Blockchain or Distributed Ledger Technology

What Is in It for the Healthcare Industry?

Nabil Georges Badr

Higher Institute for Public Health, Saint Joseph University, Lebanon

Keywords: Blockchain, Patient Data, Distributed Ledger Technology, Privacy, Security, Electronic Health Records.

Abstract: Distributed ledger technology has seen its debut into communities of practice in healthcare where the reliance

on knowledge sharing between participants postulates the foundations of secure and distributed knowledge,

especially in some sensitive context, such as patient information. This knowledge is essential for the practice

of care from patient contact to research, pharmaceutical supply chain, medication adherence and management

of the plethora of bedside data into a collection of knowledge about the patient, essential to quality care. We

introduce different schools of thought and implementation contexts of the distributed ledger technology or

Blockchain. We provide an overview of Blockchain and Distributed Ledger Technology, focused on the

Healthcare industry, as an initial assessment of the validity of an application of Distributed Ledger

Technology in a specific knowledge management model to solve problems related to knowledge sharing in

medical knowledge management systems. The paper summarizes some instances of most likely and unlikely

uses of Blockchain in the healthcare setting. The paper also introduces a few use cases where some short-term

benefits from such implementation.

1 INTRODUCTION

The growth of data in healthcare has brought a

disruptive foray of new technologies to find, manage,

move and maintain digital information. Distributed

Ledger Technology (DLT) or Blockchain will likely

not revolutionize healthcare immediately, however,

may transform it forever.

Communities of practice in healthcare rely on

knowledge sharing between participants (Jørgensen

et al, 2019) with data that must meet the foundations

of secure and distributed knowledge (Li et al, 2018),

especially in some sensitive context, such as patient

information. Practitioners must make sense of all data

presented to them and leverage technology advances

for predictive modelling that has the premise to

integrate all data sources into a single ecosystem and

accelerate the visualization of the patient’s case in

order to provide accurate evidence based diagnoses

(Rakic, 2018). Therefore, in practicality,

Blockchains could be complementary to digital

medical records. DLT with its features of handling

and anonymizing data, will likely enter the healthcare

IT market subtly, making certain service areas of the

https://orcid.org/0000-0001-7110-3718

industry more efficient. Based on dynamic ontologies

of knowledge management, which may tie into

changing state of data, and status of practice

processes and workflows (Jurisica et al, 2004), DLT

could enable healthcare staff to get information in a

shorter timeframe without searches, paperwork,

signatures, etc. Similar to how electronic medical

records (EMR), MPI (Master Patient Index) systems,

and data analytics are slowly changing workflows by

increasing the capabilities of staff in healthcare

organizations (Le Nguyen, 2018).

Treatment of patient data is an essential

component to building knowledge management

systems for managing the quality of care and

improving patient outcome (Wang et al, 2018).

However, handling patient data will never be totally

risk-free.

Patient data has had three major concerns:

Who owns it?

Who has access to it?

If they have access to it, how they can use it?

These concerns are complicated by the plethora of

conditions of privacy, confidentiality and security.

This position paper attempts to address the data

concerns through the potential implementation of

Badr, N.

Blockchain or Distributed Ledger Technology What Is in It for the Healthcare Industry?.

DOI: 10.5220/0008348902770284

In Proceedings of the 11th International Joint Conference on Knowledge Discovery, Knowledge Engineering and Knowledge Management (IC3K 2019), pages 277-284

ISBN: 978-989-758-382-7

277

Blockchain or Distributed Ledger Technology.

Which begs the research question: Blockchain or

Distributed Ledger Technology - What is in it for the

Healthcare Industry?

2 DISTRIBUTED LEDGER

TECHNOLOGY OR

BLOCKCHAIN

Distributed ledger technology (DLT) is a digital

system for recording transaction of assets in which

the transactions and their details are registered in

multiple places at the same time. Unlike traditional

databases, distributed ledgers have no central data

store or administration functionality. Basically, “a

Blockchain is a distributed, transactional database.

Globally distributed nodes are linked by a peer-to-

peer (P2P) communication network with its own layer

of protocol messages for node communication and

peer discovery” (Glaser 2017, p. 1545).

