Abstract
Blockchain technology has been gaining significant traction in the healthcare industry in the past few years. The value proposition of using blockchain technology is to augment interoperability among healthcare organizations. However, the disruptive technology comes with costly drawbacks. The aim of this paper is to explore the benefits and threats of blockchain technology as a disruptive innovation in the healthcare sector. Current blockchain applications were reviewed through studies conducted to identify uses and potential challenges of blockchain technology based on its current implementations. This literature review highlights gaps in research and the need for further blockchain studies, particularly in the healthcare domain.
Key Words: Blockchain Technology, Disruptive Innovation, Healthcare Industry, Electronic Health Records (EHRs), Applications, Benefits, Threats.
Introduction
One of the challenges encountered by the healthcare industry is the inability to safely manage and retrieve personal health information (PHI) in a timely manner. Effective management and retrieval of patient data would enable healthcare providers to capture a holistic picture of a patient’s health, improve patient-physician interaction, and achieve better use of healthcare-related data1. Interoperability has enormous potential to transform the health sector through the development of affordable cures and cutting-edge treatments for numerous diseases but depends upon smooth, effective data exchange, and distribution across all the well-known network participants and health professionals2. Privacy and security threats are common challenges faced by the healthcare industry. The rise in cybersecurity attacks and security breaches of healthcare records has stimulated the pressing need of healthcare organizations to invest in advancing security technologies3. As a disruptive innovation, blockchain technology is paving the way for new potential of solving serious data privacy, security, and integrity issues in healthcare and facilitating the paradigm shift of patient-centric interoperability, while enabling decentralization and transparency of stored information4. The global pandemic has revealed a lack of interoperability in the current healthcare system and the need for accurate clinical data that can be widely distributed to healthcare providers in an efficient and secure manner5.
Blockchain is seen as a key breakthrough that will likely have a considerable influence on a myriad of different industries such as healthcare, supply chain management, and business. A peer-to-peer network called blockchain was initially proposed by Satoshi in 2008 and then commercialized in 2009 when Bitcoin emerged as its first use case 46. Kassab et al reported that in 2016, “healthcoin” was developed by Diego Espinosa and Nick Gogerty as the first platform based on blockchain to manage and reward Type-2 diabetes prevention39. Users submit their biomarkers into the blockchain. If the biomarker is an improvement, the system rewards the patient with digital tokens: healthcoin that can be applied toward government tax breaks and/or discounts on multiple fitness brands6. Future technology may open the door to significant opportunities, ranging from research and economics to interactions between patients and physicians 7. Blockchain technology conflates complexity, novelty, and diversity, which has posed challenges in gauging the value proposition of incorporating the technology47. Due to its complexity, blockchain may be used for managing business processes or as a workflow system8.
Several research studies have been conducted on the benefits and challenges of blockchain technology in the healthcare industry. However, some of the potential applications have not yet deployed9. The objective of this literature review is to explore the research studies that have been conducted on applications of blockchain technology as a disruptive innovation in healthcare industry10, addressing current and potential uses, benefits, and threats of the technology based on the historical research studies. Several researchers suggested studying the outcomes of leveraging blockchain technology in the context of improving security of health records, meeting social determinant of health needs, and improving health outcomes11,12, 3, 4. Based on this context, the previously available scholarship on blockchain were analyzed through a systematic review as an assessment tool. The findings convey key insights on the current state of research investigation on blockchain, including benefits and implications as a disruptive innovation in healthcare industry 13. The study also highlights the gaps in research and the need for further blockchain research in healthcare domain.
This paper was framed to guide future researchers and decision-makers on the current knowledge of benefits, drawbacks, and gaps in blockchain research landscape. The findings were conveyed to proactively identify key challenges pertaining to blockchain adoption and application in the healthcare domain to support improvement opportunities and tackle challenges at their initial stages. This paper was framed to explore the theoretical lens of disruptive innovation theory and innovation diffusion theory. The study was organized to begin with a background of blockchain technology, then explore its key uses and potential benefits within a healthcare context based on the research studies and addressing possible threats discussed by literature from an organizational, social, and technological level. Finally, this review provides recommendations to guide future research, bridge the gaps identified in literature, and further examine the prototypes implemented in the healthcare sector.
