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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 3 | Page : 187-192 |
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Blockchain Technology in Healthcare: The Idea and What Lies Beyond
Abhishek Kashyap, Akash Yadav, Vineet Bajaj, Yasim Khan, Sumit Arora, Lalit Maini
Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| Date of Submission | 11-Apr-2022 |
| Date of Decision | 03-Aug-2022 |
| Date of Acceptance | 25-Aug-2022 |
| Date of Web Publication | 07-Dec-2022 |
Correspondence Address:
MS Ortho, DNB Ortho Yasim Khan
Department of Orthopaedic Surgery, HN-72 VPO Nangal Thakran, Delhi 110039
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mamcjms.mamcjms_26_22
Blockchain technology has recently been at the center stage of academic discussions. This is owing to its use in the financial sector and the rise of cryptocurrencies like Bitcoin. In essence, digital ledger technology (DLT) is shared digital data spread across multiple sites. A blockchain is a type of DLT consisting of a growing list of records, called blocks, securely linked with a time stamp. Maintaining data privacy and security is one of the core benefits of using the blockchain network. In healthcare, efficient data sharing is desirable with secure long-term access to data. In recent years, numerous applications built on blockchain infrastructure have been introduced in the healthcare sector. In this narrative review, we intend to introduce the science of blockchain technology, its core concepts, and its application to healthcare. We also describe current instances of its application in the healthcare sector, its application from the Indian perspective, and its limitations and future possibilities.
Keywords: Blockchain technology, eHealth, Telemedicine, healthcare technology
How to cite this article:
Kashyap A, Yadav A, Bajaj V, Khan Y, Arora S, Maini L. Blockchain Technology in Healthcare: The Idea and What Lies Beyond. MAMC J Med Sci 2022;8:187-92 |
How to cite this URL:
Kashyap A, Yadav A, Bajaj V, Khan Y, Arora S, Maini L. Blockchain Technology in Healthcare: The Idea and What Lies Beyond. MAMC J Med Sci [serial online] 2022 [cited 2023 Mar 25];8:187-92. Available from: https://www.mamcjms.in/text.asp?2022/8/3/187/362892 |
| Introduction | |  |
Modern medicine as we know it today has resulted from a state of constant evolution. This was made possible by continuing medical research. Technology and internet applications have recently changed how we view our world. Clinical medicine has also undergone significant advances owing to this phenomenon. Giant leaps have been made possible by modern diagnostic methods, telemedicine, robotic and computer-assisted surgeries, and the list goes on. Blockchain technology is a novel innovation that has seen significant interest from clinicians worldwide. In this review, we aim to introduce the concept of blockchain technology, its applications in healthcare, and its application from the Indian perspective. Blockchain technology is, in a broad sense, a digital ledger that is shared across a decentralized network (unlike a centralized network with no central administrator) of independent computers called nodes, which update and maintain so that the record is complete and not tampered with.[1] Simply stated, it is a data management infrastructure that can be deployed in varying ways.
Blockchain technology gained worldwide attention following the rise of Bitcoin. Bitcoin[2] was first described in a white paper in 2008 by an individual or a group of individuals under the pseudonym Satoshi Nakamoto, an individual(s) whose true identity is yet unknown.[3] It is a decentralized digital currency without a central bank or regulatory authority, which can be sent from user to user using the Bitcoin blockchain network.[4] Although Bitcoin is the most widely known application of blockchain technology today, both are not synonymous. Bitcoin is an application of blockchain technology that provides the ecosystem in which digital transactions are conducted, and their records are maintained. Cryptocurrencies other than Bitcoin have also become widely used, including Ethereum,[5] Dogecoin, Litecoin, and numerous others, using blockchain technology.[6]
Blockchain technology has now been used for building numerous applications in various areas of interest. This includes data management and sharing, engineering and telecommunications, business and economics, logistics and supply chain management, healthcare, internet of things (IoTs) applications, research and extensive data analysis, and more.[7],[8],[9]
Mettler[10] published a review in 2016 on the possible uses and current applications of blockchain technology in healthcare. He described Gem, a US-based start-up that launched the Gem Health Network based on the Ethereum blockchain technology. A shared network infrastructure allows different healthcare specialists to access the same information quickly and safely. This provides instant access to the latest information to all stakeholders, resulting in streamlining and improving patient care and promoting research work in apex institutes worldwide. He also described Guardtime, a start-up that operates a healthcare platform based on blockchain technology in Estonia. It allows Estonian citizens, healthcare providers, or health insurance companies to retrieve all information on medical treatments performed in Estonia using a connected peer-to-peer system. Healthbank, a global Swiss digital health start-up, offers its users a platform on which they can store and manage their personal health information in a secure environment.[11] Users have complete freedom to share the data for physician visits or medical research. He also described the use of blockchain technology to fight counterfeited drugs in the pharmaceutical industry. Hyperledger[12] is a research network across industries that recently launched the Counterfeit Medicines Project, under which every drug produced is marked with a timestamp. This can be utilized to track a drug or other product from its point of origin to its end user. This will allow consumers to use their smart devices to check the authenticity and side effects of the drugs purchased with a simple click.
