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==Introduction==
==Introduction==
The healthcare domain has been revolutionized over the last century by technological advancement. [1] This revolution aims to improve the diagnosis of diseases and their causes, the quality of medical supplies, and the quality of medical treatment, as well as establish prevention plans on a global scale. The traditional client-server-based healthcare systems [2,3,4,5,6] suffer from [[Cybersecurity|security]] and privacy issues and lead to scattered patient’s medical history, delaying patient treatment. [7,8] Moreover, a patient needs to repeat medical tests when moving to another [[hospital]]. This increases the cost and time to the patient and affects the patient’s health due to repeated exposure to tests, such as X-rays and MRIs, each with their own potential side effects. [9] In addition, healthcare organizations are required to install and maintain infrastructure with up-to-date functionalities while complying with healthcare standards and regulations for the management of [[electronic health record]]s (EHRs). This leads to a high total cost of ownership. To address these limitations of the client-server-based approach, the on-premises database migrated to the [[Cloud computing|cloud]], where health records are maintained by a cloud service provider.
The healthcare domain has been revolutionized over the last century by technological advancement.<ref>{{Cite journal |last=Ismail |first=Leila |last2=Materwala |first2=Huned |last3=Karduck |first3=Achim P |last4=Adem |first4=Abdu |date=2020-07-07 |title=Requirements of Health Data Management Systems for Biomedical Care and Research: Scoping Review |url=https://www.jmir.org/2020/7/e17508 |journal=Journal of Medical Internet Research |language=en |volume=22 |issue=7 |pages=e17508 |doi=10.2196/17508 |issn=1438-8871 |pmc=PMC7380987 |pmid=32348265}}</ref> This revolution aims to improve the diagnosis of diseases and their causes, the quality of medical supplies, and the quality of medical treatment, as well as establish prevention plans on a global scale. The traditional client-server-based healthcare systems<ref>{{Cite journal |last=Rind |first=D. M. |last2=Kohane |first2=I. S. |last3=Szolovits |first3=P. |last4=Safran |first4=C. |last5=Chueh |first5=H. C. |last6=Barnett |first6=G. O. |date=1997-07-15 |title=Maintaining the confidentiality of medical records shared over the Internet and the World Wide Web |url=https://pubmed.ncbi.nlm.nih.gov/9230004 |journal=Annals of Internal Medicine |volume=127 |issue=2 |pages=138–141 |doi=10.7326/0003-4819-127-2-199707150-00008 |issn=0003-4819 |pmid=9230004}}</ref><ref>{{Cite journal |last=Schoenberg |first=R. |last2=Safran |first2=C. |date=2000-11-11 |title=Internet based repository of medical records that retains patient confidentiality |url=https://pubmed.ncbi.nlm.nih.gov/11073513 |journal=BMJ (Clinical research ed.) |volume=321 |issue=7270 |pages=1199–1203 |doi=10.1136/bmj.321.7270.1199 |issn=0959-8138 |pmc=1118958 |pmid=11073513}}</ref><ref>{{Cite journal |last=Uckert |first=Frank |last2=Görz |first2=Michael |last3=Ataian |first3=Maximilian |last4=Prokosch |first4=Hans-Ulrich |date=2002 |title=Akteonline-an electronic healthcare record as a medium for information and communication |url=https://pubmed.ncbi.nlm.nih.gov/15460705 |journal=Studies in Health Technology and Informatics |volume=90 |pages=293–297 |issn=0926-9630 |pmid=15460705}}</ref><ref>{{Cite journal |last=Grant |first=Richard W. |last2=Wald |first2=Jonathan S. |last3=Poon |first3=Eric G. |last4=Schnipper |first4=Jeffrey L. |last5=Gandhi |first5=Tejal K. |last6=Volk |first6=Lynn A. |last7=Middleton |first7=Blackford |date=2006-10 |title=Design and Implementation of a Web-Based Patient Portal Linked to an Ambulatory Care Electronic Health Record: Patient Gateway for Diabetes Collaborative Care |url=http://www.liebertpub.com/doi/10.1089/dia.2006.8.576 |journal=Diabetes Technology & Therapeutics |language=en |volume=8 |issue=5 |pages=576–586 |doi=10.1089/dia.2006.8.576 |issn=1520-9156 |pmc=PMC3829634 |pmid=17037972}}</ref><ref>{{Cite journal |last=Gritzalis |first=Dimitris |last2=Lambrinoudakis |first2=Costas |date=2004-03 |title=A security architecture for interconnecting health information systems |url=https://linkinghub.elsevier.com/retrieve/pii/S1386505603002144 |journal=International Journal of Medical Informatics |language=en |volume=73 |issue=3 |pages=305–309 |doi=10.1016/j.ijmedinf.2003.12.011}}</ref> suffer from [[Cybersecurity|security]] and privacy issues and lead to scattered patient’s medical history, delaying patient treatment.<ref>{{Cite journal |last=Ismail |first=Leila |last2=Materwala |first2=Huned |date=2020-06-22 |title=BlockHR: A Blockchain-based Framework for Health Records Management |url=https://dl.acm.org/doi/10.1145/3408066.3408106 |journal=Proceedings of the 12th International Conference on Computer Modeling and Simulation |language=en |publisher=ACM |place=Brisbane QLD Australia |pages=164–168 |doi=10.1145/3408066.3408106 |isbn=978-1-4503-7703-4}}</ref><ref>{{Cite journal |last=Ismail |first=Leila |last2=Materwala |first2=Huned |last3=Khan |first3=Moien AB |date=2020-07-08 |title=Performance Evaluation of a Patient-Centric Blockchain-based Healthcare Records Management Framework |url=https://dl.acm.org/doi/10.1145/3409934.3409941 |journal=Proceedings of the 2020 2nd International Electronics Communication Conference |language=en |publisher=ACM |place=Singapore Singapore |pages=39–50 |doi=10.1145/3409934.3409941 |isbn=978-1-4503-7770-6}}</ref> Moreover, a patient needs to repeat medical tests when moving to another [[hospital]]. This increases the cost and time to the patient and affects the patient’s health due to repeated exposure to tests, such as X-rays and MRIs, each with their own potential side effects.<ref>{{Cite journal |last=Chang |first=P. Y. |last2=Bjornstad |first2=K. A. |last3=Rosen |first3=C. J. |last4=McNamara |first4=M. P. |last5=Mancini |first5=R. |last6=Goldstein |first6=L. E. |last7=Chylack |first7=L. T. |last8=Blakely |first8=E. A. |date=2005-10 |title=Effects of Iron Ions, Protons and X Rays on Human Lens Cell Differentiation |url=http://www.bioone.org/doi/10.1667/RR3368.1 |journal=Radiation Research |language=en |volume=164 |issue=4 |pages=531–539 |doi=10.1667/RR3368.1 |issn=0033-7587}}</ref> In addition, healthcare organizations are required to install and maintain infrastructure with up-to-date functionalities while complying with healthcare standards and regulations for the management of [[electronic health record]]s (EHRs). This leads to a high total cost of ownership. To address these limitations of the client-server-based approach, the on-premises database migrated to the [[Cloud computing|cloud]], where health records are maintained by a cloud service provider.


