Blockchain: A Survey on Healthcare

Perspective and Its Challenges

Deepa Kumari, B. S. A. S. Rajita, and Subhrakanta Panda

Abstract An impeccable and flawless exchange of digital information in a health-

care domain can revolutionize the treatment process. It can be computed by encom-
passing and leveraging digital progress in infrastructure for securely storing Elec-
tronic Medical Records (EMRs). If the security of Electronic Medical Records is left
unaddressed, or failed to notice at a crucial stage of care, it could hamper the effec-
tiveness of the course of treatment. Therefore, researchers have proposed blockchain-
based solutions that will not only defend data from being damaged but will also assure
that unethical data exposure is avoided. Hence, to make this critical information more
secure, application of blockchain technology has become indispensable. The signif-
icant contribution of this paper is to introduce the existing state of blockchain-based
medical healthcare solutions. This paper also discusses the industrial, administrative
and business challenges in enactment of blockchain in the healthcare industry. The
intent of this survey paper is to discuss the literature review on real-time usability of
blockchain application in healthcare systems.

1 Introduction

An efficient healthcare system is the current focus of the government as it can lead
to a significant boom in a country’s economy through industrialization of healthcare
facilities and also improve the general well-being of the people. According to recent
study, the amount of medical data is estimated to double in every 73 days [1]. Most of
these available medical data on healthcare (approx. 80%) are in unstructured format

D. Kumari (B) · B. S. A. S. Rajita · S. Panda

BITS-PILANI Hyderabad Campus, Hyderabad, India
e-mail: [email protected]
B. S. A. S. Rajita
e-mail: [email protected]
S. Panda
e-mail: [email protected]

© The Editor(s) (if applicable) and The Author(s), under exclusive license 111
to Springer Nature Singapore Pte Ltd. 2021
T. Senjyu et al. (eds.), Information and Communication Technology
for Intelligent Systems, Smart Innovation, Systems and Technologies 195,
https://doi.org/10.1007/978-981-15-7078-0_10
112 D. Kumari et al.

[1]. Inclusion of modern technologies (in hardware, software, medication, surgical

procedures, etc.) in the evolution of healthcare facilitation can have a huge impact on
the accessibility of quality healthcare by the patients. But yet, the administration lacks
proper data management and authorization. An analysis of these collected reports is
used by the government for the organization and execution of health facilities and
programs, and also for providing funds for medical research. Medical/health record
improvement could make contributions at large scale in the healthcare system of any
nation.
A health record consists of all relevant information about an individual’s health.
Electronic Medical Record (EMR) [2] forms the digital replacement of paper records,
normally maintained by a clinical or medical practitioner. EMRs typically depict the
details of a patient’s health history, such as diagnoses reports, prescribed medicines,
results of medical tests, medicine allergy information, immunization history, and
adopted treatment procedure. EMRs are crucial, sensitive, non-public data that needs
to be shared and pooled among healthcare providers or stakeholders such as insurance
firms, pharmacies, researchers, patients (their families) and doctors, i.e., all those
associated with providing, accepting, or refunding healthcare services.
The motivation here is to relieve a patient from the burden of carrying his own
information in physical forms. This avoids the chance of misplace or loss of one’s
medical records, hence ensures ready availability of information whenever and wher-
ever it is needed. With an EMR, laboratory results or analysis reports can be retrieved
much more conveniently, thus saving time and money. This improved patient record
maintenance system could benefit healthcare by three major ways. First, EMRs can
improve healthcare distribution by enabling medical personnel with correct data
entry, quick data renewal, and access to accurate data. Second, EMR can conse-
quently enhance research activities through better availability of medical data. Third,
EMRs support better quality medical analytics for good decision making and diag-
nosis of the patients, and chances of human errors (in reading and interpretation of
data) are drastically reduced.
Managing, storing, and sharing electronic health data presents distinctive chal-
lenges for restrictive consent, and conclusively for quality of care [1]. Patients have
privacy rights on their own health data that needs to be guarded. Further, lack of
standards and authorization rules can create untoward incidences for all stakeholders
including patients, medical practitioners, corporate administrators (of insurance
firms, hospitals, etc.), researchers, and third-party payers. Misappropriation of such
medical data can happen for the following reasons: (1) for investigations never carried
out; (2) inability of the clinician (for various reasons) to correctly document the
provided digital information in correct format; and (3) lack of security to avoid
interruption, interception, modification, and fabrication.
However, EMRs may still suffer in conflicting healthcare system and lack of
ownership. This leads to inadequate data veracity and decision-making process,
which in turn, indirectly affect the quality of care of a patient. The solution to the
above lies in the implementation of blockchain-based EMRs [2]. In lieu to the sensi-
tivity associated with a person’s health data and the likelihood of its misappropriation,
it makes perfect sense to utilize blockchain [3].
Blockchain: A Survey on Healthcare Perspective and Its Challenges 113

