Unraveling a blockchain-based framework towards patient empowerment: A scoping review envisioning future smart health technologies

Abstract

The COVID-19 pandemic shows us how crucial patient empowerment can be in the healthcare ecosystem. Now, we know that scientific advancement, technology integration, and patient empowerment need to be orchestrated to realize future smart health technologies. In that effort, this paper unravels the Good (advantages), Bad (challenges/limitations), and Ugly (lacking patient empowerment) of the blockchain technology integration in the Electronic Health Record (EHR) paradigm in the existing healthcare landscape. Our study addresses four methodically-tailored and patient-centric Research Questions, primarily examining 138 relevant scientific papers. This scoping review also explores how the pervasiveness of blockchain technology can help to empower patients in terms of access, awareness, and control. Finally, this scoping review leverages the insights gleaned from this study and contributes to the body of knowledge by proposing a patient-centric blockchain-based framework. This work will envision orchestrating three essential elements with harmony: scientific advancement (Healthcare and EHR), technology integration (Blockchain Technology), and patient empowerment (access, awareness, and control).

1. Introduction

The advent of Electronic Health Record (EHR) initiated a revolution in Health Information Technology (HIT). The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided an incentive of $30 Billion for adopting EHR (Birkhead et al., 2015). According to a report, from 2009 to 2015, a 7-fold increase (from 12.2% to 84%) was found in EHR adoption (Adoption of Electronic Health Record, 2008). The increased system efficiency corroborates both the necessity and success of EHR (Quan et al., 2016)– (Cao et al., 2019a). Patients can now have easy access to their medical records. Quick consult through digital document sharing paves a secure and time-saving path toward patient care. Stored individual patient data helps care providers recommend potential treatment options through pattern recognition, report data analysis, and make data-driven decisions (Lucero et al., 2019)– (Cho et al., 2020). Other advantages include reduced risk of data loss and medical error, and real-time change of patient data (Sauer et al., 2022)– (Cerchione et al., 2022). Different built-in templates and e-prescriptions save time and boost system efficiency. Financial transaction inquiries, billing, and insurance claims have become more convenient (bin Ahmad et al., 2022). EHR contributes to the elimination of lost paper superbills by generating electronic superbills and bill insurances. Even in case of any billing anomaly, patients can easily submit claims to track and check. These advantages have changed the landscape of current hospitalization. The system provides a holistic perspective for better patient treatment. Pre-set reminders automate patient check-up appointments, report pickups and track progress. EHR also enables personalization based on patient or service requirements (Abul-Husn & Kenny, 2019)– (Oh et al., 2022). Built-in templates help care providers to document common data such as patient feedback, issues, or complaints. The communication gap between care providers and patients has been greatly reduced. Doctors can easily access, track and follow up according to patient requirements. Internal and external data sharing has become more convenient (Ghafur et al., 2020).

In order to fully exploit the revolutionary advantages of HIT and pave pathways to future research and advancements, empowering patients become extremely necessary (Agner & Braun, 2018), (Bergier et al., 2021). Patient empowerment from the context of having access, awareness, and control related to medical treatment information is crucial, especially in terms of HIT and its recent advances. Firstly, access to health data contributes to informed patients who demonstrate higher passion and enthusiasm in data sharing, shared decision-making, medical check-ups, and so on (Gamal et al., 2021). Digitized data easier access ensures rapid data collection and sharing, saving considerable time for patients. Additionally, easier access aids in better management of medical information. Errors related to documentation, duplicate records, and misinformation becomes less likely with active patient participation. Easier access then leads to greater awareness as patients become more self-conscious about their health needs for different tests and medications. Patients enjoy a higher quality of service through the improved data management system, automated alerts, and notifications regarding medical check-ups, health conditions, and scheduled appointments. A better relationship is developed with doctors, pharmacies, hospitals, and other related organizations. Patients gain greater awareness about their health, treatment, and overall-related procedures. It becomes easier to avoid unnecessary tests and other associated procedures, reducing the cost significantly. The storing of patient health records over a longer period ensures improved ability for predictive patient treatment. Finally, Improved transparency in medical billings, insurance claims, and other financial transactions ensures patients' trust in the system. All in all, patients have higher control over their health information. However, there are still certain gaps to be addressed. Occurrences like a mismatch of patient data and wrong documentation raise the question of safety and decentralization of patient data. With the integration of different mobile health technology and telecommunication, a patient record might be vulnerable to a data breach.

