Background: A blockchain is a digitized, decentralized, distributed public ledger that acts as a shared and synchronized database that records cryptocurrency transactions. Despite the shift toward digital platforms enabled by electronic medical records, demonstrating a will to reform the health care sector, health systems face issues including security, interoperability, data fragmentation, timely access to patient data, and silos. The application of health care blockchains could enable data interoperability, enhancement of precision medicine, and reduction in prescription frauds through implementing novel methods in access and patient consent. Objective: To summarize the evidence on the strategies and frameworks utilized to implement blockchains for patient data in health care to ensure privacy and improve interoperability and scalability. It is anticipated this review will assist in the development of recommendations that will assist key stakeholders in health care blockchain implementation, and we predict that the evidence generated will challenge the health care status quo, moving away from more traditional approaches and facilitating decision making of patients, health care providers, and researchers. Methods: A systematic search of MEDLINE/PubMed, Embase, Scopus, ProQuest Technology Collection and Engineering Index will be conducted. Two experienced independent reviewers will conduct titles and abstract screening followed by full-text reading to determine study eligibility. Data will then be extracted onto data extraction forms before using the Cochrane Collaboration Risk of Bias Tool to appraise the quality of included randomized studies and the Risk of Bias in nonrandomized studies of Interventions to assess the quality of nonrandomized studies. Data will then be analyzed and synthesized. Results: Database searches will be initiated in September 2018. We expect to complete the review in January 2019. Conclusions: This review will summarize the strategies and frameworks used to implement blockchains in health care to increase data privacy, interoperability, and scalability. This review will also help clarify if the strategies and frameworks required for the operationalization of blockchains in health care ensure the privacy of patient data while enabling efficiency, interoperability, and scalability.
Background: A blockchain is a list of records that uses cryptography to make stored data immutable; their use has recently been proposed for electronic medical record (EMR) systems. This paper details a systematic review of trade-offs in blockchain technologies that are relevant to EMRs. Trade-offs are defined as “a compromise between two desirable but incompatible features.” Objective: This review’s primary research question was: “What are the trade-offs involved in different blockchain designs that are relevant to the creation of blockchain-based electronic medical records systems?” Methods: Seven databases were systematically searched for relevant articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Papers published from January 1, 2017 to June 15, 2018 were selected. Quality assessments of papers were performed using the Risk Of Bias In Non-randomized Studies—of Interventions (ROBINS-I) tool and the Critical Assessment Skills Programme (CASP) tool. Database searches identified 2885 articles, of which 15 were ultimately included for analysis. Results: A total of 17 trade-offs were identified impacting the design, development, and implementation of blockchain systems; these trade-offs are organized into themes, including business, application, data, and technology architecture. Conclusions: The key findings concluded the following: (1) multiple trade-offs can be managed adaptively to improve EMR utility; (2) multiple trade-offs involve improving the security of blockchain systems at the cost of other features, meaning EMR efficacy highly depends on data protection standards; and (3) multiple trade-offs result in improved blockchain scalability. Consideration of these trade-offs will be important to the specific environment in which electronic medical records are being developed. This review also uses its findings to suggest useful design choices for a hypothetical National Health Service blockchain. International Registered Report Identifier (IRRID): RR2-10.2196/10994
Background: The decentralized nature of sensitive health information can bring about situations where timely information is unavailable, worsening health outcomes. Furthermore, as patient involvement in health care increases, there is a growing need for patients to access and control their data. Blockchain is a secure, decentralized online ledger that could be used to manage electronic health records (EHRs) efficiently, therefore with the potential to improve health outcomes by creating a conduit for interoperability. Objective: This study aimed to perform a systematic review to assess the feasibility of blockchain as a method of managing health care records efficiently. Methods: Reviewers identified studies via systematic searches of databases including PubMed, MEDLINE, Scopus, EMBASE, ProQuest, and Cochrane Library. Suitability for inclusion of each was assessed independently. Results: Of the 71 included studies, the majority discuss potential benefits and limitations without evaluation of their effectiveness, although some systems were tested on live data. Conclusions: Blockchain could create a mechanism to manage access to EHRs stored on the cloud. Using a blockchain can increase interoperability while maintaining privacy and security of data. It contains inherent integrity and conforms to strict legal regulations. Increased interoperability would be beneficial for health outcomes. Although this technology is currently unfamiliar to most, investments into creating a sufficiently user-friendly interface and educating users on how best to take advantage of it would lead to improved health outcomes. International Registered Report Identifier (IRRID): RR2-10.2196/10994