BLOCKCHAIN TECHNOLOGY APPLIED IN MEDICINE: A SYSTEMATIC REVIEW

ABSTRACT

Objective: Develop an articles review to evaluate the existing evidence on blockchain technology applied in medicine.
Methods: The study was of a documentary type, bibliographic design, framed in a systematic review. The harvest of articles was carried out in the Scopus, Web of Sciences, Pro Quest and ScienceDirect databases from January 1, 2018 to July 31, 2023. The descriptors were blockchain, technology and medicine. The PRISMA diagram was prepared considering the inclusion criteria: original articles, with open access; that address the subject and in any language. The search yielded 70 articles, of which 11 formed the sample.
Results: The various applications of blockchain technology in medicine were discussed, including its integration with artificial intelligence (AI) for data-centric analysis; regarding the development of traceability systems, however, its greatest applicability is in the registration of medical records of patients, whose application was successful. Despite this, its incipient use in medicine was verified due to the lack of studies in this regard.
Conclusions: The application of blockchain technology in medicine is very scarce, despite the potential it has for the registration and safeguarding of medical data, therefore, its study should be deepened.

Keywords: blockchain, artificial intelligence, traceability, medical records (Source: MeSH).


RESUMEN

Objetivo: Desarrollar una revisión de artículos para evaluar la evidencia sobre la tecnología blockchain aplicada en la medicina.
Métodos: El estudio es de tipo documental, diseño bibliográfico, enmarcado en una revisión sistemática. La recolección de los artículos se realizó en las bases de datos Scopus, Web of Sciences, Pro Quest y SienceDirect, desde el 1 de enero de 2018 hasta el 31 de julio de 2023. Los descriptores fueron blockchain, tecnología y medicina. Se elaboró el diagrama PRISMA y se consideró los criterios de inclusión: artículos originales, con acceso abierto que aborden el tema y en cualquier idioma. Se hallaron 70 artículos, de los cuales 11 conformaron la muestra.
Resultados: Se analizaron las diversas aplicaciones de la tecnología blockchain en la medicina, entre ellas su integración con inteligencia artificial (IA) para el análisis centrado en datos; en cuanto al desarrollo de sistemas de trazabilidad, sin embargo, su mayor aplicabilidad está en el registro de historias médicas de pacientes, cuya aplicación fue exitosa. A pesar de esto, se comprobó su uso incipiente, en la medicina, debido a la ausencia de estudios al respecto.
Conclusiones: La aplicación de la tecnología blockchain en la medicina es muy escasa, a pesar del potencial que posee para el registro y resguardo de datos médicos; por lo tanto, se debe profundizar el estudio de la misma.

Palabras clave: blockchain, inteligencia artificial, trazabilidad, historias médicas (Fuente: DeCS-BIREME)

INTRODUCTION

Given the undeniable technological advancements in the field of medicine, there arises the need to incorporate blockchain technology into this area, which involves a database that allows for the collection and storage of large amounts of information that can be shared in a decentralized manner. Its growth has been substantial over the last decade. Considered as the fundamental basis of cryptocurrencies, including Bitcoin, various authors have analyzed its application in other fields due to its characteristics of security and privacy. In this regard, it has been used in medicine for different purposes, such as data recording, transactions, and maintenance through smart contracts ⁽¹⁾.

Indeed, the emergence of blockchain technology, as a responsible and transparent way to store and distribute information, is creating the foundation to address serious issues of privacy, security, and data integrity in the field of medicine ⁽²⁾. In a general context, blockchain technology is a tool for the distributed ledger of digital data transactions through a peer-to-peer (P2P) network, which can be distributed publicly or privately to users, allowing for the reliable and verifiable storage of any type of information ^{(3, 4)}.

On the other hand, unlike other types of databases managed by third parties, blockchain is a decentralized chain of blocks, implying that no single user can control its transactions personally. Decentralization is a fundamental characteristic of blockchain, as it gives control to the system rather than the user, allowing for greater transparency and security ^{(5, 6)}.

Within this framework, the management of blockchain technology has five basic principles: the first is constituted in data control, which is independent; that is, no one controls the data, however, each user can verify their records; the second is communication, which only occurs between peers; the third indicates that users can remain anonymous or provide proof of their identity; the fourth principle refers to the fact that current transactions cannot be changed; finally, the fifth principle indicates that each transaction is linked to the previous one ^{(7, 8)}.

