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Applications of Blockchain Within Healthcare Liam Bell,1 William J Buchanan,1 Jonathan Cameron,2 Owen Lo1

Authors 1The Cyber Academy, Edinburgh Napier University, Edinburgh, UK, 2NHS NSS, Edinburgh, UK.

Corresponding Author Prof. William (Bill) Buchanan, OBE, PhD, FBCS, FIET, CEng, BSc (Hons), Cisco Regional Instructor, Professor of Computing, Edinburgh Napier University, 10 Colinton Road, Edinburgh. EH10 5DT. [email protected].

Keywords: Asset Tracking, Blockchain, Drug tracking, Ethereum, Healthcare, Internet of Things, IoT

Section: Review

There are several areas of healthcare and well-being voting,4 real estate,5 supply chain management,6 and of that could be enhanced using blockchain technologies. course, healthcare.7 Healthcare is prime for disruption as These include device tracking, clinical trials, it has a variety of problems in the industry that pharmaceutical tracing, and health insurance. Within blockchain can solve through its immutability, fraud device tracking, hospitals can trace their asset within a prevention and capability to share data between blockchain infrastructure, including through the organizations without requiring trust. Current issues complete lifecycle of a device. The information gathered within modern healthcare industry are listed in Table 1. can then be used to improve patient safety and provide 8 after-market analysis to improve efficiency savings. This A key challenge, as identified by Frost & Sullivan, is to paper outlines recent work within the areas of tag medical equipment with a usable ID and in pharmaceutical traceability, data sharing, clinical trials, integrating trust in device identification and tracking. and device tracking. When a device, such as an infusion pump is shown to have malfunctioned, the tracking of the device can reveal lockchain is a distributed ledger technology, the source of the problem and prevent unnecessary with the potential to disrupt many industries. repurchasing in the case of lost devices. A strong trust Indeed, with $1.4 billion invested in blockchain infrastructure based around the identification of medical B 1 related startups in 2016; and with this projected to grow devices is likely to reduce these threats. The report further in 2017 the hype cycle shows no sign of slowing. estimates that only 20% to 30% of medical devices are At the time of writing, a lot of the attention around connected within hospitals due to security and privacy blockchain has centered on cryptocurrency, issues. predominantly Bitcoin2 and the effect that blockchain is predicted to have on the financial sector. This effect led Within the pharmaceutical industry, blockchain can help to the established consultancy Accenture labeling it as overcome the increasing risks around counterfeit and one of three technologies that will change the financial unapproved drugs. As with device tracking, it is possible services world.3 Despite this focus on financial services, to define smart contracts for drugs and then identify pill there are many other areas prime for disruption including containers, with integrated GPS and chain-of-custody logging. Blockchain in Healthcare Today™ ISSN 2573-8240 online https://doi.org/10.30953/bhty.v1.8

