Artificial Intelligence in Health

REVIEW ARTICLE

Enhancing health-care security: The role of

blockchain and consensus mechanisms
Asmaul Hosna1, Nujhat Tabassum Rahman1, Supriya Dewanjee1, Zulfikar Alom1,
Elmustafa Sayed Ali2,3*, Mohammad Abdul Azim1, and Rashid A. Saeed4
1
Department of Computer Science, Asian University for Women, Chattogram, Bangladesh
2
Department of Electrical and Electronic Engineering, Faculty of Engineering, Red Sea University,
Port Sudan, Sudan
3
Department of Electronics Engineering, Faculty of Engineering, Sudan University of Science and
Technology, Khartoum, Sudan
Department of Computer Engineering, College of Computers and Information Technology, Taif
4

University, Taif, Saudi Arabia

Abstract
Blockchain technology has gained prominence recently by virtue of its strong
security features for clinical data. Automation of blockchain transactions enables
data transactions and records, providing decentralized, secure, and dependable
access. Through intelligence-sharing agreements, it can also manage member
relationships without the need for a middleman or other third party. Researchers
in the health-care industry using blockchain algorithms to safeguard security of
data, which is properly stored, are on the rise. In addition, this technology is patient
adaptive. Patients and other health-care users can now trust the technology because
it prevents any third party from accessing the medical data. Many platforms intended
*Corresponding author: for use in the health-care domain are emerging, including Gem Health Network
Elmustafa Sayed Ali and MedRec. Using blockchain in health-care protects user data and grants them
([email protected])
full authority over their data. However, blockchain technology is also confronting
Citation: Hosna A, Rahman NT, challenges and limitations regarding data privacy and storage capacity. This paper
Dewanjee S, et al. Enhancing
health-care security: The role explores the implementation of blockchain within health-care sector while providing
of blockchain and consensus an overview of this technology and the different consensus algorithms used in
mechanisms. Artif Intell Health. blockchain technology.
https://doi.org/10.36922/aih.2580

Received: December 29, 2023

Keywords: Blockchain; Health-care security; Electronic health records; COVID-19
Accepted: February 26, 2024 pandemic; Genetic algorithm; Consensus mechanisms
Published Online: April 16, 2024

Copyright: © 2024 Author(s).

This is an Open-Access article
distributed under the terms of the 1. Introduction
Creative Commons Attribution
License, permitting distribution, Blockchain is an arrangement of a central node of control that connects distinct nodes.
and reproduction in any medium, A peer-to-peer distribution database communication allows for safe data storage,
provided the original work is
properly cited. verification, and transduction within the network. The growing utilization of blockchain
Publisher’s Note: AccScience technology has led to a compassionate project coordinated by the United Nations to help
Publishing remains neutral with refugees who have lost their identity papers such as qualification documents and also
regard to jurisdictional claims in
published maps and institutional
to track pharmaceutical manufacturers that supply products in particular hospitals.1 In
affiliations. the UK, health-care applications and validation were initialized to develop a digitized

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Artificial Intelligence in Health Blockchain for health-care security

health-care system through the help of government and such as Apple and Google have developed contact tracing
policy. However, the health-care applications cannot applications to track COVID-19 patients.8 However, these
securely share data through the application with data applications are not decentralized, so patients’ data can be
resources.2 Personal health-care record (PHR) technology easily accessed, resulting in a breach of data privacy. Data
has been introduced to safeguard and store the patients’ in a centralized system are prone to fraud, deletion, and
medical records, which the patients control. modifications, undermining the data integrity of these
The PHR secured some confidential governance. systems. Blockchain technology can assist in lowering the
A previous study2 has highlighted the harmful impact impacts of the COVID-19 pandemic while providing high
of poor record sharing on patient treatment, suggesting security and ensuring that a failed attack does not occur.
that the patients become part of the health-care platform This is due to the decentralized feature of blockchain, and
that requires advanced tools and capabilities. Al Mamun all the data and records of transactions stored in blockchain
et al.3 asserted that patients should control their medical are transparent to all the network members.1,9 Therefore,
data through electronic medical records. Since electronic data are more reliable and trustworthy.
medical records consist of confidential and sensitive To make data immutable, hashing or cryptographic
information, the robust security system should be algorithms are applied in the blockchain, linking one block
transparent. Blockchain ensures safe transduction and to another.10,11 Smart contracts are also used by blockchain
transparent medical history records – an important technology to automate business processes and resolve
attribute that helps build patients’ trust. For instance, based health-care collaborators’ disputes. Blockchain technology
on the medical records of HIV patients, cancer patients employing intelligent contracts can be applied to the logistic
have to endure long-duration treatment.4 The electronic supply management of COVID-19 polymerase chain
medical record services with integrated blockchain reaction testing kits.12 This can help track supplies of these
technology make the process of data storing and securing kits, recognize faulty or fake kits, monitor the condition of
incredibly easier by storing the results of laboratory test testing kits while shipping, and allow government officials
reports, post-treatment reports, etc. to analyze the supply and demand of testing kits in specific
The Commonwealth Health Alliance took the initiative locations. The paper will discuss the algorithms used for
to secure the patients’ electronic health records (EHRs) blockchain security and technology in health-care sector
efficiently. Medical and health-care services are becoming in the aspect of protecting medical records.13 The main
increasingly important in the present environment, contributions of this paper are illustrated as follows:
and they must be supplied on time, securely, and safely.5 (i) Comprehensive overview: To provide a summary of
Disease identification has become a crucial responsibility blockchain technology and discuss its various uses
for medical practitioners. Many viral and cardiovascular and implications for the health-care industry.
disorders, including COVID-19 and diabetes, should be (ii) Security concerns in health care: To outline how
diagnosed in the early phase for optimal treatment. Given blockchain technology resolves important security
its rapid dissemination, detecting coronavirus has become a issues in the medical field and promote it as a
critical endeavor. However, deep learning holds significant dependable means of protecting clinical data.
value for detecting diseases by analyzing large volumes of (iii) Blockchain security algorithms: To provide a useful
image data, with blockchain allowing for decentralized and insight into the technical aspects of using blockchain
secure data access.6 technology to secure medical records by discussing
Researchers are continuously struggling to improve the algorithms used for blockchain security.
disease detection models. To achieve this, hospitals, testing The rest of this paper is organized as follows: Section 2
laboratories, research centers, and other organizations summarizes related works and motivations, and section 3
can share their data and work together to improve the introduces the background of blockchain technology. The
learning model. As the security of personal information blockchain based on consensus algorithms in health-care
held in hospital databases is of paramount importance sector is reviewed in section 4. Section 5 encapsulates
concern, every party needs to commit to protecting data a blockchain-based EHR system for Healthcare 4.0
privacy.7 However, accurate and efficient learning models Applications. The taxonomy of blockchain technology
are still required for various applications. Due to ethical in health care is discussed in section 6. In section 7, the
and regulatory concerns about medical data privacy, data strength of blockchain technology in the health-care sector
sharing among organizations are limited. is reviewed. Section 8 discusses blockchain technology
Many applications have been deployed in the battle and applications in health care. The research gap and
against the COVID-19 pandemic. For example, companies technical limitations of blockchain in health care, and the

