Why Your EHR's Identity Model is Fundamentally Broken

Patient identity is a database key. Your medical self is a foreign key in a proprietary Epic or Cerner schema, not a sovereign entity you control. This model fragments your history across incompatible systems.

Data integrity is unverifiable. You cannot cryptographically prove the provenance or immutability of your own records. This contrasts with Verifiable Credentials (W3C) and Soulbound Tokens (SBTs) which provide user-centric attestations.

Consent is a binary gate, not a ledger. Granting access is an all-or-nothing permission slip, not an auditable, revocable transaction. Systems like OAuth 2.0 and UCANs demonstrate finer-grained, user-delegated authorization models.

Evidence: The 2023 ONC report found over 50% of hospitals still exchange records via fax or mail, a direct consequence of this broken identity and trust layer.

Centralized identity silos are liabilities. Each organization becomes a single point of failure for user data, creating massive honeypots for attackers. The 2024 UnitedHealth breach exposed data for 1 in 3 Americans, proving the model's systemic risk.

Data ownership is inverted. Users do not own their health records; they rent access from each provider. This creates friction for care coordination and locks data within proprietary systems like Epic or Cerner.

Verifiable Credentials (VCs) and decentralized identifiers (DIDs) invert this model. Standards like W3C VCs allow users to hold portable, cryptographically signed attestations from issuers, breaking the silo dependency.

The liability shifts from data custodianship to credential issuance. A provider's role changes from storing PII to signing claims, drastically reducing their attack surface and compliance overhead.

Provider-Centric Identity is the root flaw. Every hospital's EHR system, from Epic to Cerner, issues its own internal patient identifier. This creates a federated identity model where the hospital is the central authority, not the patient. The patient's identity is a local database entry, not a portable credential.

Data silos are a direct consequence. A patient's record at Hospital A is completely isolated from their record at Clinic B. This forces manual faxing and phone calls for care coordination, a process that fails 50% of the time according to a 2023 JAMA study on care transitions.

You are forced to copy sensitive data. To enable any interoperability, the only option is to duplicate PHI (Protected Health Information) and send full copies. Each copy creates a new attack surface and a new compliance burden, violating the core security principle of minimizing data replication.

Liability concentrates on the data holder. Under HIPAA, the entity storing the data bears the legal and financial risk for breaches. This perverse incentive makes hospitals data hoarders, not data sharers, as sharing increases their liability exposure without tangible benefit.

Contrast this with user-centric models. In web3, protocols like Ethereum (EOA accounts) and Clerk for web2 demonstrate user-owned identity. The user controls a private key or token, granting permissioned access to services without creating a permanent, liable copy of their data on every server.

Centralized Health Information Exchanges (HIEs) aggregate patient data from disparate providers into a single, queryable source. This architecture solves the immediate problem of data silos by creating a centralized intermediary for permissioned access, avoiding the need for point-to-point integrations between every hospital and clinic.

The FHIR standard provides semantic interoperability, defining a common API and data format for electronic health records. This allows different EHR systems from Epic, Cerner, and others to theoretically speak the same language, reducing the friction of data exchange compared to older HL7v2 messages.

The governance model is established and familiar. A centralized authority, whether a state HIE or a large health system, manages access controls, audits logs, and ensures compliance with HIPAA. This provides a clear, legally accountable entity, which is the primary argument against decentralized models.

Evidence: Over 90% of hospitals and 80% of office-based physicians use a certified EHR, with FHIR adoption mandated by CMS regulations like the Interoperability and Patient Access Final Rule. This creates massive institutional momentum.

Centralized identity is a single point of failure. Your EHR's monolithic user database is a honeypot for attackers. A breach of this single system compromises all patient data, creating catastrophic liability and violating regulations like HIPAA and GDPR.

Siloed identity creates user friction. Patients must manage dozens of separate logins for providers, insurers, and pharmacies. This fragmented experience degrades care coordination and increases administrative overhead for your IT team.

The verifiable credential standard (W3C VC) is the alternative. Protocols like SpruceID and Veramo enable patients to hold cryptographically signed credentials from issuers (doctors). They present only the necessary proof (e.g., age > 18) without revealing their full identity, shifting the burden of proof from your servers.

Your role shifts from custodian to verifier. Instead of storing and protecting vast PII databases, your system verifies the authenticity of user-presented credentials. This reduces your attack surface, compliance scope, and infrastructure costs while giving users true data portability.