Literature Review
Blockchain is considered a relatively recent invention that first appeared in 2008 and provided the technical foundation for the birth of the cryptocurrency known as "bitcoin." In general, blockchain may be thought of as a method of network organization that combines distributed ledgers and databases. In this design, records are updated or maintained by a certain authority but are dispersed over all computers connected to the network so that no one node has the power to change the data that is being stored. For the handling of sensitive data, such as health information or financial transactions, this specific component might be useful14. The healthcare industry, one of the biggest in the world, frequently must deal with a complicated network of interrelated stakeholders that are subject to a variety of rules and have their patient data dispersed across numerous databases. Blockchain technology can help healthcare professionals in this difficult situation address the present inefficiencies in the sector15.
Healthcare data management systems encounter issues including data transparency, traceability, immutability, audit, data provenance, flexible access, trust, privacy, and security. By overcoming these obstacles and bringing about significant advances, blockchain technology can completely transform healthcare data administration, blockchain establishes confidence in health data by enabling the tracking of changes from their source to their present form. Current projects and recent case studies show how useful blockchain technology is for a range of healthcare applications. However, there are issues that need to be resolved for blockchain to be successfully adopted in the healthcare industry. Overcoming these difficulties and further investigating the possibilities of blockchain in healthcare data management should be the main goals of future research8.
Several review articles on blockchain technology's use in industries including banking, the internet of things (IoT), the energy sector, government, and privacy and security are now available in the open literature. A broad thorough critical assessment of the most recent research on blockchain-based healthcare applications is not addressed, despite a few review papers discussing the uses of blockchain technology in healthcare. For instance, most of the studies give a brief overview of blockchain-based healthcare applications. Despite being the first to provide a high-level overview of new blockchain-based healthcare applications, the study largely focuses on the practical applications and advantages of this technology16.
Blockchain technology can change the topology of a healthcare network such that data are added in a decentralized fashion. Blockchain improves data security, confidentiality, and interoperability while allowing patients to integrate themselves into an ecosystem17. Bibliometric analyses of blockchain technology in the healthcare sector are few. In this regard, there is a growing body of literature examining and debating the potential and current applications of blockchain in healthcare. To our knowledge, however, none of these studies examine the potential environmental and health effects of this industry’s potential use of blockchain. This lack of attention should be addressed because, in theory, any technical improvements to the healthcare sector should be made in a way that does not hurt either the environment or people's health. This study addresses blockchain technology and healthcare studies to bridge the gap. It also discusses potential directions for future research with the right depth and breadth in pertinent areas.
Theory
Disruptive innovation theory has analyzed and addressed growth driven by innovation18. The theory was originally initiated by Clayton Christensen et al. in 1995 and has pervaded the clinical healthcare dialect over the past years. Increased adoption of blockchain technology in the healthcare domain will lead to a disruptive shift in the foundation of the healthcare system13. Despite the growing use of the concept in literature, there are gaps in comprehending disruptive innovations in a healthcare context as there is no objective definition in healthcare literature19. In addition, there is no published literature that compares perceived healthcare disruptive innovations. Therefore, key innovations in the sector remain in silos, which limits our ability to identify disruption.
Innovation diffusion theory states that characteristics of innovation affect how organizations gather knowledge, which consequently affects the decision to adopt or reject the innovation. These characteristics are: (1) relative advantage; (2) compatibility; (3) complexity; (4) trialability; and (5) observability20. Haleem and Hartley3, 20 have noted that lack of blockchain understanding is a barrier to technology diffusion. Given the relatively early stage of blockchain development, most healthcare organizations often rely on consultants when adopting modern technology 2. Additional barriers to diffusion success are switching costs and the network effect10.
Methodology
Systematic reviews are an effective way of evaluating and interpreting research relevant to a particular research question, topic area, or phenomenon of interest based on previous research outcomes21. Systematic reviews are common in the medical field and healthcare domain. Nonetheless, there are many research studies addressing blockchain technology applications in healthcare4, 13, 22, 23. For example,24 conducted a systematic review of the adoption of blockchain platforms in healthcare and how they improved the industry outcomes.