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Artificial Intelligence in Health Blockchain for health-care security

relevant future directions, are given in sections 9 and 10, distributed, immutable, open-source, public digital ledger
respectively. The paper is concluded in section 11. distributed among network peers. It is a ledger made up
of a chain of blocks. This ledger keeps a permanent record
2. Related works and motivations of all transactions and interactions among participants
Multiple studies on blockchain utilization in health-care on the distributed and decentralized blockchain network.
sector have been conducted. One of the papers14 narrates In addition, blockchain can be highly cost-effective in
the history of blockchain development, with a focus on removing the requirement for a centralized authority to
the technology of intelligent health-care management for control and verify interactions and transactions between
assisting patients. Krishnamurthi and Shree15 discussed multiple users.24 Every transaction in the blockchain is
several blockchain census algorithms and comparatively cryptographically signed and validated by all mining
analyzed the algorithms. Another published study16 nodes, which keep a copy of the whole ledger made up
presented a model to solve a confidentiality issue inherent of chained blocks of all transactions.25 This provides
in wearable medical devices used to monitor and care for unchangeable, secure, synchronized, and shareable time-
patients, circumventing privacy intrusion and security stamped documents.
concerns stemming from the transfer and recording of
3.1. Types of blockchain
medical data. A new framework has been proposed for
modified blockchain models for internet of things devices The three basic blockchain types are public permissionless,
and other privacy and security features. consortium public permission, and private blockchains.26
They differ in terms of who has access to, writes to, and
Yazdinejad et al.17 proposed a new decentralized
reads the data on the blockchain. Anyone can see the data
authentication of patients in a distributed hospital
in a public chain, and anyone can join and contribute to
network, by leveraging the blockchain. This proposed
both consensus and make changes to the core software
model protects health-care networks for patients and
in principle. The public blockchain is commonly
allied health professionals. After the analysis, the results
utilized in cryptocurrencies, and the two most popular
of the simulations showed that they demonstrated a
cryptocurrencies, Bitcoin and Ethereum as the main
high performance in ensuring confidentiality of the
chain, are public permissionless blockchains. Only a few
proposed structure among a distributed affiliated hospital
specified groups of companies can monitor and participate
network. Another study18 expounded the different types
in the consensus procedure on a consortium blockchain,
of blockchain, such as public, private, and consortium
which can be considered semi-centralized.27 The private
blockchain, with elaborations on the uses of different
blockchain network is distributed yet often centralized.
algorithms in the health-care sector and the security
Only specific nodes can join the network, and a central
purposes. Sharma et al.21 proposed a framework for
authority frequently manages them.
community interaction and developed a smartphone
application to encrypt messages between researchers and 3.2. How blockchain empowers secure data sharing
research groups. in health-care system
A survey conducted by Nguyen et al.20 illustrated the The technologies blockchain with deep learning can
contribution of blockchain and artificial intelligence (AI) improve health-care systems.28 Utilization of blockchain
in the health-care sector to combating COVID-19. Table 1 technology in health-care domains helps secure data
summarizes the most important features and contributions sharing and train deep learning models for diagnosing and
of the previous studies. These studies highlight the huge predicting diseases. Other problems include data privacy
dependence of the next-generation health-care networks concerns and compromised security in data flow between
and applications on the use of the blockchain for security businesses. Therefore, the information was shared across
and user privacy.22 Accordingly, this paper aims to the organization based on external and internal policies.29
comprehensively discuss the theoretical concept about the In addition, some fascinating research focuses on safe
most critical blockchain issues related to the health-care health-care data brain stimulation and biomedical and
sector, in addition to the impact of blockchain approaches e-health data exchange for the central database built on
and consensus algorithms in health-care application. the private blockchain by authorized users. In addition,
to minimize risk, the remote patient monitoring system
3. Blockchain technology uses the Ethereum protocol.30 Likewise, other authors
Blockchain is one of the most hyped disruptive innovations recommended using encryption to store data from
in recent years. It has garnered growing attention as a publicly accessible organizations. Several writers created
horizontal technology used in various sectors.23 It is a a blockchain-based framework for sharing data on cloud

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Artificial Intelligence in Health Blockchain for health-care security

Table 1. Summary of related works on blockchain for securing medical data

Study Blockchain Blockchain Algorithms Taxonomy Remarks

in COVID‑19 strength in health
pandemic care
Mettler (2016)14 No No No No Describing the history of blockchain development from bitcoin
and intelligent health‑care management for patient guidance.
Krishnamurthi and No No Yes No Presenting a comparative analysis of the algorithm, a brief
Shree (2019)15 overview of blockchain and challenges using algorithms.
Dwivedi et al. (2019)16 No Yes Yes No Demonstrating a blockchain‑based IoT model for the security
and privacy of any IoT‑based remote monitoring system to
protect business security.
Yazdinejad et al. (2020)17 No No Yes No Presenting a designed model for the safe data recording
in a geographically diverse hospital network based on a
blockchain‑based approach.
Sharma et al. (2021)18 No No Yes No Proposing a cryptographic framework to create a
blockchain‑based secure community.
Saranya and Murugan No No Yes No Explaining the blockchain types and uses of different algorithms
et al. (2021)19 in the health‑care sector.
Nguyen et al. (2021)20 Yes No Yes No Combining blockchain and artificial intelligence for emergency
health‑care services used in the COVID‑19 pandemic.
Abbreviation: IOT: Internet of things.

