Nick Arora is Director of Medical Information at xCures, an AI-based precision oncology platform that tightly integrates cancer research and care, and Chief Health Advisor of Rymedi and Remedichain, blockchain-enabled efforts refocusing the way that life science companies capture, track, and share data. He has also spent the past twelve years as Special Advisor to the CEO of Sai Sudha Hospital in India. 

Previously, Nick served as Chief Business Development Officer at Solaster, a consumer-driven health ecosystem working on global interoperability of decentralized, distributed health applications and blockchains. Beforehand, he was Co-founder and Chief Strategy Officer at LINKCHAIN, a blockchain-based supply chain company. 

Nick has lectured on blockchain, supply chain, and health at Stanford University and has been the co-host of Blockchain in Health Care SF, the largest blockchain health meetup organization in Silicon Valley. Nick studied for his BA at Johns Hopkins, MD at Rutgers, and MPH in Yale’s Health Care Management Program.

The Politic: Tell me about your path into blockchain!

Nick Arora: I don’t know that there is a traditional path for being in the blockchain world, but mine is definitely not common. I’ve always been interested in holistic health and wellbeing, emerging technologies, and new business models. I studied public health at Hopkins in undergrad and worked pretty extensively in the U.S. and India with universities, healthcare payers, providers and organizations like the WHO and the Clinton foundation to improve health systems and integrate emerging technologies. I loved biology and wanted to make an impact at an individual level, so I went to medical school as part of a Humanism in Medicine tuition scholarship, which also gave me resources to improve healthcare beyond just studying. 

I had some incredible mentors and knew I wanted to do something which combined entrepreneurship and global health, so in addition to med school, I joined the healthcare management masters program at Yale. The program was led by Howie Forman and was between the School of Public Health and the School of Management (SOM). I was working the whole time on my own consulting efforts and startups, so I designed my curricula across schools at Yale and elsewhere to supplement what I was actually building, not just studying. 

Back in 2013, some of my smart, rebellious buddies from high school decided to leave their stable jobs and work in the Bitcoin space full-time. At that time, nobody was taking bitcoin or blockchain seriously on a mainstream level, so I took note of the fact these smart friends of mine took the full-time leap in 2013. That being said, I was doing my own thing in startups and medical school, so I didn’t get to dive in fully at that time.

When I graduated, I moved to India to work on a startup I co-founded while I was at Yale. Unfortunately, my dad was diagnosed with Amyloidosis, so I had to come back to the U.S. to take care of him. This was late 2015 and around the time that Ethereum was making its debut. I reconnected with some of those friends who had been in the blockchain space and learned about its decentralized, immutable nature and use for payments, data-sharing, addressing multi-party trust issues, and all these other problems I was dealing with and interested in because of my work in global health and even one-on-one patient care. I thought to myself, “Wow, this is incredible.” None of it seemed real. It was straight out of a video game.

So, I started reading more about blockchain. It was wild and almost too good to be true for a little while, but as I learned more, I decided to put a little bit of money into the space because the technology seemed promising and it addressed a huge need. I did that, and I actually forgot about it for awhile as I was taking care of my dad. When I looked at my account again, I thought, “What happened?” I bought Ethereum soon after it came out, and it had gone up a significant amount.

What came next?

At that point, I decided that I had to figure out what was going on here– whether the technology and the prices were legit. I spent a lot of 2016 reading everything I could find online and on Reddit. It’s important to mention that at this point, there were just way more non-legit people than there were people doing real work, at least from a more mainstream perspective. I hadn’t connected with Yale alums or others doing real work in the space yet. I was just taken aback by the technology, and eventually, I did meet some other people who were doing legitimate work.  

At that time I was in Seattle and fortunately my dad had responded to chemo, but I started feeling like I was on the periphery of the innovation, learning about breakthroughs after the fact of their development. So as my dad’s health stabilized, I moved out to Silicon Valley, where I knew people that were more at the heart of the innovation and doing some truly interesting work.

I connected with Miko Matsumura (Yale alum), and he had some Facebook groups and meetups that he’d been putting together. I thought it was a cool community. I started meeting more people, and with a mentor of mine, I actually co-founded a blockchain and supply chain company. We were working on how to apply this technology to pharmaceuticals, supply chain, the ability to use smart contracts to process payments and facilitate supply chain management via track and trace, and so on.