Blockchain implementation can be public, open

to the public, where the only protection is provided

by encryption. As “everyone can see everything” on

a Blockchain network. In contrast, Private

Blockchains are Blockchains with organizational

level implementations where varying levels of control

of who can access data, who can modify data, and

who ultimately has authority in the system (Yip,

2016).

Some claim that new technology implementations

that involve a high volume of data collection, such as

the case of Internet of Things (IoT), lend themselves

well to novel Blockchain applications, as do networks

and machine visualization, public key cryptography,

web applications, certification schemes and the

secure storage of Personally Identifiable Information

(PII) (Taylor, et al, 2019).

While Blockchain may have significant potential

to improve data interoperability (Brodersen, et al,

2016), and address issue in security and privacy

(Esposito et al, 2018), it is important to note the

boundaries of the technology: Blockchain is not a

substitute for an enterprise database and are not

optimized for high volume data exchange necessary

for applications in an organization. Blockchain

solutions are designed to record specific

transactional data events that are meant to be shared

across a network of parties where transparency and

collaboration are mission critical (RJ Krawiec, et al,

2016). Each party on the Blockchain has access to the

whole database; no single party controls the

information. Communication is directly between

peers, each node stores and forwards information to

other nodes; transactions occur between Blockchain

addresses (pseudonyms); once the record is entered,

it cannot be altered (Iansiti and Lakhani, 2017).

Furthermore, though debatable, the literature has

touted the “transparency and trust” element of

Blockchain technology (Agbo et al, 2019). The

inherent data verifiability of Blockchain could add an

atmosphere of trust, however, trust is still a difficult

factor to establish as it relates to data quality, access,

security and other human factors.

2.1 Two Schools of Thought

There are two schools of thought on the use of DLT

for healthcare. One professes that a Blockchain could

unlock the true value of interoperability (Krawiec, et

al, 2016). Another, more centred on protecting data

privacy, recognizes the fundamental role of the

Blockchain as an access-control manager for health

records and data (Linn and Koo, 2016).

In broad terms, both directions support principles

of integration of healthcare information across a

range of uses and stakeholders. There are varying

levels of control of who can access the data, who can

modify the data, and who ultimately has authority in

the system.

With a distributed ledger technology, all

participants would have access to the distributed

ledger to maintain a secure exchange without

complex brokered trust. Thus, establishing a “Trust

Network” that would reduce the complexity of

sharing clinical information among different

healthcare information systems, as an intermediary to

establish point-to-point sharing and “book-keeping”

of what data is to be exchanged (RJ Krawiec, et al,

2016).

2.2 The Healthcare Context

In the healthcare context, research has concentrated

on applications using distributed ledger technology to

focus on integration, integrity and access control of

health records and related patient data (Dagher et al,

2018). However, other diverse and interesting

applications are emerging, addressing clinical trials

(Nugent et al, 2016), biomedical databases (Kleinaki

et al, 2018) and medical insurance (Zhou et al, 2018).

Some works have advanced architectures that aim at

protecting data and sense-making of data collected by

embedded devices, wearables (Brogan et al, 2018),

and sensors (Angeletti, 2017), designs to build

building tamper resistant M-health devices

(Ichikawa, 2017), in addition to proposals for

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extending the technology to manage medicines

supply chain (Tseng, et al, 2018),

Recently, this subject has occupied the forefront

of the biomedical research. Scholars have reported on

the potential of using DLT to maintain the integrity

and access control of data collected in clinical trial

records (Benchoufi, 2018) and presented use cases

where medical transaction records (Tseng, et al,

2018), consent forms (Benchoufi, 2018), and

financial records, have been managed by a form of

DLT implementation for features of traceability,

provenance, and non-repudiation. Drosatos and

Kaldoudi, 2019, for instance, summarize current

coverage of the literature on DLT in the biomedical

domain (Figure 1).

Figure 1: Blockchain application in the biomedical domain

(from Drosatos and Kaldoudi, 2019; Fig 7).

Similarly, practitioners have positioned DLT in

Healthcare IT implementations, to address Master

Patient Index (MPI) challenges that arise from the

need to synchronize multiple patient identifiers

between systems while securing patient privacy.

