Older adults are in triple jeopardy during COVID-19: compared with younger people, older adults are (1) more likely to develop serious conditions and experience higher mortality;(2) less likely to obtain high quality information or services online; and (3) more likely to experience social isolation and loneliness. Hybrid solutions, coupling online and offline strategies, are invaluable in ensuring the inclusion of vulnerable populations. Most of these solutions require no new inventions. Finding the financial resources for a rapid, wellcoordinated implementation is the biggest challenge. Setting up the requisite support systems and digital infrastructure is important for the present and future pandemics.

Background The widespread death and disruption caused by the COVID-19 pandemic has revealed deficiencies of existing institutions regarding the protection of human health and well-being. Both a lack of accurate and timely data and pervasive misinformation are causing increasing harm and growing tension between data privacy and public health concerns. Objective This aim of this paper is to describe how blockchain, with its distributed trust networks and cryptography-based security, can provide solutions to data-related trust problems. Methods Blockchain is being applied in innovative ways that are relevant to the current COVID-19 crisis. We describe examples of the challenges faced by existing technologies to track medical supplies and infected patients and how blockchain technology applications may help in these situations. Results This exploration of existing and potential applications of blockchain technology for medical care shows how the distributed governance structure and privacy-preserving features of blockchain can be used to create “trustless” systems that can help resolve the tension between maintaining privacy and addressing public health needs in the fight against COVID-19. Conclusions Blockchain relies on a distributed, robust, secure, privacy-preserving, and immutable record framework that can positively transform the nature of trust, value sharing, and transactions. A nationally coordinated effort to explore blockchain to address the deficiencies of existing systems and a partnership of academia, researchers, business, and industry are suggested to expedite the adoption of blockchain in health care.

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More than 500,000 people experience homelessness in America each day. Local and federal solutions to the problem have had limited success because of the fragmentation of services and lack of valid and timely information. Billions of dollars spent to provide reliable, timely, and actionable information in health care have exposed the difficulty of establishing such a system using the prevalent information technology solutions. However, relying on successful examples of the use of blockchain to help refugee populations and poor farmers internationally, we have partnered to propose an innovative solution to this problem using the case of people experiencing homelessness in Austin, Texas. This paper aims to describe one of the first applications of blockchain technology for addressing homelessness in the United States by creating a digital identity for people experiencing homelessness and engaging emergency medical services and clinical providers. The authors argue that a lack of documentation to prove personal identity and the inability to access own records are major hurdles for empowering persons experiencing homelessness to be resilient and overcome the life challenges they face. Furthermore, it is argued that this lack of information causes misdiagnosis, duplication, and fragmentation in service delivery, which can be potentially addressed by blockchain technology. Further planning for creating a program on the ground with additional funding will demonstrate the results of using blockchain technology to establish digital identity for persons experiencing homelessness.

Objective Healthcare systems suffer from a lack of interoperability that creates “data silos,” causing patient linkage and data sharing problems. Blockchain technology’s unique architecture provides individuals greater control over their information and may help address some of the problems related to health data. A multidisciplinary team designed and tested a blockchain application, MediLinker, as a patient-centric identity management system. Methods The study used simulated data of “avatars” representing different types of patients. Thirty study participants were enrolled to visit simulated clinics, and perform various activities using MediLinker. Evaluation was based on Bouras’ criteria for patient-centric identity management and on the number of errors in entry and sharing of data by participants. Results Twenty-nine of the 30 participants completed all study activities. MediLinker fulfilled all of Bouras’ criteria except for one which was not testable. A majority of data errors were due to user error, such as wrong formatting and misspellings. Generally, the number of errors decreased with time. Due to COVID-19, sprint 2 was completed using “virtual” clinic visits. The number of user errors were less in virtual visits than in personal visits. Discussion The evaluation of MediLinker provides some evidence of the potential of a patient-centric identity management system using blockchain technology. The results showed a working system where patients have greater control over their information and can also easily provide consent for use of their data. Conclusion Blockchain applications for identity management hold great promise for use in healthcare but further research is needed before real-world adoption.

Background In the homeless population, barriers to housing and supportive services include a lack of control or access to data. Disparate data formats and storage across multiple organizations hinder up-to-date intersystem access to records and a unified view of an individual’s health and documentation history. The utility of blockchain to solve interoperability in health care is supported in recent literature, but the technology has yet to be tested in real-life conditions encompassing the complex regulatory standards in the health sector. Objective This study aimed to test the feasibility and performance of a blockchain system in a homeless community to securely store and share data across a system of providers in the health care ecosystem. Methods We performed a series of platform demonstrations and open-ended qualitative feedback interviews to determine the key needs and barriers to user and stakeholder adoption. Account creation and data transactions promoting organizational efficiency and improved health outcomes in this population were tested with homeless users and service providers. Results Persons experiencing homelessness and care organizations could successfully create accounts, grant and revoke data sharing permissions, and transmit documents across a distributed network of providers. However, there were issues regarding the security of shared data, user experience and adoption, and organizational preparedness for service providers as end users. We tested a set of assumptions related to these problems within the project time frame and contractual obligations with an existing blockchain-based platform. Conclusions Blockchain technology provides decentralized data sharing, validation, immutability, traceability, and integration. These core features enable a secure system for the management and distribution of sensitive information. This study presents a concrete evaluation of the effectiveness of blockchain through an existing platform while revealing limitations from the perspectives of user adoption, cost-effectiveness, scalability, and regulatory frameworks.

Background The COVID-19 pandemic has presented new challenges surrounding end-of-life planning and has been associated with increased online discussion about life support. Research Question How has online communication about advance care planning (ACP) and specific life-sustaining interventions (LSIs) changed during the pandemic? Study Design and Methods Conversations on Twitter containing references to LSIs (e.g., ‘ECMO’) or ACP (e.g., ‘DNR/DNI’) were collected from January 2019 to May 2021. User account metadata was used to predict user demographic information and classify users as either organizations, individuals, clinicians, or influencers. We compared the number of impressions across these user categories and analyzed the content of tweets using natural language processing models to identify topics of discussion and associated emotional sentiment. Results There were 202,585 unique tweets about LSIs and 67,162 unique tweets about ACP. Users who were younger, men, or influencers were more likely to discuss LSIs online. Tweets about LSIs were associated with more positive emotional sentiment scores than tweets about ACP (LSIs: 0.3, ACP: -0.2; P < 0.001). Among tweets about ACP, most contained personal experiences related to the death of loved ones (27%) or discussed discrimination through DNR orders directed at the elderly and disabled (19%). Personal experiences had the greatest retweet-to-tweet-ratio (4.7), indicating high levels of user engagement. Tweets about discrimination contained the most negative net sentiment score (-0.5). Interpretation The observed increase in tweets regarding LSIs and ACP suggests that Twitter was consistently utilized to discuss treatment modalities and preferences related to intensive care during the pandemic. Future interventions to increase online engagement with ACP may consider leveraging influencers and personal stories. Finally, we identified DNR-related discrimination as a commonly held public fear, which should be further explored as a barrier to ACP completion and can be proactively addressed by clinicians during bedside goals-of-care discussions.

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