Cloud computing<ref>{{Cite web |last=Mell, P.; Grance, T. |date=September 2011 |title=The NIST Definition of Cloud Computing |url=http://faculty.winthrop.edu/domanm/csci411/Handouts/NIST.pdf |publisher=National Institute of Standards and Technology |accessdate=27 May 2021}}</ref> allows convenient and on-demand network access to a shared pool of configurable computing resources. Motivated by the pay-as-use cloud model, medical organizations use cloud computing to manage EHRs, reducing the cost of ownership. The five-year cost of $11 million for an on-premises healthcare system can be reduced to $3.2 million using cloud. This also reduces the infrastructure set-up time from 16 weeks to one week (Healthcare system cost reduction using cloud-based approach.<ref>{{Cite web |last=Foote, E.; Montalto M. |date=21 October 2019 |title=How Cloud EHR Reduces Operating Costs, Increases Computing Power |work=EHR Intelligence |url=https://ehrintelligence.com/news/how-cloud-ehr-reduces-operating-costs-increases-computing-power |publisher=XTelligent Healthcare Media |accessdate=27 May 2021}}</ref> In addition, cloud computing provides multiple healthcare providers with efficient access to health records from a shared storage, improving patient care. The number of health records is increasing at a rapid pace with the introduction of smart healthcare and [[internet of things]] (IoT) devices with biosensors for personalized patient-centric healthcare. The scalability and elasticity of cloud computing aid in health records management, which requires powerful computing and large storage, for near real-time patient care. However, a cloud-based system suffers from the issues of security, i.e., data integrity, where the health records are under a constant threat of being modified, and privacy, i.e., unobservability or data leakage, in which the patients’ health records are being used without any tracking.<ref>{{Citation |last=Pfitzmann |first=Andreas |last2=Köhntopp |first2=Marit |date=2001 |editor-last=Federrath |editor-first=Hannes |title=Anonymity, Unobservability, and Pseudonymity — A Proposal for Terminology |url=http://link.springer.com/10.1007/3-540-44702-4_1 |work=Designing Privacy Enhancing Technologies |publisher=Springer Berlin Heidelberg |place=Berlin, Heidelberg |volume=2009 |pages=1–9 |doi=10.1007/3-540-44702-4_1 |isbn=978-3-540-41724-8 |accessdate=2021-10-29}}</ref>
Recent years have witnessed a bit of a revolution, with blockchain being adopted for many applications in the healthcare domain, such as health records management<ref>{{Cite journal |last=Azaria |first=Asaph |last2=Ekblaw |first2=Ariel |last3=Vieira |first3=Thiago |last4=Lippman |first4=Andrew |date=2016-08 |title=MedRec: Using Blockchain for Medical Data Access and Permission Management |url=http://ieeexplore.ieee.org/document/7573685/ |journal=2016 2nd International Conference on Open and Big Data (OBD) |publisher=IEEE |place=Vienna, Austria |pages=25–30 |doi=10.1109/OBD.2016.11 |isbn=978-1-5090-4054-4}}</ref><ref>{{Cite journal |last=Dagher |first=Gaby G. |last2=Mohler |first2=Jordan |last3=Milojkovic |first3=Matea |last4=Marella |first4=Praneeth Babu |date=2018-05 |title=Ancile: Privacy-preserving framework for access control and interoperability of electronic health records using blockchain technology |url=https://linkinghub.elsevier.com/retrieve/pii/S2210670717310685 |journal=Sustainable Cities and Society |language=en |volume=39 |pages=283–297 |doi=10.1016/j.scs.2018.02.014}}</ref><ref>{{Cite journal |last=Li |first=Hongyu |last2=Zhu |first2=Liehuang |last3=Shen |first3=Meng |last4=Gao |first4=Feng |last5=Tao |first5=Xiaoling |last6=Liu |first6=Sheng |date=2018-08 |title=Blockchain-Based Data Preservation System for Medical Data |url=http://link.springer.com/10.1007/s10916-018-0997-3 |journal=Journal of Medical Systems |language=en |volume=42 |issue=8 |pages=141 |doi=10.1007/s10916-018-0997-3 |issn=0148-5598}}</ref><ref>{{Cite journal |last=Fan |first=Kai |last2=Wang |first2=Shangyang |last3=Ren |first3=Yanhui |last4=Li |first4=Hui |last5=Yang |first5=Yintang |date=2018-08 |title=MedBlock: Efficient and Secure Medical Data Sharing Via Blockchain |url=http://link.springer.com/10.1007/s10916-018-0993-7 |journal=Journal of Medical Systems |language=en |volume=42 |issue=8 |pages=136 |doi=10.1007/s10916-018-0993-7 |issn=0148-5598}}</ref><ref>{{Cite journal |last=Dey |first=Tushar |last2=Jaiswal |first2=Shaurya |last3=Sunderkrishnan |first3=Shweta |last4=Katre |first4=Neha |date=2017-12 |title=HealthSense: A medical use case of Internet of Things and blockchain |url=https://ieeexplore.ieee.org/document/8389459/ |journal=2017 International Conference on Intelligent Sustainable Systems (ICISS) |publisher=IEEE |place=Palladam |pages=486–491 |doi=10.1109/ISS1.2017.8389459 |isbn=978-1-5386-1959-9}}</ref>, medical supply chain management<ref>{{Cite journal |last=Jamil |first=Faisal |last2=Hang |first2=Lei |last3=Kim |first3=KyuHyung |last4=Kim |first4=DoHyeun |date=2019-05-07 |title=A Novel Medical Blockchain Model for Drug Supply Chain Integrity Management in a Smart Hospital |url=https://www.mdpi.com/2079-9292/8/5/505 |journal=Electronics |language=en |volume=8 |issue=5 |pages=505 |doi=10.3390/electronics8050505 |issn=2079-9292}}</ref><ref>{{Cite journal |last=Jayaraman |first=Raja |last2=Salah |first2=Khaled |last3=King |first3=Nelson |date=2019-04 |title=Improving Opportunities in Healthcare Supply Chain Processes via the Internet of Things and Blockchain Technology: |url=http://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/IJHISI.2019040104 |journal=International Journal of Healthcare Information Systems and Informatics |language=en |volume=14 |issue=2 |pages=49–65 |doi=10.4018/IJHISI.2019040104 |issn=1555-3396}}</ref>, and medical insurance claim management.