I started attending these meetups and eventually helped co-host and build up Blockchain in Health Care SF, what’s now the largest blockchain health meetup organization in Silicon Valley. The community brings interesting speakers and people together to discuss which areas of blockchain offer real value. While I was doing that, I was asked to lecture at Stanford about this exact issue: where there’s actual value in blockchain. So, I was looking at the supply chain side and the healthcare industry.

Then, I got an offer to join this company called Solaster as the Chief Business Development Officer where Rick Kimball (Yale alum) who had been a mentor to me was an advisor. We worked to build an interoperability standard in healthcare using blockchain. We were working to build on some of the standards like HL7 FHIR, or the Fast Healthcare Interoperability Resources.

What were some of the collaborations you worked on at Solaster?

The company was based in Nashville and we had connections with the Center for Medical Interoperability. We also collaborated with Vanderbilt University to pilot not only how to best transfer people’s medical records, but how to create our own type of HealthKit to better secure data. We had a chance to meet and talk with some interesting people like Aneesh Chopra, the first Chief Technology Officer of the United States, who was interested in helping people own their personal health data. He was also curious about these emerging technologies and business models. 

I was then contacted by Jason Cross, one of the co-founders of Rymedi. Jason was a former Duke University professor and Co-founded Rymedi with David Stefanich. The idea was to use blockchain in global health to improve multi-party trust issues, prevent value-based contracting, and improve access to medications by better tracking their movement on the blockchain ledger. These efforts have increased the trust of pharma companies to start selling their drugs in other countries where they previously lacked interest. They now know whether their products are safe from tampering and the black market.

Rymedi had created an incredible blockchain-based program with the country of Mongolia, the World Bank, the Onom Foundation, and Big Pharma to eradicate hepatitis C and track the movement of medications from manufacturers all the way to patients. They asked me to join as Chief Health Officer, which I did in December, and I’ve been in that role and as an advisor ever since. Rymedi has been doing some amazing things. I introduced Rick Kimball to Rymedi, and he signed on as the President in the past few months. Rymedi’s doing a bunch of stuff related to blockchain, supply chain, healthcare and pharmaceuticals including the hep C space. They’re doing everything from tracking the supply chain all the way to using blockchain for clinical trials.

At the moment, I’m advising Rymedi, but I’m actually working full time with a company called xCures. It’s not blockchain specific, but it’s using AI to try and create a better learning system for cancer therapeutics and a better clinical trial system. That being said, we’re looking at blockchain for underpinning the data framework to improve data integrity, provenance, privacy, and to enable a more secure and effective sharing of individual and patient data for use cases like drug development and approval.

Is Rymedi’s technology the same as what Walmart uses for tracking the supply chain of mangos, let’s say, or is there something fundamentally different?

I’ll give two examples. The basic answer is that, in concept, there’s a bunch that’s the same, but there are a couple of points that are unique with what Rymedi is doing. With the Walmart example, that’s the whole “track and trace” deal, which is also happening with Rymedi. We’re slapping QR codes on products as soon as they’re manufactured, scanning them, and then putting them on the blockchain in order to track where and when they’re produced and how they move at each step in the supply chain. We also scan and verify the credentials of pharmacists, physicians, and the identity of the patient themselves to make sure that it’s licensed, legitimate professionals and the actual patient receiving the medication. This is huge. We can actually see the movement of a $100,000 dollar drug from its manufacturing to its delivery. We know the drug ends up with the actual patient rather than the black market, and we know there’s been no tampering.

That’s similar to what’s happening with Walmart, but with Rymedi we’re using blockchain to actually expand markets and create entirely new streams of revenue. It’s not just cost savings. It’s creating a new model that truly aligns all stakeholders including Big Pharma with nonprofits like the Onom Foundation, public entities like the government of Mongolia and international bodies like the World Bank along with physicians and patients on the ground. I think this is what’s really game changing. 

Where do you think blockchain will have most value in healthcare and beyond?

This is the second example I’m talking about, and to me, this is the aspect that’s more interesting: using blockchain along with progressive regulatory policies and new, effective business models to actually bring people together who wouldn’t normally trust each other at all. 

