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Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University
Brent I. Fox, Pharm.D., Ph.D.
Joshua C. Hollingsworth, Pharm.D, Ph.D.,

THE INTERNET OF THINGS! Quantum computing! Artificial intelligence! Digital detox! What do these terms have in common? They are some of the most popular buzzwords in the technology industry today. The savviest of ComputerTalk’s readers can likely add several more words to our list. In fact, many readers are probably having one of those “duh” moments, as they wonder why blockchain is not included in the list above. If forced to rank the technologies that are receiving the most hype and buzz, we would in fact select blockchain as number one. Rarely a day passes when an article or video on blockchain does not cross our paths in one form or another. Try this: Search Google or Bing for “blockchain” and review the page titles (after skipping over the promoted search results).

Most likely, your results are going to range in scope from blogs and commercial sites to sites from established organizations whose goals are to provide informative, objective information. Additionally, in today’s world, most people mentally link blockchain with its currently most widely recognized application: cryptocurrency. And the cryptocurrency that is most established and well known is Bitcoin. But our goal in this column is to provide ComputerTalk’s readers with a shared, foundational understanding of blockchain technology and how it may play a role in pharmacy.

As history buffs, we have to start at the very beginning (it seems a perfect place to start… remember “The Sound of Music”?). The first known reference to using cryptography to secure blocks of data to ensure that timestamps could not be altered dates to 1991 (https://link.springer.com/article/10.1007%2FBF00196791). Fast forward to 2008 when Satoshi Nakamoto published a paper describing a method to secure an electronic system of currency (https://bitcoin.org/bitcoin.pdf). The system was based on the blockchain (and cryptography), and it solved the problem of previous digital currencies: How to prevent someone from spending the same currency more than once. Bitcoin was born. Adding to the intrigue, Satoshi Nakamoto is a pseudonym. While some believe the CIA knows the true identify of Satoshi Nakamoto (the person or persons), no one has publicly and verifiably been identified as the inventor of Bitcoin.

WHAT IS A BLOCKCHAIN?

At this point, we should clarify relevant terms and draw several important distinctions. A blockchain is a distributed, electronic ledger that consists of a series of blocks (i.e., transactions) linked together through cryptography. Cryptography is the use of complex mathematical processes to store and transmit data to ensure that it is only accessed by authorized users. Blockchains are built in a sequential, longitudinal order and cannot be deleted. All computers that access a blockchain must approve the addition of new blocks. If a block is not approved, it is not added to the chain. One of the most important aspects of blockchains is that they are peer-to-peer networks.

What does this mean? Blockchains exist in the digital world and are accessed through software (and even phone apps), although the average consumer will likely not see the actual blockchain. Blockchains are distributed so that all parties connected to the blockchain have a shared version of the records on the chain. New blocks (i.e., transactions) are added to a blockchain only after all parties verify the authenticity of the block. Once added to a blockchain, a block cannot be altered. This is often referred to as “immutability” and is important for establishing trust in the chain. Collectively, these characteristics of blockchains lead to one of their most important features: They eliminate the need for an intermediary to verify transactions between entities. Whereas traditional banks served as the intermediary between parties involved in a transaction, the blockchain allows parties who do not necessarily know each other to conduct transactions without actually needing to trust each other. Instead, the parties trust the blockchain.

Hopefully, the previous discussion helps clarify why Bitcoin is receiving so much attention, both positive and negative. Because it is built on a blockchain, Bitcoin (and other cryptocurrencies) allows individuals to securely and privately conduct transactions without the need for an intermediary.

POTENTIAL USE IN PHARMACY

What about other applications of blockchain besides currency? Can you think of anything that is commonly encountered in pharmacy that is shared electronically between multiple people? It contains private information and should only be accessed by authorized individuals. This “thing” ideally should have an associated audit trail that verifies its authenticity and history, and cannot be altered or deleted. Yes, you guessed correctly: Prescriptions are an obvious blockchain-use case. Consider that multiple pharmacies on a shared blockchain would have access to the single “truth” regarding any prescription on that blockchain. The blockchain could serve as the source for information about any individual prescription, as well as provide patients’ complete medication histories.

Another and related potential application of blockchain is the supply chain. Two factors are currently driving interest in securing the pharmaceutical supply chain: controlled substance diversion and the Drug Supply Chain Security Act (DSCSA). In both contexts, the ultimate goals are to identify if drugs “leak” from the supply chain or are introduced by an unauthorized entity, and to enable authenticity of returned medications. In 2017, several pharma companies, along with McKesson and AmerisourceBergen, initiated the MediLedger Project, which aimed to evaluate blockchain as a mechanism to track and trace medications throughout the supply chain. In other words, could a blockchain-based system meet DSCSA requirements? An important challenge in this context was to ensure data privacy while maintaining pharma business intelligence and provenance. Ultimately, the MediLedger Project demonstrated that a blockchain-based solution was able to meet DSCSA requirements.

Other potential use cases for blockchain that are currently being explored include documenting when an EHR (electronic health record) is accessed and modified. Porsche is examining blockchain as a mechanism for maintaining automobile records. The disparity of these two examples illustrates the fundamental utility of blockchain technology: It is a method to securely maintain transaction records in a peer-to-peer network without the need for an intermediary. But is the hype realistic? The answer remains to be seen. One looming challenge is quantum computing, which experts are predicting will provide the computational capacity to “break” the immutability of blockchain cryptography. To overcome this pending limitation, others have recommended creating quantum blockchains, which include quantum particles. While the engineers tangle with quantum blockchains, we will continue to explore the role of blockchains in pharmacy and healthcare. Please let us know if you have any thoughts on this topic. CT

Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, and Joshua C. Hollingsworth, Pharm.D, Ph.D., is an assistant professor, Pharmacology and Biomedical Sciences, Edward Via College of Osteopathic Medicine, Auburn Campus. The authors can be reached at foxbren@auburn.edu and jhollingsworth@auburn.com.edu.

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