VISVESVARAYA TECHNOLOGICAL UNIVERSITY

Jnana Sangama, Belagavi – 590018

A TECHNICAL SEMINAR REPORT

ON

“Blockchain Technology in Healthcare”

A Dissertation Submitted in partial fulfillment of the requirement for the degree of

BACHELOR OF ENGINEERING

In

COMPUTER SCIENCE & ENGINEERING

Submitted by
MOHAMMED WAQAR (1RG17CS032)
Under The Guidance of
Mrs. Deepti

Asst Professor, Dept of CSE

RGIT, Bengaluru city – 32

Department of Computer Science & Engineering

RAJIV GANDHI INSTITUTE OF TECHNOLOGY
Cholanagar, R.T. Nagar Post, Bengaluru-560032
2021 – 2022
 RAJIV GANDHI INSTITUTE OF TECHNOLOGY
(Affiliated to Visvesvaraya Technological University)
Cholanagar, R.T. Nagar Post, Bengaluru-560032

Department of Computer Science & Engineering

CERTIFICATE
This is to certify that the Seminar Report titled “Blockchain Technology in
Healthcare” is a bona fide work carried out by Mr. Mohammed Waqar
(1RG17CS032) in partial fulfillment for the award of Bachelor of Engineering
in Computer Science and Engineering under Visvesvaraya Technological
University, Belagavi, during the year 2021-2022. It is certified that all
corrections/suggestions given for Internal Assessment have been incorporated in
the report. This technical seminar report has been approved as it satisfies the
academic requirements in respect of technical seminar (17CSS86) work prescribed
for the said degree.

Signature of Guide Signature of HOD

Mrs. Deepti Mrs. Arudra A
Asst. Professor Asst. Professor

Dept. of CSE, Dept. of CSE,

RGIT, Bengaluru
RGIT, Bengaluru

External Evaluation
Name of the Examiners Signature with date

1.

2.
 VISVESVARAYA TECHNOLOGICAL UNIVERSITY
Jnana Sangama, Belagavi – 590018

RAJIV GANDHI INSTITUTE OF TECHNOLOGY

DEPARTMENT OF COMPUTER SCIENCE & ENGINEERING

DECLARATION
I hereby declare that the technical seminar report entitled “Blockchain Technology in
Healthcare” submitted to the Visvesvaraya Technological University, Belagavi during
the academic year 2021- 2022, is record of an original work done by me under the
guidance of Mrs. Deepti, Asst Professor, Department of Computer Science and
Engineering, RGIT, Bengaluru in the partial fulfillment of requirements for the award of
the degree of Bachelor of Engineering in Computer Science & Engineering. The
results embodied in this technical seminar report have not been submitted to any other
University or Institute for award of any degree or diploma.

MOHAMMED WAQAR (1RG17CS032)

 ACKNOWLEDGEMENT
I take this opportunity to thank my college Rajiv Gandhi Institute of
Technology, Bengaluru for providing me with an opportunity to carry out this
seminar work.

I extend my sincere regards and thanks to Dr. Nagaraj A M, Principal, RGIT,

Bengaluru and to Mrs. Arudra A, Associate Professor and Head, Department of
Computer Science and Engineering, RGIT, Bengaluru, for being a pillar of support
and encouraging me in the face of all adversities.

I would like to acknowledge the thorough guidance and support extended

towards us by Mrs. Deepti, Assistant Professor, Dept of CSE, RGIT, Bengaluru.
Their incessant encouragement and valuable technical support have been of
immense help. Their guidance gave me the environment to enhance my knowledge
and skills and to reach the pinnacle with sheer determination, dedication and hard
work.

I also want to extend my thanks to the entire faculty and support staff of the
Department of Computer Science and Engineering, RGIT, Bengaluru, who have
encouraged me throughout the course of the Bachelor’s Degree.

I want to thank my family for always being there with full support and for
providing me with a safe haven to conduct and complete my technical seminar. I will
ever grateful to them for helping me in these stressful times.

Lastly, I want to acknowledge all the helpful insights given to me by all my

friends during the course of this technical seminar.

MOHAMMED WAQAR (1RG17CS032)

i
 ABSTRACT
Since blockchain was introduced through Bitcoin, research has been ongoing to extend its
applications to non-financial use cases. Healthcare is one industry in which blockchain is expected to
have significant impacts. Research in this area is relatively new but growing rapidly; so, health
informatics researchers and practitioners are always struggling to keep pace with research progress
in this area. This paper reports on a systematic review of the ongoing research in the application of
blockchain technology in healthcare. The research methodology is based on the Preferred Reporting
Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and a systematic mapping
study process, in which a well-designed search protocol is used to search four scientific databases, to
identify, extract and analyze all relevant publications. The review shows that a number of studies
have proposed different use cases for the application of blockchain in healthcare; however, there is
a lack of adequate prototype implementations and studies to characterize the effectiveness of these
proposed use cases. The review further highlights the state-of-the-art in the development of
blockchain applications for healthcare, their limitations and the areas for future research. To this end,
therefore, there is still the need for more research to better understand, characterize and evaluate the
utility of blockchain in healthcare.

ii
 CONTENTS
Acknowledgement i

Abstract ii

CHAPTER NO TITLE PAGE

NO
1 INTRODUCTION 1
2 Overview 4
2.1 Research Methodology 4
2.2 Use-Cases 4
2.3 Discussion 5
3 CONCLUSION
4 REFERENCES
INTRODUCTION
CHAPTER 1 INTRODUCTION

Blockchain gained popularity as a distributed ledger technology following the Bitcoin white
paper published in October, 2008 . As the underlying technology for Bitcoin, the main utility
of blockchain is that it makes possible the exchange of electronic coins among participants in a
distributed network without the need for a centralized, trusted third party. Transactions
involving the exchange of electronic currencies between persons or companies have
traditionally relied on a trusted third party (TTP), such as a bank, as a mediator. The reliance
on a TTP is not desirable for a number of reasons. A trusted third party may malfunction, fail
or be compromised maliciously to render the financial system unavailable or insecure; thus, a
TTP undermines a system potentially as a single point of failure. A TTP also charges
transaction fees and adds some transaction delays. The motivation behind Bitcoins is,
therefore, to overcome these limitations associated with the reliance on TTP in electronic
transactions.