On a different note, Blockchain is a disruptive innovation with the potential to reconfigure the traditional medical, financial, political, and cultural landscape with its' decentralized marketplace concept and greater security. Blockchain can be considered an accumulation of decentralized, distributed, peer-to-peer blocks of digitally stored, shared, and immutable data entities chained sequentially (Nakamoto, 2022). Blockchain can ensure data transparency and security through decentralized databases with no primary ownership (Kuo et al., 2017), (Nugent et al., 2016). Any data update in the blockchain requires verification before recording to the chain. Once verified, users are eligible to share data entities with other verified users ensuring accountability, efficiency, and scalability (Xia et al., 2017, p. 4). The process can be public and private based on the verification process and level of governance and accessibility. A public model of blockchain requires no vetting, and anyone can participate, such as in Bitcoin (Blockchain: Opportunities for health care, 2022). Alternately, a private blockchain model is regulated and governed by a trusted consortium that evaluates candidates. A form of computer-coded smart contract aids in automating and executing different agreements and contracts (Ethereum Whitepaper ethereum, 2022). Blockchain can be of great importance in HIT as it deals with rich, complex, and sensitive patient data vulnerable to a data breach. Both private and public blockchain models can be implemented based on medical applications and needs, which can have a profound impact on the security aspect of data access in HIT (Rutschman, 2018).

The ubiquitous field of blockchain can contribute to empowering patients in terms of access, awareness, and control. Easier access raises the question of safety and authenticity pertaining to patient data. Occurrences such as misinformation, data loss, duplicate data, and change of information can be inhibited with the integration of a systematic procedure involvement that will oversee and verify every data entry, and blockchain will be at the core of the overall system. The adoption of blockchain enables patients to have a greater awareness of their medical health records and the safety aspects. The alteration of any crucial medical information might prove to be very deleterious concerning patient-doctor shared decision making, anomaly detection, disease recognition, medical prescription, etc. Patients will be entitled to higher control over their medical information and treatment. They can hold the complete authority of ‘selective sharing’ of their medical information and treatment records (Shi et al., 2020). With the implementation of different personalized governance and regulations that suit patients' purpose and ensures control, blockchain can have a revolutionary impact. Various public and private domain-based applications of blockchain can aid in that cause. Even schemes like ‘smart contracts’ pertaining to blockchain can give patients the rightful authority over their medical data and records. The implementation of blockchain can easily be extended to other secondary medical treatment issues, such as financial transactions and insurance claims. Greater control from the context of transparency in finance and accessibility and awareness in medical fields can be achieved with secured information exchange with the help of blockchain technology.

This article-- standing in the intersection of blockchain technology and healthcare-- concentrates on patient empowerment with regard to access, awareness, and control over their electronic health records (EHR) and associated primary and secondary healthcare concerns. The unique contributions of this paper reflect in answering the following Research Questions (RQs):

RQ1

How can we critically interrogate the existing EHR paradigm and identify the roadblocks (challenges) that hinder patients' empowerment in the healthcare ecosystem?

RQ2

How can Blockchain Technology empower patients by leveraging the digital traces left by the patients?

RQ3

What are the existing limitations reflected in the state-of-the-art towards empowering patients in a Blockchain Technology-entailed paradigm?

RQ4

How can we objectively design a Blockchain Technology-entailed EHR paradigm to empower patients considering the varying temporalities of the healthcare ecosystem?

The rest of the paper includes 7 sections. Section 2 describes the study identification and selection procedures. Next, RQ1 is addressed in section 3. Section 4 elaborates different features of blockchain technology pertaining to healthcare. Then section 5 addresses RQ2. The following two sections (section 6 and section 7) delineates RQ3 and RQ4 subsequently. Finally, section 8 summarizes the study with future work recommendations. Fig. 1 depicts the taxonomy of the paper (see Fig. 2).

