Abstract
Healthcare industry is one of the most important service sector for every nations in terms of well-being of the people and economical development. It has some problems in existing Electronic Health Records system, such as every hospital having their own data, not sharing with other medical organizations leading to competitive advantage over them, patients needing to carry documents from one hospital to others, doctors are not awering of the full history of the patients because of missing data, having frauds, cyber -ttacks etc. Blockchain technology having its own characteristics can solve the problems and the needs of the current system at the healthcare industry. By this way, blockchain can bring its own advantages including interoperability, security, integrity, universal access, data sharing, validating qualifications of medical staffs, data quality and qualification for medical research. It is also beneficial in drug supply chain, clinical trials, billing management and remote control with technological devices. Although it has these advantages, it also has some challenge, including scaling, not updated in real time, technical infrastructure, coordination be6tween stakeholders, cultural change, initial costs and regulations. As it is a new technology, these unclear parts can be addressed in time.
Problems in Healthcare Industry
Healthcare is one of the most important industry for every nations in terms of wellbeing of people, development of the countries and economical figures. Healthcare sector is consuming more than 10% of the GDP (Gross Domestic Product) of the developed countries (Katuwal, Pandey, Hennessey & Lamichhane, 2018). So, improvements that will be made in that sector plays a significant role. There are numerous interactions between the patients and the medical staffs, including doctors and nurses. As every interaction creates a new data recording, it will result in a huge data transaction. The Department of Health and Human Services Office for Civil Rights has 13 million of healthcare data recordings in one year in 2018 (Chen, Jarrell, Carpenter, Cohen & Huang, 2019). When it comes to think about the cost of analysing that number of data, it can be easily estimated that it will be high and requires a great effort. That industry and its applications cost too much to the countries. Spending in the healthcare industry in only one country, in USA, is $3.55 trillion in 2017 and it is forecasted that in 2025 that figure will be increase by nearly $2 trillion. However, 20-30% of these costs are stemmed from nonvalue added activities, including inefficient treatments, tests and frauds. Misunderstandings between doctors and the hospital staffs cause 875$ million arises from repeating the same services (The Institution of Engineering and Technology, n.d.).
As we are living in a digitalized world, people can meet their daily needs by using digitalized products and services. They are also expecting to solve their healthcare issues by using technology similar to how they are doing financial issues by using online banking services. To make digitalize the healthcare data, hospitals benefit from the digitalized system called Electronic Health Records (EHR). Currently for saving the data of the patients in terms of their information, such as ID, date of birth, telephone number and also the treatments that he/she has taken, EHR is used. Every hospital is recording its own data in a secure repository. The data for the healthcare service that patients are taken are stored centrally, so that other hospitals or healthcare institutions cannot reach to these information (Quaini, Roehrs,da Costa, & da Rosa Righi, 2018). Storing information about the doctor examination, medical tests and treatments only in one hospital does not help to the patients and doctors. As patients may visit different doctors from different hospitals, tracking their healthcare story is not possible. So, doctors cannot know about their former records and it makes difficult to make the right treatment as they are some missing data in the story. Although EHR system is helpful to the patients as they do not need to carry the medical papers when they visit the doctors each time, it is open the cyber attacks, so will be a problematic in terms of cyber security and privacy of the records of the patients (Padmavathi & Rajagopalan, 2019). In addition to that, patients do not have a control over their recordings. To address this issue, Personal Health Record (PHR) was developed. PHR is more customized compared to EHT as it makes possible to control by the patients who are the owner of the data. Interoperability – exchange the medical records information to other healthcare institutions- is one of the requirements serve more customized healthcare information to the users. Sharing that information is problematic because of technical infrastructure, information policies, ethics, governmental and organizational issues (Leeming, Cunningham & Ainsworth, 2019). Also, hospitals do not want to share that data with others as they want to retrain that patients and do not want them to go to other hospitals for doctor examinations, tests or treatments. It may be a lost of that patient.
Transparency is also another need in terms of the patients to control over their data sharing with the others (Katuwal, Pandey, Hennessey & Lamichhane, 2018). It is significant in terms of clarity because of the fact that they want to know which information is shared with whom and want to control that sharing process.
