Blockchain tech in veterinary medicine

A case study on digital data

Steve Joslyn (pictured) graduated from Murdoch University and completed a residency in veterinary diagnostic imaging at the University of Glasgow. While on faculty at the University of Illinois he developed the clinical 3D printing service to assist with surgical planning in orthopaedics, ophthalmology and oncologic surgery. He was also involved with image processing techniques in pulmonary imaging with automated disease detection algorithms. He consults with referral and general practice hospitals on practice design, focusing on the imaging services and work-flow efficiencies. Steve started a new company, VetDB, which combines his passion for veterinary medicine and informatics, with new technologies such as blockchain and machine learning.

There seems to be increasing publicity of new and emerging technologies that have implications or benefits for veterinary medicine. We see them often listed together, and always with some success or proof-of-concept that was tested in human healthcare. Without attempting to group these together, they are often used in the same headline.

You could probably guess what I’m about to list: Virtual Reality (VR), Big Data, Machine Learning, Internet of Things (IoT), Wearables and 3D printing to name the usual suspects. However, there is a lesser understood cousin of these technologies that is sometimes listed, mentioned, referenced to human healthcare, and then perhaps forgotten.

Blockchain. 

It comes with many names, which may be part of the problem. Blockchain, Distributed-ledger-technology (DLT), and, of course, Bitcoin to name a few terms. Personally, I have been directly involved in veterinary technologies such as computer aided diagnoses, image processing, diagnostic coding, Big Data, 3D printing, machine learning, etc., but nothing excites me more than what is coming with Blockchain technology.

Blockchain has solved a big problem across many industries. However, the problem is so deep rooted in our everyday systems that we have simply come to accept it as normal. And then we ignore it.

The problem is trust.

Trust, or the lack thereof, is the mechanism behind middle men, central authorities, notaries, payment processors etc. We lack trust because there is so little transparency on everyday transactions and interactions. To mitigate this our financial services collect trillions of dollars’ worth in fees to provide a level of trust. In healthcare we close doors, lock our files, and make it very hard to collaborate. In a digital world, where everything becomes zeros and ones, amongst malicious actors behind firewalls and dark networks, dealing with valuable digital data is prone to copying, falsifying and corrupting; the trust issue has gotten a lot worse.

Bitcoin, the first implementation of Blockchain technology, solved the problem by removing trust, completely. “Trust-less” is the new term. Trust is no longer a factor. Bitcoin did this, through the use of cryptography and some other complex computational maths, and in turn developed a system of global truth. Distributed truth.

In the basic form, Bitcoin, and other blockchains, offer a transparent record for every user. Bitcoin, in the most fundamental action, is a ledger of who paid whom, how much and when. Starting from time zero, it knows the balances of each and every participant. “It” being the collective network. Each participant of the network has a copy of the entire history of bitcoin transactions. And every 10 minutes, their copy gets updated collectively. The important bit is that everyone can verify for themselves that they have the same up-to-date copy. Overall, this distributed truth becomes distributed consensus.

The same distributed truth is referenced at all times. It is therefore impossible, without tricking the entire network, to falsely claim you have an extra 100 bitcoin. Everyone can check their copy and see that is incorrect. It would be easier, albeit impossible, to go back in time, than it is to trick this distributed truth model.

Despite the complex maths behind blockchain technology, what I think is magical is that everyone, with absolute mathematical certainty, can verify that they have the same copy as everyone else. And if you pay Bob 1 bitcoin, for example, everyone can see that your address sent that address 1 bitcoin.

So, what the hell does this have to do with human or veterinary healthcare?

Well. We also have trust issues. Especially with respect to patient data. The integrity of data. The authorised access to data, and whether or not medical data has been changed. This applies to collaborative research, clinical medicine, patient/results pairing, patient confidentiality, and insurance claims. Data is valuable, it’s sacrosanct and it’s currently corruptible, untrustworthy, and inaccessible.

