Daniel Toshio Harrell, Muhammad Usman, Ladd Hanson, Mustafa Abdul‐Moheeth · 10 authors
Objective: Clinical data in the United States are highly fragmented, stored in numerous different databases, and are defined by service providers or clinical specialties rather than by individuals or their families. As a result, linking or aggregating a complete record for a patient is a major technological, legal, and operational challenge. One of the factors that has made clinical data integration so difficult to achieve is the lack of a universal ID for everyone. This leads to other related problems of having to prove identity at each interaction with the health system and repeatedly providing basic information on demographics, insurance, payment, and medical conditions. Traditional solutions that require complex governance, expensive technology, and risks to privacy and security of the data have failed adequately to solve this interoperability problem. We describe the technical design decisions of a patient-centric decentralized health identity management system using the blockchain technology, called MediLinker, to address some of these challenges. Design: Our multidisciplinary research group developed and implemented an identity wallet, which uses the blockchain technology to manage verifiable credentials issued by healthcare clinics, banks, and insurance companies. To manage patient's self-sovereign identity, we leveraged the Hyperledger Indy blockchain framework to store patient's decentralized identifiers (DIDs) and the schemas or format for each credential type. In contrast, the credentials containing patient data are stored 'off-ledger' in each person's wallet and accessible via a computer or smartphone. We used Hyperledger Aries as a middleware layer (API: Application Programming Interface) to connect Hyperledger Indy with the front-end, which was developed using a JavaScript framework, ReactJS (Web Application) and React Native (iOS Application). Results: MediLinker allows users to store their personal data on digital wallets, which they control. It uses a decentralized trusted identity using Hyperledger Indy and Hyperledger Aries. Patients use MediLinker to register and share their information securely and in a trusted system with healthcare and other service providers. Each MediLinker wallet can have six credential types: health ID with patient demographics, insurance, medication list including COVID-19 vaccination status, credit card, medical power of attorney (MPOA) for guardians of pediatric or geriatric patients, and research consent. The system allows for in-person and remote granting and revoking of such permissions for care, research, or other purposes without repeatedly requiring physical identity documents or enrollment information. Conclusion: We successfully developed and tested a blockchain-based technical architecture, described in this article, as an identity management system that may be operationalized and scaled for future implementation to improve patient experience and control over their personal information.
In “Experience” Emerson announces his readiness “to die out of nature, and be born again into this new yet unapproachable America I have found in the West” (CW 3:41). Whatever personal manifest destiny the passage expresses, it arises from Emerson's deep affinity for Eastern philosophy. The inscription in Emerson's notebook “Orientalist” is “Ex oriente lux,” or “Light out of the east” (1993, 39), and, as Ronald Bosco notes in his introduction to the notebook, Emerson believed that the light of the East “has the power both to nourish otherwise impoverished individuals and nations and to transmute … the crime of materialism into wisdom” (1993, 14). His west is far to the east in “the sunbright Mecca of the desert,” not Huckleberry Finn's territory, the pioneer's prairie, or the miner's rocky west, and unlike miners, settlers, land speculators, governments, and most Western philosophers, he does “not make” or stake a claim; he “arrive[s] there, and behold[s] what was there already” (CW 3:41). Emerson's approach to the west entails the death or disappearance of “all mean egotism” (CW 1:10) and the open flexibility of a Zen practitioner's mind. The grand sense of entitlement and the mission of proliferation that sent most European Americans west are quite foreign to Emerson's acknowledgment and receptivity. All a miner knows is by penetration into the earth; all Emerson knows “is reception” (CW 3:48). “I am and I have,” he writes, “but I do not get, and when I have fancied I had gotten anything,” as countless westward-bound adventurers have fancied, “I found I did not” (CW 3:48).The attentive, appreciative reception Emerson practices is the strategy used by the Taoist sage, the Sufi mystic, and the Zen meditator, and the delight he consequently experiences, clapping his “hands in infantine joy” and filled “with the love of the new beauty” (CW 3:41), is the good humor of Chuang Tzu, the ecstasy of Attar and Rumi, the satori of the Zen practitioner. The reception and delight are not complacent, unproductive spectatorship, nor do they signal an erasure of the subject/self. They are the condition and result of the creative work that constitutes the unfolding of human experience and insight. As Emerson knew all too well by the time of “Experience,” we must be receptive to what is rather than to what we would prefer, what would be convenient, what we assume, or the fraction of reality that our selective attention happens to register. The “life of truth is cold, and … mournful,” he writes in “Experience” (CW 3:46), because truth is experienced (received) rather than chosen (begotten). Living in the light of truth requires acknowledging the world's indelible inscription rather than forcibly inscribing or scarring the earth with our ambitions. The world's inscription comes as a “series of surprises” (CW 2:189) unforeseen and sometimes very painful. Remaining “fearlessly available to experience whatever life presents” (Klein 1995, 202) is the challenge Emerson meets in “Experience.” Holding to this cold and mournful life of truth, just as ninth-century Chinese poet-hermit Han Shan (who also believed that crass materialism is criminal) kept to Cold Mountain, underwrites the only creative expansion Emerson finds sustainable and ethical, both individually and nationally. For Emerson “expansions” must be “organic” and mutual because “the mind does not create what it perceives, any more than the eye creates the rose” (CW 4:46); seer and seen arise mutually.In the light of the East, Emerson developed a distinctly American version of creative and ethical self-expansion that is both predictive of and a precursor to contemporary American interest in Eastern philosophy. Though clearly attracted to the Eastern philosophical ideas he encountered, he kept to his “own orbit” and wrote his “own books” (CW 1:56). His insights about self, subjectivity, and creativity arose in the context of his personal experience and the American behaviors and commitments that deeply troubled him. His response is a theory-practice of creative expansion born of the silence, stillness, and mindfulness necessary to cultivate wisdom and to transmute consumerism into thoughtful, respectful exchanges. It is a highly relevant part of our philosophical inheritance that we have yet to put into practice fully. In his well-known work on Emerson's “Experience,” Stanley Cavell challenges us to put philosophical insight (what Emerson calls “genius”) “into practice” and bring it “to earth,” saying that “America has deprived us of the reasons” not to and that “the very promise of it drives you mad, as with the death of a child” (1989, 95).Many Eastern philosophies, particularly Buddhism, have long described self as relational, interdependent, and contiguous with all; nothing is inherently separate or autonomous. Distinctions such as those between self and other, and their correlative parallels such as mind and body, are common in Western thinking but understood in Eastern traditions as distinctions in name only. At the beginning of Nature, Emerson distinguishes between the “Soul” and “the NOT ME,” relegating even his “own body” to the not-me (CW 1:8), but he sees the trap in taking name as actuality. In “Self-Reliance,” he warns against preferring “names” to “realities” or “customs” to “creators” (CW 2:29). The problem with customary names is our propensity to settle for them. We limit ourselves to the horizons they define, thus blinding ourselves to both reality and possibility. Emerson is not the only person who has fallen under the spell of the originary, seductive name “I” to the peculiar extent of including his own body in the “not-me.” As Alan Watts notes, customarily in the West “we do not regard I, myself as identical with our whole physical organism. We regard it as something inside it” (1980, 2) and accord “I” the power to survive the death of the body.“Truth” is a similarly seductive name. In contrast to I's autonomous interiority is Truth's autonomous exteriority. In the West, we take “Truth,” reified, capitalized, and impersonal, to denote something “out there” on which multiple investigations converge. Even though contemporary Western science increasingly acknowledges that distinctions between, for example, mind and body, self and other, or observer and observed are convenient concepts rather than actual realities, it largely avoids the ethical ramifications of this insight in the name of an objectivity grounded in a dualistic ontology that distinguishes subject/mind from object/body. The tension between the insight of interrelatedness and the attachment to separateness also gives rise to the language of problems that we use in Western philosophy: the “mind/body problem,” the “problem of other minds.”The “problem” of self/other or mind/body differences disappears in Eastern monistic accounts of ontology, not by eliding difference but by resisting the urge to view it as an inherent problem of ontological significance, reconsidering difference instead as a set of experienced appearances that we imbue with nominal or conceptual significance. Watts writes, “It is completely absurd to say we came into this world” as some alien, separate novelty when “we came out of it” (1980, 6). Though we typically experience ourselves as having appeared precipitously on the scene, “all our scientific knowledge about living organisms shows us that we grow out of this world, that each of us might be called a symptom of the state of the universe as a whole” (Watts 1980, 6). Watts agrees with the “biologists [who] show us very clearly that there is no way of definitively separating a human organism from its external environment. The two are a single field of behavior” (1980, 38), but these findings have not yet transformed how we think about ourselves in relation to our environment, history, and others. 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Walden will always be associated with Henry Thoreau. It should also be associated with Emerson. Everyone knows that Thoreau built his cabin on Emerson's land at Walden Pond; it is less often recalled that Emerson not only owned land out there (which his family made sure would be kept open to public forever) but also that Emerson himself had a primary, crucial, spiritual connection to Walden. Emerson loved pond woods, they were absolutely vital to his own life work. For Emerson, who walked out to Walden almost every day for many years, Walden meant renewal, new possibilities, morning of mind, from his Walden walks came his writings. He once thought of calling his second published book Forest Essays. Perhaps he should have. ********** On October 4, 1844, which just happened to be day after Herman Melville stepped ashore at Boston from his years of travel in South Seas, Emerson, out at Concord, wrote to his brother William in New York that he had lately added an absurdity or two to my usual ones, which am impatient to tell you of. In one of my solitary wood-walks by Walden Pond, met two or three men who told me they had come thither to sell buy a field, on which they wished me to bid as a purchaser. Emerson is quick to point out that this is not just any old field. As it was on shores of pond, now for many years had a sort of daily occupancy in it, bid on it, bought it, eleven acres for $8.10 per acre. The next day carried some of my well-beloved gossips to same place they deciding that field was not good for anything if Heartwell Bigelow should cut down his pine-grove, bought, for 125 dollars more, his pretty wood lot of three or four acres, so am landlord waterlord of 14 acres, more or less, on shore of Walden, can raise my own blackberries. The purchase of course had consequences. I am now, like other men who have hazarded a small stake, mad for more.... Mrs Brown wishes me to build her a cottage on some land near my house; dreaming Alcott is here with his Indian dreams that helped him to some house farm in Spirit Land! Emerson had just sent off proofs for Essays: Second Series. He explained to his brother that his purchases were the light-headed frolics of a hack of a scribe when released at last from months of weary tending on printers devil. (1) Brother William was unimpressed, partly because times were hard neither brother had money to spare. But it is also clear from William's reply that he thought Walden area was already ruined, indeed violated, not worth acquiring. If you had bought shores of Walden Pond he wrote his brother, before they were thrown open to garish eye of railroad traveler, should not have marveled. But confess shall hardly think those years bring you wisdom, if you throw away even these cheap acres upon such a sieve (pardon confusion of metaphor) as orphic philosopher. William obviously didn't think much of Bronson Alcott, but he added, gamely, If you want any money to complete your purchase, will furnish whatever you call for. (2) Whatever William might think, purchase was clearly an important one for Emerson. To his English friend Thomas Carlyle he wrote; and when shall show you a pretty pasture woodlot which bought last week on borders of a lake which is chief ornament of this town called Walden Pond. One of these days, if should have any money, may build me a cabin or a turret there high as treetops spend my nights as well as days in midst of a beauty which never fades for me. (3) But it wasn't Alcott, or Lucy Brown or Emerson who came to Walden built a cabin; it was Henry Thoreau who did so, perhaps in response to a letter from Ellery Channing suggesting that he, Thoreau, go out to Walden begin grand process of devouring yourself alive. …