Healthcare 8 (2020) 100391

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Healthcare
journal homepage: www.elsevier.com/locate/healthcare

Original research

S2HS- A blockchain based approach for smart healthcare system T

a,∗ a b
Gautami Tripathi , Mohd Abdul Ahad , Sara Paiva
a
Department of Computer Science and Engineering, Jamia Hamdard, New Delhi, 110062, India
b
Instituto Politécnico de Viana do Castelo, Portugal

A R T I C LE I N FO A B S T R A C T

Keywords: Healthcare domain has emerged as one of the most preferred use cases of IoT and its related technologies.
Blockchain However, its widespread adoption is still a distant dream. The primary reason behind this is the security and
Sensors privacy of the data and the participating entities. To overcome this, blockchain technology has emerged as a
Healthcare convenient means to improve the security and privacy of the data and its users. With the deluge of medical data
Internet of Things
generated through electronic medical records and other ICT based mechanisms, blockchain has found in-
Smart healthcare system
numerable opportunities in the healthcare domain. The traditional healthcare systems are radically adopting
Electronic medical records
modern day technologies for transitioning into the smart healthcare ecosystems. The convenience of the users
and ease of use are the primary factors driving this transition. Even with smart healthcare systems (SHS) there
exist numerous challenges and issues related to the security, transparency and privacy of the data and users. This
paper explores the technological and social barriers in adoption of SHS by analyzing state-of-the-art expert views
and user's perception. It further proposes a blockchain based SHS framework to provide intrinsic security and
integrity of the system. Finally, the future research directions and use cases of blockchain in healthcare domain
are discussed.

1. Introduction brought together medical equipments, clinical trials, medical tourism,

The evolution of “Internet of Things (IoT)” and related technologies
has led to the concept of smart ecosystems where all entities (living and
nonliving) are interconnected to facilitate capturing, storing, commu-
nicating and sharing of information. Technologies like Bluetooth,
wireless sensor networks (WSN), Wi-Fi, Li-Fi, RFID etc are acting as a
catalyst in this fast transformation of traditional systems into smart
systems.4,12,17,23 Today, almost all sectors including education, agri-
culture, transportation etc. are paving their way towards this transi-
tion.24,26 With great potential and scope for improvement healthcare
sector has also shown tremendous growth by achieving some level of
automation. We are already witnessing the emergence of a smart
healthcare system (SHS) where all stakeholders are interconnected to
achieve ubiquitous and holistic healthcare facilities. The rapid expan-
sion of healthcare in terms of investments, awareness and policies has
further accelerated this transformation. Fig. 1 below provides the status
of healthcare industry with respect to Indian context.
According to “India Brand Equity Foundation (IBEF)” report the
“healthcare industry” in India has grown into one of the largest sectors
in terms of revenue and employment generation.21 The public as well as
the private healthcare sectors have flourished at an exponential rate.
Today, the healthcare sector has expanded beyond hospitals and has
health insurance, medical devices and telemedicine. With such vast
expansion of the healthcare sector the market size is also increasing at a
brisk pace.
It is estimated that by the year 2022 the healthcare market in India
will cross the mark of US$ 372 billion. Also, the hospital industry will
see a three folds increase to US$ 133.44 billion by 2023, growing at a
CAGR of 16–17%. This boom in the healthcare market is driven by the
increase in the average income of people, health awareness, lifestyle
issues, reforms in the insurance sector and government policies.33 Fig. 2
gives an overview of the growth in healthcare sector in the Indian
context. In recent years, many developing and developed nations have
exploited the healthcare domain to their advantage and brought about
reforms to benefit the common people.
With such vast market and user base, the concept of smart health-
care system is surely a way forward. However in order to make this SHS
penetrate into the core of population at the remotest areas, there are
several internal and external social and technological barriers. Lack of
knowledge, reluctance to adopt new technology, conventional and ir-
rational mindset and absence of core infrastructure are the common
social limiting factors in rural areas. Data security, privacy of the users
and lack of skilled manpower are the other technological factors which
are seen as potential barriers in successful adoption of SHS among

∗
Corresponding author.
E-mail addresses: gautami1489@gmail.com (G. Tripathi), itsmeahad@gmail.com (M.A. Ahad), sara.paiva@estg.ipvc.pt (S. Paiva).

