Blockchain as a trust bridge between medical and fitness

Chronic diseases — such as heart disease, obesity, cancer, diabetes, and even substance abuse— have become a global pandemic that negatively impact population health and economic efficiency. According to the CDC in the U.S. alone, 86% of the nation’s $2.7 trillion annual health care expenditures go towards people living with chronic and mental health conditions

Top health organizations have concluded that making lifestyle modifications such as getting sufficient exercise and eating a well-balanced diet may prevent and treat certain chronic diseases. There are many benefits to exercise which include improved physical and mental functioning, quality of life, and various other dimensions of health and wellbeing.

The American College of Sports Medicine (ACSM) and American Medical Association (AMA) co-launched a non-profit initiative in 2007 called Exercise Is Medicine (EIM) as a way to combat chronic diseases and mental health conditions.

While the main three objectives of EIM are to improve health outcomes, cost-effectiveness, and care coordination, the ultimate aim of EIM is to slow, stop, and reverse the progression of chronic diseases by urging healthcare providers to assess the physical activity levels of patients, and provide qualified patients with basic exercise prescriptions and referrals as part of medical treatment and prevention plans.

The EIM solution

• Assessment — Patients receive physical activity evaluations from certified EIM professionals
• Prescription — EIM professionals provide qualified patients with basic physical activity prescriptions
• Counseling — EIM professionals walk qualified patients through the prescriptions
• Referral — EIM professionals refer qualified patients to EIM fitness professionals

There are three essential domains that work together to bring about the vision for EIM:

1. Healthcare systems and providers: physicians, nurse practitioners, physician assistants, nurses, physical therapists, and other supporting health care providers interacting with electronic health records (EHRs);
2. Physical activity resources: EIM places, EIM programs and EIM or ACSM accredited professionals;
3. Digital health technologies: electronic health records, population health management applications, patient-centered home applications, and health information exchange.

Problems with EIM

While the EIM solution aims to build a trusted, coordinated care system for people living with chronic diseases, through partnerships between local medical practices and community fitness resources, it has failed to achieve mainstream adoption for several reasons:

Trust

• While EIM is an initiative geared towards patient health, there is some doubt about the authenticity or agenda of some of its biggest partners such as The Coca-cola company. Big soda has been accused of sponsoring and supporting health organizations and chronic disease research to sway health policies and have more control over health education and organizations like Crossfit have taken action to get Big soda out of health sciences.
• The Coca-Cola was the founding corporate partner of EIM in partnership with the ACSM and AMA to combat chronic disease.

Incentives

• The cost of EIM services is not covered by insurers because there lacks a sound incentive model for insurers to cover exercise as a medicine;
• One major incentive problem for U.S. insurers is that due to the employment-based insurance model, patients only stay with a given insurer on average 4.5 years before switching jobs and policies. This means chronic issues are likely to be “passed on” to a future insurer and there is little incentive to pay for more preventive or chronic care;
• Health and fitness practitioners lack proportionate pay and health benefits in relation to the amount of care provided;
• Patients do not necessarily see incentive to adhere to fitness programs or prescriptions if it cuts into work or family time. Adherence with exercise regimens is one of the main reasons chronic issues continue to plague society.

Regulation

• In order for exercise data to be evaluated by a healthcare team, all members of the team must comply with HIPAA and potentially GDPR laws that guarantee privacy and confidentiality for patients;
• This includes how exercise data is collected, stored and used by affected fitness facilities, fitness technology and biotechnology companies.

Interoperability

• If exercise data is to be shared between local medical practices and community fitness resources, then a trusted data infrastructure with common data standards is needed;
• EHRs also need a common place for records of detailed exercise data to be accessible so that healthcare teams can have greater visibility into disease progression and regression in patients.

Education

• Medical practitioners are not trained to prescribe exercise as medicine;
• Fitness practitioners are not trained to treat disease or pain.

If local medical practices and community fitness resources are to collaborate, then a trusted and flexible infrastructure with common data standards and a sound incentive model is needed.

Blockchain as an infrastructure for EIM

The EIM solution might benefit from a decentralized infrastructure, in which blockchain is utilized, to enable a trusted coordinated care system for people living with and looking to prevent chronic diseases.

Blockchain, the technology underpinning the digital asset Bitcoin, is the most secure unique open-sourced computer database combining elements of computer science, economics, and game theory. Blockchain represents a paradigm shift in how we trade value and input, store, retrieve and share value over the internet and in-person.

Blockchain first began with the launch of the Bitcoin network on January 3rd, 2009 and has since given rise to many other blockchain solutions. The goal of Bitcoin was to create a decentralized payment system for peer-to-peer transactions over the internet using blockchain, rather than a trusted intermediary, to keep a well-structured, immutable, track record of all Bitcoin transactions.