2. Study identification and selection

This section describes the logical sequence of steps and reasons for choosing a fixed set of study articles included in this review. PRISMA (Page et al., 2021a), (Page et al., 2021b) was used as a meta-analysis tool for identifying and screening eligible articles as showed in Fig. 1. PubMed and Google Scholar were the two bibliographic databases of our study. Since our review intends to delineate the different aspects of blockchain in healthcare and EHR, concerning patient empowerment, we chose the search keywords as follows: blockchain AND healthcare AND “patient empowerment” AND “Electronic Health Record” for Google Scholar. As PubMed includes only medical-related articles, to accumulate the possible number of papers based on our lens of review, the search keywords for PubMed were: blockchain AND healthcare AND (patient empowerment OR Patient Centric) AND (Electronic Health Record). Blockchain is a recent technology in the medical sector. Therefore, our review includes articles from the year range 2018 to 28 June 2022. The total number of articles found based on the discussions above was 138, where PubMed included 11 articles and Google Scholar included 127. Fig. 1 illustrates how PRISMA was used to choose research articles. The number of articles initially found was 138.10 articles were omitted because the full texts weren't available. Thesis (n = 17), book (n = 24), out of context (n = 31), incomplete articles (n = 11), and poor quality (n = 8) were additional exclusion criteria. For the writing of the final review, 35 articles were chosen.

The rest of the article will focus on answering the four RQs as discussed before. Firstly, we will identify and elaborate on the existing issues in the present EHR paradigm. Then we will discuss how blockchain works and different terms/concepts associated with blockchain might solve these problems from the context of patient empowerment (access, awareness and control). After that, we will discuss some practical applications using different technologies and techniques pertaining to blockchain from the context of patient empowerment. Later into the article, we will discuss about some of the probable negative outcomes of blockchain integration in the EHR system and possible ways to overcome them. Finally we will suggest a Blockchain Technology-entailed EHR paradigm considering the various aspects highlighted in the article that can be implemented across healthcare facilities.

3. Problems associated with present EHR (RQ1)

Although the application of EHR has brought about revolutionary changes in the healthcare facilities, there are still some limitations that are yet to be resolved. Some of those problems and their associated application fields with references have been listed out in Table 1 .

A data breach might happen with any kind of digital information. It is more challenging to ensure data security and safety. Devastating circumstances can result from several data breach instances (Seh et al., 2020, p. 133)– (Biggest Healthcare Data Breaches Reported, 2022). Due to patient care and ongoing research needs, medical data is crucial. All medical establishments have databases that include sensitive patient data. Therefore, being sure of safety becomes particularly important. Data breaches are a possibility with the current EHR system. Emphasis should be given to maintaining both ease of data access and security aspect of its’ uses. However, Safety still cannot be guaranteed if data input mistakes and discrepancies occur.

Incorrect entries and poor data management lead to information silos. There will be major ramifications for the treatment process if one patient's data is mixed up with another's, or if some data is lost in the system (Otero et al., 2022)– (3 Consequences of Patient Matching, 2022). A unified system is of dire need to deal with these problems. Moreover, in terms of a broader application among different healthcare facilities, having identical or similar data input and interpretation methods has become a necessity. The lack of interoperability is evident as there isn't a single report template available for all healthcare facilities. Additionally, patient data is not theirs to possess, control, or have access to. Aside from the essential tasks related to healthcare, the EHR paradigm has certain limitations pertaining to financial management such as patient tracking, claim resolution, and so on. However, several aspects of blockchain technology can solve these problems and open the door to a resolution. In the next section, we will discuss different features of blockchain technology pertaining to the RQs of this article.

4. Blockchain technology

A blockchain is a shared distributed database or ledger between computer network nodes. It serves as an electronic database for storing data in digital form. There are various features of the blockchain technology that can be used from the context of patient empowerment in healthcare sector as shown in Fig. 3 .

5. Blockchain technology in addressing existing EHR issues (RQ2)

Although EHR provides numerous benefits, there are still some deficiencies as described in section 3. This section elaborates on the many EHR-related challenges and describes how blockchain technology may handle them. The use of blockchain is capable of not only resolving several problems with the current EHR paradigm but also generating numerous potential to enhance the overall healthcare ecosystem.

6. Potential limitations of blockchain on current healthcare applications (RQ 3)

Blockchain networks do not have all the answers. Implementing a remote monitoring system, for instance, on a shared ledger would increase complexity and jeopardize continuous data collection. Medical professionals must be able to act on health data sets promptly once they are sent by medical devices to the cloud. The use of chains in healthcare is also subject to various non-technical restrictions. The cost of creating a decentralized app is expensive due to the scarcity and high demand for blockchain engineers. When required personnel are added and patient training is ensured, the cost of development rises over that of typical software development. One major issue is that providers frequently serve as the guardians of patient health data, but blockchain genuinely aims to put customers in charge by rewarding outside parties for developing solutions. The capacity to save, analyze, and share data across various places is provided by distributed information systems, which is a method of exchanging data across several systems in different site networks. Additionally, standardization is required so that other medical centers may acquire patient data for improved care coordination and continuity of treatment when using an EHR.