Distributed Ledger Technology could use private and

public identifiers secured through cryptography, to

create a singular, more secure method of protecting

patient identity. Varying data standards reduce

interoperability because records are not compatible

between systems. Distributed Ledger Technology

could enable near real-time updates across the

network to all parties. Other institutions, in

Population Health management, have identified a

benefit in Distributed Ledger Technology that could

enable secure access to patient longitudinal health

data across the distributed ledger. Blockchain

technology can provide the means to aggregate and

identify where data are – so that organizations can

access patient data on a large scale in an

interoperable, secure and traceable form. Distributed

Ledger Technology could therefore establish low

cost, near-real time, rule-based methods for accessing

patient data that can be permissioned to selected

health organizations.

Before initiating Blockchain projects, hospital IT

leaders and decision makers, should consider whether

the technology is suitable to the hospital’s needs. Not

all problems require a DLT solution. That said, DLT

promises to be truly effective when multiple parties

generate transactions that change information in a

shared repository where intermediaries are inefficient

or not trusted as arbiters of truth - If this condition is

not met, a shared database may be a more appropriate

solution.

3 PROMISING USES OF

BLOCKCHAIN FOR THE

HEALTHCARE INDUSTRY

Figure 2 below, published by Chartier-Rueg and

Zweifel (2017) shows an illustration for promising

uses of Blockchain for the healthcare industry.

Figure 2: Promising uses of Blockchain in healthcare

(simplified from Chartier-Rueg and Zweifel, 2017).

Patient generated data, clinical data and health

record data are maintained in what is referred to as a

data lake, a repository that holds a vast amount of raw

data [BigData] in its native format until it is needed.

A data lake architecture usually incorporates search

and analytics techniques for decision-making,

reporting, legislation and census. Blockchain

implementations in this context can provide a

complete index history of the patient’s unique

identifier and an encrypted link to health records.

Each record is time stamped. Providers use health

applications to access data, patients may use mobile

devices to assign access permission to data. The

patient has control over the permissions on whom to

share data with and what portions of the data.

Blockchain network consensus enables the

automation of claim processing through predefined

Blockchain or Distributed Ledger Technology What Is in It for the Healthcare Industry?

279

inherent Blockchain features referred to as Smart

Contracts [ensuring tokenization of the data and

anonymization].

3.1 Likely and Unlikely Uses of

Blockchain in the Healthcare

Setting

The dynamic nature of health data and its

expansiveness prohibits replicating all health records

to every member in the chain, as is in the case of

traditional Blockchains, this would prove bandwidth

intensive, wasteful on resources and cause serious

data throughput concerns (Linn and Koo, 2016).

In the immediate, for healthcare to realize benefits

from distributed ledger technology, the distributed

ledger technology would need to function, primarily,

as an access-control manager for health records and

data (Linn and Koo, 2016). That said, likely uses for

distributed ledger technology in Healthcare aim at

improving medical record management, enhancing

insurance claim process and accelerating

clinical/biomedical research (Kuo et al, 2017).

Distributed ledger technology may also prove

effective as provider and patient directories, and care

plans, as historical ledgers of patient care data, in

support of pharmaceutical research and supply (Agbo

et al, 2019) chain and medical research and in

hospitals as back office component for admission,

discharge, and transfer systems (ADT/ATD) (Yip,

2016).

Likely Uses:

 Improved medical record management

 Historical ledgers of patient care data

 Provider directory

 Patient directory and care plans

 Enhance insurance claim Processing

 Accelerate pharma/ medical research

 ADT back office component

Unlikely Uses:

 Full featured Electronic health record systems

 Global patient ID software

 Public Health Data Access

3.2 Improve Medical Record

Management

Implementation of Blockchain technology may clear

obstacles to patients acquiring copies of their

healthcare records or transferring them to another

healthcare provider (Patel, 2018). Records signed by

the source and added to the Blockchain allow

legitimacy of records to be verified. Data are stored

in the private Blockchain cloud. Blockchain may

guarantee unalterable patient records, as encrypted

data in the Blockchain can only be read with the

patient’s private key (Kuo et al, 2017), which would

empower patients to control access to their sensitive

data (Esposito et al, 2018), which is Consistent with

the European General Data Protection Regulation

(GDPR) and other healthcare security regulation

(HIPAA).