There are some infrastructural issues containing centralized data centre and transforming these data to others which is risky in terms of security and may result in privacy issues. Interoperability of healthcare data to other organizations or medical staffs requires structure and semantics. Structure is required because of ensuring the homogeneous of the medical data in terms of interpreting and semantics is needed to code the data in same way (Peterson, Deeduvanu, Kanjamala & Boles, 2016). To transfer the data and to interpret the data coming from another medical organization, it is important to have the data in the same format and structure.
It is needed to have a network where patients, doctors and hospitals are involved and data are securely stored and shared with the selected ones. It is needed to share these information where patients have a control over the system, meaning that can select to share with whom it can be shared or not. It is also needed a verification in terms of the privacy issues.
Blockchain Technology
As the usage of the digital solutions increasing, some security issues arise because of the fact that it is difficult to verify the IDs through the Internet. In order to verify the transactions, generally it can be made by the centre of the bank or by the government. But when it comes to the Internet, it is not easy to verify the people as there is not any trusted organization that can make verification process easily where a fraud risk and an attack may occur. Here, technologies like blockchain plays an important role. It is developed by Satoshi Nakamoto is 2008 based on distributed ledger technology. It is a based on blocks and each block comes from other block where they can build a chain in a peer to peer network. Each block represents one of the transaction with a timestamped, so that in that chain the history of each transaction can be traced and followed easily. Each block includes a hash and changing the data is impossible as each hash of block contains also the one before. So that it can be verified without any middleman, it is decentralized.
In blockchain technology, peer-to-peer network is a technical basement that enables to share data with other entities, cascaded encryption is used for security and distributed database is for enabling all the parties to access the data where there is not any centralized database. Security is supplied by the usage of cryptography (Sadiku, Eze & Musa, 2018).
All the transactions are recorded in blockchain technology, so that they can be traced easily with its timestamps. It has “fingerprint” which gives an opportunity to digitally traceable and “transaction cloud” which enables to securely store without loosing any type of information (Brodersen et al., 2016). By this way, digitally all the information is secured not to be deleted. Digital identities are provided by public and private keys. Although every people can access through public keys as they resemble to the general addresses, private keys can be read and accessed by the pre specified people, not everyone (CitiusTech, 2018). These digital id verification plays an important role to mitigate risk of fraud.
In blockchain the system is like following: After a transaction request comes, it is signed by the public key and it is distributed in peer to peer network to the others where the transaction is in blocks. These blocks are in a chain, meaning that also includes the other blocks before. Other entities in that network tries to estimate the hash function of the blocks. If it can achieve that, by this way, a new block can be added to the network. So that, making any modification is not possible anymore and the transaction process ends (Chen, Jarrell, Carpenter, Cohen & Huang, 2019). By having that mechanism, without any centre, the system itself can verify transactions in a secured way and share these right data with the others included in the network system.
In addition to bitcoin that is helpful for the id verification, other platforms like Ethereum was developed based on Solidity language. It is helpful to develop the smart contracts (Quaini, Roehrs, da Costa & da Rosa Righi, 2018). Smart contract enable to make the transactions automatically if the predefined set of rules are met without needing any intermediary.
The characteristics of the blockchain technology, being secure, having not a centralized system, serving as single source of truth, being not modified, being synchronized, having personal data storage clouds and having techniques for encryption bring advantages to multiple industries (The Institution of Engineering and Technology, n.d). At the first glance, it seems like that it is more related to finance industry. But in addition to finance, it has been started to used also in other industries, including healthcare to use the advantages of that technology.
Blockchain Addressing the Issues in Healthcare
Blockchain having a character of general aimed format of data enables to apply it to the other sectors in addition to digital currency, such as healthcare where the transaction will represent every medical records of the patients via Uniform Resource Locators (URL). By this referencing method, fragile data can be stored out of that blockchain technology (Peterson, Deeduvanu, Kanjamala & Boles, 2016). Instead of using financial transactions, each records of the patients can be thought as the all blocks in that system. A study that was reported in IBM- “Healthcare Rallies for Blockchain” reported that 16% of healthcare intuitions apply blockchain, This figure is expected to reach 56% in 2020 (Sharma, 2018). It can be understood that blockchain is started to be used in healthcare serviced and estimated to be used at more hospitals.