| What is a Blockchain? | | |
Blockchain is a digital ledger technology (DLT) that allows a system with a data source to be decentralized, open, safe, and trusted.[1],[13] Data are stored in discrete units called blocks which are connected, hence the term blockchain. Each block is timestamped and contains the data stored on it, its hash function, and a hash function from the preceding block. Data, once entered, cannot be changed; it is immutable. These data are stored on a decentralized network of multiple interconnected devices, known as nodes. Each node stores a full copy of the ledger, and changes made therein are communicated to all participating nodes. Each node is a fully functional unit responsible for verifying the added data. There is, therefore, no need for a central agency to monitor the system, and it cannot be altered for personal gains by a mere group of people.
| Understanding Hash | | |
In such an open public ledger, safety and privacy are maintained using cryptographic hash functions that create a digital fingerprint for any data. Each block has hash values from the preceding block and its own. This provides continuity to the data and allows any changes to the data to be tracked. This is because any change in the data would lead to a change in the hash value of the block, which all the nodes can identify. Blockchain systems use a cryptographic hash function like SHA 256 (National security agency, USA, 2001), a 256-bit encryption function, to achieve this.[1],[13] It converts the data into a pseudorandom alphanumeric sequence which is one way. A hash value is unique and cannot be solved in a reciprocal way to arrive at the parent data. Security over the blockchain network is also maintained using public and private security keys. This dual check system enhances safety and ensures that the data on such an open network is stored on all nodes but accessed by only those it is intended for, using a private key [Figure 1]. | Figure 1 Diagram showing components in a blockchain and how the nodes having hash are connected with the time stamps.
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| Decentralized Peer-to-Peer Systems | | |
At the core of blockchain technology is a decentralized peer-to-peer connected system of nodes. A decentralized system has interconnections between all participating nodes, and there is no central unit. New nodes can be added without affecting the existing system, and the failure of one or a few nodes does not disrupt the entire system. On the other hand, a centralized system has all the nodes connected to a central server. The central unit in such a system coordinates and organizes the work of all other nodes. This unit is also responsible for verifying and monitoring all the data and their authenticity. This makes a centralized system vulnerable to malicious interference as one needs only to take control of the central server to take control of the entire network. On the other hand, in a decentralized peer-to-peer connected system, each node verifies the work done by all other nodes. Although technically, a decentralized system may be taken control of by capturing at least 51% of the total nodes, this is practically impossible or, at the very least, quite difficult to achieve. This is because one would be required to calculate the new hash values for 51% of the nodes on such an extensive and geographically distributed network. The time and the computational work required to do so and the economic and energy cost of such an attempt would make the network practically unhackable.[14] So, a decentralized system ensures the integrity of the data [Figure 2]. | Figure 2 Centralized and decentralized systems in blockchain showing a decentralized network as more secure.
Click here to view |
| What are Smart Contracts? | | |
Blockchain technology is put to the application using what are known as smart contracts. Smart contracts are self-executing contracts in a blockchain network.[1] They regulate the functioning of the blockchain application, including what kind of data can be entered, how it is processed and shared, and maintain a system of rewards and punishments [Figure 3]. | Figure 3 Diagram showing how smart contracts work. Based on the inputs, it can automatically execute reward or punishment functions.
Click here to view |
| Concept of Proof of Work | | |
Rewarding nodes for submitting valid blocks is a core concept of the blockchain algorithm. All nodes maintain the same data and can process data. Adding or verifying data requires a node to solve its hash puzzle. The block generated by the node which provides the block with the highest quality in the shortest time is chosen as the valid block. This is then added to the existing blockchain. The quality of the block is determined by the computational work required to solve its hash puzzle. This concept is known as proof of work.[13],[14] This computational work is called mining in blockchain technology, and specialized nodes which carry out such activity are called miner nodes. In the Bitcoin network, miners are rewarded by giving them bitcoins for their work.[2],[4] Similarly, miners in healthcare networks could be rewarded by giving them digital incentives like access to anonymized health data for research or initiating a system of credits.
| Types of Blockchain Networks | | |
There are three types of blockchain networks depending on the functional structure of the network and how participants interact with it. They are:- Public permissionless: All the data in a public permissionless blockchain are accessible and visible to the public. Anyone can join the blockchain without approval and act as a simple node or miner. Bitcoin and Ethereum are examples of public permissionless networks. Digital incentives reward participating nodes in such a system for their excellent work.