Several works have been done using the features of blockchain technology in the EHR paradigm. In (Dubovitskaya et al., 2020) the authors suggest a permissioned blockchain-based framework for integrating and exchanging EHR data. To create the blockchain network, each hospital will supply a node that is connected with its own EHR system. Patients and physicians will start EHR-sharing transactions via a web-based interface. They employ a hybrid approach to data management, storing just management metadata on the chain. On the other hand, actual EHR data will be encrypted and kept off-chain in cloud storage that complies with the Health Insurance Portability and Accountability Act. To protect shared EHR data, the system employs digital signatures and asymmetric encryption based on public key infrastructure. They created ACTION-EHR, a system for patient-centric, blockchain-based EHR data exchange and administration for patient care, namely radiation therapy for cancer. The Hyperledger Fabric permissioned blockchain framework, which is open-source, was used to build the prototype. Chaincode was utilized to create data sharing transactions, which were then exposed as representational state transfer APIs for the patient and user web site.

Additionally, a lot of work has been done using the blockchain's smart contract capability. A private Ethereum blockchain system with several smart-contract features is implemented in (Zhuang et al., 2020). Two modules are present in the system architecture: (1) the Link-age module: once the EHR is ready, a system administrator from each hospital will set up a touchpoint for every patient visit and input the pertinent primary data into a smart contract for future indexing. (2) The Request module: Patients provide doctors access to their data by adding doctors to the smart contract's “authorized list” of people who can access the data. After receiving access to the patient's information, clinicians can choose records through the touch points without disclosing the hospitals that are holding those documents. The blockchain technology will be used to send and receive decryption keys throughout the following data exchange amongst the concerned distant healthcare institutions.

Another similar work, in (Bowles et al., 2021), authors want to provide patients with the tools to share their medical information while maintaining control over who gets access to what parts of their data and for how long. The advantage for patients is in making it easier for them to comprehend who has access to what elements of their data and how they may regulate that access by expressly permitting or disallowing data access. They created a platform with three main elements—data tags, rules, and the blockchain—to do this. A group of preset keys known as tags have been chosen to serve as general labels for different data subsets that are accessible in the data lake. Element types like appointment, drug, procedure, gadget, and so forth are examples of potential keys. For the healthcare provider who defines the tags, the definitions are kept as JSON objects in the data lake. Rules specify how the data will be shared, whereas tags specify which data can be shared. Each rule explains who it applies to, what data it refers to, whether it should give or deny access to the professional(s), how long it should be in effect, and which tags it covers. Both patients and healthcare professionals can create rules. When it comes to which healthcare professionals have access to specific patient data and what they may view, smart contracts offer an access flag.

The difficulties in implementing various clinicogenomic registry features and blockchain features to overcome them were covered in (Silva et al., 2022, p. 713). Smart contracts and governance features can be used to offer patients choice over how their data is utilized in the future. Health systems and patients can be encouraged to exchange data by using monetization, smart contracts, and characteristics of digital ledgers. Governance layers and smart contracts may be able to reduce the transactional frictions associated with the exchange of health data. Smart contracts may also provide a solution to the problem of unauthorized use or duplication of fungible data. Additionally, smart contracts and digital ledger features can assist in removing the lack of granularity in bulk data when it comes to various compliance reports.