Requirements and problems that are existing at the current system of healthcare can be addressed by the features of the blockchain technology. Security, assurance, immutability, authentication, data access, data sharing, decentralized storage and mobility are the key features of the blockchain technology. When it is looked to the needs of the healthcare sector, including security, interoperability, data sharing and data access it can be understandable that they are the things that are covered by the blockchain features (McGhin, Choo, Liu, He & 2019). The needs for the healthcare is the subset of the characteristics of the blockchain technology. It can offer a solution for the problems of that industry.
Requirement of interoperability can be addressed by APIs so that standardized data can be shared with others. By this way, several entities related to healthcare data can communicate with each other. Private key of the blockchain technology ensures the security issue of the network. By this way, conserving the private health related data of the patients will not be a concern anymore, the data sharing to the others can be done in a secure way. The integrity problem will be solves as there is non-centralized one reliable source, so that the data will be accessed by all the nodes in the network system. So, also accessing to the data will not be a problem (CitiusTech., 2018). Requirements of the patients and healthcare centres can be met with the qualifications of the blockchain technology: By this way, patients can select which medical data can be shared with whom and the entities can transfer and share these data each other. So that, the medical story of the patients can be properly evaluated by the doctors and the medical staffs without any missing records.
In addition to the care and the treatment of the patients, usage of blockchain technology has also other application areas and brings its own advantages. It is useful in terms of researches, by using the non-missing and proper data and analysing them. It will improve research and development area by using the data and enable to find new solutions to the medical care. Using blockchain technology has its advantages in terms of not only quality, but also quantity of the data in the medical research area (Ekblaw, Azaria, Halamka & Lippman, 2016).
Applying blockchain technology into the healthcare sector also brings its security advantage because of the fact that technology has an underlying feature of unalterable. That means that, editing or deleting the data that exist in the history of the transactions is not possible. It is useful and beneficial in terms of preventing undesirable cases. Irreversible characteristic of blockchain technology has advantages against the risk of fraud and imposture in medical drugs (Katuwal, Pandey, Hennessey & Lamichhane, 2018). Security can also be applied on the verification of the doctors. By this way, it can be ensured about which educations and certificates does the medical staffs and doctors have. Doctors can submit their qualifications, like educational records and certifications, so that they can be proven out from a single and a reliable point (Pirtle & Ehrenfeld, 2018). Ensuring and validating about which doctors have which qualifications can also be done by blockchain which is another form about ensuring the security.
The process of the application of the blockchain technology into the healthcare sector begins with hospitals storing the medical data up to the blockchain technology via APIs with public ID. All the transactiosn and steps are recorded and cannot be modified or deleted. Other hospitals or the healthcare entities can access to the required data and make their own analysis by using them. With using the private key, patients can give an access right to the other healthcare related entities into the network in terms of viewing the data. They have the rights to specify their data sharing preferences (Alkhushyni, Du’a & Kengne, 2019). The process of blockchain in healthcare helps to hopistals, doctors and patients to meet their needs.
Positive Effects of Applying Blockchain in Healthcare
As it was stated, blockchain technology will meet the requirements of the healthcare sector in terms of security, interoperability, data sharing, integrity, universal access, data quality and qualifications for the research and development, approval of education records and certifications of the doctors and preventing unwanted case, like frauds with its own characteristics. They all bring its advantages and develop the healthcare industry by this way.
Thanks to blokchain technology, patients do not need to carry all the updated documents with themselves each time they visit a doctor. With the interoperability feature, data sharing will be possible and patients will just specify the access rights to the ones that they want to share their data. They can also specify these access rights for a limited time. So, it transforms the healthcare industry, where patients become an important actor to manage their own data. So that, healthcare industry become from hospital driven interoperability into patient centered interoperability (Yoon, 2019). It is so important that patients will specify their data sharing rules.