A year after the publication of the famous white paper on Bitcoin, the Bitcoin cryptocurrency
was implemented, with the code released as open-source, which made it possible for others to
modify the code and improve on it to create different generations of blockchain-based
technologies. The first implementations of blockchain-based cryptocurrencies, such as the
Bitcoin, constitute the first generation of blockchain technology, which is also referred to as
blockchain 1.0 .

Other blockchain 1.0 technologies include Monero , Dash and Litecoin, to name a few. The
second generation of blockchain technology (blockchain 2.0) is associated with the
introduction of smart properties and smart contracts. The smart properties are those digital
properties or assets whose ownership can be controlled by a blockchain-based platform, while
the smart contracts are the software programs that encode the rules of how the smart properties
are controlled and managed. Examples of blockchain 2.0 cryptocurrencies include Ethereum,
Ethereum Classic, NEO and QTUM .
Building on the above, the third generation of blockchain technology (blockchain 3.0)
is now concerned with the non-financial applications of blockchain. To this end, efforts have
been made to adapt the technology to other application areas, outside finance, so that other
industries and use cases can benefit from the interesting features of blockchain.
Consequently, blockchain is now considered as a general purpose technology that has found
applications in different industries and use cases, such as identity management, dispute
resolution, contract management, supply chain management, insurance and healthcare, to
name a few.
With the growing fascination for blockchain and its adoption in different organizations
and industries, healthcare has come to represent a significant area where a number of use
cases have been identified for the application of blockchain. However, blockchain being a
relatively new technology and with a lot of hype in the press as well as in grey publications
in the form of opinion pieces, commentaries, blog posts, interviews, etc, there is a lot of
inaccurate information, speculations and uncertainties about the potential utility of
blockchain in the healthcare industry. Members of the research community and practitioners
would want to understand the specific areas of application or use cases of blockchain in the
healthcare industry; and of these identified use cases, what blockchain-based healthcare
applications have been developed, What are the challenges and limitations of the
blockchain-based healthcare applications, how are these challenges currently being
addressed and what are the areas for improvement.
This Seminar reports on the systematic review that is conducted to address the above
questions. While there exist some interesting reviews in the literature that are related to this
topic.ours is different in terms of the methodology and the objectives. In the review
conducted, they identify some examples of the application of blockchain technology in
healthcare. These include the Guardtime, a firm which operates a blockchain-based
healthcare platform for the validation of patients’ identities for the citizens of Estonia;
and the MedRec project, which was created to facilitate the management of permissions,
authorization and data sharing between healthcare entities. Similarly, Engelhardt outlines a
collection of ‘noteworthy’ examples of blockchain technology companies in the healthcare
sector. These companies are grouped under different healthcare use cases, namely;
prescription drug fraud detection, patient-centered medical records and the dental industry.
This review is equally similar to the one conducted by Mettler where he reports some
examples of blockchain-based applications and companies in the areas of public health
management, medical research and drug counterfeiting in the pharmaceutical industry. On
their part, Ku et al, publishes the key benefits of blockchain when compared to traditional
databases for healthcare applications. They go further to explain how these benefits can be
harnessed to improve medical record management, enhance insurance claim processes,
improve clinical research and advance healthcare data ledgers. Lastly, Roman-Belmonte et
al, in their review cover the existing and potential applications of blockchain in different
fields of medicine, which include the fields of legal medicine, health data analytics,
biomedical research, electronic medical records, meaningful use, payment for medical
services and so on.
Our approach departs from the ones adopted in the aforementioned reviews in that we
follow the guidelines for systematic literature review and systematic mapping study process
and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)
statement in conducting and reporting our review. Our systematic review is based on a well-
designed research protocol that ensures a holistic and unbiased sampling of all the
published peer-reviewed articles that are relevant to the subject matter.

Based on this protocol, we retrieve from reputable scientific databases the relevant articles
which we classify and map into different categories to unravel the truestate of the ongoing
research in the application of blockchain technology in healthcare. The resulting map from
our research will be very valuable to practitioners and researchers in understanding the
domain state-of-the-art and the areas for future research. To the best of our knowledge, this is
the first literature review on the application of blockchain in healthcare that follows the
systematic mapping study process. The systematic review conducted by Yli-Huumo et al.
inspired our choice of this methodology; however, their review on the technical challenges
of blockchain technology is unrelated to our topic, which is the application of blockchain in
healthcare. The systematic review by Holbl et al.,is also similar, but ours differs markedly in
scope.
It is also worth noting that the objective of this review is not just to identify the use
cases or the examples of blockchain-based applications in healthcare, but also to understand
the limitations and challenges for the blockchain-based healthcare applications as well as
the current trends in terms of the technical approaches, methodologies and concepts
employed in developing these applications (and in overcoming the limitations) in a view to
unravel the areas for future research. Moreover, this review covers many new materials
which had not been published at the time of the previous reviews. As noted earlier, the
application of blockchain in healthcare is a relatively new paradigm which is growing
rapidly, and as such, there are many new publications on the topic. To illustrate this point, 32
of the 65 selected papers for this study were published in 2018 whereas most of the existing
reviews were published in 2017 or earlier.
Overview of Blockchain
The detailed technical underpinnings of the blockchain technology is outside the scope
of this report. However, for the purpose of our discussion going forward, it is important to
shed light on some blockchain concepts, features and terminologies that will foster the
understanding of how blockchain is applied to solve healthcare problems.
Perhaps, the most obvious and outstanding benefit of blockchain is the fact that it
removes the need for a centralized trusted third party in distributed applications. By making
it possible for two or more parties to carry out transactions in a distributed environment
without a centralized authority, blockchain overcomes the problem of single point of failure
which a central authority would otherwise introduce. It also improves transaction speed, by
removing the delay introduced by the central authority, and at the same time, it makes
transactions cheaper since the transaction fees charged by the central authority is removed. In
place of a central authority, blockchain uses a consensus mechanism to reconcile
discrepancies between nodes in a distributed application. The difference between centralized
and decentralized systems is illustrated in Figure1.
In Figure1a, there are multiple ledgers but all the records are held in one central place, in
this case, the Regional Health Information Organization (RHIO). In essence, the RHIO
maintains the state of the ledger. When there is a disagreement between two nodes about the
“true state” of the ledger, the RHIO is consulted as the final arbiter to determine the “true
state” of the ledger. On the contrary, in Figure1b, there is only one ledger, but all the nodes
have a copy of the ledger and some level of access to its contents. To maintain the integrity
of the ledger, the nodes must have a means to agree on the “true state” of the ledger, in the
absence of a central authority. When the nodes agree on a particular “true state” of the
ledger, it is referred to as consensus. The different ways in which consensus is achieved in
blockchain will be explained in the remaining part of this Section.
 Figure 1. Centralized vs. decentralized system. In (a), there are multiple ledgers but all records are held in
RHIO, whereas in (b), there is only one ledger but every node has some level of access to that ledger. The
decentralized architecture removes the need for trusted third party, makes transactions faster, and removes the
transaction fees charged by the trusted third party (RHIO).