storage without the need for a third party.31 Recent research The POW algorithm is used in the health-care
has focused on real-time health-care systems’ diagnosis transaction. The work has traversed different consensus
and treatment of patient conditions. approaches in blockchain technology and is principally
recommended for health care.34 The sensors connect with
4. Blockchain based on consensus intelligent devices and distribute the data for all possible
algorithms in health-care sector events. Since automatic intelligent contracts are executed,
Several lists of algorithms are used in blockchain the data are reliable. For instance, a sensor is connected to
networks such as proof of work (POW), proof of stake the human body so that the master device gathers data from
(POS), practical byzantine fault tolerance (PBFT), the sensor to telecast it to the blockchain. Once medical
recovery algorithm for fast tracking (RAFT), and data are stored on the blockchain, the POW technology
delegated POS (DPOS). These algorithms are discussed guarantees that it is safe and unalterable. Since the POW is
in the following. known to be decentralized. The network is more resistant
to attacks because of its decentralization which offers fail-
4.1. POW safe mechanism to protect itself against a single point of
POW technique required mining nodes for solving failure.29,35 This can improve the system’s overall security
complex mathematical puzzles. After solving puzzles and and dependability in the health-care industry by guarding
node validation, the block is added to the blockchain against unauthorized access and guaranteeing the ongoing
network. The rest of the mining nodes approve the availability of vital patient data.
authenticity of the blocks.32 When the miners confirm
4.2. POS
that the block is authorized, the block is attached to the
blockchain by recompensing submitter mining nodes. With POS consensus mechanisms, miners are selected based
There is lesser chance to get a false reward unless the on the quantity of cryptocurrency they own and are prepared
attackers accommodate more than 50% of the mining to stake as collateral, thereby replacing the conventional
nodes. The consensus processes-based POW provides data POW mining method’s intricate computational puzzle
integrity, immutability, and reliability on the blockchain, approach. In health-care applications, the medical chain is
improving the security of health-care applications.33 a systematic scheme of data sharing that can be executed
Consensus techniques ensure that all participants have for health-care systems using blockchain technology.34
an accurate representation of the data by assisting in The incidence of attack against POS-based blockchain is
reaching an agreement on the current state of distributed lesser than that against POW-based blockchain. In POS,
database. it is very difficult for an attacker to obtain the majority of

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Artificial Intelligence in Health Blockchain for health-care security

the blockchain supply. This protects patient data integrity 4.4. PBFT
and increases the resilience of PoS-based health-care
PBFT can solve the byzantine problem, as presented
blockchains against threats. For health-care applications in a published paper.30 A byzantine fault is a defective
based on blockchain, switching from complicated algorithm. Byzantine fault tolerance can ensure the safety
computational problems to POS results in lower energy and efficiency of the system so that hardly [(n-1)/3 duplicate
consumption and enables randomized validator selection, data are defective over the system in a lifetime. In medical
node participation incentives, performance-based rewards, science, PBFT algorithms create an efficient impact
and continuous work to resolve distribution issues.36 because several nodes are being shared and maintained by
The security, effectiveness, and dependability of health- several nodes.36,40 The fact that they hinder medical data
care blockchain applications are all improved by these from being disclosed or accessed by attackers significantly
contributions taken together. enhances the trustworthiness of PBFT.
Moreover, using the POS consensus mechanism in
4.5. RAFT
the context of an EHR system indicates that health-care
applications built on blockchain technology are more secure RAFT has five server nodes with three states, namely
and efficient in terms of making smart decisions. Real-time leader, follower, and candidate. Modified RAFT nodes
modifications to patient records can be made easier with work in a category accepting the same transitions. For
POS, which has advantages including faster transactions and instance, if a person is selected from a category assigned
less energy usage. In addition, the tasks of verifying patient as a leader, he must accept clients’ requests.37,41 The
records are carried out by trusted health care providers who leader must replicate the log to other servers and the
use health care networks to ensure reliability and efficiency.37 data flow from the leader to the server. The leader’s task
POS is a good option for applications where timely access is divided into three subtasks: leader election, leader
to patient data is crucial and environmental concerns are log replication, and safety. A new leader is elected when
present since it combines the benefits of decentralization the assigned leader fails to monitor the works. In log
with a fast and streamlined consensus process, which replication, the leader can guide and command the
enhances the system’s overall security. followers to execute changes made by the leader.34,41
Finally, RAFT uses different commands for the same log
4.3. DPOS index when the server changes the state of machine for
safety concerns. Figure 1 shows the process of cluster
DPOS is a decentralized model with high efficiency but
algorithm of RAFT.
low consumption. There is an option to vote for creating a
panel with restricted trusted parties known as witnesses.33,38 By comparing these five consensus algorithms, as
Some users act in the reputation system. It can create blocks shown in Figure 2, the POW algorithm stands outs as
and add them to the blockchain. The DPOS census is cost- the most efficient for the health-care sector because it
efficient and time-saving. Since few nodes are eligible has a robust security system, which is the primary goal of
for DPOS to be centralized, the central node can easily initiating blockchain algorithms in health-care sectors. The
monitor the election process. DPOS cannot maintain all summary of compared algorithms is shown in Table 2.
the nodes effectively, undercutting the trustworthiness in A previous study29 provides a framework for
security. Nowadays, the health-care domain is undergoing implementing the algorithms discussed previously, where
advancements through the incorporation of blockchain.34,39 a number of computers with the same specifications were
The implementation of the DPOS algorithm ensures the used to act as nodes for the blockchain.38 By considering
privacy of EHRs through secure transactions. With this the typical framework with a computers of core I7, with
technology, the patients maintain control of their EHRs. the specifications of 16 GB memory size, and Window 10
The patients may share their medical records with different operating system, the experimented POW, POS, DPOS, and
institutions. PBFT algorithms with data size of 100 M/times can deliver
Blockchain technology can ensure the privacy and performance depicted in Figure 3. An extended period of
security of shared data. Once a doctor updates the EHR, it time is required to implement the proposed model in the
is encrypted by the SHA256 hashing algorithm, and then, system, as per empirical experiences, to compensate for the
it is stored in a different block.35,40 The doctor receives a random delay between nodes.
unique key from the patients through mail for accessing the The analysis also showed that the POW algorithm
medical data. The DPOS algorithm secures the patient data takes longer time compared to DPOS and POS algorithms.
with a trustworthy guarantee and lowers the computational Furthermore, the PBFT consensus algorithm requires
time and minimizes the entire cost of processing EHRs. shorter time compared to other algorithms. The performance

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Artificial Intelligence in Health Blockchain for health-care security

of the PBFT algorithm is significantly different because the

blockchain nodes are shared and maintained by multiple
nodes, complicating the process of detecting medical data
and protecting them from potential attackers.29
In general, the performance of these algorithms directly
affects the utilization of medical data systems based on
blockchain frameworks. However, depending on the
kind of health-care application, the time delay during
these algorithms processing will negatively impact the
Figure 1. Recovery algorithm for fast tracking algorithm cluster diagram. performance and utilization the blockchain-based health-
Source: Schematic created by the authors. care systems.