Among the challenges facing the medical industry, one of the principals is the lack of secure and reliable mechanisms for data storage and access. In this sense, blockchain technology allows information to be stored and shared in a secure and decentralized way, which restricts unauthorized individuals from modifying it. Additionally, this technology has the ability to track the history and authenticity of medical products, such as prescribed medicines and medical devices. This capability allows for the identification of adulterations and ensures that patients receive genuine and safe medications.

In this context, blockchain provides a mechanism for pharmaceutical companies to achieve complete traceability of a medication, allowing them to reliably access production data, reported side effects, and supervision of the necessary conditions for its transportation and storage ⁽¹¹⁾.

In this regard, the study by Farahat et al. ⁽¹²⁾ proposes the design of an IoMT (Internet of Medical Things) system to store patients' medical information, which is remotely sent via the internet. The proposed model suggests that each medical record is stored through blockchain technology, using a block connected to the previous one by a hash function: a cryptographic operation that produces unique and irreversible identifiers from a given data ⁽¹³⁾.

Similarly, the study by Sonkamble et al. ⁽¹⁴⁾ addresses the decentralized management of patients' medical data within the framework of blockchain-based electronic health records (EHR) to ensure confidentiality, access control, and record privacy. The architecture of this model was patient-centered and focused on the secure storage control of their data in EHRs. Likewise, the study by Mendoza et al. analyzes the use of blockchain to generate an algorithm that develops a smart contract for users of a medical records platform. This algorithm helps to solve the authentication and reliability issues of access to healthcare platforms. The study proposes an algorithm in which medical history management operations are executed and integrated automatically in a distributed environment.

In a different context, the study by Albakri & Alqahtani proposes the development of an IoMT through an intelligent blockchain-based smart healthcare system, which employs encryption with an optimal deep learning model (BSHS-EODL). The BSHS-EODL method allows for the secure transmission of blockchain-assisted images and diagnostic models for the IoMT environment. This model combines data classification, data collection, and image encryption. Despite these evidences, there are a number of challenges associated with the use of blockchain technology for designing medical information networks, including patient perception towards such networks, security and privacy risks, transparency in data exchange, processing requirements, and implementation costs ^{(16, 17)}.

Additionally, there are inherent limitations and restrictions of blockchain technology, such as mining incentives, mining threats, key management, as well as data security and confidentiality; not to mention legislative constraints, the absence of laws regulating the use of blockchain technology in medicine, which generally require permissions, scalability, and agreements for sharing records ⁽¹⁹⁾.

One of the most relevant aspects for adopting blockchain technology in medicine is data security. In this regard, most healthcare providers and hospitals have improved their data security precautions. However, current firewalls for medical data can hinder medical research and collaboration in healthcare treatment. On the contrary, cloud computing and the use of big data involve sharing medical data among various users and organizations, which is necessary to enable analysis and provide more effective healthcare services, as well as innovative treatment plans ^{(20, 21, 22)}.

Indeed, with the application of blockchain, the widespread use of patients' medical information could pose challenges in terms of processing, costs, and limited scalability. At the same time, ethical dilemmas may arise, as improper handling could compromise or infringe upon patients' right to maintain the anonymity of their medical history ^{(23, 24, 25)}.

Considering that the security and privacy of medical data are crucial elements that must be ensured, it is essential to preserve the confidentiality, integrity, and authentication of the server during data transfer. The main goal is to share health data in a practical way, using various approaches to achieve the ultimate goals. Blockchain-based storage and infrastructure platforms offer a new perspective in medical informatics, with several advantages over traditional methods ^{(26, 27, 28)}.

However, there are several examples of this model implemented in medicine, such as MedicalChain, designed to address issues such as slow access times to medical information, the disaggregation of a patient's records across different medical institutions, and security risks in safeguarding medical information, among others. To address these issues, the proposal suggests that patients have a single verified and reliable electronic record containing their entire medical history that can be shared with doctors to facilitate new diagnoses ⁽²⁹⁾.

Similarly, various proposals have been developed, such as the case of Lluncor et al. ⁽³⁰⁾, who developed a blockchain-based model with the purpose of preventing the alteration of forensic medical reports from the Instituto de Medicina Legal y Ciencias Forenses of Cajamarca, Peru. The proposal considers an improved model based on blockchain technology to strengthen the security of the content of FME reports, generated through the DICEMEL System (Central Forensic Medical Division System). These reports are processed in the administrative and medical fields and are requested by competent authorities such as the Peruvian National Police, Criminal Prosecution Offices, DEMUNA, and the Judiciary, among others.

