Computers in Industry 122 (2020) 103290

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Computers in Industry
journal homepage: www.elsevier.com/locate/compind

Blockchain in healthcare: A systematic literature review, synthesizing

framework and future research agenda
Anushree Tandon a , Amandeep Dhir a,b,c,e,∗ , A.K.M. Najmul Islam d,f , Matti Mäntymäki a
a
Turku School of Economics, University of Turku, Finland
b
School of Business and Management, LUT University, Lappeenranta, Finland
c
Optentia Research Focus Area, North-West University, Vanderbijlpark, South Africa
d
Department of Future Technologies, University of Turku, Finland
e
Norwegian School of Hotel Management, University of Stavanger, Stavanger, Norway
f
LUT School of Engineering Science, LUT University, Lappeenranta, Finland

a r t i c l e i n f o a b s t r a c t

Article history: This study presents a systematic literature review (SLR) of research on blockchain applications in the
Received 4 January 2020 healthcare domain. The review incorporated 42 articles presenting state-of-the-art knowledge on current
Received in revised form 22 May 2020 implications and gaps pertaining to the use of blockchain technology for improving healthcare processes.
Accepted 13 July 2020
The SLR findings indicate that blockchain is being used to develop novel and advanced interventions to
improve the prevalent standards of handling, sharing, and processing of medical data and personal health
Keywords:
records. The application of blockchain technology is undergoing a conceptual evolution in the healthcare
Blockchain
industry where it has added significant value through improved efficiency, access control, technological
Healthcare
Systematic literature review
advancement, privacy protection, and security of data management processes. The findings also sug-
Medical data gest that the extant limitations primarily pertain to model performance, as well as the constraints and
costs associated with implementation. An integrated framework is presented to address potential areas
wherein future researchers can contribute significant value, including addressing concerns regarding
regulatory compliance, system architecture, and data protection. Finally, the SLR suggests that future
research can facilitate the widespread deployment of blockchain applications to address critical issues
related to medical diagnostics, legal compliance, avoiding fraud, and improving patient care in cases of
remote monitoring or emergencies.
© 2020 Published by Elsevier B.V. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).

1. Introduction services, such as medical research and health insurance (Campbell

et al., 2000), and (c) beneficiaries of medical and health-oriented
Blockchain was originally introduced as a mechanism to power services, i.e. patients, or the public. In the present study, we con-
Bitcoin 2022, but has now evolved to the point of being referred sider the healthcare system to be inclusive of contact-based and
to as a foundational technology for multiple decentralized applica- technology-based remote monitoring services extended by con-
tions (Iansiti & Lakhani, 2017). Blockchain is being touted as a useful stituent service providers in an effort to promote, maintain or
technology for managing sensitive data, especially within the sec- restore the health of beneficiaries (Liao et al., 2012; Devadass et al.,
tors of healthcare, medical research and insurance (Meinert et al., 2017). In the field of healthcare, privacy and security breaches are
2019). Healthcare may be understood as a system that includes purportedly increasing every year, with over 300 breaches reported
three primary constituents: (a) core providers of medical care ser- in 2017 and 37 million medical records affected between 2010 and
vices, such as physicians, nurses, hospital administrations, and 2017 (Talesh, 2017; McCoy & Perlis, 2018). The increasing digi-
technicians, (b) critical services that are associated with medical tization of healthcare has further led to the acknowledgment of
concerns related to secure storage, ownership, sharing of patients’
personal health records, and allied medical data (Meinert et al.,
2019). Blockchain has been suggested as a way to solve critical
∗ Corresponding author at: School of Business and Management, LUT University,
challenges faced by healthcare, such as secured sharing of med-
Lappeenranta, Finland.
ical records and compliance with data privacy laws (Rupasinghe
E-mail addresses: anushree.tandon@utu.fi (A. Tandon), amandeep.dhir@lut.fi
(A. Dhir), najmul.islam@utu.fi (A.K.M.N. Islam), matti.mantymaki@utu.fi et al., 2019).
(M. Mäntymäki).

https://doi.org/10.1016/j.compind.2020.103290
0166-3615/© 2020 Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
2 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

Yet, prior research has made limited attempts to holistically Saade, 2019) and stores immutable blocks of data that can be shared
encapsulate extant knowledge by utilizing systematic literature securely without third-party intervention (Hölbl et al., 2018). Data
reviews (SLRs) (e.g. Angraal et al., 2017; Hölbl et al., 2018; Agbo are preserved and recorded with cryptographic signatures and use
et al., 2019; O’Donoghue et al., 2019; Jaoude & Saade, 2019). For of consensus algorithms that are enacted as key enablers of its
instance, Hölbl et al. (2018) employed bibliometric techniques to application (Mendling et al., 2018). This ability for data preserva-
present an overview of blockchain elements and research trends tion is a significant reason that has driven the use of blockchain in
pertaining to the application of blockchain in healthcare. Angraal, healthcare (Kuo et al., 2019a), wherein a significant amount of data
Krumholz, and Schulz (2017) detailed the various platforms that is subject to extensive exchange and distribution (Meinert et al.,
have been developed to deploy blockchain in healthcare. Agbo et al. 2019).
(2019) discussed different instances of the adoption of blockchain The evolution of blockchain technology and its application in
technology in healthcare, the challenges faced, and possible solu- diverse contexts has occurred in various phases. The first phase of
tions. O’Donoghue et al. (2019) discussed specific tradeoffs and blockchain evolution was related to cryptocurrency and the second
design choices executed by researchers in various scenarios where pertained to the application of smart contracts in areas such as real
blockchain technology was applied. Jaoude and Saade (2019) estate and finance (Swan, 2015; Agbo et al., 2019). The third gen-
curated studies pertaining to blockchain applications across mul- eration of evolution was focused on the applications of blockchain
tiple industries and broadly discussed the different usage contexts in nonfinancial domains such as government, healthcare (Swan,
for this technology. Recently, Hasselgren et al. (2020) analyzed 39 2015; Miau & Yang, 2018), and culture (Efanov & Roschin, 2018).
studies to present summary statistics on popular platforms and Additionally, driven by innovative technological features such as
targeted areas wherein blockchain has been applied to improve data immutability (Yli-Huumo et al., 2016), blockchain is now con-
healthcare. sidered to be in its fourth stage of evolution with the incorporation
While these SLRs have contributed to the extant body of knowl- of artificial intelligence (AI) (Angelis & da Silva, 2019). Blockchain’s
edge, their focus has primarily been on synthesizing or delineating asserted diversity in its scope of applications may be attributed
trends (e.g. Hasselgren et al., 2020) and areas of blockchain applica- to its potential for creating decentralized (Silva et al., 2019) and
tion (see Risius & Spohrer, 2017; Hölbl et al. 2018; Agbo et al. 2019; trustless transaction environments (Zhang et al., 2018).
Jaoude & Saade, 2019). However, due to the extent and diversity The healthcare industry is a prime candidate for blockchain
of prior research on blockchain, researchers would benefit from technology (Kuo et al., 2017; Alla et al., 2018; Cios et al., 2019);
a focused discussion on the ramifications of its adoption (Risius & as blockchain has the potential to address critical concerns, such
Spohrer, 2017), as well as specific challenges and areas for improve- as automated claim validation (Angraal et al., 2017) and public
ment for advancing the field (Agbo et al., 2019). Review-based health management (Mettler, 2016). This technology may allow
studies can assist in meeting these needs by assimilating existing patients to own data and choose with whom it is shared (Dimitrov,
knowledge and explicating focal areas that need significant schol- 2019), thereby addressing extant concerns about data ownership
arly attention (Agbo et al., 2019; Ozdagoglu et al., 2020). and sharing (Zhang et al. 2018; Ji et al., 2018). Concurrently, it
We address this need by conducting an SLR on the use of enables data records to be unified, updated, securely exchanged,
blockchain in healthcare (Kitchenham et al., 2009). SLRs can pro- and accessed in a timely by appropriate authorities with the use
vide a valuable summarization of current knowledge in a field of of consensus protocols (Alla et al., 2018). This is a major advan-
research (Aznoli & Navimipour, 2017) and allow for the identifi- tage afforded by the application of blockchain technology within
cation of existing knowledge gaps and, consequently, avenues for the healthcare space because current practices require data to be
future research (Gopalakrishnan & Ganeshkumar, 2013). This study stored with third parties (Hölbl et al., 2018). Finally, blockchain can
contributes to the current literature on blockchain in healthcare potentially bring transparency to data management processes (Ito
by adding to prior SLRs in two ways. First, it provides a themati- et al., 2018) while also reducing the chances of data mishandling
cally organized, state-of-the-art classification of prior studies with or misuse because of possible human error (Alla et al., 2018).
respect to their application areas, limitations, and recommenda- Despite the positive connotations of blockchain’s effect on soci-
tions. Second, based on the findings of the SLR, we propose a etal and business transformation, there seems to be a debate on
synthesizing framework to detail potential themes that require its prevalent advantages and derived benefits in comparison to
scholarly attention to advance the current body of knowledge. This previously established expectations. A recent report suggests that
contribution is made by addressing four research questions: RQ1. although organizations will undertake significant investments in
What is the state-of-the-art research profile for blockchain appli- implementing blockchain-based technologies in the future, they
cations in the healthcare domain? RQ2. What are the primary areas will likely adopt a cautiously pragmatic approach because of a
of healthcare wherein blockchain has been applied? RQ3. What are prevalent belief that the benefits may be over-hyped. It may be said
the emergent limitations and challenges that the literature posits that this technology is yet to meet its touted expectations (Iansiti &
for this research area? RQ4. What are the future avenues in health- Lakhani, 2017), a fact that may be attributed to certain challenges
care that might benefit from the application of blockchain? to the widespread implementation of this technology, especially in
The remainder of the paper is structured as follows. Section 2 terms of regulatory barriers (Pawczuk et al., 2019). Another impor-
provides an overview of blockchain technology. Section 3 expli- tant challenge in promulgating the deployment of blockchain is the
cates the methodology adopted for the current SLR. The findings unfamiliarity of the public and individual users, such as patients
are presented in the Section 4, followed by a discussion of these or doctors, with the way this technology works, its technical fea-
findings in Section 5. Section 6 presents a detailed discussion of tures (Alla et al., 2018) or its benefits for data management. Iansiti
the implications of the insights derived from the findings of this and Lakhani (2017) suggest that due to social, organizational, and
study, limitations and future scope of research. The last section is implementation barriers, such as security or governance, signifi-
dedicated to discussing concluding remarks. cant time may be required for blockchain to generate the expected
levels of business transformation. This may be additionally com-
pounded by a general uncertainty about blockchain’s usage with
2. Blockchain technology respect to legal compliance and government regulations (Swan,
2015; Alla et al., 2018). Current research is focused on aiding the
Blockchain is a distributed public ledger database that is main- operational evolution of blockchain and accelerating its prevalence
tained by a network of verified participants or nodes (Jaoude & by addressing these challenges and barriers.
 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290 3

Fig. 1. The protocol for a systematic literature review.