At its very core, blockchain uses cryptographic primitives to derive most of its
capabilities. Participants in a blockchain network are represented as nodes and each node
uses public key infrastructure (PKI) to create and propose transactions. Each participant
possesses a pair of public and private keys. The public key serves as the public address of
the user while the private key is used to authenticate the user. When a transaction is created,
it has to include the public key of the user who created the transaction, the public key of the
receiver of the transaction and the transaction message. All of these are bundled together
and cryptographically signed using the user’s private key and subsequently broadcast to the
other nodes in the blockchain network. When this is done, the user is said to have proposed a
transaction.
A block is a collection of valid transaction proposals that are received within a period
of time, say 10 min.A valid transaction proposal is one which satisfies the validation
requirements. The process of validation ensures that the proposed transaction is legitimate,
for example, that it originates from an authorized user (node). The consensus algorithm
determines the order in which the validated blocks are appended to the ledger. There are
special nodes in a blockchain network that are responsible for running the consensus
algorithms (i.e., for validating transactions and determining the order in which transaction
blocks are added to the blockchain). These special nodes are called miners and the process of
validating transactions and ordering them in the blockchain is referred to as mining. Once a
transaction proposal is received by a miner, the miner proceeds to check if the transaction
is valid. Validated transactions are included into a block. After a period (or block) of time,
the new block of validated transactions is linked (or chained) to the previous blocks, creating
a chain of blocks, known as blockchain. The blockchain is replicated among all the nodes in
the network, such that every node has an identical database or ledger of all the transactions
in the network.
It is important to understand how blocks are chained to form the blockchain, but let us first
explain the different types of blockchain. In some implementations of blockchain, e.g.,
Bitcoin, any node is free to join the network and to participate in the mining process (that is,
take part in validating new blocks and chaining them to the existing ones). This sort of
blockchain implementation in which any node is free to join the network and to participate
as a miner without requiring any authorization or access permission is referred to as public or
permissionless blockchain. In contrast, permissioned blockchain is one in which participants
must be authorized and have the right access permissions before they can join and participate
in the network. In permissioned blockchain, only certain nodes may be permitted to
participate in the mining process. By virtue of their characteristics, permissioned blockchain
networks are more likely to be smaller, faster and more secure than the public blockchain
networks.
 A permissioned blockchain may further be classified as a private or a consortium
blockchain. The distinction between private and consortium blockchains is based on the
number of nodes permitted to be miners. If only one node is permitted to be a miner, it is
more aptly referred to as private blockchain. Note, however, that when only one node is the
miner, then that node serves more or less as a central authority, in which case some of the
advantages of decentralization is lost. Consortium blockchain is one in which two or more
nodes are permitted to take part in the mining process, yet the blockchain network remains
permissioned, in the sense that only authorized users can be part of the network. The
consortium blockchain, therefore, has the advantages of decentralization as well as the
improved security and privacy inherent in the private blockchain. More information about
the different types of blockchain (public, permissioned: private and consortium) can be
found in.
Let us get back to how blocks are chained to form a blockchain. The chaining of blocks is
achieved through another cryptographic primitive which involves the use of hash functions.
A hash function takes a message of arbitrary length and crunches it into a hash output of a
fixed length, referred to as a message digest or a digital fingerprint. An interesting
property of hash function is that it is collision-resistant, i.e., no two different messages will
produce the same hash output. This property is the basis of block chaining. To chain a new
block to the blockchain, the hash of the previous block header is included in the new block
header. Thus, the last block in the blockchain contains the fingerprint of the transactions in
the previous block, which in turn contains the fingerprint of the transactions in the
preceding block and so on (Figure2).

Figure 2. A simplified example of how blocks are chained to form a blockchain. Notice that each block contains
a header and a number of transactions. The transactions in a block are hashed to generate a fixed-length hash
output which is added to the block header. After the creation of the first block, every subsequent valid block
must contain the hash output of the previous block header. The hash of the previous block header which is
contained in every block serves as the chain that links every valid block to the ones before it. Thus, by linking
every block to the previous blocks, a chain of blocks (blockchain) is established.