Figure 2. Performance analysis of consensus algorithms. Source: Schematic created by the authors.

Table 2. Comparative analysis of blockchain algorithm properties

Issues Algorithms
POW POS DPOS PBFT RAFT
Developer Markus Jakobsson Developer Markus
Jakobsson
Energy efficiency Not enough Limited Limited Yes Efficient
Languages C++, LLL Michaleson Improvised Java Haskell programming language
Advantages Secure network, extensive and Advantages Secure network, extensive Advantages Secure network, extensive and
decentralized control over the and decentralized control decentralized control over the network
network over the network
Limitations High consumption of electricity, not Limitations High consumption of electricity, not
concordant with small networks concordant with small networks
Abbreviations: POW: Proof of work; POS: Proof of stake; PBFT: Practical byzantine fault tolerance; RAFT: Recovery algorithm for fast tracking; DPOS:
Delegated proof of stake.

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Artificial Intelligence in Health Blockchain for health-care security

5. Blockchain-based EHR system for A study reported that EHRs of medical data consist of
healthcare 4.0 applications sensitive information and patients are permitted to share
this information with health-care centers, doctors, and
EHRs are medical records that can be managed and secured consultants.15,41 EHRs are favorable for patients because
by a blockchain system supported by genetic algorithm and
they simplify the storage of laboratory reports and medicine
discrete wavelet transform.32,41 The scope of a blockchain
lists and ease the appointments with attending doctors and
platform for industrial health care gives a new vision and
the clinical consultations, especially for patients requiring
future opportunities for Healthcare 4.0 Applications. The
state-of-the-art focusing on the uses of blockchain with treatment for diseases with an extended data history, such
EHR in the health-care sector is summarized in Table 3. as cardiovascular disease, cancer, HIV, etc.38,42 For patients
who often visit different medical institutions, organizing
and securing their medical history reports in the EHRs
with the help of blockchain technology proves to be
convenient for them. Through the data sharing features,
medical research institute may collaborate with different
health-care organizations under a regulated and secure
data sharing environment.
Blockchain is known as a cryptographic protocol
for conserving shared information records through a
collection of computer networks where complete trust is
not mandatory among the nodes. The implementation of
Figure 3. Consensus algorithm performance in blockchain framework. blockchain in the health-care sector ensures data security
Source: Diagram created by the authors. for both patients and providers.21,43 As a decentralized

Table 3. State of the art of blockchain use in health‑care domain

References Category Components Merits

Tanwar et al. Electronic health • Advantageous blockchain for health‑care • A description of EHR work is presented
(2020)48 records scenario • Transaction process in blockchain is explained
• Securing and storing health‑care clinical • Blockchain in the health‑care ecosystem is overviewed
data
• Data authentication for decentralized
network
Farouk et al. Electronic health • A brief description on the blockchain with • Secure data sharing through excellent regulation
(2020)24 records EHR to share patients’ information with the
health‑care centers and doctors
Hussein et al. Security and • A brief description of blockchain • Proposed method on managing and securing clinical data
(2018)27 management of networking system • Restriction on the access to the data using discrete wavelet
clinical records • Discrete wavelet transform for creating transform algorithm
distinctive hash decrypted key • Enhancing data reliability using genetic algorithm
• Genetic algorithm for enhancing data
reliability
Wang et al. The SecNet • Al‑based algorithms to protect computing • Two aspects of SecNet are evaluated
(2019) 46 platforms • Vulnerability of architecture and revenue for contributors is
• Smart contract algorithm i considered
• Implementation of SecNet in medical data • An alternative storage model of the SecNet is proposed
sharing
Alqaralleh Health‑care • An effective model for secure • A data‑gathering method is carried out to collect patient
et al. (2021)4 diagnosis model blockchain‑enabled intelligent IoT information using IoT devices
• New health‑care diagnosis model • The GO‑FFO (grasshopper with the fruit fly optimization)
algorithm with elliptic curve cryptography is utilized for
confidential image transmission for starters
• NIS‑BWT (neighborhood indexing sequence with burrow wheeler
transform) approach is used to encrypt hash value
• Deep belief network model is applied for diagnosing disease
Abbreviation: IOT: Internet of things.

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Artificial Intelligence in Health Blockchain for health-care security

system, the involvement of third parties is not allowed SecNet is an architecture proposed by Wang et al.,46
in blockchain. Thus, health-care service maintained by combining actual big data with AI to enhance the
blockchain technology can only permit sharing of data robustness of cyber security. A large-scale Internet setting
contained within the blockchain architecture. The patients offers safe data storage, computation, and sharing. It
who use blockchain technology are facilitated with cost- primarily consists of three components. Blockchain-based
efficient data distribution.39,44 Moreover, the patients are data sharing with ownership guarantees allows trusted
privileged with an extensive network for secure health- data exchange to create massive data in a large-scale
care systems, medical data exchange through blockchain, context. In addition, AI-based safe computing systems
health-care data protection, EHR facilities with attribute- come with more intelligent security rules, which aid in the
based cryptosystem, and facilities for monitoring clinical creation of more trustworthy cyberspace. Moreover, they
emergencies. There are four stages of securing clinical data purchase security services through trust value exchange,
in the health-care industry: a method for participants to receive financial rewards for
(i) First step: At first, various health-care data, including sharing their data or service, promoting data sharing, and
patient’s personal information and ID, are sent improving AI performance.47 Furthermore, the authors
to the blockchain network through application describe a scenario of using conventional SecNet and its
programming interface (API). The current health IT potentially alternative deployment method and evaluate its
system tracks and stores all the data.43 network security and economic revenue.
(ii) Second step: Blockchain technology has an internal
transaction process through a smart contract. Entire Alqaralleh et al.4 developed a deep learning model for
transactions attached in the blockchain contain safe image transmission and diagnosis on the Internet
only patients’ public ID rather than their personal of Medical Things environment. Data gathering, secure
information. transactions, hash value encryption, and data classification
(iii) Third step: A permanent ledger is connected with the are among the procedures included in the model.49 The
block. Thus, all sections become distinctly identifiable. elliptic curve cryptography (ECC) is used primarily, and
The API processes queries from the health provider the hybridization of the grasshopper with the fruit fly
in a reverse manner. The database of blocks stores optimization technique is used to generate the best ECC
anonymous patient data, e.g., gender, age, and illness. keys. The hash values are encrypted using the neighborhood
(iv) Fourth step: The patient will have a private key. The indexing sequence (NIS) with burrow wheeler transform
health-care provider can only access the patient’s (BWT) (NIS-BWT). Finally, a deep belief network is used
information after the patient shares the private key. in the categorization process to diagnose the presence of
The data stand is restricted to people who do not have disease. To identify the analysis of the optimal results of
a private key. the proposed model, substantial experimental validation
Hussein et al.27 proposed an extensive and prosperous is performed, and the results are examined from many
system for handling the clinical record and information perspectives.
using blockchain technology. The method implements
a different cryptographic technique for strong security
6. Taxonomy of blockchain technology in
management of sensitive clinical data and adaptability of health care
the patients to simplified data access.44 Discrete wavelet Blockchain technology utilizes network technology with
transform using hash function generation process was tamper-resistant data. In blockchain technology, current
employed to boost the strength and restrict the access of transactions cannot be changed. Instead, the transactions
data users. Moreover, genetic algorithms lower the time of can be updated using hash values. The taxonomy of
transaction nodes to enhance data reliability and designate blockchain technologies in health care is illustrated in
the data requests. Figure 4. Different features make blockchain technology
There are separate blocks in the blockchain network distinctive from others:
that is shaped by establishing chain events from the (i) Distributed ledger: In a distributed system, transactions
current block to the original block. After obtaining event are added to retrieve the system by removing failure
details, the block broadcasts into a network.45 Once the points.
chain forms, the block is locked and cannot be reformed, (ii) Census mechanism: If every verified user of the network
updated, and deleted. Any exploitation of data handling grants a permission transaction, the transaction can
policies by users in the group will prompt data tracking be updated.
by data forensics team so as to secure and manage clinical (iii) Provenance: The entire data history is obtainable on
records. the blockchain network.