3. Methodology drawn from a review of prior studies (i.e. SLRs) in this field that used
similar keywords, i.e. blockchain, healthcare (or health*), and med-
SLRs offer readers comprehensive knowledge of the literature in ical (or medic*) (see Hölbl et al., 2018; Alla et al., 2018; Agbo et al.,
a field through a holistic and organized précis that adheres to stan- 2019; Hasselgren et al., 2020). Subsequently, appropriate articles
dard protocols (Afrooz & Navimipour, 2017; Aznoli & Navimipour, were screened according to specific selection criteria for determin-
2017; Ahmad et al., 2018; Mehta & Pandit, 2018). SLRs also assist in ing quality, relevance, and robustness (Webster & Watson, 2002).
explicating existing knowledge gaps and consequent identification The summary protocol and the review and selection process for all
of avenues for future research (Gopalakrishnan & Ganeshkumar, three phases are illustrated in Fig. 1.
2013). The current study adapted protocols set forth by Behera, Bala The quality of articles selected for the final sample was assessed
and Dhir (2019), which synthesized comprehensive article assess- to ensure that the outcomes of the current SLR presented transpar-
ment criteria from previously published SLRs. Our SLR protocol ent and unbiased results (Behera et al., 2019; Mehta & Pandit, 2018).
consisted of three main phases, namely planning, execution, and Two authors completed this assessment and resolved differences
reporting assimilated information (see Fig. 1). To address RQ1, the in individual evaluation through discussion to reach consensus on
present SLR addressed the obtained descriptive statistics related the final inclusion or exclusion of a study. In cases where the two
to the following: (a) number of articles published per year; (b) authors could not achieve consensus, a third author was involved
average citations per year received by a reviewed article; and in review and discussion. The Fleiss’ Kappa value for inter-coder
(c) scholarly contributions in the field regarding publishers, jour- agreement was 0.87, which indicates a strong agreement between
nals, and countries. To address RQ2, RQ3, and RQ4, four modular the two coders (Landis & Koch, 1977). Quality scores were cal-
queries were created, as suggested by prior literature (see Afrooz culated for all articles per the criteria presented in Table 2. Six
& Navimipour, 2017): (a) identifying previously investigated study articles were removed at this stage for not meeting the predeter-
contexts and primary constructs; (b) identifying current intellec- mined threshold value of 4.5 (50 % of maximum score, see details
tual capital by summarizing findings and limitations; (c) extracting in Table 3), and 41 studies remained after a quality assessment.
focal implications from practical and theoretical perspectives; and Backward and forward citation chaining was conducted to address
(d) identifying emergent research gaps and potential avenues for feedback loops. This resulted in the identification of three articles,
future research. These queries allowed for a focused synthesis and of which two were excluded for not meeting the quality evaluation
analysis of selected studies and derive pertinent insights to answer criteria. The final sample comprised 42 articles.
the RQs.
Four databases—PsycINFO, PubMed, Scopus, and Web of
Sciences—were identified by prior studies as popular sources of 3.1. Research profile
information for articles related to health informatics (Zhang et al.,
2017; Behera et al., 2019). Article selection was based on specific Reviewed articles were profiled to understand the status of
inclusion and exclusion criteria, as recommended by prior research research on blockchain applications in healthcare. This review sug-
(Zhang et al., 2017). These were adapted from Behera et al. (2019) gests that blockchain has seen a recent integration in the healthcare
(see Fig. 1) wherein the adaptations were developed and agreed domain because the earliest article included in the sample was pub-
upon by the authors (see note in Table 2 Three keyword combina- lished in 2016. However, a sharp increase in the number of yearly
tions were found to be appropriate for a database search performed publications (see Fig. 2) and average citations for the selected stud-
in July 2019 —“Health management”, “blockchain in healthcare”, ies (see Fig. 3) suggests that the academic focus on this field has
and “medical management” (see Table 1). These keywords were intensified over the last few years. Cristiano André da Costa (Brazil)
and Alex Roehrs (Brazil) emerged as the top authors in the field with
4 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

Table 1
Database search summary.

Database Keywords Total hits appeared Abstracts read* Full text downloadeda

“Blockchain”, “Healthcare” 39 39 31
PsycINFO “Blockchain”, “Health management” 30 30 22
“Blockchain”, “medical management” 37 37 16
“Blockchain”, “Healthcare” 68 68 34
PubMed “Blockchain”, “Health management” 38 38 11
“Blockchain”, “medical management” 37 37 7
“Blockchain”, “Healthcare” 284 284 26
Scopus “Blockchain”, “Health management” 146 146 18
“Blockchain”, “medical management” 121 121 19
“Blockchain”, “Healthcare” 140 140 37
Web of Science “Blockchain”, “health management” 55 55 12
“Blockchain”, “medical management” 51 51 17

Note: Results include articles from multiple disciplines such as medicine, genomics, information science, banking etc. Multiple sources and document types were reflected
in the search results including journals, trade magazines, books etc.
Results of the search were sorted for “relevance” before reviewing abstracts.
a
Individual studies may be duplicated in multiple cells of this column.

Table 2
Quality Evaluation (QE) criteria.

QE# Criterion

QE1 Explicit discussion of data analysis: “quantitative (+2)”, “qualitative (+1.5)” or “no evidence (+0)”.
QE2 Discussion of advantages and challenges of the topic of interest: “yes (+2)”, “partially (+1.5)” and “no (+0)”.
QE3 Are the discussed outcomes aligned with and valid with respect to the utilized methodology and topic of interest:
“yes (+2)”, “partially (+1.5)” and “no (+0)”
Note: partial justification pertains to a limited or unavailable explanation for an employed technique or methodology
QE4 Peer-recognition of the article and source reliability:
(+2) sum of citations and H Index is > 100
(+1.5) sum of citations and H Index is > = 50 and < = 99
(+1.0) sum of citations and H Index is > = 1 and < = 49
(+0) sum of citations and H Index is 0
QE5 Comparability of the utilized method(s) with methods popularly used in prior studies:
“yes (+1)”, and “no (+0)”

[Note: based on Behera, Bala and Dhir (2019 with the following adaptations:
QE1: Quantitative data analysis was considered equivalent to the availability of a detailed algorithm (protocols, architecture, coding script), AND results from experimental or
simulation-based performance evaluation; Qualitative analysis was considered equivalent to evidence of (detailed algorithm) OR (limited details on algorithm with limited
results of performance evaluation).
QE2: Discussion of advantages has been adapted to current context as: yes (detailed discussion on applicability of results to healthcare context), partially (limited discussion
on applicability of results to healthcare context), no (no discussion on applicability of results to healthcare context).
QE5: In terms of comparability of utilized methods, the scoring was adapted to the context of methods used by other studies focused on applying blockchain in healthcare.].

Fig. 2. Yearly distribution of publications.

Note: Publication count for 2019 is inclusive of studies published and available
online until July 2019.
Fig. 3. Average citations per year. Note: Detailed description in Table 3.

two publications each (see Table 3). This suggests that this area of
research is witnessing conceptual and theoretical development as India (n = 3), and Brazil (n = 3), cumulatively represented 65 % of
a way to identify possible avenues for further contribution. the sample (see Fig. 4). The inclusion of both developed and devel-
The first authors of the reviewed articles were found to be affil- oping economies in the sample suggests a global recognition of
iated with institutes located across 17 countries. Five countries, blockchain’s potential application within healthcare. The selected
namely China (n = 12), United States (n = 6), South Korea (n = 4), studies were published in multiple journals (see Fig. 5). However,
Table 3
Quality assessment results.

Quality Evaluation (QE) Citations per year Average citations

Authors
per year
Total Citations H-index QE1 QE2 QE3 QE4 QE5 QSScore 2016 2017 2018 2019

Badr, Gomaa & Abd-Elrahman (2018) 3 51 2 1.5 1.5 1.5 1 7.5 0 0 1 2 1.5
Brogan, Baskaran & Ramachandran (2018) 12 31 2 2 2 1 1 8 0 0 4 8 6
Casado-Vara & Corchado (2019) 1 8 0 1.5 2 1 0 4.5 0 0 0 1 1
Chattu et al. (2019) 0 0 0 1.5 2 0 0 3.5
Dagher et al. (2018) 39 36 0 2 2 1.5 1 6.5 0 0 16 23 19.5
Dhagarra et al. (2019) 0 28 0 2 2 1 0 5 0 0 0 0 0
Dimitrov (2019) 1 21 0 1.5 1.5 1 0 4
Dwivedi et al. (2019) 10 84 0 2 2 1.5 1 6.5 0 0 0 10 10
Fan et al. (2018) 2 50 2 1.5 2 1.5 1 8 0 0 0 2 2
Firdaus et al. (2018) 11 45 0 2 2 1.5 1 6.5 0 0 20 19 19.5
Griggs et al. (2018) 32 45 0 2 1.5 1.5 1 6 0 0 11 21 16