As depicted in the diagram in Figure2, if any of the transactions in a block is changed,

even if slightly, the corresponding hash output will change drastically, which will break
the chain to the subsequent blocks in the blockchain. Therefore, any alteration to the
contents of a block in the blockchain is easily detected in the network. For this reason, once
a transaction is added to a block and chained to the blockchain, that transaction cannot be
altered or undone. Thus, information on the blockchain are said to be immutable.
Immutability is an important property of blockchain which ensures that records, once
created, cannot be retrieved or modified. To update a record on the blockchain, a new record
must be created, hence, blockchain is also said to be an append-only ledger. The process of
chaining blocks to the blockchain also ensures that the transactions are time-stamped,
 As explained previously, the approaches to mining and reaching consensus differ across
the different types of blockchain. In public blockchain, such as Bitcoin, there are usually
more than one miner in the blockchain network, with the miners potentially receiving the
transaction proposals in varying order, so it is possible that different miners will produce
different valid blocks in which the ordering of transactions are different. In order for every
node to have an identical copy of the blockchain, miners in the network must agree on the
order in which the validated blocks are appended to the blockchain. In other words, only one
of the miners is allowed to append a valid block per cycle. This can be done in different ways
according to the consensus protocol in use. A popular example of a consensus protocol is the
Proof of Work (PoW) used in Bitcoin.
Proof of Work (PoW) is a protocol based also on cryptographic hash function, in which
the miners are required to solve a computationally difficult problem to determine the miner
whose block is accepted to be added to the blockchain. In PoW protocol, a predetermined
pattern of digital fingerprint is given, and the miners are required to find a random number
which can be added to the transaction messages and hashed together to produce an identical
pattern to the one given. In each cycle, the first miner to finish solving the mathematical
problem is allowed to add a block to the blockchain. There are other examples of consensus
protocols in the wild but their main purpose is the same, which is to ensure a consistent
“true state” of the ledgers in the distributed nodes, without relying on a centralized trusted
third party.

From the foregoing, blockchain can be defined as an immutable ledger or database,

shared by peers in a network, in which records of events or transactions are appended
in a chronological order. Evidently, blockchain embodies some interesting features that
are beneficial to healthcare applications. One important feature of blockchain that is
clearly beneficial to healthcare applications is decentralization which makes it possible
to implement distributed healthcare applications that do not rely on a centralized
authority. Additionally, the fact that the information in the blockchain is replicated among
all the nodes in the network creates an atmosphere of transparency and openess,
allowing healthcare stakeholders, and in particular the patients, to know how their
data is used, by whom, when and how. More importantly, compromising any one node
in the blockchain network does not affect the state of the ledger since the information
in the ledger is replicated among multiple nodes in the network. Therefore, by its
nature, blockchain can protect healthcare data from potential data loss,
corruption or security attacks, such as the ransomware attack.
In addition, the immutability property of blockchain which makes it impossible to alter or
modify any record that has been appended to the blockchain aligns very well with the
requirements for storing healthcare records—it is very important to ensure the integrity and
validity of patients’ health records. What is more, the use of cryptographic algorithms to
encrypt the data stored on the blockchain ensures that only the users who have legitimate
permissions to access the data can decrypt them, thereby improving the data security and
privacy. Furthermore, since the identities of the patients in a blockchain are pseudonymized
through the use of cryptographic keys, the health data of patients may be shared among
healthcare stakeholders without revealing the identities of the patients. Blockchain also
supports smart contracts that can be used to program the rules that allow the patients to be in
control of how their health records are shared or used. This is particularly relevant to the
European General Data Protection Regulation (GDPR) which prohibits the processing of
sensitive personal data of patients unless explicit consent is given, or specific conditions are
met.Therefore, blockchain can facilitate the development of a GPDR-compliant EMR
management system, by encoding in the smart contract a set of rules that ensure that
patients’ sensitive data cannot be shared or used without appropriate authorizations. The
potential benefits of blockchain to healthcare applications are summed up in Table1.
 Table 1. Benefits of blockchain to healthcare applications.
Decentralization The very nature of healthcare, in which there are distributed stakeholders, requires a
decentralized management system. Blockchain can become that decentralized health data
management backbone from where all the stakeholders can have controlled access to the same
health records, without any one playing the role of a central authority over the global health data.
Improved data security The immutability property of blockchain greatly improves the security of the health data stored on
and privacy it, since the data, once saved to the blockchain cannot be corrupted, altered or retrieved. All the
health data on blockchain are encrypted, time-stamped and appended in a chronological order.
Additionally, health data are saved on blockchain using cryptographic keys which help to protect
the identity or the privacy of the patients.
Health data ownership Patients need to own their data and be in control of how their data is used. Patients need the
assurance that their health data are not misused by other stakeholders and should have a means to
detect when such misuse occurs. Blockchain helps to meet these requirements through strong
cryptographic protocols and well-defined smart contracts.
Availability/robustness Since the records on blockchain are replicated in multiple nodes, the availability of the health
data stored on blockchain is guaranteed as the system is robust and resilient against data losses,
data corruption and some security attacks on data availability.
Transparency and trust Blockchain, through its open and transparent nature, creates an atmosphere of trust around
distributed healthcare applications. This facilitates the acceptance of such applications by
the healthcare stakeholders.
Data verifiability Even without accessing the plaintext of the records stored on blockchain, the integrity and
validity of those records can be verified. This feature is very useful in areas of healthcare where
verification of records is a requirement, such as pharmaceutical supply chain management and
insurance claim processing.

Research Methodology
In conducting and reporting this seminar,I adopted the guidelines for systematic
literature review and the process for systematic mapping study ,as well as the guidelines
described in the PRISMA statement. As explained in, the goal of a systematic mapping
study is to get an overview of the research area, and to complement this by investigating the
state of evidence in specific topics. In this case, the results of the mapping study would help
us to identify and map the blockchain use cases in healthcare, and to understand the extent to
which blockchain-based applications have been developed in relation to the identified use
cases. They would also help us to identify areas of possible research gaps. The systematic
review would again enable us to investigate the current trends in terms of the technical
approaches, methodologies and concepts employed in developing blockchain-based
healthcare applications. In what follows, we go through the systematic mapping process as
shown in Figure3.

Figure 3. The systematic mapping process steps.

1.1. Definition of Research Questions
As the first process step in the systematic mapping study, we defined the following four
research questions in line with our objective which is to unravel the state-of-the-art in research
on the application of blockchain technology in healthcare.