For various healthcare applications, including the administration of health records, health data analytics, audit trail, supply chain management, and medical research, an integrated Blockchain-Cloud (BcC) healthcare system is proposed (Ismail et al., 2021, p. 3753). There are several blockchain services already in existence that can help with that as mentioned in (Ismail et al., 2021, p. 3753). Azure Backend as a Service (BaaS) with integrated consortium management is a service that provides speedy network deployment and operations with support for smart contracts. Blockchain networks may be easily created with Amazon Managed Blockchain. The platform makes use of a voting API, which enables network users to decide whether to add or remove members. Using a Visual Studio code extension, IBM Blockchain Platform enables the development, testing, and deployment of blockchain applications with smart contract functionality. For the creation of smart contracts, the platform supports a variety of languages. With simple API connectivity, Google Blockchain makes it possible to develop blockchain apps. It enables the update/query of blockchain data using a conventional SQL database. The SAP Cloud Platform Blockchain Service enables the creation and deployment of blockchain applications from scratch, as well as the connection of external blockchain nodes to the cloud or to SAP's HANA, a robust memory data platform, to an external blockchain. With the incorporation of smart contracts, HPE Mission Critical Blockchain enables the construction of highly scalable and fault-tolerant blockchain applications. Blockchain solutions may be created and deployed quickly thanks to Alibaba Cloud BaaS, which is built on top of Alibaba's cloud container service for Kubernetes clusters. Blockchain solutions may be easily created, deployed, and managed thanks to Huawei Blockchain Service, which is built on Huawei containers. With functionality for multichain and smart contracts, Baidu BaaS makes the creation and deployment of blockchain applications simple.

Moreover, the rate of health record digitalization directly supports the viability of a blockchain solution. How rapidly patient records are transcribed, recorded, digitalized, and made accessible in EMRs directly impacts problems with a lack of flow across the health system, a lack of emphasis on the main health system, and network latency. In (Cadoret et al., 2020), authors suggested implementing blockchain in four stages for the management of health data in British Columbia. Phase 1. involves integrating blockchain technology into private clinics; Phase 2. integrating PharmaNet; Phase 3. integrating hospitals by creating a data warehouse; and Phase 4. extending to more hospital authorities in British Columbia.

Similarly, the goal of (Sadaiyandi, 2022) is to use blockchain technology to build a trustworthy and secure EMR knowledge sharing and management system. Blockchain features include a consensus mechanism, peer-to-peer communication, confidence-building without the need of a third party, and a transaction regulated by conditions and functions utilizing the intelligent contract methodology. The work (Sadaiyandi, 2022)demonstrated a web application that uses blockchain for functions like scheduling appointments, logging in as a receptionist, a doctor, a patient, or maintaining your medical history.

Several of the blockchain technology's potential applications are covered in (Durneva et al., 2020), including mobile informatics management systems, personal health records, mobile health, ubiquitous social networks, data preservation systems, health information exchange, remote patient monitoring, telemedicine, medical image sharing, clinical trial and research platforms, and predictive and classification modeling.

Based on all these potential applications of blockchain technology, the purpose of (Sung et al., 2020) was to investigate if patients could successfully confirm that their primary care clinical medical data were being monitored in a system based on blockchain technology. This research included 70 patients in total. The study was performed with an emphasis on topics including blockchain knowledge, understanding changes to medical records, digital literacy, and more. According to the study's findings, blockchain can promote patient empowerment by ensuring the openness of medical records.

In (Singh et al., 2022), authors looked into a number of blockchain-based healthcare data systems. The BurstIQ (Home, 2022) platform's job is to assist healthcare companies in securely and safely maintaining a record of information or data connected to patient medical records. They support HIPAA requirements by assisting with the licensing, sharing, and storage of data that can be utilized in an emergency. It improves the exchange and utilization of medical data by utilizing blockchain technology. Factom (Factom Blockchain Data Integrity, 2022) creates a group that allows the healthcare sector to securely keep documents digitally on the company's blockchain network, which is only accessible by hospitals and healthcare managers. The physical paper that contains the patient-related data that can only be saved and utilized by an authorized institution is furnished with special Factom security chips. Factom guarantees that blockchain technology is capable of securely preserving the patient's digital health record. To create a comprehensive ownership record, Tierion's (Tierion, 2022) blockchain checks information about accounts, prescriptions, and data. The company employs certificates and timestamps to guarantee the reliability of the medical supply chain. The company keeps a comprehensive record of ownership throughout medical supply chains by using blockchain technology.

Moreover, authors in (Maher & Khan, 2022) asserted that blockchain-based solutions like MedRec (Your Personal Electronic Health Record, 2022) can be executed as a separate module and incorporated with native data sources through application programming interfaces (APIs) without disrupting native data management systems and culture. This assertion is undoubtedly advantageous for the technology adaptation process. Additionally, because they are opensource, MedRec-like technologies may significantly contribute to the secure data gathering from current data management systems and the aggregation of an EHR under the patient's control. Patients may safely authorize access to various types and lengths of de-identified data using smart contract and IPFS/cloud storage systems.