3.3 Enhance Insurance Claim

Processing

Implementation of Blockchain technology may

provide the ability to maintain verifiable claim

transactions to support healthcare financing tasks and

facilitate real-time claim adjudication by replacing

the health plan intermediation with transparent

Blockchain technologies. Blockchain’ s transparency,

immutability and auditability of records stored can be

of great value to payers and insurance providers

(Boulos et al, 2018). In addition to increased security

of patient medical insurance information, payers,

private and government insurers, and individual

payers have the benefits of audits facilitation and

better fraud detection based on Blockchain

immutability (Crawford, 2017).

3.4 Accelerate Clinical/Biomedical

Research

Several firms contemplate accelerating secondary use

of clinical data (ie, clinical and biomedical studies

and research) using Blockchain technology (Roman-

Belmonte et al, 2018). The decentralized but traceable

functionality of Blockchain may imply that, each

institution can keep full control of their own

computational resources, while collaborating with

other institutions for data sharing and analysis

without ceding control (Benchoufi and Ravaud,

2017). Clinical trial would have a solid dataset,

reducing the risk of underreporting and exclusion

(Shae and Tsai, 2017). Furthermore, the immutability

property of Blockchain would be useful to certify the

integrity of data collected through Blockchain for

clinical study.

Personal patient-generated health data may now

become available to researchers. If anonymized and

then tracked in the research process with a timestamp,

this secondary source of data would engage millions

of individuals, healthcare providers, healthcare

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entities and medical researchers to share vast amounts

of genetic, diet, lifestyle, environmental and health

data with guaranteed security and privacy protection

(Boulos et al, 2018).

3.5 Illustrative Use Case: Back Office

Component for Admission,

Discharge, and Transfer Systems

(ADT).

Below is a description of how a hospital (or

healthcare organization) may likely adopt Blockchain

into its infrastructure (Yip, 2016).

Yip, 2016 proposed, as an illustration (Figure 3), a

use case of a network of public hospitals using

different and disconnected electronic medical record

systems (EMR).

Figure 3: Illustrative Use Case: Back Office Component for

Admission, Discharge, and Transfer Systems from (Yip,

2016, Fig 1).

The public hospitals, in lieu of normalizing their

systems, which can be a costly endeavour, with often

unsurmountable challenges, have implemented

Blockchain technology to identify patients going to

the hospital and clinics and determine whether were

part of the network. The hospital IT team has setup a

Blockchain with nodes at each of the hospitals and

clinics, plug-ins and interface engines were used to

connect the Blockchain with the different EMR

systems at each point of care setting. For our case, we

consider a patient who has moved from one city to

another and now seeks admission in the local clinic in

the public/national hospital network.

1. The patient’s ADT information is transmitted to

the MPI.

2. The MPI queries the Blockchain for patient

information. [If the MPI finds no record of the

patient, suggesting that the patient is a new

patient in this hospital. Noticing this, staff asks if

the patient wants to self-register and quickly

enrolls the patient through a web interface on the

intranet that connect to the Blockchain].

3. The patient directory information, with care plan

data, in the Blockchain, are returned to the ADT

system as a response.

4. ADT messages are sent during the admission

time and discharge time respectively to the

Blockchain.

5. After completion of the intervention, the patient

is now waiting to be discharged.

The clinical staff admit the patient for the

procedure or check-up. The Blockchain automatically

updates the patient records and care plan. [In this

hypothetical case, the Blockchain adds a

recommendation to put the patient into an ER

diversion program after noticing that the discharge

message was for a minor diagnoses and this has

marked three ER visits for minor diagnoses in the last

month].

Similarly, as reported by Yip, 2016, on the

payer’s side of the data interchange, each of the

hospitals and clinics used the interface engine to

connect their claims system and providers to the

Blockchain.

Payers were able to connect directly to the

national record for the patient and process insurance

claims and payments, while avoiding costly

processing workflows and delays in duplicate records

management.