Currently we can’t trust that patient records are verifiably linked to the patient. Animals move between veterinary institutions and we have limited access to the complete medical history. And if we do, it may be PDF print-outs of clinical histories.

Blockchain technology provides us with a virtually free tool to solve the trust problem. Even without revealing the entire medical record for all to see.

Through complex mathematical functions or algorithms (eg SHA256, Merkel root signatures, public and private keys), we can anchor any piece of digital data to the blockchain – using just its signature. By doing so we time-stamp the existence of this data forever in the distributed ledger. We can reference back to it at any time, proving the integrity of whatever information we have, matching what was committed and proving it hasn’t changed. We can provide independent parties to check data authenticity themselves, without having to trust any one party. The signature itself does not allow you to reconstruct the original data or medical record and only those authorised to view records have access to it. But an impartial third party could easily attest that both untrusted stakeholders are using the same data, without seeing it themselves!

If we can prove the authenticity of clinical data at the start, we can prove the same state at the other end. We can control who has access to it, ensure it hasn’t been changed, ensure it hasn’t been falsified, and begin massive collaborative initiatives using verifiable data of which we can prove the purity with each stakeholder.

Blockchain technology in veterinary and human medicine solves confidentiality issues, but it also allows doctors, researchers, and health officials to trust that the medical data represents the correct patient, and that no one has altered it. Researchers can collect verifiable data in realtime without knowing the exact dog or owner – accessing just the relevant data. Clinicians can have immediate access to clinical notes across the animal’s entire journey from hospital to hospital.

Some blockchain examples which VetDB has developed include the ability for researchers to have instant real-time data on vaccinated populations (exact constituent strains, animal signalments, sites of injections, adverse reactions, etc.). They could see this live and verify the information themselves. However, none of the owner’s or vet’s information would be viewable, so nothing confidential is available.

For infectious disease outbreaks, local government could assess de-identified geospatial densities of the vaccinated population without revealing confidential information. This would help guide any eradication program for an efficient and targeted vaccination response.

Veterinary vaccine manufactures or the Veterinary Medicines Directorate  could issue notifications directly to the affected owners and clinics which have been implicated in a faulty batch recall.

Garbage in. Garbage out.

Blockchain doesn’t clean up data, or suddenly prove its authenticity. It helps various stakeholders ensure they are using the same data, but that doesn’t mean that data is correct, or even complete.

Large data collection initiatives like VetCompass spend a massive number of man-hours and resources cleaning up clinical data.1–5 New technologies like natural language processing (NLP) continue to have problems deciphering what one vet writes versus another, through various syntax differences, human grammatical errors or colloquialisms.3,5,6 Furthermore, a recent study found that over 35% of clinical problems discussed in GP consultations were omitted from the medical records.7 Surprisingly, this study also found that more than 40% of observed actions taken during consultation were omitted completely.

To use Blockchain technology effectively we need to be improving, automating and supporting robust clinical recording technologies. Remove the points of human data entry errors and make it easy for vets to work up their cases. At VetDB we are starting on this path by assisting veterinarians to collect reliable and verifiable data, and then securing it with blockchain technology. We have created a global digital vaccination certificate that links permanently to the animal’s microchip. Wherever that animal goes, a simple scan of the microchip will allow the attending vet instant access to the vaccination history. There are no physical cards or paper passports to lose, and it is impossible to falsify. Our tool scans the vaccine vial and automatically pulls the pertinent information meaning no writing or manual recording. We therefore save time for other aspects of the preventative health consultation.

As we build applications that produce verifiable clinical data, secured with Blockchain technology, we hope to start a new trend of high quality prospective clinical data collection. Open to immediate collaboration, powering big data initiatives, internet of things and other veterinary technologies. All of this to support the original primary care veterinary surgeon and maintaining privacy for them and the owner.