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
Guo et al. (2018) 46 57 2 1.5 1.5 2 0 7 0 0 22 24 23
Hang et al. (2019) 0 0 1.5 0 1.5 0 1 4
Hussein et al. (2018) 37 19 2 2 2 1.5 1 8.5 0 0 23 14 18.5
Hyla and Pejaś (2019) 0 18 2 1.5 2 1 1 7.5 0 0 0 0 0
Islam et al. (2019) 0 68 2 1.5 2 1.5 1 8 0 0 0 0 0
Jamil et al. (2019) 0 0 1.5 0 1.5 0 0 3
Ji et al. (2018) 8 45 2 2 2 1.5 1 8.5 0 0 2 6 4
Kaur et al. (2018) 15 45 0 1.5 1.5 1.5 0 4.5 0 0 2 13 7.5
Kuo, Gabriel & Ohno-Machado (2019) 2 62 2 1.5 2 1.5 1 8 0 0 0 2 2
S.H Lee & Yang (2018) 3 42 2 2 2 1 2 9 0 0 2 1 1.5
S.J. Lee, Cho, Ikeno & Lee (2018) 1 29 2 1.5 1.5 1 1 7 0 0 0 1 0.5
H. H. Li et al. (2018) 18 45 2 1.5 1.5 1.5 1 7.5 0 0 4 14 9
X. Li et al. (2019). 4 57 2 2 1.5 1.5 1 8 0 0 0 4 4
Mamoshina et al. (2018) 45 86 2 2 2 2 1 9 0 2 17 25 22
Nagasubramanian et al. (2018) 0 54 2 2 1.5 1.5 1 8 0 0 0 0 0
Nguyen et al. (2019) 0 57 2 2 2 1.5 1 8.5 0 0 0 0 0
Noh et al.(2017) 1 27 2 2 2 1 1 8 0 0 1 0 0.33
Al Omar et al. (2019) 4 68 2 2 2 1.5 1 8.5 0 0 0 4 4
Patel (2019) 25 21 0 1.5 1.5 1 0 4
Pourvahab & Ekbatanifard (2019)* 0 89 1.5 0 0 1.5 0 3
Quaini et al. (2018) 0 0 1.5 1.5 2 0 1 6 0 0 0 0 0
Rahmadika & Rhee (2019) 0 22 2 2 2 1 1 8 0 0 0 0 0
Roehrs et al. (2017) 50 50 2 2 2 1.5 1 8.5 0 1 29 20 16.67
Shen, Guo & Yang (2019) 2 29 2 2 2 1 1 8 0 0 0 2 2
Silva et al. (2019) 0 22 1.5 1.5 1.5 1 1 6.5 0 0 0 0 0
Siyal et al. (2019)* 2 0 0 1.5 1.5 1 0 4
Tian, He & Ding (2019) 0 45 2 1.5 1.5 1 1 7 0 0 0 0 0
Uddin et al. (2018) 10 57 2 2 2 1.5 1 8.5 0 0 2 8 5
H. Wang & Song (2018) 15 45 2 1.5 1.5 1.5 1 7.5 0 0 1 14 7.5
S. Wang et al. (2018) 9 0 0 1.5 1.5 1 0 4
Wong, Bhattacharya & Butte (2019) 3 240 1.5 1.5 1.5 2 1 7.5 0 0 0 3 3
Xia et al. (2017) 121 57 2 1.5 1.5 2 1 8 0 3 60 27 30
Yang et al. (2019) 1 29 2 2 1 1 1 7 0 0 0 1 1
Yue et al. (2016) 246 45 0 1.5 1.5 2 0 5 4 36 115 91 61.5
A. Zhang & Lin (2018) 21 45 2 1.5 2 1.5 1 8 0 0 5 16 10.5
P.Zhang, et al. (2018) 41 31 1.5 2 2 1.5 1 8 0 0 10 31 20.5
Zhang, Xue & Huang (2016)* 77 57 2 1.5 2 2 1 8.5 0 11 31 35 19.25
Zheng et al. (2019) 0 82 0 2 1.5 1.5 0 5 0 0 0 0 0
Zhou, Wang & Sun (2018) 14 45 2 1.5 2 1.5 1 8 0 0 4 10 7
Total citations 4 53 383 451
Avg. citation count 0.09 1.23 8.91 10.49

Note: Articles marked by * were considered through backward citation chaining search result. No relevant article was found through forward citation search.
Articles marked by a broken underline failed to meet quality criteria and were excluded from further analysis.

5
6 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

Fig. 5. Number of articles per publication.

Fig. 6. Articles per publisher.

the leading sources were Journal of Medical Systems (n = 10), IEEE

Access (n = 6), and Applied Sciences (n = 3), with Springer (n = 12),
Elsevier (n = 8), and IEEE (n = 7) emerging as the leading publishers
(see Fig. 6).
Furthermore, analysis of author-indicated constructs through
word clouds showed that the primary focus of research pertained
to “patients,” “data,” “hospital,” “provider,” and “devices,” which
Fig. 4. Publications by country. are graphically presented in Fig. 7 (a). Similarly, author-indexed
Note: Country reflects the location of the institute to which the first author is affili- keywords offered by prior studies revealed that “medical,” “health,”
ated.
“data,” and “sharing” were the most frequently used keywords (see
Fig. 7b).
 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290 7

Fig. 7. (a) Key framework constructs (b) Author provided keywords.

4. Findings technology advancement, efficiency enhancement, and data man-

agement. The results of the review indicate that continual scholarly
The current SLR utilized a meta-ethnography-based approach efforts have been directed at refining conceptual and technical
(Noblit & Hare, 1988) to review and synthesize insights from knowledge to enhance the efficiency of healthcare, the associated
the pool of 42 studies that qualified for inclusion. The process processes, and data management protocols through the application
resulted in the development of research themes and identification of blockchain.
of research gaps and limitations. Further, extant recommenda-
tions from reviewed studies were synthesized, and in conjunction 4.1.1. Conceptual evolution
with the explicated gaps in prior research, were used to develop The results of the review indicate that research in the domain
a research framework to advance scholarly work in this domain. of blockchain in healthcare has been largely directed at promoting
These findings are discussed at length in the following sections, the development of concepts that assist scholars in deriving multi-
and a brief overview is presented in Table 4 and 5. domain (Kaur et al., 2018) and feasible applications for blockchain
in healthcare. The feasibility of applications (Quaini et al., 2018)
4.1. Research themes has been developed and tested through research efforts that can
be classified into three sub-themes: concept development, benefit-
Content analysis (Krippendorff, 2018) was employed to analyze based applications, and building predictive capabilities.
the reviewed studies and delineate four explicit thematic areas
of research that represent focal issues addressed by the reviewed 4.1.1.1. Concept development. The results of the review show that
studies (Table 4). These thematic areas are conceptual evolution, significant attention has been paid to developing new proofs and
8 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

Table 4
Summarizing past research: Themes, limitations & future research recommendations.

Thematic classification of scope of Limitations Future research recommendations

study

Conceptual evolution Performance Technical advancements

• Concept development • Platform • Framework optimization
• Benefit based application • Algorithm features • Replication & extension
• Promoting decentralization • Node management • Nuanced technology development

Technology Advancement Assumptions Enhanced data & privacy protection

• Developing intelligent • Framework development
healthcare ecosystems Improving medical diagnostics
• Technical improvements to
architecture
• Building predictive capabilities
Efficiency enhancement Constraints
• Process • Costs
• System • Data & Analysis
• Platform elements
• Societal

Data Management Ethics & security

• Data privacy
• Data protection
• Data handling

Table 5
Suggested future research agenda.

Research Gaps (identified based on the SLR) Directions for future research

Managing medical data obtained from multiple IoT-based sources, e.g. sensors Holistic purview for adoption
Investigating user-centric and societal barriers for adoption Blockchain architecture optimization
Data management & legal compliance
Strategic perspective of blockchain adoption by an organization
Integration with other technologies
Nuanced application
Methodological advancements for obtaining real-time data on actual performance and usage
Contribution to value chain & supply chain

algorithms, e.g. proof of primitiveness of data (H. Li et al., 2018; Z. classified under this theme have focused on blockchain application
Li et al., 2018), proof of familiarity (Yang et al., 2019), and simpli- for developing healthcare-specific benefits, such as collabora-
fied workload for proof of work (Lee & Yang, 2018). Studies have tive medical decision-making (Yang et al., 2019). For example,
also focused on refining frameworks that enable blockchain exe- blockchain adoption has been posited to have positive connota-
cution through inclusion, as well as testing of novel constructs tions in clinical trial management (Wong et al., 2019), DNA data
and elements in system architectures. Examples include previously transmission (S.J. Lee et al., 2018), remote patient monitoring
utilized attribute-based cryptosystems (Wang & Song, 2018), the (Griggs et al., 2018; Dwivedi et al., 2019) as well as drug discovery,
Stackelberg game approach (Li et al., 2019), sibling intractable func- biomarker development, and preventive healthcare (Mamoshina
tions (Tian et al., 2019), and homomorphic computations (Zhou et al., 2018).
et al., 2018) for more efficient frameworks. For instance, Xia et al.
(2017) proposed a new blockchain-based data scheme (BBDS) for 4.1.1.3. Promoting decentralization. Extant research has also
security and privacy preservation for data transactions. Zhang, Xue focused on promulgating the major benefits of blockchain within
and Huang (2016) invoked the idea of the human body as a trans- healthcare ecosystems to promote fairness and effective decen-
mission medium in their attempt to develop a novel protocol for tralization (Noh et al., 2017; Zhang et al., 2018; Zheng et al., 2019).
a pervasive social network (PSN) based blockchain network. Islam For instance Li et al. (2019) developed a framework to promote
et al. (2019) utilized fog computing to construct a computation- revenue maximization and decentralized fair trading, whereas
ally efficient and accurate model for human activity recognition for Dagher et al. (2018) discuss the necessity of trade-offs for mining
promoting remote e-health monitoring. Fan et al. (2018), in turn, incentives. Scholars have also discussed the potential of blockchain
focused on incorporating multiple time sources in their framework for promoting transparency in data transactions (Hyla & Pejaś,
to avoid a single point of failure. In conclusion, studies classified 2019), e.g. by incorporating fair client roles (Kuo et al., 2019a,b).
under this theme have focused on explicating ways to maximize the Thus, it may be said that prior studies on the evolving adoption
efficiency of previously developed blockchain-based algorithms of blockchain in healthcare have focused on disseminating the
and frameworks. concepts of decentralization and its associated benefits.