- Consortium (public permissioned): Consortium blockchain or Federated blockchain is a blockchain technology where multiple organizations (e.g., insurance companies, financial institutions, and governmental institutions) govern the platform. It is a permissioned platform open for public use while still having established a partially centralized trust responsible for generating consensus.
- Private: Here, only a single organization will have access and authority over the network. It is, in reality, a partially decentralized network. Although such a network does not offer transparency like a public network, it is much faster and cost-effective due to the limited number of users.
| Need for Blockchain Technology | | |
Blockchain technology offers a unique set of advantages, making it a potential solution to current challenges. These advantages are:- The resilience of the network against breakdown and outside interference.
- Reliable and authenticated data ledger.
- Decentralized structure and transparency.
- Security, cryptography, and fraud prevention.
- Data collection and sharing over vast geographies, allowing collaboration.
- System of rewards and punishments.
- Ability to expand and restructure.
| Applications of Blockchain in Healthcare | | |
Blockchain technology has gained significant traction in the health sector in recent years. With ongoing work, new domains for the use of blockchain technology in healthcare will emerge.[15],[16],[17],[18] Healthcare involves the generation of large amounts of data in the form of patient records. Efficient sharing, analysis, and verification of such data could be the key to providing better healthcare. This is where the application of blockchain technology seems most apparent, to maintain decentralized health records. This would provide all relevant stakeholders with transparent and clear access to the latest treatment information and past health records. This can limit medical negligence due to outdated information. Further, it will allow medical experts involved to accurately track the interactions between the patient and health system which have taken place in the past. This creates an immutable audit of electronic health records (EHRs) which can be accessed from anywhere. This system places the patient at the center of personal healthcare by allowing him to control what data can be accessed and by whom. This brings transparency to the system and bridges the gap between healthcare professionals and their patients. Patients can also share whole or part of their health data for research purposes entirely anonymously. This would allow the seamless collection of large amounts of valuable clinical data and further medical research. Ekblaw et al.[19] published a white paper on MedRec (MIT Media Lab, Cambridge, MA), a prototype for EHRs and medical research data based on blockchain technology. MIT Media Lab has developed it in collaboration with Beth Israel Deaconess Medical Center. MedRec allows patients to maintain a comprehensive and immutable log with easy access to all the stored data, which can be shared at the patient’s discretion. In return for sustaining and securing the network via proof of work, miners here are rewarded by giving access to aggregated, anonymized data. It gives patients autonomy over their data and provides access to a large amount of anonymized data for medical research. Blockchain technology could also be utilized to improve the quality of research work.[20],[21] Trust in research work depends on ensuring transparency and preventing falsification of records for favorable outcomes. Data integrity in a blockchain is ensured by the cryptographic validation of each data entry. This is important to ensure the sincerity of the data. Further, traceability and historicity of the data are among the core functionalities of the technology, as each entry is timestamped. This will increase confidence among researchers and peer groups by increasing data collection and processing transparency.
Through smart contracts, blockchain technology can be used to collect and process data in a prespecified way to develop applications for specific purposes. Hussain et al.[22] have developed a digital orthopedic rehabilitation platform that comprises a mobile phone app, a portable activity tracker, and a clinical web portal that engages patients with self-management tasks for surgical preparation and recovery. This also gives remote feedback to the clinical team by giving timely updates about patient recovery and performance. The researchers concluded that the application allowed better rehabilitation in Total knee replacement (TKR) patients and enhanced cooperation between the patient and the treating team. IoT is the internetworking of electronic devices connected to the internet to enable the exchange of data between devices for specific domain applications. IoTs like smartwatches, mobile phones, sensors, etc., could be utilized to collect personal health data like pulse rate, temperature, number of steps, proprioception, sleep–wake cycle, etc.[23],[24] These data can be collected using the blockchain network, and smart contracts can be used to apply these data in specific situations. Blockchain technology could potentially bring reliable health technology into the hands of common people and allow unprecedented collaboration between patients and healthcare providers.