To compile data and insights on blockchain in healthcare research, meta-analysis was conducted and identified studies were included in the review using a list of relevant terms through the search of several electronic databases including PubMed, MEDLINE, Scopus, EBSCO, and IEEE Xplore, and other databases for research including ScienceDirect, and Google Scholar. By choosing the mentioned databases, the intention was to focus on peer-reviewed articles that have been published in healthcare journals. The database was searched to determine whether a publication contained at least one of the keywords or search terms in the title, abstract, or keywords. In total, 1,830 articles were identified. The Boolean operator was utilized with a combination of “AND/OR” of search terms. The following search string was used: blockchain AND (healthcare OR medical) AND (challenge, threat, OR benefit OR uses OR 1 application). Following this process, 37 articles were determined to be relevant to the study. Subsequently, a backward reference-list checking was conducted to identify other relevant literature5. As a result, 10 more articles were identified. In total, 47 articles were identified to be relevant to this literature review.
To narrow down the literature selection process to the relevant articles, all publications that are fully available in English language and published between 2016 and 2022 were included. Duplicate articles, book chapters, and papers that discussed blockchain from a technical and engineering perspective were excluded. Based on figure 1, 33 articles were identified in the final population for analysis as relevant literature. EndNote software was utilized for duplicate removal and final screening. To ensure reliability, the search process was comprehensively documented to identify studies, assess relevance, and synthesize the structure of the paper. The goal was to find research articles focused on blockchain applications, benefits, and threats in healthcare domain. This literature will answer the following research questions: How has blockchain been defined in literature? What are the potential blockchain applications in healthcare domain? What are the blockchain benefits in healthcare literature? What are the possible threats of blockchain technology in the healthcare industry? For the purposes of the review, blockchain research was categorized into three categories: 1) Applications in healthcare industry, 2) Benefits of blockchain, and 3) Threats of the technology.
Fig.1. PRISMA for Identification and Inclusion Process of Systematic Review
Background
Most of the scholars describe blockchain using their properties13, 48 defined blockchain as a decentralized transparent ledger with transaction records. Blockchain technology is characterized as “an open, distributed network that may record transactions between two individuals rapidly and in a verified and conspicuous way.” Blockchain is described by several authors as a digitized decentralized ledger to allow recordkeeping of all peer-to-peer transactions without the need for a centralized authority19. Blockchain was also described as “a distributed ledger system, which maintains all transactions synced across users”25. Researchers highlighted that information that has already been used in a transaction cannot be altered or deleted, and users can openly and transparently audit any transactions. The technology protects data from manipulation and alteration. The studies addressed that blockchain offers tremendous efficiency and affordable solutions in the healthcare industry. The essential technology characteristics include decentralization, traceability, immutability, and provenance26.
Since 2016, the demand for blockchain technology has increased globally, and several large technology firms, such as IBM, Intel, and Microsoft, are heavily invested in blockchain technology development. The World Economic Forum estimates that, by 2025, 10 percent of the global gross domestic product will be stored on blockchain technology27. The marketplace for blockchain technology was estimated to be worth around $339.5 million globally in 2017, and it is expected to increase to $2.3 billion by 2021. By 2030, blockchain is anticipated to provide $3.1 trillion in economic value. According to International Data Corporation (IDC), worldwide spending on blockchain will increase from about $1.5-$2.9 billion in 2018- 2019 and rise?? to $11.7 billion in 202210. For the anticipated period of 2017–2022, the anticipated annual compound growth rate is 73.2 percent49. The US healthcare industry is the world’s largest and absorbs more than $1.7 trillion per year28. Today, the average annual cost of healthcare per person in America is $10,739, which is more than residents of any other country28. Abdel-Basset5, noted that blockchain technology can be used to manage pandemics by considering different data sources, which can be statistically analyzed to extract essential features and patterns for healthcare professionals and the government.