<ref>{{Cite journal |last=He |first=Xinchi |last2=Alqahtani |first2=Sarra |last3=Gamble |first3=Rose |date=2018-07 |title=Toward Privacy-Assured Health Insurance Claims |url=https://ieeexplore.ieee.org/document/8726522/ |journal=2018 IEEE International Conference on Internet of Things (iThings) and IEEE Green Computing and Communications (GreenCom) and IEEE Cyber, Physical and Social Computing (CPSCom) and IEEE Smart Data (SmartData) |publisher=IEEE |place=Halifax, NS, Canada |pages=1634–1641 |doi=10.1109/Cybermatics_2018.2018.00273 |isbn=978-1-5386-7975-3}}</ref><ref>{{Cite journal |last=Ismail |first=Leila |last2=Zeadally |first2=Sherali |date=2021-07-01 |title=Healthcare Insurance Frauds: Taxonomy and Blockchain-Based Detection Framework (Block-HI) |url=https://ieeexplore.ieee.org/document/9520214/ |journal=IT Professional |volume=23 |issue=4 |pages=36–43 |doi=10.1109/MITP.2021.3071534 |issn=1520-9202}}</ref> The characteristics of blockchain give it great potential for providing a patient-centric healthcare system, involving health stakeholders such as patients, health professionals, insurance providers, pharmaceutical firms, and health governmental authorities.
From a technical aspect, blockchain is a peer-to-peer distributed system, which enables users to maintain a ledger of transactions that is replicated over multiple servers.<ref>{{Cite journal |last=Ismail |last2=Materwala |date=2019-09-24 |title=Article A Review of Blockchain Architecture and Consensus Protocols: Use Cases, Challenges, and Solutions |url=https://www.mdpi.com/2073-8994/11/10/1198 |journal=Symmetry |language=en |volume=11 |issue=10 |pages=1198 |doi=10.3390/sym11101198 |issn=2073-8994}}</ref> The architecture allows all the network participants, i.e., healthcare stakeholders, to verify and process health data transactions without the need for a trusted third party. In addition, the data stored in the blockchain is immutable, i.e., once the data is stored, it cannot be modified or deleted, leading to enhanced security. This immutability enables an [[audit trail]], bringing in accountability, adding trust to the system, and alleviating privacy concerns.<ref>{{Cite journal |last=Bordel |first=Borja |last2=Alcarria |first2=Ramon |last3=Martin |first3=Diego |last4=Sánchez-Picot |first4=Álvaro |date=2018 |title=Trust Provision in the Internet of Things using Transversal Blockchain Networks |url= |journal=Intelligent Automation and Soft Computing |language=en |volume=25 |issue=1 |pages=155–70 |doi=10.31209/2018.100000052 |issn=}}</ref><ref>{{Cite journal |last=Le Nguyen |first=Bao |last2=Laxmi Lydia |first2=E. |last3=Elhoseny |first3=Mohamed |last4=V. Pustokhina |first4=Irina |last5=A. Pustokhin |first5=Denis |last6=Mohamed Selim |first6=Mahmoud |last7=Nhu Nguyen |first7=Gia |last8=Shankar |first8=K. |date=2020 |title=Privacy Preserving Blockchain Technique to Achieve Secure and Reliable Sharing of IoT Data |url=https://www.techscience.com/cmc/v65n1/39555 |journal=Computers, Materials & Continua |language=en |volume=65 |issue=1 |pages=87–107 |doi=10.32604/cmc.2020.011599 |issn=1546-2226}}</ref> These distinctive features of blockchain have triggered its wide adoption for health records management to address [[information security]] and [[Information privacy|privacy]] issues, while providing access to patient’s health history to multiple stakeholders for patient-centric health services. However, blockchain poses scalability issues as the network grows<ref>{{Cite journal |last=Ismail |first=Leila |last2=Materwala |first2=Huned |date=2020-07-22 |title=Blockchain Paradigm for Healthcare: Performance Evaluation |url=https://www.mdpi.com/2073-8994/12/8/1200 |journal=Symmetry |language=en |volume=12 |issue=8 |pages=1200 |doi=10.3390/sym12081200 |issn=2073-8994}}</ref>, and consequently more hardware and human resources have to be provisioned for the operation and maintenance of the blockchain platform, thus increasing the health organization’s on-site cost. Moreover, blockchain suffers from the issues of high energy consumption<ref>{{Cite web |last=Hern, A. |date=27 November 2017 |title=Bitcoin mining consumes more electricity a year than Ireland |work=The Guardian |url=https://www.theguardian.com/technology/2017/nov/27/bitcoin-mining-consumes-electricity-ireland |accessdate=27 May 2021}}</ref><ref>{{Cite web |date=2021 |title=Bitcoin Energy Consumption Index |work=Digiconomist |url=https://digiconomist.net/bitcoin-energy-consumption |accessdate=27 May 2021}}</ref>, adding to blockchain operational cost.