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Artificial Intelligence in Health Blockchain for health-care security

Figure 4. Taxonomy of blockchain. Source: Schematic made by the authors.

(iv) Immutability: Since all data are secure and trustworthy, (iv) Distributed peer-to-peer network: The data are
not even a single record cannot be changed or updated and distributed through the network and
redesigned. distributed to different users.
(v) Finality: After completing the transaction, no one can (v) Mining: Miner helps attain the hash values in the
change any data. network. The hash values can be easily computed for
(vi) Smart contract: The codes are automatically executed acquiring the award.
within a specific time limit. The codes generated in
the blockchain network and nodes are activated after 6.2. Blockchain and machine learning achievements
executions. Consequently, blockchain hinders third Blockchain has become a hot research topic since its
parties from accessing the transaction, thus promising inception. The concept of blockchain was first exemplified
data security.17 in digital currency, for example, Bitcoin in 2008. It has
brought tremendous changes in health-care sector owing
6.1. Blockchain techniques and services to its data obscurity, stability, and propagation features.
Blockchain incorporates various techniques and services
such as Census Protocol, Hash Cryptography, Rigid 6.2.1. Safe management of electronic medical records
Ledger, Distributed Peer-to-Peer Networking, and Mining, The accessibility and management of medical data in
which are briefly explained in the following:45,49 electronic medical records are not completely protected
(i) Census Protocol: There is a substantial restriction in from any risks. The security and confidentiality of patients’
allowing transactions. Through the Census Protocol, confidential information, such as disease reports, medical
only specific users have access to the network assigned history, and personal information, are not guaranteed. The
to grant permissions for transactions. solution to this hurdle is combining the interplanetary file
(ii) Hash Cryptography: The NSA has developed the system framework for electronic medical records in the
SHA256 hash with 64 characters to add transactions health-care industry.40,50 Inter Planetary file system (IPFS)
used by blockchain. Hash algorithms have several uses, allocates a peer-to-peer storage structure for reserving and
such as one-way cryptography, quick computation, accessing the encrypted huge volume of electronic medical
avalanche effect, and inevitable combat impact. records while needed. If any file needs to be deleted from
(iii) Rigid Ledger: It is not possible to delete or modify version-control history, IPFS accumulates files with content
because the blockchain network is stored and address hash from a distributed hash table. IPFS uploads
recorded. the hash value of the data as an alternative to keeping all

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Artificial Intelligence in Health Blockchain for health-care security

medical data. IPFS makes a distinctive content address for 7. Strength of blockchain technology in
storing and retrieving the data.3,50 health-care sector
6.2.2. Blockchain achievements during COVID-19 The intrinsic properties of blockchain technology are
pandemic highly compatible with applications in the health-care
Blockchain ensures that all databases are synchronized, sector. The strength of blockchain technology contributes
secure, and verified. Nowadays, researchers and health- to various applications in the health-care sector, as shown
care professionals leverage blockchain technology to in Figure 5. There are clear parallels between blockchain
curb the spread of COVID-19 pandemic and create alerts technology and the essential requirements of the current
about future pandemics. There are several blockchain- health-care infrastructure.41,52 Table 5 encapsulates some
based practices applied in realm of health care during the characteristics of blockchain technologies that can facilitate
COVID-19 pandemic, including tracking of infectious resolution of certain hurdles facing the current health IT
disease outbreaks. By virtue of its ability in safeguarding environment.
data security, blockchain can also efficiently keep track of
the public health data regarding infectious disease such 8. Blockchain technology and applications
as COVID-19.41 Blockchain also assists with the accurate in health-care sector
delivery of responses and helps with treatment decision- In 2016, the National Coordinator for Health Information
making soon after the early detection of symptoms so Technology Office requested proposals on blockchain
as to curb the spread of pandemic. Moreover, it guides applications in health-care sector, with a focus on data
health administration to keep track of the viral activity and validation, auditing, and authorization. Such a move is driven
suspected COVID-19 cases.51 by the potential obstacles laid ahead of the incorporation
6.2.3. Donation tracking of blockchain technology in health-care domain, such as
privacy concerns, compliance with regulatory requirements,
Blockchain technology can be applied to track donations. and technical issues with data storage and distribution, even
It notifies the donors of any exigencies requiring an urgent though this technology enables storage of complete health-
inflow of funds and, most importantly, the receipt of their care records of an individual as a blockchain use case.42,52
monetary contributions.
Blockchain technology offers numerous opportunities
6.3. Management of medical supply chains in health-care sector for the secure sharing and storage
of patients’ data and medical records, and coupled with
With the help of blockchain technology, medical supply consensus methods, provides effective schemes in solving
chains in different industries can be properly managed, security issues in the health-care industry in recent real-
through a series of procedures involving records
world applications. Leveraging medical chain is one
collection, demands tracking, and product supply during
prominent example of using blockchain technology to
the pandemic. It also keeps track of the usage of tools and
protect EHRs and give people control over their personal
instruments by doctors and patients in a bid to prevent
health information. The emphasis on decentralization is
the inadvertent use of contaminated items.42,51 Proper
consistent with maintaining the confidentiality and integrity
guidelines governed by several AI sectors pertaining to data
of patient records, even though the precise consensus
security have been introduced to fight against COVID-19
procedure is not usually mentioned.44,52
and any other pandemics in future. These categories are
given in Table 4, which describes the AI technologies used Several security companies like Hashed Health in the
in medical supply chain management. USA are committed to using blockchain technology to