With the help of Hyperledger, fresh ideas may be nurtured, supported by necessary resources, and the outcomes can be broadly disseminated, as explained in (Ciampi et al., 2021, pp. 29–67). With a modular design, Fabric's (Hyperledger Fabric – Hyperledger Foundation, 2022), (Androulaki et al., 2018) platform for creating distributed ledger solutions offers high levels of secrecy, flexibility, robustness, and scalability. A special-purpose distributed ledger called Indy (Hyperledger Indy – Hyperledger Foundation, 2022), (Leng et al., 2021)offers resources, libraries, and reusable parts for building and using independent digital identities that are based on distributed ledgers like blockchains. Iroha (Hyperledger Iroha – Hyperledger Foundation, 2022) is a simple to use, modular distributed blockchain technology that supports multiple signatures and has its own proprietary crash fault tolerance consensus and ordering service algorithms. With Sawtooth (Ampel et al., 2019, pp. 59–61), (Hyperledger Sawtooth – Hyperledger Foundation, 2022), the core system and application domain are separated by a flexible and modular architecture, allowing smart contracts to define the business rules for applications without being aware of the core system's internal structure. Practical Byzantine Fault Tolerance is one of the consensus techniques supported by Hyperledger Sawtooth (PBFT).

PICASO (Povilionis et al., 2018) facilitates cross-sector collaboration among caregivers, enabling care to be provided from the clinical setting to the patient's private home. Electronic health records (EHR) are sourced from and given to PICASO through operational data stores, which are part of the Care System Clouds that make up the PICASO Infrastructure (ODS). Hospitals, nursing facilities, general practitioners, etc. are possible data suppliers. DIVA is in charge of providing access tokens and securing, policy-based access control to services and data in cloud infrastructures. Patients are given secure tablet devices to access their data and PICASO services, while clinicians are only permitted access from established secure places.

We can systematically identify several issues related to the deployment of blockchain based on the discussions from Table 2 . Table 3 provides an overview.

7. Approach and framework for adopting blockchain (RQ4)

Based on the discussions of the previous section, the strongest use case for blockchain in healthcare, is a private distributed EHR (integration) with strong cryptography and safe cloud data management architecture. However, before any significant advancements in state-level public health, blockchain technology and healthcare still have a long way to go. Hence, determining whether or not a healthcare institution genuinely need the integration of blockchain is vital. Here are some criteria for testing it: 1. Multiple transactions from different sources should happen at the same time on a shared ledger (patients, medical facilities etc.). 2. Direct benefits are being received by patients. 3. Automation plays a crucial role, and minimizing or eliminating intermediaries is desired.

The next step is to comprehend the constraints of current blockchain applications in healthcare and develop methodically resolving each issue. We are aware that public blockchain (permissionless networks) are infamously sluggish thanks to our past conversations. Because scalability is being hampered by the constant growth of data, it will continue to slow down. Building private blockchains can fix this, but the basic benefit of having everyone on the same decentralized chain rapidly vanishes. One can choose a more recent chain that has fewer users but a better block throughput as an alternative. On a chain, each transaction carries a price. This problem can also be resolved by a private blockchain since we can set the cost of transactions to zero.

Creating a private blockchain-based EHR solution is a strategy that will need authorization from all new users before they can begin conducting transactions on the platform. Additionally, blockchain must be designed so that network nodes only keep on-chain meta-data. Regarding patient health information, it must be kept in a secure cloud that is connected to the blockchain ledger. As a result, EHR activities will go much more quickly. As a result, while developing an EHR solution utilizing blockchain, APIs will be used to combine blockchain with trusted cloud technologies like Amazon Web Services. It will be feasible to integrate with off-chain data sources in this manner.

However, these integrations and related IoT security must be handled independently. International consumers must be served while adhering to the General Data Protection Regulation (GDPR) (General Data Protection Regulation, 2022) and EU Medical Device Regulations (The European Union Medical Device, 2017). As patients can very well become a chain-based system's weakest link, they need to be taught on security best practices. However, by employing ransomware, social engineering, DDoS assaults, and other methods, hackers can still take advantage of weaknesses in centralized systems linked to blockchain. Fortunately, there isn't a single point of failure in the system. Additionally, running a cloud-based PaaS (Yasrab, 2018) system requires maintaining redundant nodes across availability zones.