In this example with Mongolia, pharmaceutical manufacturers of hep C treatments like Gilead charge up to $100 thousand for the full course of treatment, and the GDP of Mongolia is a fraction of that per person ($3-4 thousand per year), so without this use of blockchain alongside innovative business models, cross-organizational buy-in by the Mongolian government, Onom Foundation (Mongolia’s largest nonprofit) and the World Bank, there’s no way that the citizens or country could afford that. Hep C treatment is a decent-sized market in Mongolia with the country‘s Hep C prevalence being roughly 1 in 10 people. Still pharma companies wouldn’t have any confidence or faith that, if they were to ship this medication to Mongolia, the drugs would actually get where they’re supposed to go. It’s an even bigger liability than just a bad business proposition. You have to think about drug resistance and bad actors that could actually magnify the problem instead of reducing it.

We’ve been able to do something different from anything I’ve come across in and outside of blockchain; we’ve been able to talk to the country of Mongolia, the World Bank (which is really interested in this movement to eradicate hep C), the Onom Foundation, and Gilead. We’ve been able to say, “Look, we have this technology that’s immutable so that if you’re manufacturing and distributing products, we’ll go as far as to actually verify the credentials of the pharmacists and the identity of the patient, so you can actually see the entire way the drug you’re manufacturing, and you can make sure that the licensed doctor is giving it to the right patient.” We ask them, “If you were part of this system, would you want to look at capturing this market?” In Mongolia, the burden of hep C is mind-boggling. With a prevalence of one-in-ten, that’s significant in terms of absolute numbers. 

Now that there was this technology which would give Gilead confidence about where the drugs were going, they said, “Maybe we have more confidence in this kind of a system, but Mongolia still can’t afford $100,000 per patient.” That’s where innovative business models and lateral thinking come into play. We said that if they follow this Netflix model which the State of Louisiana is also interested in for Hep C, where you could pay a flat fee now that you’re more confident about where the medication is going and now that you can see that process in real time on the Blockchain Explorer, would you now be willing to pay a flat rate like $10 million for one thousand patients, rather than $100 thousand a pop? And there’s actually some buy in. 

We can’t release the exact details, but by being able to stitch together the technology, and knowing that Gilead is interested in expanding the markets and their revenue streams rather than only cutting costs is what we did differently at Rymedi, we said: “We’re going to create this really high-quality assurance, supply chain management system that’s going to expand markets for you, and in that way, we will connect the World Bank, Mongolia, and all of these private companies.” That’s where blockchain combined with the right regulatory landscape and business models is mind-blowing, because you’re incentivizing people to come together in ways that wouldn’t exist without the technology.

That’s amazing.

It really is. This is something that I was dealing with every single day. Even in college, when I was studying public health and working with the Clinton Foundation, you would watch people dying because manufacturers didn’t want to or couldn’t effectively ship their vaccines. Now, to have this technology and be smart with the business approach, for making the shipment of something like vaccines actually sensible because manufacturers can make money, and to be a part of this whole process, that’s been very cool.

Where are we at now with blockchain and health from the enterprise and regulatory perspectives? 

There are all of these potentially useful applications of blockchain, and we’re beginning to see what it could look like when their value is borne out more broadly. But we’re at this point where healthcare and pharma are industries with so much nonsense in terms of relationships and politics that adopting this technology will take a little bit of time. There are very few people with deep health/life science expertise and training working in blockchain, so you see even more of a disconnect between the vision and day-to-day realities  of those on the ground. Having some background in the domain has helped me strike that balance between the bigger vision for blockchain and the realities for healthcare providers, payers, and ultimately doctors and patients.

We also have to be real about where the technology is at and what it can and can’t do beyond all the hype and over-marketing. There are also all sorts of these unique challenges the technology and companies in the space have to work through and adapt for health/life sciences specifically. This is a big part of what I consult/advise companies on– it’s not easy and requires deep industry expertise with forward thinking business approaches and people who can get granular to know the nuances of how and why the tech would actually be used. 

That being said, what’s encouraging to me is that agencies like the FDA, NIH, and Health & Human Services (HHS) have put forth pilots that are validating blockchain and moving things forward. Jose Arrieta, the Chief Information Officer of Health & Human Services actually received the first official federal approval for blockchain usage. They are working on using blockchain for procurement.