1.1.1. What Are the Use Cases of Blockchain in Healthcare?

The primary question in this research is to understand the different areas of healthcare
that blockchain has been shown to find application. By reviewing the relevant articles from
scientific databases, we are be able to identify what healthcare problems that blockchain
can solve, and by so doing, isolate those problems which are better solved using other
techniques. Given the frenzy in the media in which a lot of problems are deemed solvable
by blockchain, a map of problem domains in healthcare in which blockchains are applicable
will help researchers and practitioners to focus their interest on those promising areas of
blockchain application in the industry.
1.1.2. Of the Identified Use Cases, What Blockchain-Based Applications Have Been Developed? Many areas
of application of blockchain have been proposed in scientific literature. However,
not all of these proposals have been translated into working prototypes. It is therefore
important to understand the extent of real-world implementations of blockchain-based
healthcare applications in relation to the identified use cases. This will help to highlight areas
where there are research gaps and the need to shift research focus to these areas.
1.1.3. What Are the Challenges and Limitations of the Blockchain-Based Applications?
This question seeks to understand the challenges facing the implementations of
blockchain-based healthcare applications. Based on the prototype applications that have been
developed, what are the limitations of this new technology in meeting the expected goals of
solving healthcare-related problems?
1.1.4. How Are These Challenges and Limitations Currently Being Addressed?
This research question seeks to understand the approaches taken to develop
blockchain-based healthcare applications with a view to guiding future projects, so that there
will be no need to reinvent the wheels. Since the first blockchain implementation in Bitcoin
cryptocurrency, several modifications and improvements have been made to the technology
to make it adaptable to non-financial use cases. This research question looks at the current
trends in terms of the technical approaches and methodologies that are employed in
developing blockchain-based applications for healthcare.
1.1.5. What Are the Open Research Issues and the Areas for Future Research?
The last question addresses the issues for future research. Identifying research gaps and
the challenges in the field will help researchers to streamline their future research to focus
on addressing these research gaps and challenges.
Electronic Medical Record (EMR)
One of the popular use cases of blockchain in healthcare is the management of electronic
medical records (EMRs). EMRs, which are sometimes used interchangeably with electronic
health records (EHRs) or personal health records (PHRs), have to do with the electronic
creation, storage and management of patients’ personal, medical or health-related data. Indeed,
EMR use case of blockchain is a major research topic in the literature, with 48% (32) of the
65 selected papers addressing the topic. Blockchain’s property of decentralization,
immutability, data provenance, reliability, robustness, the smart contracts, security and privacy
are being canvassed as the features that make it very suitable for storage and management of
patients’ electronic medical records (EMR). Some of the papers are focused on how to
facilitate patient-centric data sharing among different healthcare stakeholders, such as
providers, researchers and insurers. Consistent with the European General Data Protection
Regulation (GDPR) which prohibits the processing of sensitive personal data of patients
unless explicit consent is given by the patients, blockchain is widely proposed as a viable
technology to build the healthcare platform that can empower patients to be in control of how
their data are shared, processed or used.
Guardtime, a company that uses a blockchain-based platform to secure over 1 million
patients records in Estonia is cited in other reviews as a popular example of the use of
blockchain for the management of EMR, another such example is the MedRec project, a
project of MIT Media Lab and Beth Israel Deaconess Medical Center, which aims at giving
patients agency over their own data, to determine who can access them, through some fine-
grained access permissions built on blockchain. The Gem Health Network (GHN) is yet
another example, which is developed by the US startup, Gem, using the Ethereum
blockchain platform. GHN allows different healthcare practitioners to have shared access to
the same data, Healthbank, a Swiss digital health company, is similarly working on
empowering patients to be in full control of their data using blockchain platform, the
author discusses the Medicalchain project, whose blockchain-based platform will facilitate
the sharing of patients’ medical records across international healthcare institutions, and the
Healthcoin initiative, which aims at constructing a global EMR system. Other players
working on different initiatives and projects based on blockchain-enabled patient-centric
EMR include Factom, HealthCombix, Patientory, SimplyVital, IBM’s Watson, BurstIQ,
Bowhead, QBRICS and Nuco .
Some of the barriers to blockchain-enabled patient-centric electronic medical records
include interoperability among disparate blockchain-based EMR solutions (because of lack
of standards), scalability (high volume of clinical data), patient engagement (not all patients
are willing and able to manage their own data), data security and privacy, and lack of
incentives.

Some workarounds have been proposed to tackle some of these challenges. For
example, as a countermeasure to the challenge of scalability, given the large volume of
clinical data involved, the trend is to store the actual healthcare data on the cloud and store
only the pointers to the data on blockchain, along with their fingerprints. A good number of
the technical papers report on the implementation of blockchain-based EMR applications in
which different approaches are adopted to address these challenges. Yet, some publications
propose different solutions to improve the security and privacy of the EMR data on
blockchain.
 HealthChain is an EMR application developed as a permissioned, private blockchain
network using the IBM Blockchain’s Hyperledger Fabric and deployed on Bluemix. The
modular architecture of Hyperledger Fabric enables HealthChain to achieve health data
confidentiality, scalability and security. HealthChain also incorporates chaincodes (smart
contracts) that control authorizations and access privileges on the blockchain network.
There is also another blockchain-based framework, Ancile , which similarly utilizes smart
contracts, but is built on Etherum blockchain platform to achieve access control, data
security, privacy and interoperability of electronic medical records. MedRec earlier
discussed) and the medical data preservation system (DPS) developed by Li et al. are
two other examples of blockchain implementations of EMR that utilize the Ethereum
blockchain platform. Other blockchain-based EMR applications include MedBlock [64],
BlockHIE , FHIRChain and MeDShare.
In the area of security and privacy of the sensitive data stored on blockchain-based
EMR, some cryptographic schemes are proposed to strengthen the security and validity of
the EMRs stored on the blockchain. Hussein et al. propose a blockchain-based access
control method to EMR that employs Discrete Wavelength Transform and Genetic
Algorithm to enhance the security and optimize the performance of the system. An attribute-
based signature scheme with multiple authorities is also proposed, in which the patient is
able to endorse a message to be added to the blockchain based on attributes of the
message, without disclosing any sensitive information. This protocol is shown to resist
collusion attack and is demonstrated to be computationally secure. In a similar way, an
attribute-based encryption (ABE), identity-based encryption (IBE) and identity-based
signature (IBS) are proposed to be used with blockchain in , Other security-related
proposals for blockchain-based EMR include the key management schemes by Zhao et al.
Zhang and Poslad propose an architecture called GAA-FQ (Granular Access Authorization
supporting Flexible Queries) which provides secure authorization at different levels of
granularity without requiring public key infrastructure (PKI).
Shifting emphasis to privacy, Zhang and Lin propose a blockchain-based secure and
privacy-preserving EMR scheme which uses private and consortium blockchains to store
the actual EMR and the pointers to the EMR respectively. This scheme also relies on
asymmetric encryption but also implements mechanisms for conformance testing to ensure
the system’s availability. In the authors propose a privacy-preserving platform, MediBchain
that employs cryptographic functions to deidentify patients’ data in blockchain-based EMR
systems. Yeu et al. in also propose an architecture called Healthcare Data Gateway (HDG)
for blockchain-based EMR application which allows patients to own, control and choose
how to share their data in a privacy-preserving manner.
1.1.6. Drug/Pharmaceutical Supply Chain