Table 4. Management of medical supply chain with the aid of AI technology

Issues Sector 1 Sector 2 Sector 3 Sector 4

Description Application of AI with AI tools Crowd source project Description Application of AI with AI tools
AI contribution Develop systems for drugs and Ensure data security (pandemic AI contribution Develop systems for drugs and vaccines
vaccines against COVID‑19; situations) against COVID‑19; enhance diagnosis
enhance diagnosis and improve and improve public health
public health
Implementation Quick diagnosis of COVID‑19 Cognitive impact of COVID‑19 IEEE declaration for Implementation examples
examples using medical images (Mexico, (USA); COVID‑19 symptom ethical implementation
Singapore) study (UK) of AI system

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Artificial Intelligence in Health Blockchain for health-care security

Table 5. List of the characteristics of blockchain technology and their descriptions

Characteristics Description
Decentralization • Blockchain technology is a serialized data structure used to establish a decentralized ledger.
• Decentralization allows parties to transact data in the health‑care sector without involving a third party, reducing financial bias and fraud.
Trustlessness Payments are made only when the balance is available on the blockchain, a feature that is essential to secure financial balances.
User‑centricity • The user‑centricity attribute of blockchain technology ensures patients in control of their personal financial data.
• Blockchain allows the patient to become the key mediator in distributing his or her medical data.
• Patient or family member must expressly grant the provider access to the patient’s medical record governed by the patient’s private
key signature for every new medical interaction.
• Every access to patient’s data is recorded in the immutable transaction history of the blockchain, providing a clear record of who has
accessed and edited the patient’s record.
Transparency • Every transaction data in the blockchain is publicly viewable.
Immutability • Blockchain is impervious to data manipulation.
• The immutability of the blockchain ledger means that transactions cannot be changed or removed once they have been recorded.
• Blockchains serve as a data timekeeping system, allowing easy data history reporting.
Speed • Blockchain technology helps enhance the efficiency of verification for health‑care sector transactions between financial institutions.
Cost • Blockchain technology obviates the need to pay transaction fees by removing intermediaries from the health‑care transaction.

applications.18,44 There are other applications that have used

blockchain technology in the field of health care, which are
explained in the following subsections.

8.1. Blockchain for health-care management

Blockchain technology carves out a revolutionary niche
in the health management sector due to the advances and
benefits it brings to cloud storage of EHR data, privacy
protection, etc., as shown in Figure 6. With blockchain,
we can improve data sharing, management, and storage.
Data can then be easily shared with health-care providers.
The steps of how blockchain could be used in health-care
domain summarized by Khezr et al.32 are given in the
following:
(i) Step 1: While interacting with the doctors, the recent
information about the patient are integrated into the
medical records, serving as the primary data.
(ii) Step 2: EHR of the patient is shaped using the primary
Figure 5. Summary of how blockchain technology is applied in health- data collected.
care sector. Source: Schematic made by the authors. (iii) Step 3: The control over and access to the contents
embodied in EHR is granted to the EHR’s owner only.
expedite health-care transactions and minimize fraud, Permission of the EHR’s owner must be obtained for
while enhancing operational security and efficiency. others to access EHR data.
Keyless Signature Infrastructure (KSI) is utilized by other (iv) Steps 4, 5, and 6: These three steps form the central
applications, including the ones developed by the Estonian part of database and cloud storage (for storing patient
E-Health Foundation, to assure the immutability of health records) as well as data security conferred by the
records, prevent unauthorized adjustments, and improve blockchain technology.
overall security.18,36 In addition, a different health-care (v) Step 7: This is where health-care providers and other
facility uses blockchain technology to improve the security, parties like the hospitals and care centers, collectively
traceability, and transparency of medical payments in an known as the end-users, who request access to patients’
effort to lower fraud and errors in the system. According data. Records of patients’ health data will be available
to these real-life examples, it is clear that blockchain wherever they are as they are stored and validated in
technology can significantly add value to health-care the blockchain’s distributed ledgers.

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Artificial Intelligence in Health Blockchain for health-care security

Figure 6. Health-care management using blockchain. Source: Schematic made by the authors.

8.2. Blockchain platforms used in health-care 8.2.3. Med-rec

domain
Med-Rec, built from a collaborative project between MIT
Gem Health Network, Guard-time, Med-Rec, and Health- Media Lab and Beth Israel Deaconess Medical Center, is a
bank are some of the blockchain platforms developed for blockchain-based platform deals particularly with EHRs.46
use in health-care domain. These platforms enable secure The non-seamless design of EHRs in managing multi-
sharing of medical information with different health-care institutional and lifelong records is the prime reason for
providers. data loss as patients’ data may become scattered as they
move from one organization to another.13 Med-Rec can
8.2.1. Gem health network
provide its users with all of their records, which are credible,
Gem Health Network is a blockchain platform developed easily accessible, and most importantly, immutable. It also
based on the Ethereum Blockchain Framework that can allows management permissions, authorization, and data
allow the sharing of medical data supplied by health- sharing among health-care providers and systems using a
care specialists. Gem Health Network merges businesses, decentralized approach.
specialists, and patients to enhance patient-centered
care. This network allows medical stakeholders to have Blockchain in the Med-Rec platform grants patients the
transparent access to any latest information.44 On this power to authorize individuals who can access their health
platform, outdated information can be removed, thereby records. This project is tested as a proof of concept with
reducing the risk of medical negligence starting from the medication data. Med-Rec was further enhanced in terms
early stage of treatment. Medical experts can also track all of data types as well as number of data contributors and
the interactions between patients and their doctors. users.47

8.2.2. Guard-time 8.2.4. Health-bank

Guard-time, a blockchain-powered data security platform Blockchain can also be applied in the area of patient-
based in the Netherlands, is used in Estonia to operate generated data. Built by a Switzerland-based digital
public health infrastructure, especially in patient identity health startup, Health-bank stands as a great example
validation. Estonian citizens are given smartcard that link of this application. Users can store and manage their
their EHR data with their corresponding blockchain- personal health-care information secured on the
based profiles. Citizens of Estonia, health-care providers, Health-bank platform. All the users have full control
and insurance companies can acquire information about over their own data.49 User data in Health-bank are
medical treatments done in Estonia through Guard-time. also made available for medical research. In addition,
Updates made to the EHR are assigned with a hash and users will be financially compensated for share their
registered in the blockchain network. Thus, patients’ data. Blockchain implemented in health-bank allows for
records are immutable and are protected from malicious tracking personal patient-generated health data, which
modifications.45 Along with that, health-care database researchers can use, by means of timestamp. Users
information, such as time and date of appointments, are who have contributed to medical research can also be
also signed cryptographically in a block. identified using blockchain.