Hospital management was able to make a

dashboard of cost vs. quality measures.

Patients received access to portals connected to

this Blockchain; they are able to view their medical

and financial records. The Blockchain was able to

provide information with a single source of truth.

4 CONCLUSION

Blockchain or distributed ledger technology (DLT)

has the potential to become the backbone for digital

health, incorporating data from patient-based

technologies and the electronic medical records to

provide a pool from which authorized users, such as

providers and patients, have access.

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The paper has touched upon the initial research

question by demonstrating the potential of DLT

technology to address major concerns in data

ownership, access and use. All data are stored in a

decentralized manner, with no single entity storing or

having singular authority to access. This technology

has already made its impact in improved medical

record management, enhanced insurance claim

processes and accelerated clinical/biomedical

research. We conclude that DLT has a promising

proposition to define data ownership and access to

sensitive data; however, the jury can still be out on

controlling use.

Implementation of Blockchain for healthcare are

at their burgeoning stage: HealthChain, for instance,

is an EMR application that uses smart contracts, or

chain codes that are developed on IBM Blockchain’s

Hyperledger Fabric and deployed on Bluemix

(Ahram et al, 2017), to control authorizations and

access privileges.

4.1 A Winning Proposition

The growth of the distributed ledger technology and

its premise to fuel incremental innovations will

eventually become indispensable for proper data

stewardship for the proper use of patients, providers,

payers, pharma, medical researchers and public

health analysts while respecting the privacy,

confidentiality and integrity of the data asset.

For healthcare organizations that have decided to

initiate Blockchain projects, the next step is to design

the use cases. In this paper, we presented one

illustrative use case on the effectiveness of

Blockchain implementations in enhancing the

security, ensuring integrity of the system and

maintaining the originality of the data.

For MedTech, the use of embedded blockchain-

like technology can provide a real-time mechanism to

track data ownership, collection, usage and when it is

used and for what purposes. A value added

proposition for medical technology companies who

are looking to participate in the Internet of Medical

things ecosystem

. These companies can now

leverage the added privacy, security and data

protection, by design, which would improve enhance

practitioners’ and patients’ access to trusted

information, improve diagnosis, care and treatment,

thus advancing the vision of medicine that is

https://www2.deloitte.com/content/dam/Deloitte/global/

Documents/Life-Sciences-Health-Care/gx-lshc-medtech-

iomt-brochure.pdf

predictive, preventive, personalized and participatory

(‘P4’) (Hood et al, 2012).

However, essentially, it seems like, until more

rigor is placed on managing public keys and

protecting against data loss due to hacks or otherwise,

issues related to transparency and confidentiality may

prohibit the use of DLT for public healthcare data.

Whereas, private Blockchain implementations, with

some level of control over access, would likely be the

norm in healthcare settings (Dagher et al, 2018).

4.2 A Position Paper

Blockchain is among the top health technologies

touted to streamline healthcare operations, lower

costs and enhance quality of care. Artificial

intelligence (AI), voice search, chat-bots and virtual

reality (VR) are also among the list most promising

health technologies in 2019

Our position paper is an attempt to socialize the

enigmatic distributed ledger technology and highlight

its potential value in the healthcare setting. We invite

researchers and practitioners to use to start the

practical discussion of the technology. At this stage,

a set of questions that remain without answer:

How far could public Blockchains be useful at a

larger scale for public healthcare?

What will the advantages be in public health and

epidemic management?

Can DLT be useful at the service of the consumer

through integration with Consumer Heath

Informatics?

How resilient can this technology be in correcting

user errors introduced by practitioners?

How scalable could DLT become in order to

integrated data and analytics from the ever-increasing

integration of medical devices; scaling to accept

internet of things (IoT) big data storage levels?

Can clinical researchers and practitioners obtain

authorized access to clinical trials before a major drug

announcement? or, to report certain reactions by their

patients, then have that information be joined with

other decision support criteria for drug interaction

management? This would inevitably be a step in the

right direction as medical trials expand into real time

field data capture. Etc.

https://healthcareweekly.com/health-technologies/

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