One other identified use case of blockchain is in health supply chain management, particularly in
the drug/pharmaceutical industry. The delivery of counterfeit or substandard medications can
have dire consequences for the patients, yet this is a common problem faced in the
pharmaceutical industry. Blockchain technology has been identified as having the capability to
address this problem .

Engelhardt, in his survey, mentions some companies that are working on how
blockchain can be used to detect prescription drug fraud. The companies mentioned
include Nuco, HealthChainRx and Scalamed ,The general idea is to record every
transaction relating to the prescription of drugs on the blokchain network to which all
the stakeholders (manufacturers, distributors, doctors, patients and pharmacists) are
connected. This way, any alteration or malicious modification of the prescription by any
of the parties can be detected. Mettler also mentions the Counterfeit Medicines Project
that is launched by Hyperledger (the developers of Hyperledger Fabric )to combat drug
counterfeiting. Only one paper in this review presents an implementation of an
example blockchain-based application for pharmaceutical supply chain management.
Modum.io AG is a startup that uses blockchain to achieve data immutability while
creating public accessibility of the temperature records of pharmaceutical products
during their transportation so that their compliance to quality control temperature
requirements can be verified ,Mackey and Nayyar, however, report that they found
from grey literature many examples of prototypes and research initiatives related to the
application of blockchain in the area of pharmaceutical supply chain management ,This
indicates that industrial players may have released many commercialblockchain-based
products to combat the fake medicine
trade even when there are still limited academic publications on the subject.

1.1.7. Biomedical Research and Education

Blockchain has an interesting use case in biomedical research and education. In

clinical trials, blockchain can help to eliminate falsification of data and the under-reporting
or exclusion of undesirable results of clinical research, makes it easier for patients to grant
permission for their data to be used for clinical trials because of the anonymization that is
inherently encoded in the data ,Additionally, the immutability property of blockchain certifies
the integrity of data collected through blockchain for clinical study. The transparent and
public nature of blockchain also make it easier to replicate research from blockchain-based
data. All these are some of the reasons blockchain is expected to revolutionize biomedical
research ,Blockchain has also been noted to have the potential to revolutionize the peer-
review process for clinical research publications based on its decentralized, immutable and
transparent properties ,Another potential application of blockchain to health professions
education (HPE) is presented ,where Funk et al. make a case for using blockchain to build
an HPE system that will be value-based, competency-based and offer credentialing services
without relying on a third-party.
A proof of concept implementation of consent traceability in clinical trial using blockchain
protocol is presented in ,Similarly, Nugent et al. present their research in which they
demonstrate how smart contracts on Ethereum blockchain platform can be used to improve
data transparency in clinical trials. The Ethereum platform is also used to implement
another blockchain-based solution that is proposed to notarize documents retrieved from
biomedical databases.
1.1.8. Remote Patient Monitoring (RPM)

In this Section, we look at how blockchain technology facilitates remote patient

monitoring (RPM). Remote patient monitoring involves the collection of biomedical data
through body area sensors (or IoT devices) and mobile devices to be able to remotely
monitor the status of the patient outside.traditional healthcare environments such as the
hospital. Blockchain has been proposed as a means for storing, sharing and retrieving the
remotely-collected biomedical data .
In Griggs et al. demonstrate how smart contracts on the Ethereum blockchain platform
can support real-time patient monitoring application with capability to provide automated
interventions in a secure environment. Liang et al. present a Hyperledger-based
implementation of blockchain-enabled data collection and sharing among healthcare
stakeholders in a mobile healthcare environment. Similarly, blockchain is employed to
develop SMEAD, mobile-enabled assisting device for monitoring diabetes patients Another
example application is presented in where mobile devices (smartphones) were successfully
used to transmit data to a blockchain-based application on Hyperledger Fabric. Ashraf
Uddin et al. also developed a blockchain-based patient centric agent (PCA) to achieve end-
to-end data security and privacy in a continuous remote patient monitoring application In
the authors proposed to use practical swarm optimization (PSO) for root exploit
detection and feature optimization in blockchain-based mobile device medical data
management. Lastly, Ji et al. proposed a scheme known as BMPLS (Blockchain-based
Multi-level Privacy-preserving Location Sharing) for realizing privacy-preserving location
sharing for remote monitoring applications.
1.1.9. Health Insurance Claims
Insurance claims processing in healthcare can benefit from blockchain’s transparency,
decentralization, immutability and auditability of records stored on it A number of papers
identify insurance claim processing as a very promising area for the application of
blockchain in healthcareHowever, examples of prototype implementations of such systems
are very limited. One good example we can find is the MIStore (a blockchain-based medical
insurance storage system) which is deployed on the Ethereum blockchain platform
Additionally, talks about an initiative by a company named Pokitdok that aims to partner
with Intel to build a blockchain-based system that will facilitate insurance claim resolution
in healthcare.