4.1.1.2. Benefit-based applications. Extant studies have incorpo-

4.1.2. Technological advancements
rated blockchain in healthcare to derive specific benefits by
Existing research has made significant inroads in advancing and
identifying and testing new avenues of application for blockchain
refining blockchain technology in terms of developing targeted
technology. This includes studies focusing on enhancing tech-
applications in the field of healthcare. Based on our review, we
nical benefits derived from blockchain application, e.g. through
propose that prior studies classified under this theme are oriented
advanced image processing (Lee & Yang, 2018), efficient activity
towards three key topical issues:
recognition (Islam et al., 2019), and synchronization of Internet-of-
Things (IoT) devices (Fan et al., 2018). Additionally, most studies
 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290 9

4.1.2.1. Developing intelligent healthcare ecosystems. Some scholars computational loads (Zhang et al., 2016), communication overload
have focused on the incorporation of blockchain platform gateways (Uddin et al., 2018), convergence time and overheads (Fan et al.,
into healthcare ecosystems (Badr et al., 2018). Such incorporations 2018), and reduced energy consumption (Uddin et al., 2018).
may enable the creation of intelligent healthcare systems (Yue et al., Additionally, prior studies have focused on improving processes
2016). For instance, Casado-Vara and Corchado (2019) suggest that for timely updates (Wang & Song, 2018) and reporting for adverse
blockchain adoption can assist in the creation of an optimized e- events (Wong et al., 2019). Some studies have focused on improving
health ecosystem. Prior studies have also proposed frameworks the computational efficiency (Islam et al., 2019) of processes, and
to develop blockchain based e-health (Hyla & Pejaś, 2019) and accurate testing of proposed architectures (Lee & Yang, 2018) to
tele-medical information systems (Ji et al., 2018) that may allow ensure that the proposed blockchain architectures provide more
healthcare service providers to increase the reach of provision of reliable processing than traditional architectures (Uddin et al.,
services in future. 2018).
Furthermore, studies have made inroads into addressing the
4.1.2.2. Technical improvements to blockchain architecture. Major- purported challenges associated with managing time, manag-
ity of research in this domain has focused on enhancing the ing data, and associated costs by proposing improvements in
performance of developed systems and architectures through blockchain frameworks. For instance, some reviewed studies have
technical improvements, such as unknown root exploitation detec- developed frameworks to lower the cost of execution after the ini-
tion (Firdaus et al., 2018), use of smaller data block sizes (Yang tial set up (Yang et al., 2019), lower storage cost (Nagasubramanian
et al., 2019), and improvement of transaction propagation delay et al., 2018) and facilitate the preservation and storage of files of
(Rahmadika & Rhee, 2019). Some attention has also been directed unlimited size (H. Li et al., 2018; Z. Li et al., 2018). These developed
towards addressing issues that have been previously identified as frameworks have purported to provide significant improvements
probable problems in the effective deployment of blockchain archi- in runtime (Zhang et al., 2016), delivery time (Roehrs et al., 2017),
tectures. Such issues addressed by studies classified under this and response time (Nagasubramanian et al., 2018).
theme include storage loads (Zhang et al., 2016), memory and CPU
requirements (Zhou et al., 2018), temperature (Zhang et al., 2016),
and reliable node identification (Uddin et al., 2018). In some cases, 4.1.3.2. System. Our review of the existing literature suggests that
the effectiveness of proposed solutions to these issues has also been multiple measures have been adopted for the holistic improvement
demonstrated through analyses directed at network and algorithm of the blockchain-based healthcare system. For instance, studies
comparison (Kuo et al., 2019a,b; Yang et al., 2019). However, we have focused on improving system interoperability (Dhagarra et al.,
posit that this theme may see further advances in the future and 2019; Silva et al., 2019), and managing inter-institutional access
call for a concurrent need to focus on comparative analyses that privileges (Quaini et al., 2018; Li et al., 2019) as well as data control
can ascertain optimal effective networks and algorithms. (Brogan et al., 2018; Mamoshina et al., 2018; Zhang et al., 2018).
Scholarly attention has also addressed enhancing system scala-
4.1.2.3. Building predictive capabilities. As blockchain technology bility (Xia et al., 2017) as well as performance (Nagasubramanian
moves into its fourth phase of evolution with the increasing incor- et al., 2018; Lee et al., 2018). Researchers have focused on develop-
poration of AI (Angelis & da Silva, 2019), a similar trend can be seen ing integrated service-oriented architectures (Hyla & Pejaś, 2019)
for its use in healthcare. Recent studies have begun to incorpo- and improving the generalizability as well as flexibility of executed
rate analogous and peripheral technologies into blockchain-based blockchain systems (Kuo et al., 2019a,b; Silva et al., 2019).
system architectures that include IoT (Dwivedi et al., 2019), sen-
sors (Casado-Vara & Corchado, 2019), wireless body area networks 4.1.4. Data management
(Griggs et al., 2018), (Mamoshina et al., 2018), big data (Dhagarra Based on our review, we posit that management of medical
et al., 2019), edge computing (Zheng et al., 2019), and cloud tech- records and data has received the most substantial amount of schol-
nology (Kaur et al., 2018). arly attention in this field. Prior studies have promulgated the use
The use of such technologies is assisting researchers in build- of blockchain as a proficient method of managing medical data
ing blockchain-based frameworks with the predictive capabilities (Quaini et al., 2018; Hussein et al., 2018; Silva et al., 2019; Shen
to improve medical informatics (Lee et al., 2018) as well as diag- et al., 2019; Tian et al., 2019) and electronic personal health infor-
nostics (Lee et al., 2018; Zhang & Lin, 2018). Such frameworks mation or records (PHRs) (Roehrs et al., 2017; Dagher et al., 2018;
have been previously investigated for specific utilitarian functions Hussein et al., 2018; Guo et al., 2018). Further, blockchain may assist
that are healthcare-oriented, such as prescription fraud avoidance in creating a viable information ecosystem for managing such PHRs
(Casado-Vara & Corchado, 2019), verifiable data generation (Zhou (Mamoshina et al., 2018) by incorporating heterogeneous forms of
et al., 2018), and automatic claim settlement (Wang & Song, 2018). data (Yue et al., 2016; Shen et al., 2019; Silva et al., 2019), including
Additionally, studies have also focused on advancing blockchain medical big data (Kaur et al., 2018). Based on the SLR, we delineate
technology to assist healthcare service providers in other functions, three focal aspects of extant research in this theme:
such as population level data collection (Brogan et al., 2018) and
user identity definition (Zhang et al., 2018).
4.1.4.1. Data privacy. Preserving data privacy by ensuring autho-
4.1.3. Efficiency enhancement rized access to medical records has been a significant focal area
Multiple studies in the extant literature have focused on under- of prior literature on the data management aspects of blockchain
standing how blockchain adoption can effectually enhance the technology in healthcare. The review suggests that management
efficiency of healthcare processes. This review indicates that the of access control (Zheng et al., 2019) has especially seen exten-
focus of scholars has been directed towards two aspects of effi- sive investigation (Badr et al., 2018; Brogan et al., 2018). This issue
ciency improvement: processes and systems. is especially critical in healthcare due to the need to preserve the
privacy of sensitive medical data through greater accountability,
4.1.3.1. Process. Prior research has paid significant attention to immutability, and access control (Hussein et al., 2018). In response
enhancing the effectiveness of technical aspects of the processes to this critical need, prior studies have developed blockchain-based
required for executing a blockchain-based healthcare system. For frameworks to ensure the provision of efficient (Roehrs et al., 2017),
example, studies have focused on explicating solutions for reducing user-centric (Noh et al., 2017), and secure/encrypted access to
10 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