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Artificial Intelligence in Health Blockchain for health-care security

8.3. Benefits of using blockchain technology in enhancing the reliability of COVID-19 analytics, reducing
fighting COVID-19 pandemic the incidence of fatal consequences such as COVID-19
misdiagnosis attributed to incorrect data.43
Blockchain technology offers distributed, encrypted, and
secure digital transaction loggings. Blockchain technology 8.5. Blockchain for ensuring patient data privacy
can be employed to track the spread of coronavirus
infections by tracking citizens on a global scale while Consensus procedures combined with blockchain
maintaining patients’ personal information, tracking technology offer a strong framework for protecting
drug trials, and tracking and maintaining records of patient data privacy in health-care domain,
fundraising activities and donations.44,48 There were cases resolving a number of issues commonly seen with
of blockchain technology used to curb the COVID-19 conventional centralized methods. Ensuring the stability
pandemic. Specifically, the distributed blockchain ledger of patient data records by making them tamper-resistant
technology was utilized in logging and data visualization and immutable is one of the most crucial steps in applying
of the coronavirus outbreaks with data derived from the blockchain technology. This capability of blockchain
Centers for Disease Control and Prevention (CDC) and permits the generation of an accurate and visible record
the World Health Organziation.50 of activity that documents all data transactions in the
past53 Thus, by improving data integrity and security,
Public health blockchain consortium is another any unauthorized attempts to access or alter patient
blockchain-based platform that could pinpoint information can be promptly identified. Consensus
communities and workplaces that have yet to be affected techniques, which are addressed in section 4, are
by coronavirus outbreaks and other pathogens before essential for verifying the authenticity of data supplied
corresponding protective measures are imposed on them to the blockchain and for confirming transactions. These
in a bid to prevent further spread of infectious diseases. measures reduce the possibility of fraudulent activity and
This technology can also verify and track uninfected
unauthorized changes to patient records by demanding
individuals and restrict their movements if they have
network consensus. The network’s trust is built through
visited areas affected by outbreaks.45,51 Another example is
the consensus process, which improves the overall patient
Hyper-chain, a blockchain-based platform used in China,
data security.
which facilitates donation tracking and flags the needs of
COVID-19 patients to the health-care organizations and Blockchain networks leverage strong cryptographic
the government. algorithms to secure patient data in terms of data encryption.
An extra layer of security is added by encryption, which
8.4. Blockchain in combating COVID-19 pandemic guarantees that even in the event of illegal access, the
Blockchain is an essential tool in the fight against COVID- data cannot be read without the right decryption keys.
19. The indispensability of the blockchain technology The privacy and confidentiality of patients are greatly
can be accounted for by its ability in tracking and tracing improved by this function. By automating permissions and
personal protective equipment (PPE).52 During the access controls, smart contracts self-executing algorithms
pandemic, most countries were facing a shortage of PPEs, with pre-established rules help protect patient privacy.54
which are essential to prevent and control the COVID-19 Patients may decide the usage and accessibility of their
infection, due to the lack of reliable and correct data about data through these contracts, which can be configured to
their demand and supply. A lack of transparency in the manage and enforce detailed authorization procedures.
logistic supply chain management was also contributing Data handling in compliance with patient preferences
to the prevalence of low-quality PPEs on the market. The and legal requirements is guaranteed by this automated
utilization of blockchain technology can help facilitate the method, which also lowers the possibility of human error.
supply chain operations, secure PPE certificates, prevent Consensus mechanisms and blockchain technology
compliance violations, and identify faulty PPEs,18 creating together offer consistency, decentralization, robust
an healthy atmosphere in which committers of compliance encryption, access controls based on smart contracts,
violations will be penalized, and reliable and trustworthy transparency, and improved consent management, all
manufacturers will be recognized for their high-quality of which contribute to protecting patient data privacy
products. in the health-care industry.55 By addressing the ever-
Transactions or COVID-19 data can be recorded and evolving issues of data security and privacy in the health-
made available to health-care organizations. These records care industry, this all-encompassing strategy builds
of transactions will be rendered immutable, preventing a foundation of confidence and dependability in the
alterations by any entities. Blockchain can also help with handling of sensitive patient data.