Currently, IBM is immersed in the development of its Healthchain initiative, which aims to centralize patients' medical information in Latin America through the implementation of blockchain technology on IBM Cloud. This initiative seeks to enhance patient care by promoting precision medicine and automating administrative tasks, while ensuring the integrity of the information. Additionally, the application of blockchain could increase the effectiveness of diagnoses made by AI robots by collecting large volumes of validated information ⁽³¹⁾.

Based on the foregoing considerations, the execution of the present systematic review study is proposed with the aim of evaluating the evidence on blockchain technology applied in medicine. In summary, the study aims to determine the scientific information about blockchain technology applied in medicine, in order to systematize the studies and the most relevant findings achieved in the field and establish recommendations. On the other hand, the first specific objective consists of identifying the applications that have been given to blockchain technology in medicine, in order to evaluate the current scope of application. Meanwhile, the second specific objective refers to specifying the findings obtained in the studies where blockchain technology was applied in medicine, with the purpose of evaluating its performance and establishing the respective conclusions.

MATERIALS AND METHODS

Type and design of the research

The study is documentary in nature, characterized by focusing on the process of searching, analyzing, and interpreting secondary information, obtained from studies conducted by other authors from documentary sources ⁽³²⁾. Likewise, the design is bibliographic, which consists of interpreting data reported by bibliographic sources or if there is not enough knowledge to obtain information from reality ⁽³³⁾.

Furthermore, the present study was framed in a systematic review, which the Cochrane Handbook for Systematic Reviews of Interventions ⁽³⁴⁾ defines as studies with clear objectives, pre-defined eligibility criteria, explicit and repeatable methodology, systematic search, assessment of validity, organized presentation, synthesis of characteristics, and results of the same.

Additionally, the present study was based on the Preferred Reporting Item for Systematic Reviews (PRISMA) declaration. This methodology is a guide for conducting comprehensive systematic review studies, for which advances in techniques for selecting, analyzing, and synthesizing research are considered ⁽³⁵⁾.

Search strategies

The articles for the systematic review were searched in the databases: Scopus, Web of Sciences, Pro Quest, and ScienceDirect, and the specific search engines of each one were used. The search process was conducted from January 1, 2018, to July 31, 2023. For this purpose, a series of descriptors or keywords were used to accurately identify studies developed on the topic. In this regard, the defined descriptors were blockchain, technology, and medicine, which were searched within the title of each publication using the boolean operator: And.

Search procedure

The study was developed following the procedure described in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement, launched in 2009 with the purpose of assisting authors of systematic reviews in transparent documentation of the rationale behind the review, actions taken by the authors, and findings obtained. The updated PRISMA 2020 version replaces the 2009 edition and incorporates a new presentation guide for publications, reflecting advances in methods used to identify, select, evaluate, and synthesize studies ^{(36, 37)}.

According to Linares et al. ⁽³⁸⁾, it is crucial that the review process be meticulously planned from the beginning to minimize biases and discard irrelevant or low-quality studies. A systematic review involves the preparation of a critical and reproducible summary of the results present in publications related to a specific topic or question. With the aim of improving scientific writing, the methodology for conducting a systematic review should be presented in a structured manner.

To determine the population and sample of the study, the flow diagram contemplated in the PRISMA methodology was elaborated, which, according to Ciapponi ⁽³⁹⁾, should describe the various phases of the process: identified records, number of studies included and excluded, and reasons for exclusions. The PRISMA diagram was elaborated considering the following inclusion criteria for articles: 1) original, 2) open access, 3) addressing blockchain technology applied in medicine, 4) developed in any language. Additionally, systematic review articles, letters to the editor, and expert opinions were excluded.

Selection of studies

With the initial search, 70 publications were obtained, and the four selected databases were considered, after applying the descriptors, the Boolean operator, and the defined date range. To refine this search, the previously established inclusion criteria were applied; in this sense, 52 studies were excluded, and the search was reduced to 18 publications, which were reviewed for compliance with the inclusion criteria in terms of title and abstract. Consequently, six duplicate articles were excluded, and one for not containing the variables in the title. Consequently, the sample consisted of 11 articles.