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Table 1. Current issues within the modern healthcare appealing about this to many industries is its industry immutability. Data added to the blockchain cannot be Issue Activity modified; and therefore, a consensus-based, verifiable Healthcare Data must pass between healthcare and correct ledger of data can be created. This makes Data providers to necessary third blockchain particularly suited to tasks where data Interchange parties, insurers, and patients integrity is of utmost importance, a practical example of while meeting data protection this immutability is ProvChain,9 an architecture built on regulation in the healthcare sector. the blockchain for providing chain-of-custody for data Nationwide Having a single standard for objects on the cloud. Interoperability patient data exchange allows for ease of passing data between There are multiple implementations of the blockchain, healthcare providers, which legacy these include Bitcoin,2 the cryptocurrency token systems often do not provide. implemented on the Blockchain; Ethereum,10 the Medical Device Medical device tracking from blockchain-based ledger that features a Turing-complete Tracking supply chain to decommissioning virtual machine allowing execution of code on the allows for swift retrieval of blockchain using smart contracts; and JP Morgan’s devices, prevention of unnecessary Juno,11 an Ethereum fork using a different consensus repurchasing, and fraud analytics. method known as Quorum as well as many other Drug Tracking As with medical devices, blockchain implementations. blockchain offers the capability to track the chain of custody from Consensus methods is one of the ways in which supply chain to patients, allowing blockchain implementations differ. Bitcoin, for example, for frictionless recalls and uses a Proof-Of-Work algorithm known as HashCash,12 prevention of counterfeit drugs. and is an intentionally expensive algorithm originally designed prevent denial-of-service attacks. All Bitcoin Within clinical trials, blockchain can be used to miners validate the blockchain by performing this proof- overcome the problems of fraudulent results and of-work algorithm as a vote towards the consensus on removal of data, which do not support the researcher’s the blockchain. Ethereum also uses a Proof-of-Work 13 bias or funding source’s intention. This will enforce algorithm, Ethash, as addressed in the Ethereum 10 integrity in clinical trials. In addition, it allows an Yellow Paper, based on the Dagger-Hashimoto 14 immutable log to be kept of trial subject consent. It is algorithm. Ethereum will, however, move to a Proof- thought that the pharmaceutical industry could benefit Of-Stake Algorithm, Casper, in the future. This is to with savings of $200 billion in defining a chain-of- address the extreme energy requirements of Proof-Of- custody in the supply chain.8 Work, made clear by both Ethereum and Bitcoin using 15 similar amounts of electricity to all of Ireland. With health insurance, many areas could benefit from a trusted record of events around the patient pathway, Ethereum also differs from Bitcoin due to its including improved reporting around incidents and implementation of smart contracts. Smart contracts are automating underwriting activities. Contracts could also pieces of code executed on every node on the be clearly defined and then enacted, such as automated blockchain. They are self-executing contracts in which payments for parts of the patient pathway. the agreement is enforced on all members of the blockchain. They set out the benefits, obligations and CURRENT IMPLEMENTATIONS penalties associated with behavior related to the contract Blockchain Implementation like the way a traditional contract works. As they mimic A blockchain is ostensibly a chain of blocks secured by traditional paper contracts and laws, they can be used, cryptographic techniques. One of the features most for example, to model the HIPAA healthcare personal

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Page 3 of 7 health information (PHI) workflow to meet regulatory consent log gives clinical trial subjects ownership of and audit requirements, such as is implemented within their own data while providing an audit trail for clinical Patientory.16 staff, researchers, and regulators.

A different type of blockchain trust model is also Data Sharing emerging, that of trust in the consortium. Microsoft has Data sharing represents one of the greatest opportunities recently developed a framework named Coco which for improvements in healthcare but also one of the allows for blockchain agnostic consortiums to be largest privacy challenges. Indeed, Powles and Hodson22 created.17 These consortium models rely on a pre-defined address the need to provide transparency on how patient group of trusted parties. In healthcare this may be data are shared with 3rd parties using the case study of multiple hospitals or in the UK, NHS Trusts, as well as the DeepMind collaboration with Royal Free London medical device manufacturers and third parties. NHS Foundation Trust. The lack of patient consent in the previous case study is addressed as one of the most By executing smart-contracts solely on these trusted significant issues, despite the positive effect Google’s partner’s hardware, consensus is generated without the product suite had on patient diagnosis and treatment. On need for miners. This has resulted in a significantly the opposite end of the spectrum, IBM and the American greater performance with a Coco-optimized blockchain Sleep Apnea Association23 are using IBM’s Watson instance able to process 1600 transactions per second, a supercomputer to study sleep apnea in thousands of performance improvement bringing blockchain much Americans at home, with clear and informed consent closer to the big payment processors.18 Coco is also from patients to solve major challenges in healthcare. agnostic of trusted execution environments allowing the use of Intel Software Guard Extensions, Windows It is important to have a nationwide standard for Virtual Secure Mode and Arm TrustZone among others. interoperability in IT services in healthcare. This has been underlined in a UK NHS white paper written by Clinical Trials Wachter and Hafter24 in a comparison with the U.S. Clinical trials and the management of trial subject healthcare system, which underlined the importance of consent are an area where blockchain has the potential to interoperability in allowing access to patient Electronic increase transparency, auditability and accountability of Health Records (EHRs) across multiple hospitals, as medical practitioners and researchers.19 many trusts have different systems built by different vendors for accessing these records. And as shown in the By maintaining an immutable log of patient consent, U.S., this creates issues for doctors and nurses. Social regulators can easily monitor clinical trial standards, care and mental health are reported as having suffered as ensuring that the trial meets the country’s informed in both the U.S. and UK it is still mostly paper-based. consent regulations. This is particularly important as fabricated informed consent forms have been among the Medical device asset tracking is a current problem most common type of clinical fraud.20 this includes within the healthcare sector. A report by Harland editing records and falsifying patient consent, which Simon25 on a project justifying RFID tagging in NHS indicates that a level of trial subject authentication would Cambridgeshire asserted that 15% of a hospital’s assets be required to prevent this. This system could be further are lost every year, representing a significant cost in augmented; as proposed by Benchoufi, Porcher and repurchasing items the hospital already has. Ravaud,21 implementing a smart contract system that Additionally, according to a report published by GE prevents clinicians from using patient data until a key Healthcare [26] nurses spend an average of 21 minutes has been released at the end of an auditable smart per shift searching for devices and beds that have been contract process requiring consent at each stage of the misplaced with many hospitals, according to the study, trial. This process should also allow for the revocation of defining any device below $5000 consumable and to be patient consent. Implementing a blockchain clinical trial repurchased if they can’t be found representing