Hence, this paper aims to study and present the current state of blockchain imple-
mentation in securing the EMRs. This paper identifies industrial, administrative, and
business challenges in reification of blockchain in the healthcare industry especially
in securing the EMRs.
The remaining section of this paper is organized as follows: We provide more
details on blockchain implementation in Sect. 2 for better understanding of our
readers. Section 3 presents the research issues still persistent with blockchain. In
Sect. 4, we discuss some blockchain-based projects for healthcare data management.
In Sect. 5, we conclude our paper with some insights into our future work.

2 Background and Literature Review

Blockchain is a set of temporal, immutable data records stored across geographi-

cally distributed computer systems that could be shared across any single individual,
company, or government organization. By using cryptographic principle, every chunk
of data is protected and chained. Blockchain or a ledger for transaction works in a
distributed system as a decentralized cryptocurrency. It is because the blockchain
network is democratic rather than centralized system. Its application in healthcare
is well understood by a patient’s journey from registration for a blockchain address
to accessibility of account required by a hospital as shown in Fig. 1. It gives more
security to the EMR system by assuring that there is no scope for misuse of medical
records and all consents are being traced as per regulations or standards. It administers
the flow of informative data from one end to another.

2.1 Security in Blockchain

Trust and traceability are two important properties of a blockchain. But in some cases,
to provide an entire solution, these traits are not always assured. Hence, we can see
blockchain with strong cryptographic protocols like zero-knowledge proofs [4]. This
combination is advantageous in providing trust, traceability, security, and control
and they are base to the architectural blocks for desired critical solutions in various
management system including healthcare and supply chain. Stored information in
the blockchain cannot be altered and demolished without leaving a trace. Because
of this immutable and traceable property of the blockchain, it is more demanding in
any healthcare system. Thus, the usefulness of blockchain seems to be enormous.
The primary concerns in lieu to healthcare solutions that need to be addressed are
mentioned below. Later, we discuss how blockchain is helpful in addressing these
issues.
1. Storage security and protection of integrity
2. Privacy of data
114 D. Kumari et al.

Fig. 1 Blockchain: a use case on healthcare system [2]

3. Sharable data
4. Traceable and accountable data.
All of the above issues can be resolved distinctly by using cryptography, privacy
preserving technologies, or by the use of administrative model. In this aspect,
blockchain-based solution being a trustful decentralized ledger technology can be
called as assured adhesive glue.

2.2 Key Challenges and Future of Blockchain

Even with the massive hidden technology, there are certain limitations as of the
current state of blockchain. Apparently, the transaction processed by every node
in the network is actually inclined to make the blockchain rather slow and lags to
handle real-world transactions, which range in millions of transaction per second.
This divergence in the volume, velocity, and veracity of data, and its number of
Blockchain: A Survey on Healthcare Perspective and Its Challenges 115