(To explore Bitcoin blockchain transactions you can find more here: https://blockexplorer.com/blocks)

Technologists, economists, and scientists around the world studied Bitcoin and began collaborating and experimenting to further develop Bitcoin which led to the discovery of alternative use cases that go beyond financial applications. As a result, on July 30, 2015, a new blockchain project called Ethereum emerged. The innovation brought on by the Ethereum project is called smart contracts, which power decentralized applications (Dapps) and run exactly as programmed with zero possibility of downtime, censorship, fraud, or third-party interference. Basically, this same decentralized infrastructure is now usable for many kinds of transactions and it functions more like one big computer that anyone can read or write transactions to and access.

Ethereum Dapps have a wide range of use cases such as decentralized storage, financial services, e-gaming, social, and live streaming applications.

(To explore a list of Ethereum decentralized applications click here)

Dapps are being researched, prototyped, and tested across many industries to solve for a wide range of business use cases. While there is much research to show how smart contracts can be used to power medical industry Dapps such as user controlled EHRs, decentralized health information exchanges, and peer-to-peer insurance models, very little research has been done outlining how smart contracts could power Dapps in the fitness industry.

Dapp ideas for the fitness industry

Exercise prescription Dapps

Exercise prescriptions are fitness-related activities developed by fitness or rehabilitation professionals to help each client/patient achieve their personal health goals. If smart contracts and evidence-based protocols were used to power exercise prescription Dapps, then these “smart” exercise prescriptions could keep immutable track records of all exercise data logged and shared within a coordinated care system.

In theory exercise prescription Dapps could be integrated into cardio machines, computer-enabled strength machines and wearable sensors as exercise training modules. The fulfilled exercise prescriptions could be sent to a blockchain, allowing members of coordinated care teams to stay up to date with client/patient exercise progress. The ability for machines to help log and validate patient adherence with exercise regimes could fundamentally change the efficacy of such prescriptions, and also create opportunities for insurer-driven patient incentives.

Record of Exercise (ROE) Dapps

While hospitals and clinics use EHRs to manage patient medical data, gyms and personal training studios are currently excluded from sharing exercise data to EHRs. Gyms and personal training studios could benefit from a record of exercise dapp (ROE) which could be used to register and store member and client exercise data.

Although EHRs store basic exercise prescription data (e.g. time/intensity of exercise), they lack the capacity for detailed exercise data (e.g. exercise routine/reps/quality/frequency + lbs/kgs etc). In theory, ROEs could connect with EHRs, acting as a mechanism by which exercise data can be validated, organized, and consolidated into well structured exercise libraries, allowing medical practitioners to stay up to date with patients exercise activity.

Having well-structured and detailed exercise data might allow certified personal trainers, exercise physiologists, biomechanists, kinesiologists, cardiologists, sports medicine practitioners, and chronic disease researchers to collaborate more efficiently and extend their care and research outside of labs and clinics and into gyms. This could lead to improved exercise prescription design, thus being able to manage, predict, and improve patient outcomes at an accelerated rate.

Fitness machine Dapps

The more machines (nodes) on a blockchain-based network the more stable the network is. In most gyms there are many cardio machines, all of which are essentially computers. If these computers were to run blockchain software, then gyms might be able to reimagine new revenue streams in the future and contribute to an evolution in the fitness industry.

In theory, if fitness machine manufacturers adopted a blockchain infrastructure and allowed programmers to develop exercise training Dapps, then gym members could walk up to any treadmill, send it Bitcoin (or another crypto-asset), select a training module, and begin their workout similarly to inserting coins into an arcade game. When members finish their workouts, the machines could automatically send their performance details to their fitness activity records (FAR), as completed records of exercise (ROE).

Exercise data exchange Dapps

If exercise is a medicine, then exercise prescription data could benefit from being incorporated into health information exchanges, which is on track to become a $2.2B market by 2024.

If built on smart contracts, then exercise prescriptions could be traded across a decentralized health information exchange from client/patients to insurers, neuroscientists, chronic disease researchers, pharmaceutical companies, genomic companies and fitness technology companies.

Fitness technology companies could leverage exercise data and build personalized AI assistants. Genomic companies could leverage exercise data to better understand how exercise alters gene expression. Pharmaceutical companies could use exercise data to develop personalized drugs. Insurers could use exercise data to create dynamic health insurance policies.

A new approach for EIM

With a blockchain infrastructure and sensor-based technologies, medical and fitness practitioners would have a better foundation from which to provide a solution like EIM.