Connecting patients with medical providers using a mobile app is one potential patient-centric way forward. Patients will use a unique coin to pay for the chain's storage of their data. Patients must spend virtual money to record transactions, after which doctors and patients can encrypt and decrypt data using the underlying blockchain technology. Doctors will also have an interconnected web interface to view permission based patient data and history.

The next greatest thing distributed ledger technology can accomplish for healthcare is to support the efforts to confirm the provenance of medicines and ensure the utilization of safe, reliable medications from legitimate pharmaceutical manufacturers. Every year, fake pharmaceuticals cost the pharmaceutical business billions of dollars (Economic loss through counterfeit drugs, 2020)– (Valverde, 2012). So having a decentralized system with automatically trackable medicine and assets across the supply chain where it's practically impossible to fake a drug undoubtedly adds commercial value. Equal access to the ledger from a single source of truth for all parties is what makes blockchain so powerful in terms of patient empowerment. Delivering actual drugs to actual patients can be made possible by using blockchain technology as the back end for mobile applications. It is possible to handle data in real-time and verify personnel credentials, among other things. To improve medication monitoring, blockchain can power apps that make use of barcode and RFID technologies.

A decentralized platform like blockchain can be used to focus on research medical institutions while patients can retain ultimate control over their data. Emphasis can be given on enabling remote clinical research with a mobile app on a decentralized ledger. An app set up with multi-omics modules to collect data with built-in AI capabilities can provide advanced analytics on incoming patient data. Smart contracts are the perfect way to obtain informed patient consent for clinical trial participation because of their autonomy. Smart contracts frequently use fairly simple if-then logic and can initiate another contract or carry out a transaction automatically when certain conditions are satisfied. This ground-breaking technology is really obtaining a patient's permission and making it accessible to a wide range of cooperating researchers. The immutability of shared data upholds consent validity. Additionally, the blockchain technology's potential for the crypto-economy practically demands the creation of a market for the exchange of patient data and even bio-samples to advance medical research and enable countrywide interoperability for healthcare providers.

Blockchain can help with claim processing, one of the most time-consuming processes in the healthcare sector for both patients and the administration. By keeping track of all financial transactions in a longitudinal, visible, and unchanging record, a shared ledger safeguards all trades. Additionally, real-time claim status monitoring is available to payers and providers. The best tool for implementing claim adjudication on a blockchain is smart contracts. One strategy may be to use specialized oracles to link smart contracts to real-world situations or to use an API to link them to a central repository. Smart contracts on the chain may handle returns, credits, and resubmissions while keeping the original chargeback and billing in place.

Automating and simplifying communications between patients, clinicians, and health insurance firms may help to tackle the interoperability problem. The provision of building blocks and modular alternatives should be prioritized in order to move the whole spectrum of medical procedures on the blockchain. Prescriptions, reimbursements, invoicing, transactions, patient registration, and many more related disciplines may be consolidated under a single blockchain.

Blockchain implementation in healthcare will always contain a back-end component. Medical blockchain technology can take multiple forms and manifest through various applications: online, mobile, desktop, etc. It goes without saying that this includes the blockchain itself, self-monitoring smart contracts, and extra server databases and APIs. A program that is used by customers, whether on the web, a mobile device, or both, is referred to as a front-end component. A cryptocurrency wallet would also be a part of the front end, and it would produce a private key to lock off access to the wallet to just the intended user. Users can communicate with one another on the chain thanks to the public key as well. The essence of anonymity on the chain is comprised of the public and private keys. It is essential to completely comprehend the technical side of blockchain in order to create and develop a solution that fully exploits all of its advantages in the healthcare industry.

Utilizing one of the open-source blockchain projects might be a possibility for building the foundation of a healthcare blockchain system. Hyperledger, which was previously covered in prior parts of this article, has been one of the most well-known players in this space. Copying an existing open-source blockchain, such as Ethereum, making the required adjustments, deploying it to nodes, and launching a private network based on Ethereum are options. However, a far more sophisticated system may be developed utilizing the Hyperledger toolkit. As mentioned in earlier sections, further Hyperledger options include IPFS, Corda, IBM Blockchain Platform, BigChainDB, and others. Finally, there is always the potential to create a brand-new blockchain protocol tailored specifically for a certain purpose.