users focuses on the problem of scaling associated with blockchain for any industrial
applications.
Generally, there are three desirable properties that a blockchain strives to main-
tain such as decentralization, consistency, and scalability (DCS) [5]. But, somehow
a blockchain system can only simultaneously afford to satisfy any two out of three
aforementioned properties. Platforms such as Bitcoin and Ethereum, ensure sufficient
decentralization and consistency of data but lack in scalability. Whereas, hyperledger
blockchain assures data consistency and can scale above 10 K transactions per second
at the cost of decentralization. Since last ten years, it is noticed that blockchain has
evolved through three generations. These are: cryptocurrencies represented as first
generation and were basically devised as an alternative payment system. Then, smart
contracts (Dapps) represented as second generation provided logical abstraction and
execution that helped in controlling the transfer of digital assets between the parties
under certain conditions. Here, safety and security of smart contracts are the major
concerns. Another advantage is that smart contracts prevent monetary losses because
codes are tested and validated before its deployment on a live blockchain. The frame-
work of a pervasive multi-dimensional system made the third generation wherein
an attacker cannot intrude into the blockchain. Table 1 summarizes the challenges
and present key solutions and the findings justify the possibility of incorporating
blockchain technology for collecting, storing, securing, and sharing the health data
in real time.

3 Research Challenges

Below, we cite some potential research challenges [10] that one would come across
while incorporating blockchain into EMRs. These are as follows:
• Scalability: The increase in the number of patients has triggered an increase in the
number of everyday transactions, making the blockchain implementation very
cumbersome. Each node has to stock all transactions to certify them on the
blockchain. This is because all current transactions and their sources need to
be authenticated. Due to constraints of block size and the minimum time taken to
create a new block, a blockchain, such as Bitcoin, can only handle nearly seven
transactions per second, which is nowhere close to the real-time need. To the best
of our knowledge, based on our literature review, there exists no such solution
that is capable to accommodate such a huge number of real-time transactions.
• Privacy Leakage: Authentication and key management also possesses a major
problem in the EMR system. Patient’s data require to be saved in a protected
manner such that illegal users are not allowed to execute any malicious activity
on it. Blockchain can defend a certain amount of privacy through cryptographic
implementation in the form of public and private keys enabling the users to hide
their identities.
116 D. Kumari et al.

Table 1 Blockchain-based solution toward healthcare data challenges

Sl. No. Healthcare data challenges Key solutions
1. The different sources of health data, such These decentralized data from different
as, professionals, doctors, researchers, sources are collected in many full nodes on
corporate hospitals etc., produce data in a the Bitcoin network which then propagate
fragmented decentralised manner and the blockchain to all other nodes on the
create a challenge for health information network by using the Bitcoin peer-to-peer
processing management [1] protocol [6]
2. Lack of standards and authorization rules Immutable property [4] of the blockchain
affect timely access and concurrent enables same set of data to be accessed
analysis [1] concurrently, thus improving timely access
of the data
3. There can be a lack of trust and inability Consensus algorithm in blockchain can be
of clinician to correctly document the used to ensure trust by verifying and
available digital information [6] validating the participating blockchain
nodes and associated data [7]. The low
learning curve will enable the clinicians to
correctly document the digital information
4. Medical information sourced from several By securing IoT devices’ communication
IoT devices [8] is the bottleneck issue in through private blockchain network,
tracking the regular updates of such medical data can be collected and
sensitive information distributed easily [8]
5. Data processing cost increases [1] due to By using BLOCKBENCH (a
multiple and repetitive analysis of the benchmarking framework for quantitative
same data by several stakeholders, evaluation and comparisons of private
third-party payers, etc. blockchain), the processing cost of analysis
and distribution can be reduced [9]
6. Owner lacks authorization rights, with Data flow and permissions are secured by
exposed identity, and non-transparent use of encrypted data handling
authentication mechanism [10] mechanisms and smart contracts [11]
7. Medical information of a patient is prone With the use of blockchain, stored
to manipulation by malicious information cannot be fabricated or
stakeholders and third parties to make a destroyed without leaving a trace of it
profit out of it [12] (blockchain are immutable) [12]