Having some government bodies be progressive about the technology, and even demonstrating its value through various use cases, is valuable for the space as a whole. The FDA established a Drug Supply Chain Security Act (DSCSA) pilot to use blockchain for tracking the movement of medications from one healthcare organization to another, and just the movement and sharing of data across organizations. 

What’s a concrete example of a blockchain-based solution to the lack of data sharing?

Think about cancer care. It’s sad that there’s such great research at Yale, Harvard, or wherever else, but there’s no true collaboration, and there’s no true sharing of information and data around movement of medications across institutions. A lot of times, patients don’t get access to treatments for some of these reasons. 

With Rymedi we actually formed a consortium with Indiana Health System, UCSD, Wake Med, Good Shepherd pharmacy and some Internet of Things (IoT) companies. We were selected as one of maybe 6-7 companies to be a part of this FDA pilot showing that blockchain can be used for tracking the movement of these different specialty medications.

That’s been a nice validation of where I think blockchain will have an impact in addition to financial services: supply chain and data-sharing. It’ll be places where there are different organizations which haven’t trusted each other but will now that they’re using the technology. Of course, that’s assuming that we do it right and get all the incentives aligned properly. 

What’s the future look like?

So, the state we’re in right now is that everyone wants to do a pilot. That’s great. But what we’re going to see more of in the coming years is an expansion of the technology to companies which are already generating real goods and making money, rather than just one-off pilots. To add, one really important point is that one of the places we’re going to see real value for blockchain in the short term is on the financial side with things like payment and remittance. Bitcoin is so powerful alone for the ability to move money and the potential to be a store of value. I think that healthcare is really going to benefit from that application as well. 

Consider a medication that reaches the intended location in Mongolia where it needs to be dispensed. At that time, could there also be an automated payment via smart contracts, performed on blockchain? I’m working with a company that partnered with Western Union, and when you make transfers with Western Union, those transfers are registered on the blockchain. We’re going to see this technology advance on the regulatory side, the for-profit side, and the financial side.

Final thoughts? What most excites you, and what’s on the horizon?

To me, establishing blockchain as a foundation in nascent industries like hemp/CBD has been an encouraging sign for broader adoption. There has been a greater willingness for businesses to use the technology coupled with best practices in pharma like quality management systems (QMS) to execute current good manufacturing practice (CGMP) guidelines and compliance standards like Title 21 CFR part 11. Developing these best-in-class supply chain solutions from seed-to-sale and clinical trials is actually shaping the way regulation is being crafted by the FDA and others. They will look to real use cases in the industry to shape regulatory policy, and this might be the way more traditional slower moving healthcare and pharma players will be forced to adapt to.

A continued challenge and opportunity though will be blending what’s pragmatic and of value today with what we need to work towards for broader benefit tomorrow. There are so many individuals and companies now doing extraordinary work to build on what efforts like Rymedi are fighting for that it’s an exciting time to be in the space. For example, we’re partnering with Harmony Protocol on our work in Mongolia to demonstrate what a public version of a blockchain healthcare use case can look like beyond just a private enterprise-grade setup. This is a major challenge, but a worthy one and will create great opportunity going forward. 

It’s also important to look at places outside of the U.S. where we are seeing meaningful advancement. Some countries like Estonia have the infrastructure, policy, and enterprise environment built for technologies like blockchain. The U.S. has work to do for blockchain innovation to be more favorable, so solutions may develop elsewhere and later be adapted for the U.S. market, instead of the other way around. 

We’ll see some more interesting efforts like the MELLODDY consortium outside of the U.S., in addition to ones like the Synaptic Alliance in the States. The question will be balancing the tech and business value with the regulatory landscape. 

A good example and another worthy area is the use of blockchain in real world evidence (RWE), drug development, and clinical trials. The application has huge potential by increasing confidence in data collected, while also improving privacy, security and sharing. The FDA has issued favorable policies for RWE, and coupled with their call for blockchain-based pilots, those with regulatory-compliant technology, novel business approaches, and deep expertise capable of navigating the current healthcare system are poised to create and capture an enormous market.

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