In the current EIM model, physicians write basic exercise prescriptions indicating the time, intensity and frequency of exercise that patients should be doing, leaving it up to fitness professionals to create a more comprehensive and personalized plan.

The details and results of these plans however do not get incorporated into the current EHRs, making it challenging for chronic disease researchers and other medical practitioners to understand which exercise prescriptions are working and which ones are not. Today, there is no shared feedback loop to allow for the accurate collection, careful sharing, and coordinated approach that EIM promised.

With a blockchain infrastructure, smart contracts and sensor-based technologies, coordinated care teams could better monitor client/patient health progress. In theory, each prescription would be its own smart contract that would autonomously keep an immutable track record of every update made during its life-cycle, whereby all updates could be referenced on a blockchain. This could allow all members of a coordinated care team to efficiently collaborate, study the effectiveness of exercise prescriptions and the progression and regression of chronic disease.

The following scenario will provide a high-level example for which EIM could theoretically function on a decentralized infrastructure using smart contract technology and connected devices, allowing a certified personal trainer to efficiently collaborate with a primary care physician on a shared client/patient.

In this scenario, Alice will be a client/patient to Bob, her EIM-trained primary care physician and Carla, her certified EIM personal trainer.

Phase 1 — Assessment

• Alice goes to see Bob for a routine health assessment.
• Bob captures Alice’s core vitals (height, weight, heart rate, exercise, sleep, etc.) with trusted connected medical devices (smart scales, wearables, etc).
• The medical devices send biometric data to Alice’s blockchain-based EHR for Bob to review.
• After reviewing Alice’s results, Bob discovers that Alice’s BMI and blood pressure is high and determines that Alice is in need of more exercise.
• Bob places a new order for Alice’s exercise prescription.
• Bob signs off on the order, which generates transaction #1, in the exercise prescriptions lifecycle, labeled as “Exercise script opened”.

Phase 2 — Referral

• Bob goes into his EIM-certified personal trainer network directory and matches the prescription requirements with Carla based on her expertise, location, and overall rating.
• In the referral notes, Bob recommends to Carla that Alice would benefit from 150 minutes of exercise per week.
• Bob signs off on the referral and updates Alice’s exercise prescription which generates transaction #2, in the exercise prescriptions life-cycle, labeled as “Exercise script referred”.

Phase 3 — Prescription

• Alice goes to her local fitness community center for her first fitness consultation with Carla.
• Alice grants Carla access into her EHR where Carla is able to validate the authenticity of the referral and review the exercise prescription notes.
• Carla puts Alice through personalized fitness tests using connected fitness devices which send health and fitness data to Alice’s EHR, updating Bob.
• Carla determines that Alice would benefit from a 3 month long 4-day per week training program with 2 days working on high-intensity interval training and the other 2 days working on strength training.
• Carla signs the exercise prescription, which generates transaction #3, in the exercise prescriptions life-cycle, labeled as “Exercise script filled”.

Phase 4 — Counseling

• Carla tracks Alice’s training over a 3-month period, using trusted connected fitness equipment that inputs all exercise data into the exercise prescription.
• Bob is alerted after Alice completes every workout session, which allows Bob to monitor the effectiveness of the exercise prescription, and its relationship to Alice’s overall health.
• Once the last session is completed, Bob signs off on the exercise prescription which generates transaction #4, labeled as “Exercise script closed”.

Once the exercise prescription has been filled it gets published to a blockchain as a validated record of exercise whereby all members of Alice’s care team can stay up-to-date with her exercise journey. The ROE can be a tool that Alice can use to negotiate with her health insurer, a dynamic health insurance policy more personalized to her, her goals and her commitments. In exchange, insurers can audit the exercise prescription, validate that Alice is being compliant with the exercise prescription, and leverage the exercise prescription data to develop a personalized dynamic health insurance policy.

Things to consider

If ACSM is to adopt a blockchain infrastructure for EIM, then the current EIM model would benefit from being redesigned to fit a decentralized model that would first need common data standards. This includes reimagining how the EIM model could function with and without non-EIM certified professionals.

If exercise is to be treated as a medicine, then insurance providers will need to reimagine how they might compensate certified medical and fitness professionals for participating in the coordinated care of shared patients/clients as well as how they might provide discounts to the insured for participating in exercise programs.

To some degree, these kinds of changes to the health marketplace are happening without blockchain already. We are seeing groups like John Hancock insurance move away from traditional life insurance policies toward interactive fitness tracking-based policies, with discounts for patient incentives.

What blockchain offers is an opportunity to provide more robust frameworks around the trust, incentives, regulatory models, and interoperability of the stakeholders involved in EIM. Rather than having one group — whether Big Soda or insurers trying to get ahead of the competition — control the ways of addressing chronic disease and wellbeing for people.