==References==
==References==
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==Notes==
==Notes==
This presentation is faithful to the original, with only a few minor changes to presentation, spelling, and grammar. In some cases important information was missing from the references, and that information was added.
This presentation is faithful to the original, with only a few minor changes to presentation, spelling, and grammar. In some cases important information was missing from the references, and that information was added. The original article pastes multiple URLs into the text body for some reason; for this version, those URLs were turned into formal citations, raising the citation count notably above the original 92.


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Revision as of 21:57, 29 October 2021

Full article title A scoping review of integrated blockchain-cloud architecture for healthcare: Applications, challenges, and solutions
Journal Sensors
Author(s) Ismail, Leila; Meterwala, Huned; Hennebelle, Alain
Author affiliation(s) United Arab Emirates University
Primary contact Email: leila at uaeu dot ac dot ae
Editors Yu, Keping
Year published 2021
Volume and issue 21(11)
Article # 3753
DOI 10.3390/s21113753
ISSN 1424-8220
Distribution license Creative Commons Attribution 4.0 International
Website https://www.mdpi.com/1424-8220/21/11/3753/htm
Download https://www.mdpi.com/1424-8220/21/11/3753/pdf (PDF)
Emblem-important-yellow.svg This article should be considered a work in progress and incomplete. Consider this article incomplete until this notice is removed.

Abstract

Blockchain is a disruptive technology for shaping the next era of healthcare systems striving for efficient and effective patient care. This is thanks to its peer-to-peer, secure, and transparent characteristics. On the other hand, cloud computing made its way into the healthcare system thanks to its elasticity and cost-effective nature. However, cloud-based systems fail to provide a secured and private patient-centric cohesive view to multiple healthcare stakeholders. In this situation, blockchain provides solutions to address security and privacy concerns of the cloud because of its decentralization feature combined with data security and privacy, while cloud provides solutions to the blockchain scalability and efficiency challenges. Therefore a novel paradigm of blockchain-cloud integration (BcC) emerges for the domain of healthcare.

In this paper, we provide an in-depth analysis of the BcC integration for the healthcare system to give the readers the motivations behind the emergence of this new paradigm, while also introducing a classification of existing architectures and their applications for better healthcare. We then review the development platforms and services and highlight the research challenges for the integrated BcC architecture, possible solutions, and future research directions. The results of this paper will be useful for the healthcare industry to design and develop a data management system for better patient care.

Keywords: blockchain, cloud computing, electronic health records, health data analytics, healthcare system, security, privacy

Introduction

The healthcare domain has been revolutionized over the last century by technological advancement.[1] This revolution aims to improve the diagnosis of diseases and their causes, the quality of medical supplies, and the quality of medical treatment, as well as establish prevention plans on a global scale. The traditional client-server-based healthcare systems[2][3][4][5][6] suffer from security and privacy issues and lead to scattered patient’s medical history, delaying patient treatment.[7][8] Moreover, a patient needs to repeat medical tests when moving to another hospital. This increases the cost and time to the patient and affects the patient’s health due to repeated exposure to tests, such as X-rays and MRIs, each with their own potential side effects.[9] In addition, healthcare organizations are required to install and maintain infrastructure with up-to-date functionalities while complying with healthcare standards and regulations for the management of electronic health records (EHRs). This leads to a high total cost of ownership. To address these limitations of the client-server-based approach, the on-premises database migrated to the cloud, where health records are maintained by a cloud service provider.