Bibliography

  1. Dórea FC, Sanchez J, Revie CW. Veterinary syndromic surveillance: Current initiatives and potential for development. Preventive Veterinary Medicine 2011;101:1–17.
  2. O’Neill DG, Church DB, McGreevy PD et al. Approaches to canine health surveillance. Canine genetics and epidemiology 2014;1:2.
  3. VanderWaal K, Morrison RB, Neuhauser C et al. Translating Big Data into Smart Data for Veterinary Epidemiology. Frontiers in Veterinary Science 2017;4. http://journal.frontiersin.org/article/10.3389/fvets.2017.00110/full.
  4. McGreevy P, Thomson P, Dhand N et al. VetCompass Australia: A National Big Data Collection System for Veterinary Science. Animals 2017;7:74.
  5. McCue ME, McCoy AM. The Scope of Big Data in One Medicine: Unprecedented Opportunities and Challenges. Frontiers in Veterinary Science 2017;4. http://journal.frontiersin.org/article/10.3389/fvets.2017.00194/full.
  6. Baldwin T. Vet- Compass: Clinical Natural Language Processing for Animal Health. 2016. https://people.eng.unimelb.edu.au/tbaldwin/pubs/clinicalnlp2016.pdf.
  7. Jones-Diette J, Robinson NJ, Cobb M et al. Accuracy of the electronic patient record in a first opinion veterinary practice. Preventive Veterinary Medicine 2017;148:121–126.

Delivering Innovation in Specialist Veterinary Healthcare

 A case study on Virtual Veterinary Specialists

Nuala Summerfield graduated from the Royal (Dick) School of Veterinary Studies and completed a residency in veterinary cardiology at the University of Pennsylvania, USA. She has spent the past 15 years working as a veterinary cardiologist in academia and private practice. Nuala recently created Virtual Veterinary Specialists (VVS), which is a multidisciplinary real-time telemedicine service designed to support and educate vets in general practice.

Times change. Yet, how quickly does change permeate into traditional professions such as the veterinary profession? Will this change mean that veterinary medicine is accessed and delivered differently in the future?

Here’s a scenario that we’ve all experienced:

A vet in general practice decides they need specialist help with a patient. This usually requires referral outside their practice. This decision to refer, or not to refer, is typically based on a number of factors, including how busy the vet is and their experience and knowledge of that particular specialty. Often a phone call is made to a specialist to briefly discuss the case, plug any decision-making gaps and confirm the need for referral.

This traditional referral model works well, is reasonably efficient and ensures the pet receives the specialist care needed. However, many commonly encountered conditions that are typically referred externally should be relatively straightforward to diagnose and manage in a well-equipped first opinion practice, under the guidance of a specialist.

So, with this in mind, here’s a new scenario to consider:

What if during this initial conversation with the specialist, rather than just seeking to assess whether the patient should be referred or not, the latest real-time telemedicine technologies could be used to enable the specialist to access all the diagnostic information that they require to make a fully informed diagnosis and treatment plan. What if this could be done right then and there, without the patient or pet-owner having to leave the vet’s practice? What could be more time efficient and convenient? What if it was so simple to use this service that it could be seamlessly integrated into the normal daily running of the first opinion clinic, enabling vets to seek specialist help and advice for their patients as needed, thus speeding up clinical decision making? Could this scenario become a new alternative for vets wanting to work up their own cases to a higher level in-house?

This was the thought process behind the real-time telemedicine solution Virtual Veterinary Specialists (VVS) and the reason we created it. However, developing a service that attempts to address these questions has been a real voyage of discovery! One challenge has been pulling together the nuts and bolts of a service that meets the necessary stringent regulatory and clinical standard requirements. Clearly having the right technology is pivotal but also, very importantly, so are the people and the relationships. Whereas previously, vets in general practice and in specialty practice mainly communicated about cases, now they have the opportunity to work-up and manage these cases closely together.

Real-time telemedicine involves the use of technology to change the way that first opinion vets can access specialist healthcare for their patients. It empowers vets to upskill and to do more challenging and exciting veterinary medicine in first opinion practice, with the guidance and support of specialist colleagues. Real-time telemedicine services are ideally suited to progressive, forward thinking, first opinion veterinary practices, enabling their vets to learn from working-up their own cases, utilise their own practice infrastructure and share the case revenue, whilst improving patient outcomes and client satisfaction. They provide vets with a unique ‘hands-on’ learning opportunity, not typically associated with external referral.