Blockchain in Healthcare Today™ ISSN 2573-8240 online https://doi.org/10.30953/bhty.v1.8

Page 4 of 7 significant cost in the sector. By adopting radio- accepted fact in medical records where all healthcare frequency identification (RFID) standards for medical providers have access to this ledger. This means that device tracking, NHS Forth Valley in Scotland, though the user-interfaces may be different, their central according to another study published by Harland ledger will be identical across all providers. A challenge Simon27 were able to save almost £400,000 in cost that exists relates to the current state of health records avoidance due to not having to purchase significant across providers, which contain significant amounts of medical devices that would have otherwise been lost to the same information under different identifiers that may the system. not be linked. This creates duplication and as the blockchain grows, the performance degrades and this Drug tracking is a different problem entirely to medical level of replication of data across records would require device tracking, as the main concern is counterfeit drugs. deduplication to maintain a reasonably performant A study by the WHO28 identified that as many as 10% of system with unique, anonymized identifiers to identify the pharmaceutical supply in the U.S. is counterfeit. The patients across all services. This is a business challenge Food and Drug Administration (FDA) in the US recently in and of itself of adopting a blockchain health record, it endorsed the use of RFID to track pharmaceuticals from is important to note that health records would not start the supply chain to the patient. This allows the complete from zero as they would have to replace the existing chain of custody to be monitored, ensuring that the system which creates challenges. hospitals have bought the pharmaceuticals from a legitimate source. Pfizer29 was the first pharmaceutical Additionally, the sheer volume of data generated in company to adopt RFID “e-pedigree” where patients and healthcare environments, which is only set to increase doctors could trust the source and capabilities of their further, with Kaiser Permanente believed to have flagship medicine, Viagra, as they identified that it was between 26 and 44 petabytes of data on its 9 million among their most counterfeited drugs. This system has members from EHRs and other medical data in 2014.31 allowed wholesalers and pharmacists to verify the The volume of data logged and referenced to will only authenticity of their Viagra using a simple RFID scanner add to this scalability problem. with the cost to Pfizer being low due to the use of low- cost passive RFID tags & barcodes. Drug Tracking Drug tracking on the blockchain is another opportunity Patient Records as it leverages the immutability of the blockchain to Blockchain has significant power to disrupt healthcare develop tracking and chain of custody from and put data in the hands of patients. One particularly manufacturer to patient. Chronicled is a technology start- interesting move towards this is MedRec,30 which gives up company developing their product, Discover,32 which patients and doctors an immutable log of healthcare creates a chain of custody model showing where the records. It takes a different approach to incentivization drug was manufactured, where it has been since, and for miners by giving access to anonymized healthcare when it has been disbursed to patients, leveraging the data in exchange for sustaining the network. MedRec immutability of the blockchain to prevent fraud and theft uses Smart Contracts to map Patient-Provider of pharmaceuticals. This allows healthcare providers to Relationships (PPRs) where the contract shows a list of meet current healthcare standards regarding references detailing the relationships between nodes on pharmaceutical supply security, again with an emphasis the Blockchain. It also puts PPRs in the hands of the on interoperability between healthcare providers. patient, giving them the ability to accept, reject, or Hyperledger,33 the Open-Source Blockchain Working modify relationships with healthcare providers such as Group, recently launched the Counterfeit Medicines hospitals, insurers, and clinics. Project34 focusing on the problem of counterfeit pharmaceuticals. Using Blockchain, the origins of Blockchain offers an opportunity for interoperability in counterfeit medicines can be traced and removed from healthcare systems as having a decentralized ledger of the supply chain.