patient PHRs and other medical data (e.g. Guo et al., 2018; Badr 4.2.1. Performance
et al., 2018; Dwivedi et al., 2019) Studies have implied that certain aspects of architectural frame-
works developed for adoption of blockchain in healthcare can affect
the performance efficiency of the proposed framework (Ji et al.,
4.1.4.2. Data protection. The prevention of unauthorized access
2018; Mamoshina et al., 2018; Zhang & Lin, 2018). For instance, high
and preservation of data security to ensure data protection has been
compression ratios may affect the inherent stability of a framework,
another key issue addressed in the studies on the data manage-
and subsequently, its performance (Lee et al., 2018). The design of
ment aspects of blockchain in healthcare. The majority of reviewed
the framework and authorizations for data movement may also
studies have focused their attention on preventing unauthorized
be contingent on manual approvals by users, which may impact
access (Nguyen et al., 2019) and protecting against eavesdropping
the efficiency of the framework’s performance (Shen et al., 2019).
(Uddin et al., 2018). Multiple means, such as efficient authenti-
Mamoshina et al. (2018) also acknowledge that their proposed
cation (Nagasubramanian et al., 2018), biometric authentication
framework directed at detecting anomalies may underperform in
(Dhagarra et al., 2019), user verification (Hussein et al., 2018), and
certain cases where datasets are not labelled. The scalability and
the use of dual signatures (Li et al., 2019) have been suggested to
performance efficiency of a framework may also be affected by
achieve this objective. However, relatively less attention has been
issues such as requirements for continual upgrades by the utilized
paid to the prevention of external attacks, such as attacks on sensor
system (Kaur et al., 2018), the computational load of sensor data
data (Brogan et al., 2018), escrow, and collusion attacks (Guo et al.,
(Zhang et al., 2016), keyword set size (A. Zhang & Lin, 2018), the
2018).
amount of disk space, and the network set-up required by the type
of blockchain, e.g. Ethereum, used in the model (Quaini et al., 2018).
4.1.4.3. Data handling. Prior research has, to some degree, attended Similarly, Dagher et al. (2018) suggests that incorporating certain
to the need to ensure legally, as well as ethically compliant process- features, such as the use of global smart contracts, in developed
ing, sharing, and handling of healthcare data. Our review suggests frameworks may set-off higher performance-related costs. Further,
that few studies have acknowledged the need for regulatory com- few studies have indicated that performance-oriented challenges
pliance (Yue et al., 2016) or even the standards and goals for may also be related to the management of nodes in a proposed
compliance requirements (Zhang & Lin, 2018; Al Omar et al., 2019; framework. For example, uncertainties in a framework’s perfor-
Li et al., 2019). mance may also relate to the number of nodes, latency between
However, significant attention has been paid to the need to nodes, and attacks (Hyla & Pejaś, 2019). In the same line of thought,
maintain data integrity (Hyla & Pejaś, 2019; Tian et al., 2019; Fan et al. (2018) also suggest that higher numbers of nodes may
Shen et al., 2019). For instance, prior studies have addressed issues adversely affect system efficiency.
pertaining to authentic data mobilization (Brogan et al., 2018),
avoidance of data leakage (Zhang et al., 2016; Zhou et al., 2018) 4.2.2. Assumptions
or double spending on storage (Rahmadika & Rhee, 2019), and The effectiveness and efficiency of the frameworks proposed
perpetual data preservation (H. Li et al., 2018). With the increas- in prior literature are limited by the assumptions that they are
ing inter-institutional adoption of blockchain, scholars have also based on. These assumptions are also likely to impact an accurate
focused on the issue of storage and preservation of sensitive data assessment of a framework’s performance. For example, Uddin et al.
(Al Omar et al., 2019) from different sources such as medical devices (2018) assume that users, i.e. patients, would utilize a smartphone
(Firdaus et al., 2018), and medical insurance (Zhou et al., 2018). A to collect and store required medical data from sensors. However,
few studies have also directed attention to the facilitation of cross- all data generated may not require storage, and the devices may not
institutional data sharing (Al Omar et al., 2019), and improvements have a way to authenticate that a legitimate owner has uploaded
in efficiency as well as flexibility of data sharing (Shen et al., 2019). the generated data. Similar concerns were raised by Roehrs et al.
Furthermore, prior studies have also attended to the need for (2017), who acknowledge that the inability to guarantee the iden-
improvements in data processing (e.g. Zhou et al., 2018). The tity or authenticity of persons or devices providing medical records
reviewed studies have suggested some measures of inducing these is a significant limitation. In another study, Rahmadika and Rhee
improvements, for instance through the effective integration of (2019 proposed a framework for preserving data privacy in decen-
heterogeneous data from multiple sources (Quaini et al., 2018), and tralized shared storage on a blockchain network and base their
the integration of smart contracts (Dagher et al., 2018). framework on the assumption that the shared storage would have
These themes suggest that prior research in this field presents appropriate capacity to support the blockchain system.
an emphasized focus on (a) improvement of technical features,
(b) management of medical data, and (c) identification of dis- 4.2.3. Constraints
tinct capacities within the field of healthcare, wherein blockchain Researchers have acknowledged constraints in prior studies,
can generate significant contributions. Based on these emergent which may be classified across four dimensions. These identi-
themes, we posit that research in this domain is currently in a trans- fied dimensions imply that such constraints transcend technical
formative state, with contemporaneous aspects of healthcare being boundaries (pertaining to the costs of developing and deploy-
continually identified as potential beneficiaries of blockchain’s use ing blockchain-based frameworks, analysis of data for framework
through technological advancements. evaluation, and the constituent elements of the frameworks) and
include some societal aspects as well (e.g. trust in government,
technological infrastructure of the country).
4.2. Limitations of the current literature
4.2.3.1. Costs. This group of constraints primarily relates to the
The limitations acknowledged by prior research indicate resources, time, and monetary costs associated with executing a
technically-oriented challenges (see Table 4). We attribute this to blockchain framework. For example, Dwivedi et al. (2019) refer to
the fact that the reviewed studies have mainly concentrated on the resource constraints related to IoT, whereas Zhang et al. (2018)
developing novel algorithms, frameworks, and proofs of concept acknowledge the costs associated with deploying a decentralized
for deploying blockchain in healthcare. Based on the review, we app for deploying blockchain. Additionally, other costs indicated as
categorize the extant limitations into four categories: performance, constraints and limitations in the extant research include the lin-
assumptions, constraints, and ethics and security. ear increase in protocol costs contingent upon the characteristics
 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290 11

and attributes of the involved entities, such as patients (Guo et al., These concerns are mainly related to the technical limitations of
2018), increased operational overhead (for the patient) and access blockchain technology, such as the security of individual nodes
latency (for the requester) (Shen et al., 2019), and the transaction (Griggs et al., 2018), the level of security enabled by the crypto-
and execution costs based on variable inputs of string length & size graphic elements incorporated in framework (Tian et al., 2019), and
(Al Omar et al., 2019). the maintenance of data privacy while requesters complete their
Time-related issues have also been discussed as a constraint, computations (Yue et al., 2016).
including the time spent searching for the global smart contracts However, certain studies have also pointed to more socially-
(Dagher et al., 2018), increased time consumption (Islam et al., oriented concerns about public data sharing (Wong et al., 2019) and
2019), transmission timing (Griggs et al., 2018), time required for users’ trust in governments (Dhagarra et al., 2019). Such concerns
seeking the required data in shared storage by the data recipient may also be related to maintaining the security of the proposed
(Rahmadika & Rhee, 2019), and higher total execution time (Kuo frameworks from the users’ perspectives, for example, the users’
et al., 2019a,b). management or mismanagement of their authorized private keys
(Brogan et al., 2018).
4.2.3.2. Data and analysis. Some studies reported limitations for
data, such as non-representativeness of sample data (Quaini et al., 4.3. Future research: recommendations of the reviewed studies
2018; Firdaus et al. 2018), the limited availability of training data for
running simulations or tests (Lee & Yang, 2018), and the possibility Based on the review, we now discuss avenues in this field that
of data duplication (Roehrs et al., 2017). Other reported constraints would benefit from additional attention from scholars. Prior liter-
pertain to lack of testing using actual inter-institutional medical ature has suggested various recommendations for future research,
data (Quaini et al., 2018), and the lack of time for dynamic analysis including extending (e.g. Zhou et al., 2018) or replicating current
(Firdaus et al. 2018). Such constraints may affect the completion frameworks (e.g. Quaini et al., 2018), and developing targeted treat-
or initiation of protocol tests associated with communication and ment solutions (e.g. Mamoshina et al., 2018), to name a few. We
authentication between entities (Xia et al., 2017), and affect the per- group these proposed recommendations into three categories (see
formance evaluation for the developed framework. For example, Table 4); the first category addresses potential technical advance-
H. Li et al. (2018) reported that the performance of their frame- ments, the second is specifically directed at the improvement of
work could be affected by having a small structure/ amount of data medical services and the last relates to the need for enhanced data
that would not only waste space, but also affect multimedia image protection.
content recognition.
4.3.1. Technical advancements
4.2.3.3. Platform and framework elements. Certain elements of the The extant research revealed the need to focus on optimizing
blockchain platform and developed framework may also serve previously developed frameworks by concentrating on address-
as constraints for its deployment. Some previously reported con- ing technical issues that may optimize framework performance
straints include the necessity of a gateway layer for Tangle to during their actual usage in a healthcare ecosystem. Therefore,
establish direct communication with sensors (Zheng et al. 2019), scholars may direct their attention to issues such as the strategic
the limited storage provided by a fog layer (Silva et al., 2019), as management of nodes (Yang et al., 2019), automatic generation or
well as semantic interoperability and incompatibility with legacy uploading of data (Shen et al., 2019), and improvement of process
systems (Zhang et al., 2018). Complications may also arise as a and system efficiency (Lee & Yang, 2018; Fan et al., 2018).
result of failing to prioritize inherently associated entities, lead- Further, in order to improve the scalability (Zhang et al., 2016)
ing to conflicts–especially in the case of decision-making during and functionality (Wong et al., 2019) of previously proposed frame-
emergencies (Yang et al., 2019). Further, there is a need to ensure works, researchers have called for the need to extend the current
rewards and incentives for miners (Quaini et al., 2019), which may technical boundaries of framework development, e.g. by consid-
be adversely affected by users’ unwillingness to share data (Li et al., eration of novel blockchain platforms (Rahmadika & Rhee, 2019).
2019). A few studies have reported constraints specific to their Additionally, scholars have proposed the need for a more nuanced
developed algorithms, such as a lack of a mature scheme for PSN- development of existing technology and existing algorithms for
based blockchains for healthcare (Zhang et al., 2016), and a lack enabling more effective blockchain-based healthcare ecosystems.
of an optimized masked authenticated messaging (MAM) module To this end, future researchers may address issues such as elim-
library (Brogan et al., 2018). inating the need for global smart contracts (Dagher et al., 2018),
utilizing conjunctive keyword searches (Zhang & Lin, 2018), and
4.2.3.4. Societal environment. Comparatively, fewer studies have improved data transference (Hussein et al., 2018), among others.
discussed constraints related to the societal environment within
which blockchain-based frameworks may be used. For example, 4.3.2. Improving medical diagnostics
there may be a possibility of collusion for fabricating data (Wong Although algorithms exist for the deployment of blockchain
et al., 2019) or a healthcare system may be constrained by an inabil- that are geared towards improving healthcare processes, few stud-
ity to control clinical malpractice (Zhang et al., 2018) Dhagarra ies have proposed the need for scholars to focus on the nuances
et al. (2019) acknowledge that the performance of their proposed of improving medical diagnostics (Mamoshina et al., 2018) and
architecture would be contingent on users’ country-wide access extending their application to other areas of healthcare, such as
to Internet connectivity. Similarly, Islam et al. (2019) also admit rehabilitation (Zheng et al., 2019). This may be achieved through
that Internet bandwidth is a constraint. Dhagarra et al. (2019) fur- development of improved diagnostic tools (Mamoshina et al.,
ther posit the inaccessibility of certain groups, such as refugees, 2018), remedial interventions for specific diseases (Dhagarra et al.,
to a country’s healthcare system and the existence of a central 2019), and determining the priority of service providers’ access to
identification database for patients, as additional constraints. patient records in emergencies (Brogan et al., 2018).

