Eric M Fish is Senior Vice President of Legal Services at Federation of State Medical Boards.
The Federation of State Medical Boards might not seem like the most obvious place to find a home for a blockchain project. What got you started down the path of exploring blockchain solutions for healthcare?
Throughout American history, providing for public safety and welfare through professional licensure has largely been the domain of individual state jurisdictions. Well over 100 years ago, states began to establish state medical boards to protect the public from the unlawful and incompetent practice of medicine. A primary function of state medical boards is to set educational standards and assess competence of physicians. Creation, management, and evaluation of identity is a core component of this process and where the regulation of physicians intersects with blockchain and distributed ledgers.
In current practice, and before additional privileges to practice are granted to a physician, state medical boards and healthcare organizations must use primary source verified information to validate certain physician credentials and attestations, including medical school diplomas, specialty training or residency certificates, and licensure history. The primary source verification requirement forces the individual physician to request authentication of each identity attribute from the original issuing organization, such as a graduate medical education program, or governmental entity. Forgery of credentials and qualifications, including educational backgrounds and professional licenses, continues to be an issue that regulators face on a regular basis. Additionally, verification of credentials received from universities outside the United States is often time-consuming, and in some cases not even possible, such as in the event of loss of political unrest or loss of records in a natural disaster. These gaps contribute to an incomplete set of attributes and credentials that leaves regulators with a less than perfect picture of the identity of the physician under review. And the friction inherent in this process, from the pure number of verifying third parties to the inconsistent presentation of these identity documents, is widely critiqued as a regulatory burden.
The Federation of State Medical Boards created the Federation Credentials Verification Service (FCVS) in 1996 to address some of the issues associated with the fragmented approach to credentialing. FCVS serves as a centralized repository of verified, primary source records of a physician’s credentials that can be used during initial, and any subsequent, licensure and credentials applications. FCVS serves as the central repository over 300,000 physician records and the service is used in approximately 45% of licensing decisions. Although successful in addressing some aspects of identity management over the last 20 years, the FCVS reflects a system of recordkeeping that was designed for the paper world, and there remains a great opportunity to leverage technology to improve the product and further decrease the time and burden associated with credentialing.
Identity in a Digital World
About three years ago, FSMB Chief Information Officer Michael Dugan instituted an audacious plan to decrease processing times by automating many of the business processes associated with credentialing, resulting in a product that better met the needs of the physician and credentialing community. Part of this plan entailed the implementation of technology that would increase the trustworthiness of the information provided and relied upon, furthering patient safety by reducing the number of fraudulent or questionable credentials.
Michael deserves credit for instilling a systems-thinking approach to the redesign of FCVS. Processes were reviewed to cut out unnecessary steps and technological changes, such as use of digital signatures and electronic diplomas, were incorporated.
As part of this comprehensive review, Michael and I recognized that the solution to some of the incumbent problems was not to add another level of review or require additional documentation, but to rethink how data flows through the system and what the value of this data is at various points. As general counsel, my focus was on management of various component pieces (privacy, risk mitigation, and data management) that are part of the credentialing process. This realization occurred at about the same time that many of the non-currency based, second-generation use cases for blockchain ideas were being born. Following these developments, we both became interested in identifying if some of the promised advantages to using blockchain or distributed ledgers could be brought into the licensing and credentialing process. The pilot project, which we completed with our partner, Learning Machine, demonstrated that for educational credentials, blockchain has great promise to mitigate regulatory burdens without sacrificing transferability, reliability, physician data ownership, and trust.
How much of what you have achieving so far in terms of efficiency gains is simply down to going digital and how much extra do you anticipate will be saved from using blockchain?
Instituting technology to automate workflow and increasing the use of digital signatures and electronic notarization significantly reduced the processing time for licensure and credentialing applications. In 2013, the average cycle time was over 60 days. Today, because of these internal changes, cycle time is approximately 23 days, from the time the physician submits the initial application until the licensing or credentialing decision was issued by the third party. The reduction in cycle time responds to many of the challenges facing healthcare, as it reduces regulatory burden, decreases issues of fraud, and ultimately increases access to physician services. For each day of improvement in the FCVS cycle time, 16 full-time positions become filled. Although that number seems small, the impact on access to care is exponential.
An internal audit of cycle time illustrates the potential impact of blockchain. The FCVS processes are responsible for 33% of the time it takes to complete a credentialing application, leaving external sources and processes responsible for 66% of the processing time. No matter how efficient the FSMB becomes with its internal processes, there must be systemic change. Blockchain represents a potential opportunity to rearchitect the workflow of all parties.
How much resistance did you meet when you initially started exploring this and how much of a hurdle does educating leaders in public life continue to be?