Any blockchain solution should undergo a thorough quality-assurance procedure relative to its attributes and setup. It is important to think about issues like transaction throughput and traffic shaping (the capacity to maintain quality regardless of the number of users). Using instruments like Infura (Ethereum API IPFS API, 2022), (Panda & Satapathy, 2021) can speed up the deployment of a blockchain-based business healthcare system. A healthcare decentralized app must also be connected to other legacy systems using an Oracle. When the onus of trust is placed on a peer-to-peer connection and each community member must get authorization prior viewing the service, on-premises deployments as opposed to cloud deployment options are usual for a consortium arrangement.

Healthcare businesses may use blockchain to store shared patient information and preserve a single version of the truth with the aid of new services like Medicalchain (Home, 2022). For the purpose of completing their tasks and adding transactions to the distributed ledger, participants ask for permission to view a patient's file. One of the blockchain healthcare firms, PokitDok (Ge, 2021), is developing a platform for the exchange of interoperable healthcare transactions. Eligibility checks, claim submissions, appointment scheduling, payment optimization, patient privacy identity management, pharmaceutical benefits, and other processes are made possible by its blockchain-powered software. Pharmaceutical companies, payers, and hospitals may use services like HealthVerity (HealthVerity, 2022) to find, license, and integrate patient data from a variety of data sources to generate the best patient dataset for dispersed health. Blockchain technology can improve transparency in the medical sector by enabling ledger-based product features, advanced identification resolution, and matching capabilities.

Based on the discussions of this section, Fig. 6 shows a proposed framework for the adoption of blockchain technology in healthcare facilities.

The suggested framework in Fig. 5 has been developed with consideration for both the benefits and drawbacks of patients and healthcare institutions. The integration of blockchain for patient empowerment and ease of operation from a managerial point of view is considered. There are 5 core boxes to the entire structure colored sequentially in blue (1), green (2), yellow (3), brown (4), and black (5). 1. Patient.

• 2.

  Healthcare facility stakeholder

• 3.

  Third-party service

• 4.

  External Healthcare Facility

• 5.

  Blockchain integration

1,2,3 and 4 are all individually and separately connected with 5. This ensures the integration of blockchain in every phase.

In blue colored box 1, we see how patients are connected with 3 and 5. Each patient with his unique ID will have access to a mobile app with features as shown in Fig. 5. The data can directly go to 5, where there will be smart contracts set in place to empower patients focusing specifically on permission and access control of data. The data can also go to 3, where any third-party service providers might collaborate with healthcare facilities to get data for research and analysis. There will be layers of smart contracts here to determine how and to what extent the data will be accessed. The third-party organizations, with the necessary data, might generate value-added services for the patients or the healthcare facilities.

The green-colored box 2, emphasizes the within-facility stakeholders. There will be a web application through which they will be linked with the blockchain system (5). Smart contracts and permission rules are present here as well. Box 3, shows how integrated IOT devices or other third-party services might be integrated with the existing healthcare facility. Box 4, shows the interconnection across multiple healthcare facilities. Healthcare facility 1 will have two separate sets of smart contracts. One is dedicated to within-facility connections (1 + 2+3) and another will be dedicated to across-facility connections. Smart contracts and permissions will be set in a way that ensures a similar way of data representation across facilities. Finally, box 5 shows the blockchain integration, which is interconnected to all other boxes. A private blockchain is applied for its’ advantages as discussed earlier in this section. Sets of smart contracts and rules are present both within and across healthcare facilities. All the data finally gets stored in the cloud storage.

There are several obvious benefits of the proposed approach. Primarily, the security of the whole system will be enhanced by integrating blockchain technology into the heart of all interdependent sectors. As each data transaction is validated at each level based on the smart contracts, the possibility of information silos is avoided. Patients will be in command of their own data, giving them more accessibility. Additionally, security will be assured even while working with many third-party service providers. Furthermore, several healthcare facilities can be linked without interoperability issues.

8. Conclusion

The article unravels the potential use cases, implementation approach, and framework of blockchain in healthcare facilities from the context of patient empowerment. Although blockchain has its' advantages, it's necessary to test out if a healthcare facility needs the integration of blockchain or not. An approach towards implementation can be done using different features of blockchain as discussed in RQ4. However, there is still room for future work. The study does not cover the in-between steps of how smart contracts work. Additionally, the sequence of permission authority, specific layers of smart contracts, control authority, and governance rules across multiple healthcare facilities can be future work recommendations.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.

References

Further reading

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