4.2.4. Ethics and security 4.3.3. Enhanced data and privacy protection
Our review also suggests that users’ concerns related to the eth- Existing studies present the need to enhance current standards
ical and secure use of data may be a significant limitation that of data protection for ethically and legally compliant use of medi-
may affect the adoption of blockchain by healthcare organizations. cal data. Scholars need to focus on two topical issues. First, future
12 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

studies need to improve compliance with security and regulatory be expected with a higher integration of blockchain with health-
measures by addressing issues such as guarantees for work secu- care processes in the future. This may be done by addressing issues
rity (Dwivedi et al., 2019), and addressing system vulnerabilities such as network latency (Shen et al., 2019), throughput (Zheng et al.,
(Badr et al., 2018) to improve robustness (Firdaus et al., 2018). Sec- 2019), scalability (Quaini et al., 2019), and bandwidth (Swan, 2015).
ond, there is a need to improve data privacy and authentication by
addressing issues pertaining to shared storage (Rahmadika & Rhee, 4.5.3. Data protection and legal compliance
2019) and key distribution (Al Omar et al., 2019). A significant area for future research will pertain to address-
ing data as well as user privacy and legal issues (Griggs et al., 2018;
4.4. Gaps in the extant literature Kuo et al., 2019a,b). These may be specifically addressed by creating
blockchain protocols for managing medical data that are enforce-
Based on the SLR, we explicate four gaps in the current body able through smart contracts (Pawczuk et al., 2019) and compliant
of knowledge that exclude the limitations already acknowledged with data and privacy protection regulations, such as HIPAA (Griggs
by prior researchers. An agenda for future research that comprises et al., 2018; Alla et al., 2018; Pawczuk et al., 2019).
these gaps together with our recommendations for future research
directions is presented in Table 5. First, comparatively few stud- 4.5.4. Integration with other technologies
ies have focused on managing medical records and data sourced Blockchain’s application in healthcare may benefit from explor-
from IoT sensors. Furthermore, we also elucidate a significant gap ing a deeper integration of the technology with business processes
in terms of research that examines the potential integration of data for improved functionality (Pawczuk et al., 2019). For instance,
from multiple sources of medical records into a singular framework. scholars may focus on the further integration of edge com-
Second, we explicate a critical gap in studies that explicitly puting, artificial intelligence (AI) and machine learning (ML)
examine the barriers to the adoption of blockchain by users, includ- with blockchain-based healthcare ecosystems to create enhanced
ing beneficiaries (patients), as well as service providers, such as predictive analytics models for personalized patient care and
doctors or hospital administrators (Jaoude & Saade, 2019). Under- diagnostics (e.g. Mamoshina et al. 2018; Firdaus et al., 2018; Li
standing the perspectives of these users may assist in generating et al., 2019). Further, research may target service enhancement by
insights for more effective and efficient management of blockchain- increased integration of IoT-based sensors to improve service and
based healthcare ecosystems. Similar suggestions regarding the data accessibility, remote monitoring, and emergency services.
inclusion of users and society were made by Risius and Spohrer In addition, we propose two more potential directions that may
(2017), but their study extended to the general adoption of be considered by future scholars in order to broaden the current
blockchain across different industries and organizations. scope of intellectual boundaries in this field. First, we suggest
Third, there is a distinct lack of studies that adopt a strategic the need to study the connotations of blockchain deployment in
perspective in the implementation of blockchain in an organization healthcare in more niche, yet allied, areas such as users’ digital
focusing on aspects such as prevention of external attacks (Guo rights management (Jaoude & Saade, 2019), drug prescription man-
et al., 2018; Fan et al., 2018), value creation or governance (Risius & agement (Hölbl et al., 2018), and avoidance of prescription fraud
Spohrer, 2017). Finally, we posit a gap in the presentation of real- (Casado-Vara & Corchado, 2019), among others.
time results based on case studies. Addressing this methodological Second, research could be aimed at examining the ramifications
approach gap could provide pertinent information on the true costs of blockchain use in the entire healthcare value chain and supply
and benefits of using blockchain. chain. This could assist researchers in understanding user-related
interoperability issues and perhaps even allow them to develop
4.5. Directions for future research standardized protocols for using blockchain-based systems.

Based on the SLR, we advance a brief summarization of the the- 4.6. Synthesizing framework
matic issues (Table 5) that would demand attention from future
scholars: This review and analysis aided us in the development of a
research framework that has been synthesized from research gaps
4.5.1. Adoption of a holistic overview explicated from the extant literature and recommendations pro-
While it is imperative to find solutions for performance and posed by prior scholars. This framework has five components that
security-related issues, such as interoperability (Al Omar et al., exhibit a degree of interconnectedness and would assist in creating
2019) and access-control (Rahmadika & Rhee, 2019), we argue that a blockchain-based healthcare ecosystem that can be examined in
scholars need to adopt a holistic purview of blockchain adoption. future research (see Fig. 8).
This is imperatively needed in order to develop holistic, as well
as legally and ethically compliant (Kuo et al., 2019a,b), e-health a) Data sources. Medical and personal health records are now
ecosystems with robust data management and authentication pro- generated and managed at multiple levels through patients via
tocols (Ji et al., 2018). Further, Pawczuk, Massey and Holdowsky smart devices (Casado-Vara & Corchado, 2019), healthcare ser-
(2019) suggest that contextual factors such as people and culture vice providers, and allied industries, such as pharmaceutics,
can be critical success factors for an innovative technology. Subse- insurance, and research (Cios et al., 2019; Tian et al., 2019). These
quently, we suggest the need for testing blockchain-based e-health act as building blocks of the blockchain system’s architecture and
ecosystems in cross-national and cross-institutional contexts to need to be managed in accordance with legal and regulatory
create context-based customized healthcare solutions by collab- guidelines. Blockchain can assist in developing authenticated
oration with organizations within the healthcare ecosystem, e.g. databases to be accessed by interinstitutional authorities with
medical research centers (Lee & Yang, 2018). the appropriate permissions to support the patient’s treatment
and medical decision-making (Kuo et al., 2019a,b). With the inte-
4.5.2. Architecture optimization gration of newer technologies, for example smart devices for
Researchers may focus on ensuring improvements in perfor- patient monitoring (Griggs et al., 2018), future research needs
mance and efficiency of proposed/ tested architectures to account to focus on managing such data sources to improve the compre-
for the increased volumes of transactions (Xia et al., 2017) that can hensiveness of medical record databases.
 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290 13

Fig. 8. Research framework.

b) System architecture. As blockchain technology evolves, its healthcare, mobile technology, and wellness sectors make it
architecture will continue to witness significant changes and imperative for researchers to identify such beneficiaries to
improvements of elements incorporated into the blockchain ensure that data is accessed by the appropriate authorities. It
system. For example, utilization of permissioned consortium is also critical to ensure that data integrity is preserved in accor-
blockchain (Zhang et al., 2018) or platforms other than Ethereum dance with legal and ethical guidelines. Thus, researchers should
(Zhou et al., 2018; Rahmadika & Rhee, 2018) may improve focus on understanding users’ perspectives on the perceived
current architectures being used to deploy blockchain in health- advantages and costs of being involved in a blockchain-based
care ecosystem. Furthermore, future research needs to focus system. This could help in identifying and neutralizing critical
on developing strategies for managing developed system archi- barriers that may affect the widespread deployment and actual
tectures, especially in the context of issues that can affect usage of this technology.
performance and efficiency, such as node management (Yang e) Legal and ethical considerations. Interoperability, authentica-
et al., 2019) and key distribution techniques (Al Omar et al. tion, and secure sharing of medical data are critical issues being
2019). addressed by blockchain applications (Dhagarra et al., 2019;
c) Strategic implementation of blockchain technology. With the Dimitrov, 2019). Despite the increased focus on blockchain, the
increasing assimilation of ICT and blockchain across healthcare prevalence of such concerns may be considered a significant hin-
ecosystems, scholars need to focus their attention on the factors drance in its widespread adoption. There is a need to direct more
that can hinder or facilitate the prevalent adoption of this tech- attention to regulatory compliance (Yue et al., 2016) and ethical
nology. Based on the review, we posit the need for organizations guidelines for issues such as patients’ ownership of their data
to consider how, and whether, blockchain can be a potential and access control (Quaini et al., 2018). We suggest that future
source of value creation or value enhancement by addressing scholars may adopt a multi-disciplinary approach to identifying
the specific issues identified through this review. These include avenues for resolving legal and ethical compliance related issues
strategic issues, such as resource constraints (Dwivedi et al., for blockchain’s adoption in cross-institutional or multi-national
2019) and technical issues, such as performance uncertainty contexts. We further posit the need to positively influence the
(Hyla and Pejaś, 2019) and system requirements (Quaini et al., public and appease regulatory bodies by deliberating on and
2018). Addressing such issues may aid researchers in developing emphasizing the critical benefits gained by using blockchain
blockchain system architectures that provide more functional technology.
utility and effective performance with regards to the manage-
ment of resources and outputs. This could also assist healthcare 5. Discussion
administrators and managers in adopting a strategic and holis-
tic perspective towards the potential inclusion of blockchain as The present study performed a systematic review of the liter-
a critical part of an organizational value chain. ature on blockchain applications in healthcare to understand its
d) Beneficiaries. Blockchain-based databases are capable of pro- present status and prospective potential. For this purpose, four
viding reliable information for specific beneficiaries in the broadly framed research questions were identified. RQ1 explored
healthcare sector, including patients who retain ownership of the current profile of research on blockchain applications in health-
their personal data. Beneficiaries also include authorities, such as care and was addressed by summarizing the top contributors,
doctors, medical researchers, pharmacists, and insurance agen- publication sources, publishers, and publication trends in this
cies. They may be authorized by patients to access and use domain. The alphabetic reporting of reviewed articles in the sam-
medical data for varied purposes, such as collaborative med- ple is detailed in Table 6. RQ2 was aimed at understanding the
ical decision-making (Li et al., 2019), medical diagnostics and application contexts for blockchain and was answered by delin-
informatics (S.J. Lee et al., 2018), and avoiding fraud (Casado- eating specific themes and sub-themes that represented focal
Vara & Corchado, 2019). The blurring boundaries between the areas of blockchain’s applications in healthcare. RQ3 addressed the
 14
Table 6
Reviewed studies.