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become a multi-million-dollar problem both in the US The advantage of blockchain in drug tracking over and the UK.37,38 traditional means is the decentralization of trust and authority inherent in the principles behind the As well as traditional theft, this immutability also technology, where central authorities can be bribed or prevents devices being lost and reordered, which incurs a faked it is much harder to bribe a consensus of those on significant cost both in terms of the care provided and in the blockchain. For this reason, the current industry actual equipment costs. This system should not add standard in pharmaceutical tracking, ePedigree,29 which significant additional workload to a nurse, porter or currently uses RFID and a traditional database is moving support worker, as it would only require a tap on the towards their own blockchain solution. If device with the mobile phone or scanner and then pharmaceuticals can be modified and tracked using entering of the current location of the device. blockchain’s inherent anti-tampering capabilities at the point of manufacture, counterfeit pharmaceuticals can be While the application of blockchain within the Internet completely removed from participating supply chains. of Things (IoT) is fast developing, Huh39 defines a way for devices to intercommunicate through an Ethereum Device Tracking blockchain and use an RSA public key system. In this Medical device tracking is another opportunity for the way, a device stores their public key on the blockchain blockchain in disrupting healthcare from manufacturer to and the associated private key is stored on the device. decommissioning. The monetary savings created by asset tracking are clear, NHS East Kent Hospital found CONCLUSIONS that as a result of a case study by Harland Simon35 in Proofs of concept have been developed which bring which they implemented active RFID trackers on their blockchain technologies into the healthcare industry high waste equipment they found 98 infusion pumps however there are still many barriers to adoption. One of they had no idea they still owned across three sites. At a the most significant barriers will be the inherent cost of $1,500 each they saved $147,000 due to this resistance of the healthcare industry to change its current single case study. The use of the blockchain along with practices,40 especially relating to organizational, this technology offers the opportunity for an immutable structural, technological, and human factors. ledger, which shows not only where the device is but where it has been in its lifecycle, as well as which Funding Statement manufacturer, reseller, and the serial number are There was no public or private funding provided in the associated with the device, aiding regulatory creation of this work. compliance. This capability was addressed by Deloitte7 in a white paper as one of the potential game-changers Conflict of Interest: None for blockchain in the healthcare sector. Indeed, an IBM study36 showed that 60% of government stakeholders in Copyright holder: Edinburgh Napier University, 10 healthcare believe that medical device integration and Colinton Road, Edinburgh. EH10 5DT asset management are the greatest areas for disruption in the sector. References 1. Courbe J. Financial services technology 2020 and A blockchain approach offers several benefits over beyond: embracing disruption. PWC. 2016. p. 48. traditional location tracking products. The most obvious 2. Nakamoto S. Bitcoin: A peer-to-peer electronic of which is the immutability and tamper-proof qualities cash system. www.bitcoin.org, 2008. p. 9. of the Blockchain. This prevents a malicious user from 3. Accenture. Three technologies that are changing the changing the location history of a device or deleting it financial services game. How visionaries are from record. This is particularly important factor exploiting digital technology to reshape the future considering that medical device theft and shrinkage has of financial services. 2016.