Although understanding blockchain technology might be challenging, the fundamental ideas behind it are rather straightforward. Blockchain is a database of a group of data that is electronically stored on a computer network50. In an examination of academic literature where blockchain applications have been applied to diverse topics, it can transform the traditional industry with its features, which include decentralization, anonymity, persistency, and auditability29. The studies reviewed have covered several instances of blockchain technology being used in healthcare, as well as the issues and potential fixes. The design decisions and compromises made by the researchers were addressed in the many situations where this innovative technology was used11. The Office of the National Coordinator for Health Information Technology (ONC) has described several features critical to the development of an interoperable health system, which are addressed by blockchain9. The research studies have covered a wide range of settings for using this technology, including blockchain-based applications across many different sectors11. Then the researchers describe some aspects of blockchain technology for medical record management, insurance claim process, biomedical research, and health data ledgers30. There is a consensus among researchers that, with blockchain technology, patient data will be truly owned and controlled by the right owner of the data, which is the patient31. The healthcare industry is a suitable candidate for the use of blockchain technology since it may address critical concerns including computerized claim verification and global health management23. With the assistance of this technology, patients may maintain their personal information and choose with whom it will be shared, overcoming the present problems with data ownership and exchange. Despite the general belief that the benefits of adopting blockchain-based technology may be exaggerated, a new study suggests that enterprises will still make significant investments in this area in the future2.
It might be argued by researchers that this system has not yet lived up to expectations, a reality that may be explained by the widespread deployment of blockchain, particularly in relation to governmental restrictions and other difficulties19. Another key barrier to the widespread adoption of blockchain is that both general and specialized users such as patients or doctors are unaware of how it operates, its technological aspects, or its benefits for processing data1. The researchers proposed that it could take some time for this technology to build all anticipated and expected stages of transformational change in business, mostly due to implementation obstacles in the manner of organizational and social issues such as security concerns and governance8,19,24. This may also be made worse by widespread misunderstandings about how blockchain technology is used in government policies and regulations. By removing these obstacles, recent research aims to assist blockchain clear changes and expedite its spread32.
The papers reviewed described many blockchain uses and potential issues often at the conceptual level. However, empirical studies are limited as blockchain research remains early-stage and immature, particularly in healthcare5,11,27. Blockchain technology is a prominent example of disruptive innovation. However, poor identification can lead to poor understanding of the technical features and potential of an innovation and the possible barriers to adoption and ways to overcome them33.
Healthcare Industry Challenges
Some of the numerous concerns hospitals and other healthcare organizations deal with daily include patient data access, medication storage logs, and medical records. Patient care, information security, and privacy must all be balanced in the healthcare sector. Major challenges the healthcare sector faces include putting the patient first, privacy and access, accuracy of medical data, pricing, management of supply chains and prescription records. Even if the conventional technique of storing data through a centralized database can be damaging, as indicated in research, it can also be susceptible to hacking or even a single failure point13.
The fact that all the servers temporarily go offline while the changes are being made to the databases used to store medical data is another problem with a traditional database. Given that healthcare is a 24/7 industry, this little gap might prove to be quite deadly23. Another concern with medical records is the cost associated with transferring records among different entities. The lack of availability of test results can be dangerous in terms of delayed treatment. Also, sending data via email is considered a security risk. A system integrating patient consent and access to authorized individuals would improve efficiency and save on financial costs9. Blockchain technology is being promoted as the “solution” to issues in a variety of healthcare issues34. By doing a thorough literature review and responding to the research questions posed in the research, this study attempts to discover blockchain technology capabilities in the healthcare sector. The potential of blockchain technology has extended to the healthcare sector, enabling a change in the way the present system and its utilization of technology currently operate.
The study seeks to emphasize the potential paths for blockchain research in healthcare, as well as to emphasize the possible uses of the platform. According to literature, blockchain technology is currently being researched in the field of healthcare, where it is mostly employed for network access, data exchange, and record management23. Additionally, it demonstrates that many studies lack implementation or prototype information. The authors of literature reviewed reached the conclusion that blockchain application-based research is expanding and growing at an exponential rate5. The research has also demonstrated that the exponential growth of blockchain technology initiatives in the healthcare industry are projected to have a major influence. A systematic study method was conducted, employing a well-planned monitoring strategy to look for pertinent papers. Several studies have put out various scenarios for the application of blockchain in healthcare systems. The assessment also identifies benefits as well as shortcomings and potential future research topics. To further comprehend, define, and assess the usefulness of blockchain in healthcare, additional study is still required9.
Main Features of Blockchain Technology
The four key characteristics of blockchain were identified by research studies and serve as the foundation upon that it has expanded. Technology’s four distinguishing characteristics are: decentralization, immutability, transparency, and provenance8. Healthcare systems have used centralized systems up to the advent of blockchain to fulfill data exchange requirements. A centralized institution is employed to hold all the information in a central network, and only that entity and the user may communicate with each other. Even though centralized systems have indeed been in use for a long time, there are certain restrictions associated with this kind of network. Since the data is kept in a single main place and by a single organization, this turns into a red flag for would-be cybercriminals or hackers and even represents a lone source of potential failure36,37.