Authors Journal Classification Method mentioned in Description of method Platform System architecture Key system design
article proposed/ components
implemented
(evaluated)

Badr, Gomaa & Procedia Computer Concept Public blockchain Algorithm details given Public, multi-tier Implemented Pseudonym based
Abd-Elrahman Science implementation methodologies encryption with
(2018) different authorities
(PBEDA), elliptic curve
diffie-Hellman (ECDH)
key agreement
protocol,

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
Menezes-Vanstone
protocol and elliptic
curve digital signature
algorithm (ECDSA),
implemented through
MIRACL
Brogan, Baskaran & Computational and Concept Masked Authenticated Algorithm details given IOTA Implemented MAM for Tangle,
Ramachandran Structural implementation Messaging (MAM) for Merkle signature
(2018) Biotechnology Journal broadcasting real time scheme, Merkle hash
activity through technique, One time
wearables signature, data
structured through
FHIR and coded with
LOINC.
Casado-Vara & Journal of Intelligent Concept Edge computing One simulation for data Ethereum Proposed (one Wireless sensor
Corchado (2019) and Fuzzy Systems implementation searches done but limited simulation) network (WSN) and
information provided on WSN controller v.2,
its results and efficiency Edge computing,
Raspberry Pi, Open
Thread IPv6 protocol
Dagher et al. (2018) Sustainable Cities and Concept N.A. Performance analysis for Ethereum Proposed (Ancile), QuorumChain
Society implementation cost done with MedRec but comparative algorithm, smart
no algorithm or data performance analysis contracts (consensus,
shared (computational costs) ownership,
against MedRec classification, service
history, re-encryption),
proxy re-encryption,
Ethereum Go-client,
cipher manager,
database manager
Dhagarra et al. (2019) Business Process Conceptual analysis Unique identification Algorithm details not given Ethereum Proposed Unique identification
Management Journal number (UID) system number (UID) system,
Big Data analytics,
registration & history
contract
Dwivedi et al. (2019) Sensors Conceptual analysis/ N.A. Algorithm details given Bitcoin Proposed (security Internet of Things (IoT),
mathematical with security margins margins considered in Merkle tree, ARX
evaluated for specified model for attacks) crypto cipher (SPECK),
criteria digital ring signature
with Diffie–Hellman
key exchange
Table 6 (Continued)

Authors Journal Classification Method mentioned in Description of method Platform System architecture Key system design
article proposed/ components
implemented
(evaluated)

Fan et al. (2018)s IEEE Internet of Things Concept N.A. Algorithm details given Consortium Implemented Practical Byzantine
Journal implementation + (simulated comparison fault tolerance
laboratory experiment with STETS and TPSN consensus mechanism,
precision time protocol
(time synchronization)

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
Firdaus et al. (2018) Journal of Medical Data Analysis Practical swarm Detailed result of static Not available Implemented (training, Android debug bridge
Systems optimization (PSO) analysis for performance testing and cross (ADB), boosting for
according to detailed validation) machine learning (ML)
evaluation criteria (adaboost,
realadaboost,
logitboost, and
multiboost), root
exploit detection
system, malware
analysis (static
analysis), reverse
engineering, feature
extraction & selection,
ML classification
Griggs et al. (2018) Journal of Medical Conceptual analysis N.A. Algorithm details not Consortium blockchain Proposed IoT sensors (wireless
Systems given, no experiments or (implemented proof of body area networks
simulations concept via Solidity, (WBANs)), smart
security analysis device (oracle)
through comparison of
proposed and
traditional system)
Guo et al. (2018) IEEE Access Conceptual analysis/ Proposed Detailed computational Not available Implemented (security MA-ABS scheme,
mathematical Attribute-based and mathematical analysis and computational bilinear
signature (MA-ABS) notations provided for performance Diffie-Hellman
scheme implementation of scheme evaluation through
as well as security and random oracle model)
performance evaluation
Hussein et al. (2018) Cognitive Systems Concept Proposed Detailed results for Not available Implemented Genetic algorithm,
Research implementation + blockchain-based simulation in terms of (simulation scheme) discrete wavelet
Simulation + Data access control method input and output strings, transform,
analysis (discrete wavelet time processing and block cryptographic hash
transform) supported generation given key, MD5 strings
by genetic algorithm
Hyla and Pejaś (2019) Future Internet Concept Design-science Details for algorithm and Permissioned Implemented Practical Byzantine
implementation methodology for results test of blockchain (verification speed Fault Tolerant
proposed integrity-verification test) consensus algorithm
Blockchain-based algorithm shared
eHealth Integrity
Model

15
 16
Table 6 (Continued)

Authors Journal Classification Method mentioned in Description of method Platform System architecture Key system design
article proposed/ components
implemented
(evaluated)

Islam et al. (2019) Future Generation Concept uni model based Some mathematical Not available Implemented Error-correction-
Computer Systems implementation + human activity notations and detailed (comparative output-codes (ECOC)
laboratory experiment recognition methods results for experiments for performance framework for HAR,
+ Data analysis (HAR) performance revaluation evaluation) support vector
on three datasets shared machine (SVM), Fog
computing, multi-class
cooperative
categorization
procedure

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
Ji et al. (2018) Journal of Medical Conceptual analysis/ N.A. detailed mathematical and Not available Implemented Order-preserving
Systems mathematical + algorithmic notations (performance encryption and merkle
laboratory experiment provided along with results evaluation) tree
of experiments for
performance evaluation
Kaur et al. (2018) Journal of Medical Conceptual analysis N.A. Concept based discussion Not available Proposed Blockchain based
Systems on applicability of environment
blockchain in healthcare
Kuo, Gabriel & Journal of the Concept Newton-Raphson Details on algorithms as Permissioned Implemented Batch model learning,
Ohno-Machado American Medical implementation + Data method well as results for blockchain (experiments) blockchain
(2019) Informatics Association Analysis consensus iterations and data/network,
execution time shared. consensus learning
algorithm, concurrent
use of server and
“client” roles, Proof of
equity algorithm
Lee & Yang (2018) International Journal of Concept Image preprocessing details shared for Bitcoin Implemented Histogram of oriented
Distributed Sensor implementation + Data experimental results and (experiments) gradients (HOG), local
Networks Analysis classification training as binary pattern (LBP),
well as testing results support vector
machine, random
forest tree, deep neural
network
Lee et al. (2018) Applied Sciences Concept Compression ratio Results shared for not available Implemented Blockchain applied
implementation method, Pearson’s compression ratio and (performance FASTQ and FASTA
correlation stability performance evaluation) lossless compression
testing (BAQALC) proposed,
next generation
sequencing (NGS), LZW
modification, NCBI
sequence read archive
(SRA)
H. Li et al. (2018) Journal of Medical Conceptual analysis/ Authentication Details shared for Ethereum Implemented (security Proof of primitiveness
Systems mathematical methods (acquisition of algorithm and analysis through of data introduced,
preservation content, performance evaluation in theorems, performance preservation
verify consistency) terms of operational cost evaluation for Submission,
operational cost) primitiveness
verification
Li et al. (2019). IEEE Access Data Analysis Primal-dual Varangian Results for performance Not available Implemented Hierarchical
method evaluation of scheme (performance architecture (three
shared for reaching evaluation of layer), edge computing
Stackelberg equilibrium Stackelberg game)
Table 6 (Continued)

Authors Journal Classification Method mentioned in Description of method Platform System architecture Key system design
article proposed/ components
implemented
(evaluated)

Mamoshina et al. Oncotarget Conceptual analysis Machine learning Proposed architecture Exonum Proposed Coefficient of
(2018) illustrated with workflow inbreeding, deep
examples instead of neural network
simulation or experiment predictor, time value of
based evaluation data, utility crypto
token (LifePound)
Nagasubramanian et al. Neural Computing and Concept N.A. Limited algorithmic Not available Implemented Keyless signature
(2018) Applications implementation + Data notations but detailed (performance infrastructure,
Analysis results for performance evaluation) timestamped

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
evaluation using Apache algorithm, Merkle tree
Jmeter provided
Nguyen et al. (2019) IEEE Access Concept N.A. Details shared for code Ethereum Implemented Decentralized storage
implementation script, access control (performance interplanetary le
protocols along with evaluation through & system (IPFS), mobile
performance evaluation security analysis) cloud, attribute-based
results for access control encryption (ABE)
and network overheads.
Noh et al. (2017) International Journal of Conceptual analysis N.A. Limited preliminary Permissioned Proposed (security Proxy re-encryption
Control and notations for computations blockchain analysis considered (PRE) scheme,
Automation shared without results of theoretically)
experiments or simulations
Al Omar et al. (2019) Future Generation Concept N.A. Details of algorithmic Permissioned Implemented Elliptic curve
Computer Systems implementation + notations shared with blockchain (experiment) cryptography (ECC),
laboratory experiment results for performance MediBChain protocol
evaluation on multiple
parameters
Quaini et al. (2018) IADIS International Qualitative Case study Primarily conceptual. Case Ethereum Implemented (test Interplanetary file
Journal on study method used to scenario execution) system (IPFS),
WWW/Internet provide test case scenario
results for response time
and memory consumption
Rahmadika & Rhee Wireless Concept N.A. limited algorithmic Not available Implemented Ring signature
(2019) Communications and implementation + notations but detailed (simulation) algorithm, Cryptonote
Mobile Computing Simulation results for simulation protocol, one time
provided for performance transaction and stealth
parameters (block address
propagation & block size)
Roehrs et al. (2017) Journal of Biomedical Conceptual analysis/ Modeling and profiling Limited discussion on Bitcoin Implemented OpenEHR data
Informatics mathematical + Data methodology algorithm, with extensive (performance standard, Chord
analysis discussion on results of evaluation, algorithm, routing
mathematical model mathematical systems overlay incorporated to
testing of multiple analysis) develop OmniPHR
performance parameters architecture
Shen, Guo & Yang Applied Sciences Conceptual analysis/ N.A. Limited algorithmic Permissioned Implemented (security Elliptic curve
(2019) mathematical + notations with discussion blockchain analysis, theoretical cryptography, BFT
laboratory experiment of results from theoretical efficiency analysis, smart consensus
(mathematical) and performance protocol, modified
experiment based results evaluation through digest generation
for multiple parameters experiment) algorithm, MedChain
(prior methodology
advanced)

17
 18
Table 6 (Continued)

Authors Journal Classification Method mentioned in Description of method Platform System architecture Key system design
article proposed/ components
implemented
(evaluated)

Silva et al. (2019) Wireless Qualitative Case study Limited discussion on tests Ethereum Implemented Fog computing
Communications and conducted with Apache (performance paradigm
Mobile Computing Jmeter for access time and evaluation)
application amount for Fog,
Cloud & blockchain
environments
Tian, He & Ding (2019) Journal of Medical Simulation N.A. Limited algorithmic Hyper ledger Implemented (security Sibling intractable
Systems notations with discussion analysis, performance function families (SIFF)
of results for simulated evaluation)