Cloud computing[10] allows convenient and on-demand network access to a shared pool of configurable computing resources. Motivated by the pay-as-use cloud model, medical organizations use cloud computing to manage EHRs, reducing the cost of ownership. The five-year cost of $11 million for an on-premises healthcare system can be reduced to $3.2 million using cloud. This also reduces the infrastructure set-up time from 16 weeks to one week (Healthcare system cost reduction using cloud-based approach.[11] In addition, cloud computing provides multiple healthcare providers with efficient access to health records from a shared storage, improving patient care. The number of health records is increasing at a rapid pace with the introduction of smart healthcare and internet of things (IoT) devices with biosensors for personalized patient-centric healthcare. The scalability and elasticity of cloud computing aid in health records management, which requires powerful computing and large storage, for near real-time patient care. However, a cloud-based system suffers from the issues of security, i.e., data integrity, where the health records are under a constant threat of being modified, and privacy, i.e., unobservability or data leakage, in which the patients’ health records are being used without any tracking.[12]

Recent years have witnessed a bit of a revolution, with blockchain being adopted for many applications in the healthcare domain, such as health records management[13][14][15][16][17], medical supply chain management[18][19], and medical insurance claim management.[20][21] The characteristics of blockchain give it great potential for providing a patient-centric healthcare system, involving health stakeholders such as patients, health professionals, insurance providers, pharmaceutical firms, and health governmental authorities.

From a technical aspect, blockchain is a peer-to-peer distributed system, which enables users to maintain a ledger of transactions that is replicated over multiple servers.[22] The architecture allows all the network participants, i.e., healthcare stakeholders, to verify and process health data transactions without the need for a trusted third party. In addition, the data stored in the blockchain is immutable, i.e., once the data is stored, it cannot be modified or deleted, leading to enhanced security. This immutability enables an audit trail, bringing in accountability, adding trust to the system, and alleviating privacy concerns.[23][24] These distinctive features of blockchain have triggered its wide adoption for health records management to address information security and privacy issues, while providing access to patient’s health history to multiple stakeholders for patient-centric health services. However, blockchain poses scalability issues as the network grows[25], and consequently more hardware and human resources have to be provisioned for the operation and maintenance of the blockchain platform, thus increasing the health organization’s on-site cost. Moreover, blockchain suffers from the issues of high energy consumption[26][27], adding to blockchain operational cost.