Real-time telemedicine enables a highly interactive, live, virtual consultation between the vet and specialist. Software integrates seamlessly with diagnostic equipment in the vet’s practice, including webcams, stethoscope, ECG and high resolution medical cameras (e.g. dermascopes, otoscopes, opthalmoscopes), allowing all this important diagnostic information to be shared simultaneously and easily in real-time from the vet’s practice directly to the specialist. The specialist is able to see the patient in high resolution, to hear the patient’s heart and lung sounds in real-time during auscultation and to interpret diagnostics such as the ECG and images from medical cameras and ultrasound in real-time, as the vet records them.

From working closely with our initial veterinary customers, asking for and (very importantly) listening to their valuable feedback and implementing changes accordingly, we are developing into a new service that vets tell us they find ‘invaluable”. It is extremely encouraging to see how these new real-time telemedicine technologies have been welcomed by the vets who we are working with and that they are very willing to embrace new working practices once they experience the benefit to themselves and their clients.

It appears that this method of working is also attractive to specialists, as it offers them flexibility, convenience and the opportunity to teach and to build strong collaborative professional relationships with veterinary colleagues in general practice.

One of the challenges to the successful adoption of any new working practice is that it requires some initial effort, willingness to adapt and the desire for change. A challenge that real-time telemedicine faces is that many vets in first opinion practices are already very busy. Why would they use this type of service when it may be easier to just refer the patient outside of the practice and relinquish the case control? Although this may be the case for some, it is not the case for vets who want this additional way of accessing specialist healthcare for their patients. They understand that by using real-time telemedicine services they are able to capture more of the patient care in-house as well as improve their own clinical knowledge and skills at the same time.

There have been a number of important learning points for us thus far.

The benefits of this alternative delivery model are not obvious until they are obvious. The benefits have to be experienced before they are fully appreciated.

Any shift in working practices can create resistance. VVS is not here to fight this resistance but to work with vets who are willing to embrace this new concept.

The equipment is key. Having equipment that works is important, but is not the only objective. The service as a whole has to be convenient, user friendly, get the results that vets seek and be time efficient.

In summary, the VVS service creates additional variation and choice in the specialist healthcare delivery model and this raises the wider question: “Are we as a profession ready to embrace these new technology-enabled business practices?”

Disruptive Innovation

A case study of equine veterinary practice

Here equine vet and RCVS Senior Vice-President Dr Chris Tufnell, in the first of our series of case studies, examines how technology has helped ambulatory equine practices to develop and ‘disrupt’ the more traditional practice-based models of first-opinion equine veterinary care. Through exploring the complex and therefore frequently misunderstood concept of ‘disruption’, Chris invites us to consider what factors could lead to similar disruption in other veterinary sectors.

Whenever new businesses, innovations or emerging competitions are discussed you can be sure the term ‘disruption’ will also be bandied about. The term, however, is frequently misapplied, and as a result we are losing a critical and specific theory that helps explain the nature of innovation and why once thriving household names such as Kodak, IBM and Nokia have all been wrong-footed by emerging competition.

To illustrate what disruptive innovation really means, we will examine first-opinion equine practice and look at how adapting technology and lowered costs are changing the structure of the sector.

Innovation in equine practice

Ever since there have been veterinary surgeons in the UK, they have visited horses at their home farm or yard. Equine-specific vets began to emerge, however, as horses moved from being a source of agricultural power to being sports and recreational animals, and as the conditions they suffered from and the care that was demanded for them became more complicated and involved.

Early diagnostic equipment such as X-ray machines and ultrasound scanners were large, unwieldy and expensive, and so advanced procedures were limited to a few specialist centres, usually veterinary teaching hospitals.

