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.” [1] It is a technology that has been cited as a potential solution in a range of different domains—from currencies to banking to business contracting. An article by Funk and colleagues suggests that it could play a role in healthcare professional education. [1] Are they correct?
Blockchain is a difficult concept to explain. It is basically a software protocol used so that a group of independent peers can reach a consensus that certain things have happened and so that they can each have a record that these things have happened. A simpler way of explaining this is by using the street football analogy. [2] Imagine a group of children playing football in the street. There is no referee; there is no written record of the score; nobody is filming the game; and children join and leave at will. It sounds like a recipe for chaos and yet the whole thing works. Why? The reason is that all the children know the rules (the protocol) and they follow the rules by agreeing among themselves (consensus); they are all in charge (decentralized); and they all keep a record of the score in their heads (distributed ledger).
It sounds like a long way from how the General Medical Council does things—and it is. It is the opposite of command and control. Funk et al describe a range of applications to healthcare professional education. The last one—where they describe decentralized and open credentialing—is perhaps the most convincing. A healthcare professional education blockchain could enable a public, open, and distributed ledger of the credentials, skills, performance and outcomes of healthcare professionals. It would be available to employers, patients, and other professionals. It would enable healthcare professionals to credential and have a record of their credentials in specific areas of practice in a trustable and transparent way.
But there are reasons to be sceptical about blockchain and its application to healthcare professional education. These are less to do with healthcare or education and more to do with the technology and theoretical underpinnings of the technology of blockchain. Firstly, blockchains use a massive amount of energy to work. Secondly, the people to whom the blockchain is distributed are not always independent—they can join together into teams and can then undermine the security of the data in the chain. Thirdly, blockchain can be slow and therefore difficult to scale. Lastly the concept of a distributed ledger means that the delivery of the blockchain is inherently inefficient. This is because “all of the nodes that maintain a blockchain do exactly the same thing.” This duplication means that the ledger or record is distributed and therefore held by large numbers and so trusted. But it is not efficient. To draw another analogy, you could put one hundred locks on the front door of your house—it would be safe and no one would be able to break in—but it would hardly be efficient. And yet trust is important in credentialing and in continuous professional development. In BMJ Learning we are regularly asked about the security of the site and the measures that are in place to ensure that the users who receive the certificates are the same as those who have completed the modules. The simple answer is that we use standard secure passwords that are personalised to the individual user and that this works: we haven’t had problems.
So, should you invest all your bitcoins in blockchain for healthcare professional education? Like any other investment, it comes down to what you value. How would you weigh transparency, security, decentralisation and trust against speed, efficiency, sustainability and scalability?
Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology.
Competing interests: Kieran Walsh works for BMJ Best Practice, which produces a range of clinical decision support resources in neurodegenerative conditions.
References:
- Funk E, Riddell J, Ankel F, Cabrera D. Blockchain Technology: A Data Framework to Improve Validity, Trust, and Accountability of Information Exchange in Health Professions Education. Acad Med.2018 Dec;93(12):1791-1794.
- https://martinjeeblog.com/2017/10/10/the-best-blockchain-analogy-ever/
- https://www.enterprisetimes.co.uk/2018/10/15/blockchain-disadvantages-10-possible-reasons-not-to-enthuse/