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9. Research gap and technical limitations of triggering system failure that could greatly affect
blockchain in health-care sector access to EHR information.
(iii) How to design massive, blockchain-based globalized
Blockchain technology has a positive impact on the health- storage systems for large volumes of confidential
care sector by facilitating the businesses of the health-care health records without compromising the efficiency of
organizations. Moreover, this technology has a unique the blockchain network.
edge in securing and upgrading patient’s data, in a cost- (iv) When and how to integrate an approved and specialized
effective fashion. One of the census mechanisms, the standards formulated by global standardization
POW, required plenty of energy to operate.56 Due to the institutions into blockchain-based health-care systems
restriction in accessing sensitive information from the and into the mechanism responsible for data exchange
stored data, the public ledger system can be disrupted.45 in blockchain services.
Despite its significant role in securing medical data,
blockchain is fraught with limitations and challenges in Most recent studies present the concept of the use
technology, integration, cost, regulation, culture, energy of blockchain in health-care domain, underscoring the
consumption, and data privacy. important role of blockchain in transforming the health-
care sector. However, one of the most important research
9.1. Limitations problems surrounding the application of blockchain in
A flood of software are currently employed in the health- health-care systems is the interoperability between different
care sector, but the functionalities of some of them have health systems following the adoption and integration of
not fully matured and equivalent but enhanced software is blockchain to improve security of data sharing, especially
constantly being created and added to this growing armada. in the case of wearable devices. To investigate this aspect,
In the aspect of integration, the blockchain technology to Roehrs et al.58 evaluated the productivity of the blockchain
be applied must be compatible with the present financial performance when implementing a prototype that
technologies before their full integration.57 Furthermore, integrates and performs medical records from different
institutions will be incurred higher initial costs due to the production databases.59
implementation of new technology. On a separate note, The measurement of response time, central processing
regulatory concerns surrounding blockchain technology unit usage, memory and disk occupation, and network
have yet to be resolved by government agencies. One of the usage were monitored. Figure 7 depicts the performance of
prominent concerns is that distributed access to the whole blockchain in EHRs to query data and manipulate health
data set can be compromised even if the data have been records in a scenario containing data blocks running from
encrypted and de-identified within the blockchain.48 50 to 500 concurrent sessions in the network,60 showing
The two main issues about blockchain data storage are that there is an increase in the number of users who
confidentiality and scalability. Individuals who are linked simultaneously access the network, measured in terms of
on the same chain can access the data. As a result, data in the average load of records and the average response rate
the blockchain, which might contain sensitive information obtained.61 These results indicate that the response time is
such as medical history and X-ray report, are vulnerable almost equivalent despite the multiplicity and abundance
to breaches and not desirable in a decentralized platform. of data, underlining the potential of merging open EHR
Storage capacity in blockchain will be highly impacted standards and blockchain technologies to create an
by the data breach vulnerability.48,57 The summary of interoperable model for health data sharing with the aim of
challenges facing blockchain and the guidelines to tackle reducing the impact of various interoperability constraints.
each of them is shown in Table 6.
10. Future directions
9.2. Open research issues Several aspects concerning the future adoption of
Several vital issues confronting the adoption of blockchain blockchain technology in the health-care sector should be
for medical applications require investigations tailored to taken into consideration:
solving security problems prevalent in the EHR systems.
10.1. Enhanced performance of blockchain
These open issues are iterated in four research questions:
(i) How to build servers for blockchain-based health- Platforms using blockchain technology should be
care systems that are amenable to blockchain protocol technically enhanced in terms of scalability, resource
scalability. consumption, network latency, throughput, etc. Increasing
(ii) How to determine the levels of authority in blockchain scalability and building more lightweight blockchain
and safeguard the access to patient data without designs for health-care purposes are needed to make

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Artificial Intelligence in Health Blockchain for health-care security

Table 6. Challenges facing blockchain and guidelines to tackle them

Challenges Causes Guidelines

Security and privacy • Blockchain technology is still in its early stages of • Th e type of data shared with and among participants must be
of data development and refinement. determined since the beginning.
• There is much ambiguity when it comes to designing the • Prediction models that protect data privacy should be used.
blockchain. • It is necessary to choose a blockchain protocol – the framework
• When old corporate systems and record systems are that guides the structure of the blockchain and the development of
involved, integration issues arise. applications – and use the appropriate authorization structures.
Managing storage • Storage capacity for a large amount of data is limited. • A scalable and resilient blockchain solution is required.
capacity • Limitations in throughput capacity and storage exist. • Data storage requirements should be kept to a minimum.
Interoperability issues • Creating blockchains from a variety of communication • Evaluability should be maintained while reducing integration
services is a challenge. complicatedness.
• It is technically challenging to afford an effective • The ease of integration should be taken into consideration with
interaction platform for users and for the operations of security concerns.
medical applications.
• Gaps in communication and information sharing are
obstacles.
Decisions about • Records’ ownership • New cybersecurity risks must be addressed before patients
blockchain governance • How is permission granted? entrust a public blockchain with storing their data.
• The blockchain’s nodes, users, peers, and/or validators will
need to be defined.
Standardization • Lack of uniformity and scalability • International standardization authorities are required to
challenges • Lack of successful blockchain‑based projects for reference formulate well‑authenticated and approved standards.
• The standards will be treated as guidelines for inspecting the
exchanged data and as safety precautions.
Social challenges • Concerns about blockchain adoption due to cultural and • Organizations are encouraged to adopt technology and join a
trust issues shared network.
• Knowledge gap
• Hesitant social adoption of technology
Inadequate universally • No defined standards • Universal standards will help blockchain become more
defined standards •T ime‑ and effort‑consuming implementation of standards adaptable.
in the health‑care sector • Data format, size, and type in blockchain will be readily
determined.

be resolved. For instance, blockchain is still vulnerable to a

compromise of mutual trust, by a degree of 51%, even though
such a trust system is built upon with consensus mechanisms.59
Data hackers can capitalize on this vulnerability to hijack the
whole system developed with blockchain. For blockchains
operating on POW mechanisms in particular, an attack with
a probability of 51% may occur if one miner’s hashing power is
more than 50% of the hashing power in total. If a user’s private
key is lost, their entire blockchain will be vulnerable to tampering
by other people. Since blockchain is decentralized and does not
rely on third-party institutions for its operations,54,62 it would be
Figure 7. Interoperability performance of electronic health record systems
tough to track the whereabouts of a stolen private key and to
powered by blockchain technology. Source: Graph made by the authors. retrieve back the stolen private key if it has been changed by the
criminals. Therefore, solutions should be created to counteract
data verification and transmission of ultralow-latency the attacks and enhance blockchain security.
information more optimized.48,57
10.3. Reduction of resource consumption
10.2. Blockchain security issues Given the profound resource-consuming nature of POW
Despite the huge potential, security issues of blockchain consensus algorithm used in blockchain, a more efficient
technology that could undermine its adoption remain to mechanism is urgently warranted. A prevailing idea of

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Artificial Intelligence in Health Blockchain for health-care security

improving the existing mechanism is to develop a hybrid Author contributions

mechanism system of POW and POS. Further research and
experiments on creating better consensus mechanisms will Conceptualization: Asmaul Hosna, Nujhat Tabassum
significantly contribute to the development of blockchain Rahman, Supriya Dewanjee
systems.63 Writing – original draft: Asmaul Hosna, Nujhat Tabassum
Rahman, Supriya Dewanjee, Zulfikar Alom
10.4. Data validation and cleanup Writing – review & editing: Elmustafa Sayed Ali,
Not all data stored in the blockchain is verified, thereby Mohammad Abdul Azim, Rashid A. Saeed
prompting smart contracts to delete some codes, although
Ethics approval and consent to participate
the contract address will not be removed. Furthermore,
smart contracts either have the same codes or no codes at Not applicable.
all.59,64 In addition, most smart contracts are not published
after their execution. Therefore, data cleaning and Consent for publication
disclosure strategies must be put in place to enhance the Not applicable.
efficiency of blockchain systems.
Availability of data
10.5. Future regulations
Data are available from the corresponding author upon
In the context of applying blockchain technology in health-
reasonable request.
care domain while safeguarding data security, more efforts
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