It also plays an important role that it results in better quality of healthcare. As data can be shared with other hospitals, they will not have a competitive advantage of having the information only at their own data centre. In contrast, other hospitals can now access to these data in terms of their requirements. So, as every hospital will have the same type of information, they can only come to the forefront with their service. It plays an important role in terms of the standards of the service that patients will take. It results in result oriented service quality (Peterson, Deeduvanu, Kanjamala & Boles, 2016). It enhances the quality of the diagnosis, treatment and the general medical service at the hospitals. So that the experience of the patients, cost reduction, different and competitive processes and increased research and development cycle will be the outcomes of deployment of that technology at healthcare industry (Sadiku, Eze & Musa, 2018). This focus on the service quality may lead to an increase in health status of the population and effect on GDP of the countries. In addition to the healthcare service, after blockchain technology is healthcare, patients also can access their data. Interoperability of the blockchain technology, medical data of the patients become as a service and it works with other technological developments like wearable and remote control devices (Brodersen, et al., 2016). So, that with integrating other technological devices, it seems that it may be possible to access the desired data from other devices whenever it is needed. Also, with sensors current status of the patients can be traces and by sending notifications important remarks can be made and needed information can be given to the patients. With blockchain technology introduction, these monitoring with sensors can be made securely and also sending the notification process can be made automatically (Padmavathi & Rajagopalan 2019).
Another application area of the blockchain technology in healthcare process is the supply chain of the drugs where falsification of the drugs are widespread and so important as has a vital effects. Drugs may not involve the ingredient that it should involve or may include wrong one. It may lead to fatal consequences as other substances may not benefit to the patient. It is estimated that 30% of the drugs are counterfeits in developing countries which means that yearly it costs $200 billion all over the world. It may be prevented by the blockchain technology where every steps in the supply chain process can be recorded and cannot be modified or deleted, so that patients and chemist can ensure about the trueness of the drugs (Rabah, 2017). With blockchain technology, managing the medical data will get easy as interoperability will be introduced. By this way, research and development in healthcare industry will accelerate with increased number of data. It also leads to development of new types of drugs.
Clinical trials is another application application area of the blockchain technology. As it has a characteristic of irreversible, these data can be recorded and cannot be modified. These cases can be traced with their timestamps (Sadiku, Eze & Musa, 2018).
There may also be some kind of frauds related to billing like showing the type of the treatment differently on the paper, applying some kind of tests more than required or having a bill for the ones that are not actually applied. These kind of unwanted cases can be prevented by applying the blockchain technology to the billing management process where the steps automatized (By this way also the process with the insurance can be done automatically (CitiusTech, 2018).
Negative Effects of Applying Blockchain in Healthcare
Although blockchain technology gives several advantages that is bringing to the healthcare industry, it also some challenges to apply it. One of the challenges is that scaling. As every nodes in the blockchain network will need to have the copy of the data, it may be slower compared to real time. And as the number of nodes are increasing, having the same data at each of them also become a problem. That means that, more number of the entities in the network including the number of health organizations and hospitals are in the system, it becomes more difficult to have the same data at the real time. Among three charactreristics of not having a central database, consistency and scalability, blockchain can serve two out of these three features at the same time (Katuwal, Pandey, Hennessey & Lamichhane, 2018). So, there is a trade-off between them to decide on according to the requirements and priorities of them.
Interoperability is the one most significant characteristics and benefits of blockchain bringing to the healthcare ecosystem. While it seems that it is so life saving theoretically as it enables to share data among the partners, it needs a serious effort to bring all of the entities together. It needs a critical infrastructure that connects all of the devices, data input structures at the hospitals together with the same data structure and format in a way that others can also understand and fill the blanks. So, that it requires IT oriented and skilled people and also medical staffs and management of hospitals that are ready to accept and use it. It needs a coordination between all these stakeholders and may need to change and adopt to a new business strategy (Katuwal, Pandey, Hennessey & Lamichhane, 2018). So, there are some challenges not only at the technical infrastructure part, but also at the cultural change and the management part of the organizations. It is seriously needed because people are the ones who will use this technology, so it is needed to accept by them.
As it is a new technology, some parts of the blockchain is unclear, such as the initial costs. As transforming the whole industry needs an important effort, it is difficult to estimate how much is required as an initial cost (Sharma, R. (2018).
In addition to financial uncertainty, there is also a challenge in regulations. General Data Protection Rule, GDPR, gives a right to the people to manage their own data. It highlights that people can delete their data, make a preference to be forgotten by the system. However, the blockchain technology is contradicting with it. Deleting and modifying a transaction is impossible as it is but on blocks containing hash function (Katuwal, Pandey, Hennessey Lamichhane, 2018).