• Selfish Mining: It is well known that blockchain can be prone to attacks by selfish
miners. In this approach, selfish miners announce the private branch to the public
(only if provided obligations are accepted) and also somewhat keep their mined
blocks without transmitting to others. In particular, Eyal and Sirer [10] describe
that a small portion of hashing power is used for infringement but still network is
undefended.
In addition to the above major research challenges, there exists several resilience
barriers for EMRs. These challenges concern belief and practical guidance, compli-
ance with managerial requirements, and the hi-tech impediment related to data
storage and distribution. Determining the data sharing conventions is one of such
challenge. For example, it is an open question that how a patient can be empowered
Blockchain: A Survey on Healthcare Perspective and Its Challenges 117

to decide which data to share and with whom. A patient, as the owner of the data,
must enable a healthcare provider to access that data. If for any reason the patient is
not able to do that, it is meaningless for another person to have the rights of autho-
rization on behalf of the patient. It is also not clear that what amount of health data
need to be stored online. Whether to share the data indefinitely or for some duration
of time.
While data within the blockchain can be de-identified and encrypted, the data secu-
rity still may be vulnerable due to deficiently maintained or old-fashioned codes in an
incident involving a decentralized autonomous organization [5]. While blockchain
can prevent data block fraud, it remains a challenge to guarantee the identity and
authenticity of the informant and stakeholders.
Transitions to the blockchain technology in healthcare processes have some other
problems [13]. A sufficient amount of training is required for healthcare providers
and patients and keep the users transparent of the design and management of the
distributed controllers and network functions. Such implementations, especially as
mobile applications, may encourage people to some kind self-diagnose the symptoms
of their sickness. Additionally, there is still need for metrics to measure the efficiency
of this technology in healthcare. Some researchers propose to include metrics such as
policy compliance, high-level computation ability, authentication, interoperability,
scalability, cost-effectiveness, and domain-specific healthcare requirements.

4 Current State of Blockchain-Based Projects

for Healthcare Data Management

With the advent of many healthcare stakeholders, and enormous increase in usage
of Electronic Medical Records (EMRs), it is indispensable to ensure security. For
this reason, there is a compulsion to use the blockchain in order to secure our critical
information. Blockpharma [14] engages in countering counterfeit drugs. According
to their survey, it is reported that every year around 800,000 people die of taking
duplicate drugs. With the help of Blockpharma, the genuinity of any drug can be
detected, and an awareness can be spread among stakeholders in the supply chain.
EncrypGen [3] has been used for securely sharing of genomic data so as to make
use of cryptocurrency. Medicalchain [11] enables us to store medical records in a
secured way and also to share any pre-authorized health records. It is a decentralized
blockchain-based platform which also provides facility of telemedicine.
Coral Health [15] benefits in terms of efficient storage of health related data.
Hence, it also utilizes the potential of blockchain for individual healthcare systems.
Chronicled [8] is paired with IoT systems to increase the functionality of accounts
in the medical field. The advantage of this blockchain-based solution is attributed
to better coordination and minimized divergence. Patientory [8] is useful in creating
profiles of the patient and tracking their health history. It helps patients to easily
monitor and list their medical expenses, medications, and treatment history.
118 D. Kumari et al.

Stacked De-Noising Auto-encoders (SDA) [15] based on blockchain ledger can be

useful for auditing arrhythmia conditions. Some more advanced blockchain system
can be helpful for better interaction with the patient and healthcare system.

5 Conclusion and Future Work

In this paper, we studied the possibility of integrating EMRs in blockchain frame-

works. Its huge prospects for integrating EMR with access control and personally
identifiable information to secure patients’ medical information. It enhances autho-
rized access of records and maintenance of an interoperable system. We also high-
lighted some potential research challenges like scalability, privacy leakage, selfish
mining, etc., that one faces while incorporating blockchain technology into EMRs.
In future, we aim to make an effort to provide a solution to overcome the techno-
logical barriers existing in the current system and enable blockchain-based solutions
to scale for healthcare applications. We plan to extensively explore the key approach
for feasibility studies since it considers all three aspects of people, process, and
technology to provide a holistic view.

Acknowledgements This work is a part of the Advanced Competitive Research Grant Project,
funded by BITS-PILANI, which is currently under progress.

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