Figure 1 shows the PRISMA diagram, which describes the process of search, identification, and selection of the definitive sample of this systematic review study. Similarly, in Figure 2, the number of articles identified in each database in the initial search is presented; it is noteworthy that most publications are indexed in ScienceDirect. Similarly, in Figure 3, the number of articles in the sample published each year is described; in this regard, most of the work was developed during the years 2022 and 2023.

Additionally, these 11 publications underwent a quality evaluation process that allowed conclusions focused on their findings to be derived, and also identified observed limitations, with the aim of conducting a reproducible and bias-free verification. Although there are currently different tools for evaluating the quality of systematic reviews, this study opted to use a verification method that includes the aspects presented in Table 1.

RESULTS

Scientific information about blockchain technology applied in medicine

The selected articles were tabulated considering various aspects: author, publication date, title, journal, and methodology employed, as shown in Table 2. Consequently, the analysis of the information highlights the following: only one article was published in the years 2018, 2019, and 2020, while two in 2021 and three in the years 2022 and 2023. Furthermore, the articles were published in nine different journals. On the other hand, three were developed under a qualitative methodology, while the remaining eight according to a mixed methodology.

Applications of blockchain technology in medicine and studied populations

Table 3 presents the most used applications of blockchain technology in medicine; according to the studies that formed the sample, the following stood out: integration with artificial intelligence (AI) for data-centric analysis and information flow in cardiovascular medicine, traditional Chinese medicine (TCM) traceability system, data management for healthcare, electronic medical records management, clinical research, detection of medical fraud, neuroscience, pharmaceutical industry, and biobank management, among others.

Findings obtained in studies where blockchain technology was applied in medicine

The results achieved in the studies that make up the sample are presented in Table 4, highlighting the findings in the use of blockchain to facilitate integration with AI, to establish secure data management, or healthcare platforms. Likewise, results of blockchain use in healthcare systems are presented, to record clinical data and use data standards that can be replicated by other organizations.

DISCUSSION

The evidence in the selected databases related to the application of blockchain technology in medicine reflects the few studies developed in this regard. Indeed, 70 publications were identified, of which 11 were selected that met the inclusion criteria. It was found that all studies were published in nine different English-language journals, and there were publications in each year of the delimited period. Regarding the topics addressed, various applications and characteristics of blockchain technology in medicine stand out.

In this regard, the studies by Li et al. ⁽⁴⁰⁾, Xiao et al. ⁽⁴¹⁾, and Liu et al. ⁽⁴²⁾ addressed the application of blockchain technology to design a secure traceability system for managing traditional Chinese medicine and drug production by pharmaceutical companies.

On the other hand, the studies by Siyal et al. ⁽⁴³⁾, Radanović & Likić ⁽⁴⁴⁾, Krittanawong et al. ⁽⁴⁵⁾, Tan et al. ⁽⁴⁶⁾, and Garrido et al. ⁽⁴⁷⁾ propose the analysis and design of application proposals based on blockchain technology in the field of medicine, as well as the opportunities and challenges of its integration with other technologies such as AI, to design networks or data storage systems in medicine.

This coincides with the study by Kumar et al. ⁽¹⁾ who describe various algorithms to solve supervised and unsupervised machine learning problems, combined with deep learning algorithms such as neural networks and different platforms using blockchain technology driven by AI in the field of public health. It also discusses how AI can improve disease identification and diagnosis, and similarly, blockchain can improve the security of medical records, preserving the privacy of record owners.

In the study by Ait et al. ⁽⁴⁸⁾, the construction of a digital medical passport based on blockchain technology is highlighted, aiming to ensure the security and privacy of medical data for Moroccan government entities. Regarding the study by Ortiz et al. ⁽⁴⁹⁾, blockchain is proposed to improve the security, integrity, and traceability of processes executed in a biobank.

Similarly, the study by Azaria et al. ⁽¹⁷⁾ proposes a system called MedRec, designed as a decentralized medical record management system based on blockchain technology. The system provides patients with a complete and unalterable record, easy access to their medical information, and treatment sites. Using blockchain characteristics, MedRec manages authentication, confidentiality, accountability, and data exchange, fundamental aspects in managing confidential information.

Finally, the study by Rehman et al. ⁽⁵⁰⁾ evaluated the application of blockchain technology combined with IoMT and federated learning for healthcare 5.0, by building a health monitoring system.

These findings coincide with the study by Albakri & Alqahtani ⁽¹⁶⁾, who developed a new technique BSHS-EODL for the transmission and analysis of medical images in the IoMT environment, which allows for secure diagnosis and image transmission assisted by blockchain for the IoMT platform. This method includes data classification and collection, as well as image encryption.

