the end user (patient or employer) and the medical establishment.³²

Currently, the process of obtaining privileges to work in a hospital requires a tedious application with addresses and phone numbers of all institutions, hospitals, and employers for whom an applicant has ever worked. A staff member then typically takes several months and many person-hours of labor to independently verify the applicant’s credentials. The process of getting a state medical license also currently necessitates an applicant taking a physical copy of a medical school diploma to a state representative to verify the paper diploma.

In contrast, if the curriculum, outcomes, and performance of a specific health care professional would be transparent and available to patients, employers, and stakeholders, then the need for a third-party credential guarantor is obviated. If a blockchain exists with a succinct and validated version of public records of training, knowledge, outcomes, and behaviors, the information asymmetry becomes null. The public, as well as employers, could then engage in direct trust transactions (becoming a patient or an employer) in an efficient and rapid manner. This same technique could be used for the development of other credentialing requirements, such as maintenance of certification or particular requirements such as training on specific procedures (e.g., robotic surgery) or skills (e.g., prescribing a particular high-risk medication).^33,34 Should this process be adopted, it would thereby be driven by the patient, provider, and employer, and happen in a public and explicit way.

Concluding Remarks

Blockchain is a novel framework that may help solve some of the challenges facing HPE. The concept of an open, public, secured, distributed, and autonomous registry allowing for the creation of value¹⁷ and trust¹⁰ within educational institutions could make the management of education systems faster, more reliable, and transparent, thereby increasing efficiencies while making the flow of assets and information explicit. This, in turn, would improve the internal validity and trustworthiness of the systems in question.¹⁰ The novel network attributes of blockchain might be applied to HPE in the implementation of competency-based education, creation of value-based educational portfolios and value units, and establishment of credentialing systems without third-party guarantors. These possibilities make the idea of an HPE system built on the blockchain promising, providing a potential infrastructure to facilitate the education and training of future health care professionals.

Acknowledgments:

The authors would like to thank Nico Pronk, PhD, MA, and Benjamin J. Sandefur, MD, for their critical review of the manuscript.