References

  1. ↑ Ismail, Leila; Materwala, Huned; Karduck, Achim P; Adem, Abdu (7 July 2020). "Requirements of Health Data Management Systems for Biomedical Care and Research: Scoping Review" (in en). Journal of Medical Internet Research 22 (7): e17508. doi:10.2196/17508. ISSN 1438-8871. PMC PMC7380987. PMID 32348265. https://www.jmir.org/2020/7/e17508. 
  2. ↑ Rind, D. M.; Kohane, I. S.; Szolovits, P.; Safran, C.; Chueh, H. C.; Barnett, G. O. (15 July 1997). "Maintaining the confidentiality of medical records shared over the Internet and the World Wide Web". Annals of Internal Medicine 127 (2): 138–141. doi:10.7326/0003-4819-127-2-199707150-00008. ISSN 0003-4819. PMID 9230004. https://pubmed.ncbi.nlm.nih.gov/9230004. 
  3. ↑ Schoenberg, R.; Safran, C. (11 November 2000). "Internet based repository of medical records that retains patient confidentiality". BMJ (Clinical research ed.) 321 (7270): 1199–1203. doi:10.1136/bmj.321.7270.1199. ISSN 0959-8138. PMC 1118958. PMID 11073513. https://pubmed.ncbi.nlm.nih.gov/11073513. 
  4. ↑ Uckert, Frank; Görz, Michael; Ataian, Maximilian; Prokosch, Hans-Ulrich (2002). "Akteonline-an electronic healthcare record as a medium for information and communication". Studies in Health Technology and Informatics 90: 293–297. ISSN 0926-9630. PMID 15460705. https://pubmed.ncbi.nlm.nih.gov/15460705. 
  5. ↑ Grant, Richard W.; Wald, Jonathan S.; Poon, Eric G.; Schnipper, Jeffrey L.; Gandhi, Tejal K.; Volk, Lynn A.; Middleton, Blackford (1 October 2006). "Design and Implementation of a Web-Based Patient Portal Linked to an Ambulatory Care Electronic Health Record: Patient Gateway for Diabetes Collaborative Care" (in en). Diabetes Technology & Therapeutics 8 (5): 576–586. doi:10.1089/dia.2006.8.576. ISSN 1520-9156. PMC PMC3829634. PMID 17037972. http://www.liebertpub.com/doi/10.1089/dia.2006.8.576. 
  6. ↑ Gritzalis, Dimitris; Lambrinoudakis, Costas (1 March 2004). "A security architecture for interconnecting health information systems" (in en). International Journal of Medical Informatics 73 (3): 305–309. doi:10.1016/j.ijmedinf.2003.12.011. https://linkinghub.elsevier.com/retrieve/pii/S1386505603002144. 
  7. ↑ Ismail, Leila; Materwala, Huned (22 June 2020). "BlockHR: A Blockchain-based Framework for Health Records Management" (in en). Proceedings of the 12th International Conference on Computer Modeling and Simulation (Brisbane QLD Australia: ACM): 164–168. doi:10.1145/3408066.3408106. ISBN 978-1-4503-7703-4. https://dl.acm.org/doi/10.1145/3408066.3408106. 
  8. ↑ Ismail, Leila; Materwala, Huned; Khan, Moien AB (8 July 2020). "Performance Evaluation of a Patient-Centric Blockchain-based Healthcare Records Management Framework" (in en). Proceedings of the 2020 2nd International Electronics Communication Conference (Singapore Singapore: ACM): 39–50. doi:10.1145/3409934.3409941. ISBN 978-1-4503-7770-6. https://dl.acm.org/doi/10.1145/3409934.3409941. 
  9. ↑ Chang, P. Y.; Bjornstad, K. A.; Rosen, C. J.; McNamara, M. P.; Mancini, R.; Goldstein, L. E.; Chylack, L. T.; Blakely, E. A. (1 October 2005). "Effects of Iron Ions, Protons and X Rays on Human Lens Cell Differentiation" (in en). Radiation Research 164 (4): 531–539. doi:10.1667/RR3368.1. ISSN 0033-7587. http://www.bioone.org/doi/10.1667/RR3368.1. 
  10. ↑ Mell, P.; Grance, T. (September 2011). "The NIST Definition of Cloud Computing". National Institute of Standards and Technology. http://faculty.winthrop.edu/domanm/csci411/Handouts/NIST.pdf. Retrieved 27 May 2021. 
  11. ↑ Foote, E.; Montalto M. (21 October 2019). "How Cloud EHR Reduces Operating Costs, Increases Computing Power". EHR Intelligence. XTelligent Healthcare Media. https://ehrintelligence.com/news/how-cloud-ehr-reduces-operating-costs-increases-computing-power. Retrieved 27 May 2021. 
  12. ↑ Pfitzmann, Andreas; Köhntopp, Marit (2001), Federrath, Hannes, ed., "Anonymity, Unobservability, and Pseudonymity — A Proposal for Terminology", Designing Privacy Enhancing Technologies (Berlin, Heidelberg: Springer Berlin Heidelberg) 2009: 1–9, doi:10.1007/3-540-44702-4_1, ISBN 978-3-540-41724-8, http://link.springer.com/10.1007/3-540-44702-4_1. Retrieved 2021-10-29 
  13. ↑ Azaria, Asaph; Ekblaw, Ariel; Vieira, Thiago; Lippman, Andrew (1 August 2016). "MedRec: Using Blockchain for Medical Data Access and Permission Management". 2016 2nd International Conference on Open and Big Data (OBD) (Vienna, Austria: IEEE): 25–30. doi:10.1109/OBD.2016.11. ISBN 978-1-5090-4054-4. http://ieeexplore.ieee.org/document/7573685/. 