Likewise, the study by Pava et al. ⁽¹¹⁾ proposes that the application of blockchain in clinical data administration and IoMT medical device management allows the generation of a P6 healthcare model, as it facilitates the management of decentralized patient medical data.

Also, in the study by Ichikawa et al. ⁽¹⁸⁾, the incorporation of smartphones into a blockchain-based network for medical data recording is proposed. In this sense, electronic medical records were collected via smartphones and successfully sent to a private Hyperledger Fabric blockchain network. The mHealth application information was updated without network failures. Additionally, it was ensured that all medical information recorded in the blockchain network is resistant to manipulation and review.

The application of blockchain technology in medicine has sparked intense debate about its clinical relevance and its influence on current and future medical practice. According to Siyal et al. ⁽⁴³⁾, the transparency and immutability of medical records in a blockchain can improve diagnosis accuracy and patient monitoring, reduce medical errors, and enhance care coordination. However, Rehman et al. ⁽⁵⁰⁾ argue that the complexity of implementing this technology, along with concerns about data privacy and security, pose considerable challenges. The crucial question is whether the potential benefits of blockchain technology, such as data interoperability and traceability, will outweigh the obstacles and translate into real transformation in medical practice or whether this innovation will remain as a promising concept but not fully realized.

However, this study has limitations such as the limited number of publications analyzed. It is a brief investigation that, as previously mentioned, was based exclusively on four databases. Additionally, the adoption of this technology in medical environments is still in its early stages, limiting the availability of robust data and use cases for analysis. Also, the complexity of implementing blockchain systems in healthcare infrastructure, along with the need to ensure the security and privacy of patient data, poses a significant challenge. Interoperability between different blockchain-based electronic medical record systems is also a pending issue. Finally, addressing regulatory and ethical concerns related to ownership and access to health information stored on a blockchain is essential.

Future studies could focus on developing specific standards and regulatory frameworks for managing health data in blockchains, thus addressing privacy and security concerns. Additionally, exploring interoperability between electronic medical record systems based on blockchain is needed to ensure effectiveness in clinical practice. Research on integrating smart contracts to automate medical processes and exploring applications in medical research and clinical trials also represent areas of growing interest. In summary, future research in this area has the potential to significantly shape and improve healthcare and health data management in an increasingly digital context.

CONCLUSIONS

In the present systematic review study, the existence of 11 publications related to the research topic was confirmed. Despite considering four databases: Scopus, Web of Sciences, Pro Quest, and ScienceDirect, and a six-year search period (2018 to 2023), the presence of few investigations based on the application of blockchain technology in medicine was noted. Furthermore, most of the studies in which this technology was implemented aimed to configure a system of integration with other technologies such as AI to build networks or medical records storage systems.

The findings reflect the potential of blockchain technology for the development of data storage systems, data security and privacy in medical data, secure traceability of production, medication control, and its combination with IoMT to develop health monitoring systems. However, the great future potential of this technology in the management of medicine and people's health is envisioned.

On the other hand, the study presented certain limitations: only four databases were used, which resulted in a low number of studies comprising the sample; moreover, currently, the application of this technology in the field of medicine is in its early stages; therefore, few analytical cross-sectional studies were found to delve into the findings.

Consequently, it is recommended to conduct primary studies to analyze the implications of adopting blockchain technology in medicine, especially in other contexts that provide feasible solutions for managing and controlling healthcare systems.

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Authorship contributions: The author participated in the genesis of the idea, project design, data collection and interpretation, results analysis, and manuscript preparation of the present research work.
Financing: Self-financed
Declaration of conflict of interest: The author declares no conflict of interest.
Recevied: September 4, 2023
Approved: January 18, 2024

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Correspondence author: Christian Jairo Tinoco Plasencia
Address: Avenida Caminos del Inca 3075, Lima-Perú.
Phone: 978218729
E-mail: christian.tinoco@urp.edu.pe

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Article published by the Journal of the faculty of Human Medicine of the Ricardo Palma University. It is an open access article, distributed under the terms of the Creatvie Commons license: Creative Commons Attribution 4.0 International, CC BY 4.0 (https://creativecommons.org/licenses/by/1.0/), that allows non-commercial use, distribution and reproduction in any medium, provided that the original work is duly cited. For commercial use, please contact revista.medicina@urp.edu.pe.

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