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
security analysis and
performance evaluation.
Uddin et al. (2018) IEEE Access Simulation + Data Sessional symmetric Extensive discussion of Customized (bitcoin & Implemented Proximity user
analysis key generation simulated performance Ethereum) (simulation & authentication (PUA),
&security analysis performance analysis) HMAC (keyed-hash
message
authentication code),
mutual authentication
protocol, Trei tree
Wang & Song (2018) Journal of Medical Conceptual analysis/ N.A. algorithmic notations and Consortium blockchain Implemented (security Attribute-based
Systems mathematics syntax explained with analysis through encryption (ABE) and
defined security analysis theorems) identity-based
but no simulation or encryption (IBE),
experimental test results identity based
signature, proposed
combined attribute-
based/identity-based
encryption and
signature (C-AB/IB-ES)
Wong, Bhattacharya & Nature Conceptual analysis N.A. Limited discussion on Not available Implemented Parallel healthcare
Butte (2019) Communications results of simulated (simulation) system, artificial
blockchain based clinical healthcare, parallel
trial. Algorithm or syntax execution, interactive
not explained voice response system
(IVRS)
Xia et al. (2017) IEEE Access Conceptual analysis N.A. Results discussed for test Permissioned Implemented Cryptographic keys,
examples based on blockchain (simulation based on user-issuer protocol
assumed vendor calculated and user-verifier
transactions per unit time assumptions) protocol
(calculated) but no
experiments or actual
simulation. No algorithm
or syntax
Yang et al. (2019) Applied Sciences Concept N.A. Limited discussion on Consortium blockchain Proposed (prototype Application
implementation algorithm and results from implemented with programming
prototype implementation qualitative interface, proof of
primarily theoretical. comparison) familiarity proposed
Yue et al. (2016) Journal of Medical Conceptual analysis N.A. Limited illustration of Not available Proposed Indicator-centric
Systems computing code schema (ICS), MPC
transformation and (secure multi-party
indicator schema. No computing), proposed
experiments or simulations app (healthcare data
reported gateway (HGD))
Table 6 (Continued)

Authors Journal Classification Method mentioned in Description of method Platform System architecture Key system design
article proposed/ components
implemented
(evaluated)

Zhang & Lin (2018) Journal of Medical Concept Secure and Extensive detailing of Consortium, private Implemented Consensus mechanism,
Systems implementation privacy-preserving PHI algorithm notations, (performance Bilinear maps

A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290
sharing (BSPP) protocol system architecture along evaluation, comparison
proposed with results from protocol of security properties)
implementation and
performance evaluation
Zhang et al. (2018) Computational and Qualitative Case study Detailed description of Ethereum Proposed Public key
Structural proposed architecture and cryptography - sign
Biotechnology Journal workflow through case then encrypt
study. No experiments and mechanism, Oauth, fast
discussion on algorithm or healthcare
syntax interoperability
resources (FHIR),
Solidity smart contract
Zhang, Xue & IEEE Access Concept N.A. Detailed discussion on Not available Implemented (security Elliptical curve digital
Huang(2016) implementation + algorithm. Details also analysis through signature algorithm,
laboratory experiment provided for security and theorem proofs, secure hash algorithm,
performance evaluation experiments, IEEE 802.15.6 display
through theorems and performance authenticated
experiments evaluation) association protocol,
display-based out of
band (OOB) channels,
pervasive social
network (PSN)-based
healthcare
Zheng et al. (2019) Journal of Medical Concept N.A. Limited discussion on IOTA Tangle Implemented Masked authenticated
Internet Research implementation + algorithm but significant (experiment) messaging (MAM), IoT
laboratory experiment details provided for integration, GPS
experiment conducted to
test system feasibility
Zhou, Wang & Sun Journal of Medical Conceptual analysis/ N.A. Discussion provided for Ethereum Implemented Practical Byzantine
(2018) Systems mathematical + algorithm construction, (experiment, fault-tolerance (PBFT),
laboratory experiment and performance performance MIStore
evaluation for processing evaluation)
time and verifying
transactions

19
20 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290

limitations and challenges faced by prior researchers. The sum- 6.2. Implications for practice
marization of the primary research themes and extant limitations
allowed us to identify gaps in current knowledge in response to The study’s findings can be utilized by multiple stakeholders,
this research question. RQ4 focused on the potential areas wherein including healthcare providers, managers, and policy makers. First,
future research could offer significant insight. This question was we imply the need to adopt a strategic perspective towards the
addressed by integrating insights derived from the emergent gaps, implementation of blockchain within an organizational framework
limitations, and previously posited recommendations into a single, through a careful assessment of the potential benefits and costs of
synthesized framework. This framework may further the current implementing and running blockchain-based systems. For exam-
level of knowledge in this domain by addressing the issues (detailed ple, organizations should carefully evaluate the operating costs of
in Tables 4,5) that may be critical for the further development of blockchain considering the fact that blockchains can consume very
the field. large amounts of energy (Truby, 2018; Uddin et al. 2018).
Second, our study can inform management of healthcare to
6. Implications make decisions pertaining to technology deployment and resource
allocation. In particular, our results can help identify areas for
The findings of this SLR present significant implications for potential blockchain implementations and new applications for
both academics and practitioners involved in the development and further efficiency enhancement (e.g. Fan et al., 2018), predictive
implementation of blockchain-based technical models for the field analytics (e.g. Kuo et al., 2019a,b; Brogan et al., 2018), and improved
of healthcare. We propose five theoretical and practical implica- diagnostics (e.g. Mamoshina et al., 2018; Lee et al., 2018). This in
tions based on the present review. turn will require that organizations focus on how blockchain could
add value to their specific business models and the contribution
6.1. Implications for research this technology could make towards organizational value creation
process. Managers would then be empowered to inculcate positive
Our first contribution is a detailed review of the recent litera- attitudes towards the use of blockchain and increase the technol-
ture on the application of blockchain in healthcare. This includes an ogy’s perceived ease of use and utility.
encapsulated version of the top contributors, publishers, and publi- Third, it is possible that the increased adoption of blockchain
cation outlets. Additionally, the main areas wherein blockchain has technology will lead to disruptive changes in the current struc-
added value to healthcare have been identified through investigat- ture of the healthcare system. The insights from this study can help
ing the constructs used, research findings, and limitations faced the management of healthcare service providers as well as govern-
by researchers. These structured insights will assist researchers in mental authorities and decision-makers to evaluate the potential
understanding the focal areas of the research and identifying future disruptiveness of blockchain technology (Mäntymäki et al., 2020)
research directions. in the healthcare domain.
Our second contribution was the development of a synthesiz- Fourth, our results can inform policy makers, and legal officers
ing research framework. In doing so, our study adds to prior SLRs associated with healthcare, who may acquire ideas for creating
in the area. In particular, our synthesizing framework summarizes sustainable policies for data sharing, storage, and the privacy
key contributions made by the extant research and classifies them protection of all stakeholders. This is especially important for
under themes. Moreover, our framework marks a novel theoretical blockchain-based systems for international use that may be subject
contribution by presenting a contemporary delineation of pertinent to cross-national regulation or laws (e.g. HIPAA) for data protection
avenues to aid future researchers. This, in turn, helps to expand and preservation of the sanctity of medical records (cf. Dhagarra
the scope for future research. For example, our framework expli- et al., 2019). Such policies are currently critical because of rising
cates the collaborative role of blockchain technology in helping data incidences of security breaches involving medical data for reasons
interchanges between stakeholders, such as service providers from such as hacking (61 %), accidental exposure of data (44 %), and chal-
allied industries, patients, and permissioned medical authorities. lenges in securing legacy infrastructures (Accenture, 2018). These
Third, our review has shown that attempts have been made to policies may also be extended to incorporate international data
increase the benefits of applying blockchain technology in health- sharing to facilitate the discourse among the international health-
care through other technologies such as artificial intelligence (AI) care community, thus providing valuable insights for patient care,
and machine learning (e.g. Mamoshina et al., 2018; Kuo et al., diagnostics, and treatment.
2019a,b; Zheng et al., 2019). Future attempts may also promote Fifth, due to the highly sensitive and personal nature of the infor-
research grounded in semantics and natural language processing. mation stored, processed, and exchanged in the healthcare system,
This would allow researchers to deploy advanced data manage- issues related to social responsibility are of paramount importance.
ment solutions, such as augmented normalization in the processing As in the case of artificial intelligence, our findings suggest a need
of diseases and clinical and biomedical texts (H. Li et al., 2018). to develop governance mechanisms for the use of blockchain in
Fourth, based on the gaps explicated from the review, impli- healthcare (Arrieta et al., 2020). In particular, reducing the opac-
cations arise for the need to broader disciplinary and particularly ity associated with blockchain can be important in maintaining
methodological coverage of the research to advance the current stakeholders’ trust in the underlying technology but also in the
understanding of the field. For example, research based on survey healthcare system as a whole.
methodology or interviews can enhance the understanding of e.g.
the challenges and barriers inhibiting user adoption. 6.3. Limitations and future research directions
Fifth and finally, there is a need for more holistic approaches to
examine the adoption and utilization of blockchain in the health- The findings of the current study should be considered in light of
care domain. This in turn requires a better understanding of the its limitations. First, the review focused solely on articles appearing
interoperability of frameworks such as Ancile (Dagher et al., 2018), in peer-reviewed journals available in selected scholarly databases.
and GloreChain (Lee & Yang, 2018) that have been developed and Thus, other forms of publications, such as conference reviews and
proposed by extant research to facilitate the adoption of blockchain book chapters, were excluded. Similarly, despite the employment
in healthcare. This may be achieved by examining the utility of such of citation chaining, it is possible that articles appearing solely
frameworks for users based across multiple institutions, such as in the ACM and IEEE databases were not captured. Second, the
hospitals, pharmacies, and medical research institutes. review considered blockchain as an umbrella keyword and did not
 A. Tandon, A. Dhir, A.K.M.N. Islam et al. / Computers in Industry 122 (2020) 103290 21

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