1.1.10. Others
There are other potential areas of application of blockchain in healthcare, including areas
such as the dental industry, legal medicine and meaningful use but there are no papers in our
review that address such use cases. On the contrary, there are two papers that cannot be
classified under any of the identified use cases of blockchain, but they present relevant
research perspectives. One sets out to identify the metrics for evaluating blockchain-based
healthcare while the other studies the socio-technical implications of using blockchain
technology in healthcare.
Discussion
1.2. What Are the Use Cases of Blockchain in Healthcare?
From the mapping study, the blockchain use cases in healthcare include the
managements of electronic medical records (EMRs), pharmaceutical supply chain,
biomedical research and education, remote patient monitoring (RPM), health insurance
claims, health data analytics and other potential areas of healthcare applications.
Based on the selected papers, a substantial portion of the research (48%) concentrates
on the application of blockchain in the management of electronic medical records.
Traditionally, patients’ records are stored separately in different databases across different
service providers, with little or no interoperability. This leaves the control of the health data
mostly in the hands of the service providers and also limits the collaborative sharing of such
data among healthcare stakeholders. By applying blockchain to the management of EMRs,
patients will be in control of their own health data and be able to decide how they are used.
Data sharing between healthcare stakeholders will be easier, better controlled, transparent
and trustworthy. However, using blockchain to store EMRs brings up concerns about the
security and privacy of patients’ sensitive information, an issue that a good portion of the
research is also dedicated.
Some companies and research projects, such as Guardtime and MedRec have developed
blockchain-based EMR applications. In addition, a number of the reviewed materials
discuss the prototype implementations of different blockchain-based EMR applications
Similarly, blockchain use cases in pharmaceutical supply chain management,
biomedical research/education and remote patient monitoring have received considerable
research attention with example prototype implementations (see Table5). There is also one
example implementation of prototype application relating to health insurance claim
processing ,However, other use cases are still mostly at the conceptual level.
To identify the research trends as it concerns the identified use cases of blockchain in
healthcare, the diagram of Figure11was extended as shown in Figure13to further highlight
the number of papers published for the respective use cases from 2016 to 2018.

2016 2017 2018

17
12

6
3

3
3

3
3
2

2
4

1
1
0

0
0

Figure 13. Classification of the selected papers showing publication trend from 2016 to 2018.

1.3. Of the Identified Use Cases, What Blockchain-Based Applications Have Been Developed?
In general, the technology is still maturing and even when prototype applications are
developed, in some cases, they are just for experimental purposes with very basic
functionalities. That said, there are papers that present implementation details of applications
that have been developed for the various use cases.
 For the EMR use case, example applications include the Healthchain which is
developed on Hyperledger Fabric, Acile and MedRec both of which are developed on
the Ethereum platform. Other examples include MedBlock BlockHIE FHIRChain and
MeDShare ,Similarly, other blockchain use cases, such as the management of the
drug/pharmaceutical supply chain, biomedical research and education, health insurance
claim processing and remote patient monitoring have example use cases as discussed in
Section4.2. There are, however, some potential use cases of blockchain that are still at the
conceptual levels where prototypes have not yet been developed, such as the application
of blockchain in legal medicine , Table5gives a summary of the blockchain use cases in
healthcare and the corresponding examples of prototype applications that have been
developed for the respective use cases.
It is also interesting to observe that most of these applications are developed on popular
blockchain frameworks, such as Ethereum and Hyperledger Fabric as shown in Table6.
Table 6. Blockchain frameworks used in developing healthcare applications.

Frameworks Example Applications

MedRec Ancile [34], DPS [46], GHN [15], FHIRChain [54], MedShare [68],
Ethereum
SMEAD [79], Medium.io AG [47], MIStore [57,60,70,71]
Hyperledger Fabric HealthChain [42], MedicalChain [40,61,62,81]
Bitcoin [38]
Proprietary Guardtime [13], MedBlock [64], BlockHIE [48,50]