These challenges are needed to be overcome. As it is a new technology and new for healthcare sector, they can be improved in time.
References
Alkhushyni, S. M., Du’a, M. A., & Kengne, N. L. G. (2019, September). Blockchain Technology applied to Electronic Health Records. In Proceedings of 32nd International Conference on (Vol. 63, pp. 34-42).
Brodersen, C., Kalis, B., Leong, C., Mitchell, E., Pupo, E., Truscott, A., & Accenture, L. L. P. (2016). Blockchain: Securing a new health interoperability experience. Accenture LLP.
Chen, H. S., Jarrell, J. T., Carpenter, K. A., Cohen, D. S., & Huang, X. (2019). Blockchain in Healthcare: A Patient-Centered Model. Biomedical journal of scientific & technical research, 20(3), 15017.
CitiusTech. (2018). Blockchain for Healthcare: An Opportunity to Address Many Complex Challenges in Healthcare. https://www.citiustech.com/uploads/knowledgehub/pdf/blockchain-for-healthcare-341.pdf.
Ekblaw, A., Azaria, A., Halamka, J. D., & Lippman, A. (2016, August). A Case Study for Blockchain in Healthcare:“MedRec” prototype for electronic health records and medical research data. In Proceedings of IEEE open & big data conference (Vol. 13, p. 13).
Katuwal, G. J., Pandey, S., Hennessey, M., & Lamichhane, B. (2018). Applications of Blockchain in Healthcare: Current Landscape & Challenges. arXiv preprint arXiv:1812.02776.
Leeming, G., Cunningham, J., & Ainsworth, J. (2019). A ledger of me: personalizing healthcare using blockchain technology. Frontiers in medicine, 6.
McGhin, T., Choo, K. K. R., Liu, C. Z., & He, D. (2019). Blockchain in healthcare applications: Research challenges and opportunities. Journal of Network and Computer Applications.
The Institution of Engineering and Technology. (n.d.). Blockchain in Healthcare: How Distributed Ledger Technology Could Help Mitigate Some of the Sector’s Biggest Challenges. https://www.theiet.org/media/4478/blockchain-in-healthcare-report-web.pdf.
Padmavathi, U. & Rajagopalan, N. (2019). A Research on Impact of Blockchain in Healthcare. International journal of innovative technology and exploring engineering (IJITEE), 8(9S2).
Peterson, K., Deeduvanu, R., Kanjamala, P., & Boles, K. (2016, September). A blockchain-based approach to health information exchange networks. In Proc. NIST Workshop Blockchain Healthcare (Vol. 1, pp. 1-10).
Pirtle, C., & Ehrenfeld, J. (2018). Blockchain for Healthcare: The Next Generation of Medical Records?.
Rabah, K. (2017). Challenges & opportunities for blockchain powered healthcare systems: A review. Mara Research Journal of Medicine & Health Sciences, 1(1), 45-52.
Sadiku, M. N., Eze, K. G., & Musa, S. M. (2018). Block chain Technology in Healthcare. International Journal of Advances in Scientific Research and Engineering, 4.
Sharma, R. (2018). Blockchain in Healthcare. FCCCO: Ontario, ON, Canada.
Quaini, T., Roehrs, A., da Costa, C. A., & da Rosa Righi, R. (2018). A MODEL FOR BLOCKCHAIN-BASED DISTRIBUTED ELECTRONIC HEALTH RECORDS. IADIS International Journal on WWW/Internet, 16(2).
Yoon, H. J. (2019). Blockchain Technology and Healthcare. Healthcare informatics research, 25(2), 59.
Declaration of Authorship:
I hereby declare that the thesis submitted is my own unaided work. All direct or indirect sources used are acknowledged as references.
I am aware that the thesis in digital form can be examined for the use of unauthorized aid and in order to determine whether the thesis as a whole or parts incorporated in it may be deemed as plagiarism. For the comparison of my work with existing sources I agree that it shall be entered in a database where it shall also remain after examination, to enable comparison with future theses submitted. Further rights of reproduction and usage, however, are not granted here.
This paper was not previously presented to another examination board and has not been published.
Signature ………………………….. Date………………………………..