Blockchain offers a decentralized network as an alternative option to a centralized one, removing the necessity for a single centralized power to rule over the network22,23, discussed the idea of immutability, which states that once data or information has been generated it should not be changed. When a blockchain record has been created, it cannot be changed once it has joined the network9. This is a crucial aspect of the blockchain that may be used to stop a lot of unethical or questionable behavior in any sector41. Blockchain transparency is a term that is frequently misunderstood. With the use of sophisticated encryption, a person's identity is concealed and just their upgradable is shown8. The provenance feature of the blockchain implies that any additions to the blockchain are visible to all the patient’s network members39.
Blockchain Applications in Healthcare
Blockchain is a relatively emerging and developing technology that offers creative uses in the healthcare industry. The development of affordable cures and cutting-edge treatments for numerous diseases depends on smooth, effective data exchange and distribution across all the well-known network participants and health professionals. In the upcoming years, this will hasten the expansion of the healthcare sector. The studies reviewed highlighted that Ethereum and Hyperledger fabric seem to be the most used platforms/frameworks in this domain12. The studies unveiled blockchain technology prospects in the supply chain highlighting the benefits for the healthcare business. This is among the primary areas that the digital revolution enhances and innovates since it immediately affects living quality. Blockchain technology is also growing in popularity in the healthcare industry. It presents several significant and spectacular opportunities, ranging from research and economics to interactions between patients and physicians7. The most significant research explored and organized according to several use cases in this domain, include electronic health records (EHRs), remote monitoring of patients, pharmaceutical distribution network, and healthcare insurance claims8,10,24.
1.Electronic Health Records
The administration of health data, which might be enhanced by the capacity to integrate disparate systems and enhance the precision of EHRs, should be given priority in the effort to change healthcare. While the phrases electronic patient records (EPRs) and electronic health records (EHRs) are sometimes used interchangeably, they have different meanings. EMRs, or electronic medical records, are a more recent name for the paper charts kept by clinicians in their offices. The medical and treatment histories of patients in a single practice are recorded in an EMR. EHRs, on the other hand, put a greater emphasis on a patient’s overall health, going beyond the usual clinical data gathered at the doctor’s office and taking a more comprehensive approach to a patient's care.
According to the studies reviewed, blockchain helps manage EHRs. To handle authorization and data exchange across healthcare entities, Ekblaw et al. described MedRec, an EHR-related solution that suggests a decentralized method. The MedRec platform provides patients with information and understanding about who may access their medical records. FHIR Chain (Fast Health Interoperability Records and Blockchain) is another program that incorporates EHRs36. It is a medical record management-focused, blockchain-based platform for exchanging clinical data that is developed using bitcoin, and patients can get solutions from FHIR Chain. Nonetheless, Xia et al. introduced Medshare, an ethereum program for systems that experience a lack of communication for information sharing among cloud computing owing to the negative risks towards disclosing the content of personal data information. When exchanging medical data in cloud archives, Medshare offers data monitoring, and governance among large data organizations. MedBlock and BlockHIE are two further EMR apps built on the blockchain. MedBlock offers a method for searching records.
The suggested method keeps track of the addresses of health records blocks that are organized by health professionals. Each patient assessment has a link to the relevant blockchain record. Jiang et al. proposal for BlockHIE presents a blockchain-based healthcare system34. BlockHIE blends off-chain retention, in which data is kept in database systems of external institutions, with on-chain validation to continue taking advantage of current databases. Another blockchain-based healthcare platform addressed in the literature is called Ancile, which employs smart contracts to ensure data security, confidentiality, access management, and EMR compatibility45.
2. Remote Patient Monitoring
Remote patient surveillance refers to the gathering of medical data using smart phones, wireless body sensor sensors devices, and Internet of Things (IoT) devices to be able to monitor various patients’ conditions30. Blockchain technology is crucial for the storage, exchange, and retrieval of remotely gathered health data. It offers a solution in this setting where information is sent from mobile devices to a blo