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4. Boucher P. What if blockchain technology 19. Roma P, Quarre F, Israel A, et al. Blockchain: an revolutionised voting? European Parliament. 2016. enabler for life sciences and healthcare blockchain: 5. Deloitte. Blockchain in commercial real estate. The an enabler for life sciences healthcare. Delotte. future is here! 2017. 2016. pp. 1–16. 6. Korpela K, Hallikas J, Dahlberg T. Digital supply 20. Barrett J. Fraud and Misconduct in Clinical chain transformation toward blockchain integration. Research. Princ Pract Pharm Med. Second Ed. Proc. 50th Hawaii Int. Conf. Syst. Sci. 2017. p. 2007;4(2):631–41. 4182–91. 21. Benchoufi M, Porcher R, Ravaud P. Blockchain 7. Krawiec R, Barr D, J. Killmeyer J, et al. protocols in clinical trials: transparency and Blockchain: opportunities for healthcare. NIST traceability of consent. F1000Research. 2017;6:66. Work. Blockchain Healthc., August, pp. 1–12, 22. Powles J, Hodson H. Google DeepMind and 2016. healthcare in an age of algorithms. Health Technol 8. F. & Sullivan, “Why Healthcare Industry Should (Berl). 2017;7(4):351-67. Care About Blockchain?,” 2017. [Online]. 23. Fraser H, Kwon Y, Neuer M. The future of Available: connected health devices. Life Sci. 2011. p. 20. https://ww2.frost.com/files/8615/0227/3370/Why_H 24. Wachter K. Making IT work: Harnessing the power ealthcare_Industry_Should_Care_About_Blockchain _Edited_Version.pdf. [Accessed: 28-May-2018]. of health information technology to improve care in 9. Liang X, Shetty S, Tosh D, et al. ProvChain: A England. Report of the National Advisory Group on Blockchain-based data provenance architecture in Health Information Technology in England. 2016. cloud environment with enhanced privacy and 25. Booth C, Jarritt P, Dawkins S. The Role of RFID in availability. 17th IEEE/ACM Int. Symp. Clust. managing mobile medical devices. Harl. Simon, Cloud Grid Comput. 2017. pp. 468–77. 2013. pp. 1–28. 10. Wood G, Ethereum: a secure decentralised 26. Horblyuk R, Kaneta K, Mcmillen GL, et al. White generalised transaction ledger, Ethereum Proj. paper: out of control. How clinical asset Yellow Pap. 2014. pp. 1–32. proliferation and low utilization are draining 11. Martino W, Popejoy S, Schroeder B, and Kent L, healthcare budgets. GE Healthc. 2012. Juno distributed cryptoledger. CIB New Product 27. Hynd B, Physics M, Valley NHSF. Healthcare Development. 2016. science final report on test of change passive RFID 12. Back A. Hashcash - A denial of service counter- tracking of mobile medical devices within forth measure. Adam Beck. 2002, valley royal hospital. 2017;1:1–8. http://Www.Hashcash.Org/Papers/Hashcash.pdf. 28. WHO, International medical products anti- 13. Ethereum. Ethash. 2017. counterfeiting taskforce (IMPACT). 2010. 14. Ethereum. Dagger Hashimoto Algorithm. 2015. 29. Bacheldor B. Pfizer prepares for Viagra E-Pedigree 15. O’Dwyer KJ, Malone D. Bitcoin mining and its Trial. RFID J. 2007. energy footprint. 25th IET Irish Signals Syst. Conf. 30. Azaria A, Ekblaw A, Vieira T, Lippman A. 2014 2014 China-irel. Int. Conf. Inf. Communities MedRec: using blockchain for medical data access Technol. (ISSC 2014/CIICT 2014), 2014. pp. 280– and permission management. Proc. - 2016 2nd Int. 5. Conf. Open Big Data, OBD 2016. pp. 25–30. 16. McFarlane C, Beer M, Brown J, Prendergas N. 31. Raghupathi, R Raghupathi V. Big data analytics in Patientory: a healthcare peer-to-peer emr storage healthcare: promise and potential. Heal. Inf. Sci. network v1.0. 2017. Syst. 2014;2(1):3. 17. Microsoft. The Coco Framework. 2017. 32. Chronicled, Chronicled - Supply Chain 18. Microsoft. Microsoft announces the Coco Compliance. 2017. Framework to improve performance, confidentiality 33. Hyperledger. Hyperledger. 2017. . and governance characteristics of enterprise 34. Taylor P. Applying Blockchain Technology to blockchain networks. 2017. Medicine Traceability. 2016.

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35. Simon H. Case study tracking medical devices with project planning, implementation and evaluation. RFID. 2014. Int. J. Med. Inform. 2017;97:86–97. 36. IBM Institute for Business Value. Healthcare rallies for blockchains. 2016. Supplementary data: None 37. ADT Services. Preventing shrinkage and equipment losses in hospitals, 2011. This is an open access article distributed in accordance 38. Auditor General for Scotland. Equipped to care with the Creative Commons Attribution Non- managing medical equipment in the NHS in Commercial (CC BY-NC 4.0) license, which permits Scotland. 2001. others to distribute, adapt, enhance this work non- 39. Huh S, Cho S, Ki S., Managing IoT devices using commercially, and license their derivative works on blockchain platform. 2017, 19th International different terms, provided the original work is properly Conference on Advanced Communication cited as first published in Blockchain in Healthcare Technology (ICACT), 2017. pp. 464–467. Today™, and the use is non-commercial. See: 40. Sligo J, Gauld R, Roberts V, Villa L. A literature http://creativecommons.org/licenses/by-nc/4.0 review for large-scale health information system

Blockchain in Healthcare Today™ ISSN 2573-8240 online https://doi.org/10.30953/bhty.v1.8