Since its incorporation in 1912, the FSMB has worked on numerous projects to improve the regulatory process, from creating a unified licensing exam accepted by all state medical boards, implementing a uniform application for medical licensure, and most recently, supporting the development of the Interstate Medical Licensure Compact, which has greatly improved transferability and mobility of a medical license. Because of this history, the FSMB Board of Directors and leadership supported the exploration of blockchain and saw it as an organizational duty on behalf of its members to analyze the opportunities and risks for usage in medical regulation.
The larger educational hurdle comes when the idea of using blockchain for licensing and credentialing is discussed more generally in the healthcare community. Part of the initial resistance comes from the sordid history and constant media focus on the daily ups and downs of cryptocurrency. But more fundamentally, the resistance is born out of the very fact that decentralizing identity in a highly regulated space is to invert the known system and replace it with technology that may better represent the way patients, physicians, regulators and government interact in an increasingly digital world. Such a paradigmatic shift is understandably unsettling.
This resistance and anxiety is surmountable if blockchain is explained first by going back to the fundamental goals of medical regulation and applying the design thinking behind blockchain to the core principles of the regulatory process.
Is the real stumbling block to greater adoption of blockchain in the public sector a technical one or more of a cultural change?
The root of any success is to first get the culture right.
Technology will always move faster than government. The technical components of blockchain have shown the ability to meet or exceed currently technology used in the regulatory process. And to overemphasize any current technological failings is to miss the point, since the next iteration of that technology is already under development.
True adoption is possible only if the culture and thinking behind the processes is examined and there is agreement that blockchain can be implemented without sacrificing the known good brought about by the current approach to regulation. Getting to this point requires not just the implementation of a proof of concept but building that proof of concept into a larger redesign of the regulatory process for a digital age. Early collaboration between technologists, innovators, and regulators in the design of the governance structures of these systems is crucial. Collaboration is the only way to incorporate the technological and legal considerations necessary for the use of blockchain in areas of essential government services.
There are now over 100 government blockchain projects around the world – everything from land registry to voting to passports and so on – is there a country you admire in terms of the work the public sector there has achieved?
Comparison between public sector work in the United States and other nations is difficult. Many of the applications of distributed ledgers and blockchain address, such as licensure and land titles, would be in areas that are under the jurisdiction of each state. The United States would benefit from a systemic, harmonized approach to application of blockchain and distributed ledger technologies in the public sector. Certain states, such as Illinois, have taken a lead in studying the opportunities and risks associated with blockchain and distributed ledgers. Illinois is working to coordinate various levels of state and local government with the private sector to form unique partnerships and pilots, all designed as part of an effective strategy that may allow the promise of blockchain application in the public sector to be realized.
Globally, Malta stands out as the country that leads in the application of blockchain to a variety of use cases. The nation’s education ministry instituted an ambitious use of blockchain to issue and manage educational credentials using Blockcerts, the same platform used by the FSMB in its pilot projects. This pilot will be an important proving ground to monitor. It will identify areas of future need and, if successful, may serve to spur application and integration of blockchain into other facets of civil society. Joseph Muscat, Malta’s Prime Minister, referred to the decision to embrace distributed ledgers and blockchain throughout the public sector as a “calculated risk” to cut bureaucratic waste and improve economic prosperity. I believe the efforts in Malta represent something bolder and more admirable—impressive coordination and alignment across the public sector to think differently about the role of government in a digital world and how to leverage technology to deliver on the social contract.
What lessons do you draw from what you have done in the US that you think could be applied elsewhere, perhaps even in a UK context in the NHS?
The regulation of the practice of medicine, inclusive of the issuance of a license to practice and the subsequent enforcement of the rules of the practice, is essentially trust framework. Trust frameworks are usually discussed in the domain of commercial transactions, such as the rules surrounding electronic payment systems. All trust frameworks consist of a legally enforceable set of specifications, rules, and agreements governing a multiparty transaction. The same foundational principles that have been incorporated into the potential application of distributed ledgers in commercial sector trust frameworks apply equally to the regulatory system, with roles of banks and credit card companies replaced by state regulators, licensees, and the general public. The trust framework created by statute and rulemaking allows physicians to engage with a patient and provide medical care, and to do so in a relatively safe, consistent, and predictable manner.
If you had to sum up what it is about blockchain that makes it suitable to fix our ailing healthcare systems, what is the one thing people should take away?
Blockchain represents a new approach to solving an old problem. How do we structure a system of information for the goals of quality, reliability, transferability and efficiency while also improving regulatory compliance, quality and access to care. Current approaches may be unsustainable in an increasingly decentralized and deinstitutionalized culture, but blockchain may prove to be the foundation for the remaking of trust and regulation in a digital world.