1.4. What Are the Challenges and Limitations of the Blockchain-Based Applications?
Some identified challenges to the development of blockchain-based applications
include interoperability, security and privacy, scalability, speed and patient engagement.
The interoperability challenge stems from the fact that there is not yet an existing
standard for developing blockchain-based healthcare applications; therefore, applications
developed by different vendors or on different platforms may not be able to interoperate.
Consider, for example, the two remote patient monitoring applications, in which one is
developed on the Ethereum platform while the other is developed on the Hyperledger Fabric
platform (see Table6), it would be difficult to exchange information from one platform to the
other.
With regards to the security and privacy of blockchain-based healthcare applications,
there is a concern that despite the encryption techniques employed, it could still be possible
to reveal the identity of a patient in a public blockchain by linking together sufficient data
that are associated to that patient , In addition, there is also the potential risk of security
breaches that could arise from intentional malicious attacks to the healthcare blockchain by
criminal organizations or even government agencies that could compromise the privacy of
the patients. There have been several cases of reported attacks on the blockchain networks
that power different cryptocurrencies , The private keys that are used for data encryption and
decryption in blockchain are also prone to potential compromise which could result in
unauthorized access to the stored health data.
Furthermore, there is the concern that the immutability property of blockchain does not
augur well with the GDPR’s “right to be forgotten,” which is part of the European Union
General Data Protection Regulation which stipulates that the user has the right to request
for the complete erasure of the user’s data , Since the immutability of blockchain ensures
that data once saved to the blockchain cannot be deleted or altered, it could prove
counterproductive when it is desirable to completely wipe out the medical history of a
patient.
Scalability of blockchain-based healthcare solutions is a major challenge especially in
relation to the volume of data involved. It is not optimal, or even practicable in some cases,
to store the high-volume biomedical data on blockchain as this is bound to cause serious
performance degradation. There is also the problem of speed as the blockchain-based
processing can introduce some significant
latency. For example, the validation mechanism in the current set-up of the Ethereum
blockchain platform necessitates all the nodes in a network to participate in the validation
process .This incurs considerable processing delay, especially if the data load is significant.
One more challenge is how to engage patients in the management of their data on
blockchain. Patients, especially the elderly and the young, may not be interested or able to
participate in the management of their health data.
1.5. How Are These Challenges and Limitations Currently Being Addressed?
Some workarounds are being proposed to circumvent some of the challenges and
limitations posed by the application of blockchain in health IT (information technology)
systems. For example, as a countermeasure to the problem of scalability, it is proposed to
store the encrypted health data “off-chain,” such that only some condensed information
about the data and how they can be accessed are stored on the blockchain. This also takes
care of the GDPR’s “right to be forgotten” problem, since the actual health data stored off-
chain can be permanently deleted, even if the pointer to the data on the blockchain cannot be
deleted. However, this countermeasure has some limitations such as the fact that the
redundancy that is built into blockchain, which enhances data availability, is partially lost.
To further secure the data and protect patients’ privacy, permissioned blockchain such
as the private or consortium blockchain is used instead of the permissionless, public
blockchain for healthcare applications , In addition, by following rigorous software
development process and applying all known security measures during code development,
much of the security threats may be contained. In permissioned healthcare blockchains,
controls are also put in place to be able to reverse fraudulent or invalid transactions [24].
With the blockchain-based smart contracts , different rules can be defined and programmed
to control how the healthcare application behaves and how it handles the patients’ data.
Furthermore, to improve the performance of the system and enhance the processing
speed, only some nodes are permitted to participate in the consensus and validation
processes ,This is in contrast to the protocols in public blockchain, such as Bitcoin, in which
any node can take part in the consensus or validation process.
1.6. What Are the Open Research Issues and the Areas for Future Research?
As the blockchain technology application in healthcare is still an emerging field, there
is need for researchers to develop more prototypes and proof-of-concepts to deepen the
understanding and maturity of the technology in relation to its application in healthcare.
Many of the proposed frameworks, concepts, models and architectures, such as , need to be
implemented and tested to evaluate their strengths and weaknesses.
To guarantee interoperability between different blockchain products, there is need for
open standards. Currently, the focus is on testing the functionality of blockchain
prototypes for proof of concepts. However, for blockchain to be fully adopted and
deployed in operational healthcare environments, open standards for interoperability need
to be defined. It is therefore important that researchers start looking into the interoperability
issues and the standardization processes. There is already a standards group (ISO/TC 307)
to which researchers can send in their contributions .
The challenges of data security and privacy, interoperability, scalability and speed that
characterize blockchain-based healthcare applications are all open research issues that
require concerted further research engagements in order to improve stakeholders’ confidence
in the use of the technology and to foster its adoption in healthcare.
1.7. Limitations of the Study
Systematic mapping studies can be marred by publication or selection bias, errors in
data extraction or miscalculations.
 Publication bias arises from the tendency for researchers to publish more positive results than
negative ones because positive results are more likely to be accepted for publication and also more
likely to be cited by others. It is difficult to overcome publication bias from the perspective of the
reviewers, however; we made efforts to address this by searching different but reputable scientific
databases to retrieve as many relevant publications as possible. We were thus able to find many
papers, and our chances of retrieving any publications with negative results were significantly
enhanced. However, by searching only peer-reviewed articles and excluding grey literature in our
search protocol, we stand a high chance of missing some important grey publications such as
white papers from industries. We believe, however, that by using only scientific databases to
search for peer-reviewed articles, we have more chances of retrieving high quality scientific
publications.
Selection bias, on its part is more controllable by the reviewers since it has to do with the
tendency to exclude some relevant publications in the analysis by using a flawed search protocol.
In our case, we took the time to design a search protocol and our analysis showed that our search
protocol was able to retrieve every relevant paper. In defining our inclusion and exclusion criteria,
care was also taken to ensure that the selected papers would represent an unbiased sampling of all
the papers that were relevant to our research. However, as earlier stated, the fact that we based
our research only on peer-reviewed publications means that we were not able to access, for
example, information published on company websites, discussion forums and other such related
venues. Interestingly, we realize that most of the important information available in those grey
literatures, like the different blockchain-based healthcare applications, has been synthesized and
put into some peer-reviewed publications. For example, has a list of a number of important
blockchain applications, some of which we are not able to retrieve directly by using our search
protocol. Therefore, through such secondary publications, we were able to compensate for the
information we may have missed by not searching the grey literature.
Errors in data extraction and miscalculations could stem from the inability of the reviewers
to accurately and properly extract information and data from the selected papers. To address this
limitation, we made use of a reference management software, Mendeley, to organize and manage
all the papers we downloaded in relation to this study. We further employed Excel for recording
and organizing the extracted data items, as well as for performing statistical analysis on the
extracted data, while also being painstakingly meticulous and rigorous in our analysis to avoid
introducing any human errors.

Dept. of CSE, RGIT 2021 - 2022 Page |

11
Dept. of CSE, RGIT 2021 - 2022 Page | 13
CONCLUSION
 CONCLUSION

Blockchain technology has evolved from the time it was introduced to the world
through Bitcoin into a general-purpose technology with use cases in many industries
including healthcare. To understand the state-of-the-art of the application of blockchain
technology in healthcare, we conducted a systematic review in which we created the map
of all relevant research using the systematic mapping study process, Specifically, the
objectives of the study were to identify the blockchain technology use cases in healthcare,
the example applications that have been developed for these use cases, the challenges and
limitations of the blockchain-based healthcare applications, the current approaches
employed in developing these applications and areas for future research. Our search and
paper selection protocol produced 65 papers which we analyzed to address the research
questions.
Our study shows that blockchain has many healthcare use cases including the
management of electronic medical records, drugs and pharmaceutical supply chain
management, biomedical research and education, remote patient monitoring, health data
analytics, among others. A number of blockchain-based healthcare applications have been
developed as prototypes based on emerging blockchain paradigms, such as smart contracts,
permissioned blockchain, off-chain storage, etc. However, more research still needs to be
conducted to better understand, characterize and evaluate the utility of blockchain technology
in healthcare. Further research is also needed to supplement ongoing efforts to address the
challenges of scalability, latency, interoperability, security and privacy in relation to the use
of blockchain technology in healthcare.
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