As equipment became smaller, more refined, and more accessible, first-opinion equine practices were able to use it as well. As a result, bigger equine practices invested in small surgeries where they could bring horses in for X-rays, scans and other procedures, but building these practices and kitting them out with the latest equipment required significant investment. To cover the costs, practices needed to charge higher fees and have a higher throughput of cases, as well as a correspondingly higher number of veterinary surgeons to manage them.

Practices that invested in facilities and equipment in this way have continued to develop and advance the services they offer, and to target those clients willing to pay more for a higher level of service.

This type of innovation, which ‘offers incrementally better performance at a higher price’, is described as ‘sustaining innovation’ by Clayton Christenson, Harvard Professor and foremost disruption expert (2015).

The problem that this kind of innovation creates for any business is that over time the products and service offered will start to over-serve the needs of the mainstream market (see Figure 1), so an opportunity for ‘disruptive’ competition emerges. 

The emergence of ‘disruptive’ ambulatory practices

The barrier to entry for equine vets working on the road was much smaller than for those operating from veterinary practice premises. They only needed to invest in a vehicle and portable diagnostic equipment, and refer anything more complex to bigger hospitals. At first, however, due to the limitations of the service they could provide, ambulatory practices were not considered a threat to first-opinion practices that had invested heavily in equipment and facilities.

But as the technology became smaller, more portable and lower cost, it became accessible to ‘ambulatory’ vets. Whilst it was a challenge to perform diagnostic procedures on farms and yards rather than in the controlled environment of a surgery, they were able to perform a role that was ‘good enough’ to achieve a diagnosis and initiate treatment of conditions that would previously have only been diagnosed in a surgery scenario.

Without the overheads of buildings, staff and very complex equipment they were able to charge lower fees and so appeal to the market that was being over-served by the larger practices and to new clients that had not previously been able to access this level of diagnosis before.

The emergence of ambulatory first-opinion veterinary practices in this fashion is an example of ‘disruptive innovation’ in action, passing Christensen’s two key tests to identify ‘disruptive innovation’: it ‘originates in low-end or new-market footholds’ and is ‘initially considered inferior by most of an incumbent’s customers’.

The response of most of the practices that had invested in complex diagnostic equipment, buildings, facilities and staff was to move upmarket and try and serve more complex, difficult and involved cases, many involving surgery which cannot be performed in a yard scenario. Moving upmarket to high-margin clients and leaving the lower-end to their new disruptive competitors is a logical response of any business facing disruptive competition. The issue is that the pace of disruptive innovation means that new entrants can provide in increasingly better services at a lower cost than incumbents, forcing incumbents to move yet further upmarket.

In equine practice, we can see the challenges faced by those who have invested in equipment and facilities by the ever-increasing complexity of cases that can be managed on a yard by an ambulatory vet using the latest technology.

How to respond to disruption

Whilst such ‘disruptive innovation’ may seem an unstoppable hostile force that will ultimately ravage incumbent business, whatever sector they may be in, Christensen asserts that disruption presents opportunities for incumbents a long time before it becomes a direct threat.

For existing businesses the key to exploiting such opportunities is to identify the sources of disruption and ask why clients might be moving to other service providers. Using this market intelligence, incumbent businesses can then create new businesses to exploit the opportunities disruption can bring.

Should businesses, therefore, abandon still profitable businesses and loyal clients in the quest to seize new opportunities? The answer is, of course, ‘no’ – rather, they should simultaneously continue to improve their existing businesses, meet their core customers’ needs and engage in sustaining innovation, using the profit from these businesses to invest in new disruptive business models. Thus, when their existing businesses do eventually succumb to the inevitable tide of disruptive innovation, they will own the very companies that are disrupting them.

What innovations or technologies do you think could lead to ‘disruption’ in your area of work and what opportunities could these present?  Please leave your comments below to start a discussion.

If you would like to learn more about Disruptive Innovation, this article provides a great starting point.

Bibliography

Christensen, C. M., Raynor, M. E. & McDonald, R., 2015. What is Disruptive Innovation?. Harvard Business Review, December.