A seemingly obvious application of blockchain technology in healthcare could be the need to securely and swiftly manage funds intended for improving infrastructure or medical research. By use of cryptocurrency like Bitcoin, we could protect against fraudulent transactions and maintain a consistent, immutable ledger of all such transactions.[25] It also gives an innovative approach to insurance claims processing to prevent fraudulent claims in healthcare.[26] World Bank has also revealed plans to explore how blockchain can facilitate a mobile phone-based bond issuance program in Kenya called M-Akiba aimed at promoting savings and investment by Kenyans.[25]
Tang et al.[27] suggested the use of blockchain technology to improve current practices in implant surgery. By applying blockchain technology, the collaboration between medical researchers, doctors, patients, and other relevant stakeholders in the implant surgery field can be improved successfully.
| Application of Blockchain Technology from the Indian Perspective | | |
Blockchain technology could enable us (Indians) to develop decentralized systems for data collection and distribution in a country as geographically distributed as India. This would enable healthcare providers in the remotest areas to access vast clinical data for guiding patient care. Reciprocally, it would allow patients to interact with healthcare systems located at geographically far-off locations. It would also allow the authenticated collection of data from varying sources. For instance, the issue of data fabrication related to Coronavirus disease-2019 (COVID) cases and deaths has been regularly raised. Blockchain technology would allow data collection from different sources, such as individual patients, COVID care centers, hospitals, mortuaries, and crematoriums. This would allow seamless generation and integration of data ledgers and enable these data to be scrutinized by various sources. Similarly, blockchain could collect data related to population demographics, birth, mortality, disease prevalence, and so on. Blockchain technology can handle logistics and data maintenance in large-scale projects like the current vaccination drive. This would reduce wastage and bring transparency to the current system. Blockchains could be utilized to manage fund allocations for various health schemes and bring transparency between the authorities and the beneficiaries. This would reduce fraudulent transactions and leakage of funds, making the system more efficient. As this technology matures further, newer possible applications will come up, providing an opportunity to improve current healthcare practices.
| Limitations of Blockchain Technology | | |
Like any technology, blockchain comes with its limitations and disadvantages. Like any record, a blockchain is as good as the data entered into it. If the users enter incomplete, falsified data, it would beat the entire purpose of a blockchain. Blockchain can slow down due to the large number of users involved and the complex process of consensus generation. One major concern that has been raised against blockchain is its significant carbon footprint. Maintaining a blockchain and the process of hashing and consensus generation utilizes large amounts of energy for the computational work involved. Annualized total Bitcoin transactions have been reported to produce 97.14 megatons of CO2 annually, equivalent to Kuwait’s carbon emissions. The Bitcoin network has been reported to consume as much power as all of Thailand, around 204.50 TWh, which is an unfathomable amount of energy.[28] Further, the cost of implementing blockchain technology is enormous. Even though most blockchain solutions are open source, they require a lot of investment from the organization willing to implement them. There are costs associated with hiring developers, managing a team trained in different aspects of blockchain technology, licensing costs, and so on. There would also be a need to train the existing professionals on utilizing blockchain and ensure that all participants can understand the complexities and expected outcomes of a blockchain-powered functionality. With this background, it is imperative that advances in blockchain technology not be limited to large, private companies but rather remain as fundamentally open source technology.