  14. ↑ Dagher, Gaby G.; Mohler, Jordan; Milojkovic, Matea; Marella, Praneeth Babu (1 May 2018). "Ancile: Privacy-preserving framework for access control and interoperability of electronic health records using blockchain technology" (in en). Sustainable Cities and Society 39: 283–297. doi:10.1016/j.scs.2018.02.014. https://linkinghub.elsevier.com/retrieve/pii/S2210670717310685. 
  15. ↑ Li, Hongyu; Zhu, Liehuang; Shen, Meng; Gao, Feng; Tao, Xiaoling; Liu, Sheng (1 August 2018). "Blockchain-Based Data Preservation System for Medical Data" (in en). Journal of Medical Systems 42 (8): 141. doi:10.1007/s10916-018-0997-3. ISSN 0148-5598. http://link.springer.com/10.1007/s10916-018-0997-3. 
  16. ↑ Fan, Kai; Wang, Shangyang; Ren, Yanhui; Li, Hui; Yang, Yintang (1 August 2018). "MedBlock: Efficient and Secure Medical Data Sharing Via Blockchain" (in en). Journal of Medical Systems 42 (8): 136. doi:10.1007/s10916-018-0993-7. ISSN 0148-5598. http://link.springer.com/10.1007/s10916-018-0993-7. 
  17. ↑ Dey, Tushar; Jaiswal, Shaurya; Sunderkrishnan, Shweta; Katre, Neha (1 December 2017). "HealthSense: A medical use case of Internet of Things and blockchain". 2017 International Conference on Intelligent Sustainable Systems (ICISS) (Palladam: IEEE): 486–491. doi:10.1109/ISS1.2017.8389459. ISBN 978-1-5386-1959-9. https://ieeexplore.ieee.org/document/8389459/. 
  18. ↑ Jamil, Faisal; Hang, Lei; Kim, KyuHyung; Kim, DoHyeun (7 May 2019). "A Novel Medical Blockchain Model for Drug Supply Chain Integrity Management in a Smart Hospital" (in en). Electronics 8 (5): 505. doi:10.3390/electronics8050505. ISSN 2079-9292. https://www.mdpi.com/2079-9292/8/5/505. 
  19. ↑ Jayaraman, Raja; Salah, Khaled; King, Nelson (1 April 2019). "Improving Opportunities in Healthcare Supply Chain Processes via the Internet of Things and Blockchain Technology:" (in en). International Journal of Healthcare Information Systems and Informatics 14 (2): 49–65. doi:10.4018/IJHISI.2019040104. ISSN 1555-3396. http://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/IJHISI.2019040104. 
  20. ↑ He, Xinchi; Alqahtani, Sarra; Gamble, Rose (1 July 2018). "Toward Privacy-Assured Health Insurance Claims". 2018 IEEE International Conference on Internet of Things (iThings) and IEEE Green Computing and Communications (GreenCom) and IEEE Cyber, Physical and Social Computing (CPSCom) and IEEE Smart Data (SmartData) (Halifax, NS, Canada: IEEE): 1634–1641. doi:10.1109/Cybermatics_2018.2018.00273. ISBN 978-1-5386-7975-3. https://ieeexplore.ieee.org/document/8726522/. 
  21. ↑ Ismail, Leila; Zeadally, Sherali (1 July 2021). "Healthcare Insurance Frauds: Taxonomy and Blockchain-Based Detection Framework (Block-HI)". IT Professional 23 (4): 36–43. doi:10.1109/MITP.2021.3071534. ISSN 1520-9202. https://ieeexplore.ieee.org/document/9520214/. 
  22. ↑ Ismail; Materwala (24 September 2019). "Article A Review of Blockchain Architecture and Consensus Protocols: Use Cases, Challenges, and Solutions" (in en). Symmetry 11 (10): 1198. doi:10.3390/sym11101198. ISSN 2073-8994. https://www.mdpi.com/2073-8994/11/10/1198. 
  23. ↑ Bordel, Borja; Alcarria, Ramon; Martin, Diego; Sánchez-Picot, Álvaro (2018). "Trust Provision in the Internet of Things using Transversal Blockchain Networks" (in en). Intelligent Automation and Soft Computing 25 (1): 155–70. doi:10.31209/2018.100000052. 
  24. ↑ Le Nguyen, Bao; Laxmi Lydia, E.; Elhoseny, Mohamed; V. Pustokhina, Irina; A. Pustokhin, Denis; Mohamed Selim, Mahmoud; Nhu Nguyen, Gia; Shankar, K. (2020). "Privacy Preserving Blockchain Technique to Achieve Secure and Reliable Sharing of IoT Data" (in en). Computers, Materials & Continua 65 (1): 87–107. doi:10.32604/cmc.2020.011599. ISSN 1546-2226. https://www.techscience.com/cmc/v65n1/39555. 
  25. ↑ Ismail, Leila; Materwala, Huned (22 July 2020). "Blockchain Paradigm for Healthcare: Performance Evaluation" (in en). Symmetry 12 (8): 1200. doi:10.3390/sym12081200. ISSN 2073-8994. https://www.mdpi.com/2073-8994/12/8/1200. 
  26. ↑ Hern, A. (27 November 2017). "Bitcoin mining consumes more electricity a year than Ireland". The Guardian. https://www.theguardian.com/technology/2017/nov/27/bitcoin-mining-consumes-electricity-ireland. Retrieved 27 May 2021. 
  27. ↑ "Bitcoin Energy Consumption Index". Digiconomist. 2021. https://digiconomist.net/bitcoin-energy-consumption. Retrieved 27 May 2021. 

Notes

This presentation is faithful to the original, with only a few minor changes to presentation, spelling, and grammar. In some cases important information was missing from the references, and that information was added. The original article pastes multiple URLs into the text body for some reason; for this version, those URLs were turned into formal citations, raising the citation count notably above the original 92.

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