| Future Prospective of Blockchain Technology in Healthcare | | |
As our knowledge about blockchain technology expands, novel ways to implement it will be introduced. The cost of implementing a blockchain is the major limiting factor today. This will probably change as this technology becomes more widely adopted and innovations are made to make it more accessible. Making EHRs available to patients with a simple touch on their smartphones can revolutionize how we look at personal healthcare today. It can give patients real power over their health and assume a more active role in healthcare interventions. Supply chains and logistics stand to be transformed with blockchain technology, potentially improving efficiency. Blockchain technology offers the potential to access vast troves of information at a simple click and go from any geographical location. This would open new avenues for medical research and bring transparency to existing systems.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Yaga D, Mell P, Roby N, Scarfone K. Blockchain technology overview. arXiv preprint arXiv:1906.11078. 2019.  |
| 2. | Nakamoto S. Bitcoin: a peer-to-peer electronic cash system. Decentralized Business Review 2008:21260. |
| 3. | Popper N. Decoding the enigma of Satoshi Nakamoto and the birth of Bitcoin. New York Times. 2015;15. |
| 4. | Böhme R, Christin N, Edelman B, Moore T. Bitcoin: economics, technology, and governance. J Econ Perspect 2015;29:213–38. |
| 5. | Wood G. Ethereum: a secure decentralised generalised transaction ledger. Ethereum project yellow paper 2014;151:1–32. |
| 6. | Sovbetov Y. Factors influencing cryptocurrency prices: evidence from Bitcoin, Ethereum, Dash, Litcoin, and Monero. JEFA 2018;2:1–27. |
| 7. | Yli-Huumo J, Ko D, Choi S, Park S, Smolander K. Where is current research on blockchain technology? − A systematic review. PLoS One 2016;11:e0163477. |
| 8. | Fernández-Caramés TM, Fraga-Lamas P. A review on the use of blockchain for the internet of things. IEEE Access 2018;6:32979–3001. |
| 9. | Xu M, Chen X, Kou G. A systematic review of blockchain. Financial Innov 2019;5:1–4. |
| 10. | Mettler M. Blockchain technology in healthcare: the revolution starts here. IEEE 18th International Conference on e-health Networking, Applications and Services (Healthcom); 2016. pp. 1–3. |
| 11. | Kuo TT, Kim HE, Ohno-Machado L. Blockchain distributed ledger technologies for biomedical and health care applications. J Am Med Inform Assoc. 2017;24:1211–20. |
| 12. | Cachin C. Architecture of the hyperledger blockchain fabric. Workshop on distributed cryptocurrencies and consensus ledgers; 2016 (310). |
| 13. | Zheng Z, Xie S, Dai H, Chen X, Wang H. An overview of blockchain technology: architecture, consensus, and future trends. IEEE International Conference on Big Data; 2017. pp. 557–64. |
| 14. | Ahram T, Sargolzaei A, Sargolzaei S, Daniels J, Amaba B. Blockchain technology innovations. IEEE Technology and Engineering Management Conference (TEMSCON); 2017. pp. 137–41. |
| 15. | Engelhardt MA. Hitching healthcare to the chain: an introduction to blockchain technology in the healthcare sector. Technology Innovation Management Review 2017;7. |
| 16. | Agbo CC, Mahmoud QH, Eklund JM. Blockchain technology in healthcare: a systematic review. Healthcare 2019;7:56. |
| 17. | Angraal S, Krumholz HM, Schulz WL. Blockchain technology: applications in health care. Circ Cardiovasc Qual Outcomes 2017;10:e003800. |
| 18. | Roman-Belmonte JM, De la Corte-Rodriguez H, Rodriguez-Merchan EC. How blockchain technology can change medicine. Postgrad Med 2018;130:420–7. |
| 19. | Ekblaw A, Azaria A, Halamka JD, Lippman A. A case study for blockchain in healthcare: “MedRec” prototype for electronic health records and medical research data. IEEE Open and Big Data Conference; 2016. p. 13. |
| 20. | Benchoufi M, Ravaud P.Blockchain technology for improving clinical research quality. Trials 2017;18:1–5. |
| 21. | Kuo TT, Ohno-Machado L. Modelchain: decentralized privacy-preserving healthcare predictive modeling framework on private blockchain networks. arXiv preprint arXiv:1802.01746. 2018. |
| 22. | Hussain MS, Li J, Brindal E et al. Supporting the delivery of total knee replacements care for both patients and their clinicians with a mobile app and web-based tool: randomized controlled trial protocol. JMIR Res Protoc 2017;6:e32. |
| 23. | Joyia GJ, Liaqat RM, Farooq A, Rehman S. Internet of medical things (IoMT): applications, benefits and future challenges in healthcare domain. J Commun 2017;12:240–7. |
| 24. | Hathaliya J, Sharma P, Tanwar S, Gupta R. Blockchain-based remote patient monitoring in healthcare 4.0. IEEE 9th International Conference on Advanced Computing (IACC); 2019. pp. 87–91. |
| 25. | Till BM, Peters AW, Afshar S, Meara JG. From blockchain technology to global health equity: can cryptocurrencies finance universal health coverage? BMJ Glob Health 2017;2:e000570. |
| 26. | Gatteschi V, Lamberti F, Demartini C, Pranteda C, Santamaría V.Blockchain and smart contracts for insurance: is the technology mature enough? Future Internet 2018;10:20. |
| 27. | Tang YM, Ho G, Jack WU. Integrating blockchain for improving data sharing in implant surgery. ISER 147th International Conference; 2018. |
| 28. | |
[Figure 1], [Figure 2], [Figure 3]
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