https://doi.org/10.1016/j.hjdsi.2019.100391
Received 15 October 2019; Accepted 5 November 2019
Available online 19 November 2019
2213-0764/ © 2019 Elsevier Inc. All rights reserved.
G. Tripathi, et al.
Fig. 1. Healthcare: An Indian perspective.21
masses. This paper provides a blockchain based SHS framework in
order to provide a secured and privacy-preserved healthcare system.
The paper is organized into six sections. Section 2 provides a detailed
description of blockchain technology, its application domains and
challenges associated with its widespread adoption. Section 3 provides
a comprehensive review of the existing state-of-the-art solutions for
using blockchain technology in healthcare domain. The section also
identifies the existing research and implementation gaps and suggests
the ways to overcome these gaps. Section 4 introduces the smart
healthcare system along with the challenges and barriers in its wide-
spread adoptions. It also highlights the different types of sensors used in
wearable devices. The next section 5 provides a detailed introduction of
the proposed “Smart and Secured Healthcare System (S2HS)” with the
underlying architectural framework and the participating entities. The
final section 6 provides the conclusion and future research directions of
blockchain technology by identifying the various potential use cases.
2. Blockchain technology
Blockchain can be defined as a distributed and immutable digital
ledger that provides data transparency and user privacy.2,5,7-9 Initially
the concept of blockchain was associated with financial transactions but
with the technological advancements and its significant benefits it is
being extended to almost all areas where security of records is of out-
most importance. The concept is completely based on peer to peer ar-
chitecture where the data (blocks) is connected using cryptographic
techniques (chain). There is no central authority and the digital ledger
is shared among all peers and is open for anyone and everyone to see.
Any valuable information can be stored on the block where each block
has its unique identifier called hash. These hashes are created based on
the data stored in the block therefore a new hash is generated every
time the block contents are changed. Besides its own hash every block
also stores the hash of the previous block as shown in Fig. 3. This results
in the formation of a chain of blocks thus the name blockchain. The
interlinking of blocks provides the unique security feature to the
blockchain as any change in the data of one block requires the updation
of hash values in the entire chain making it impossible to hack and
tamper.30,33
Blockchain can be categorized in three types namely, public, fed-
erated (consortium) and private. Although the general idea behind the
development of blockchain was to provide a P2P distributed ledger but
with the new features and usage federated and private blockchains are
also being used widely. Fig. 4 highlights the key features and examples
of the three types of blockchain.30,31
Despite being a decade old technology, the blockchain evolution has
already seen three generations with a fourth generation already on its
way. Table 1 shows the three generations of Blockchain and compares
the distinct features of each generation. Fig. 4 gives an overview of the
2
Healthcare 8 (2020) 100391
different types of blockchain with their distinct features and examples.
Today, blockchain has found application in almost all areas of research
and development. The different types and generations of blockchain
help to satisfy the need of the developers. Many governments across the
globe are joining hands with the blockchain giants and the startups to
provide solutions for different sectors.20
3. Related works
The Blockchain technology has seen tremendous growth in the last
few years. Initially, the technology was confined to the crypto currency
domain but with the success of bitcoin it has become a kind of ex-
hortation in industry and academia. Since its inception in 2008 and its
implementation in 2009, blockchain has found its significance in almost
all areas of research including finance, healthcare, agriculture security
etc.7,10,12,33,41 Apart from the core features of the blockchain tech-
nology it can also enhance the security of other technologies. This
section highlights the recent researches on blockchain technology, its
applications in varied domains of computing and otherwise. The section
also showcases the challenges and limitations of blockchain technology.
The authors in Ref. 1 highlighted the concept of creating new values in
traditional economics of the society with the help of blockchain tech-
nology. The core aim of the study was to provide a conceptual decen-
tralized model of cooperation and value creation using backfeed and
blockchain approaches for promoting social sharing. The authors in Ref.
2 provided an introduction to blockchain technology highlighting the
origin, core concept, issues and challenges. The manuscript further
provided the application of blockchain technology primarily focusing
on applications in healthcare domain. It provided several real-life ap-
plications of blockchain in healthcare including Guardtime and Me-
dRec. Finally the limitations of blockchain technology were high-
lighted. In Ref. 3, the author highlighted the importance of the
healthcare and wellbeing for all age groups by quoting the third goal of
DGSs. They further emphasized that inclusive healthcare is possible by
effective, efficient and holistic monitoring covering all aspects of the
healthcare domain. The exponential rise of wearable healthcare devices
are changing the ways, the vitals of the patients are being monitored.
The emergence of non-invasive technologies has further added to the
development. The authors studied the effect and usability of wearable
healthcare device in terms of “intrusiveness”, “Comfort”, “perceived
usefulness” and perceived “ease of use”. They used the “Partial Least
Square Structured Equation Modeling (PLS – SEM)” methodology to
find the relation between concept and hypothesis. They concluded that
intrusiveness and comfort does not play a major role in adoption of
wearable devices however the potential usefulness and ease-of-use are
the prime factors of adopting wearable healthcare devices on such large
scale. The authors in Ref. 4 provided a survey on the role of IoT in
achieving smart healthcare. They discussed the core technologies, is-
sues and challenges of IoT in achieving smart healthcare. They con-
cluded that standardization of data constitutes the primary challenge in
IoT ecosystem. Finally some future directions of applications of IoT in
healthcare domain were highlighted. The applications of blockchain
technology in clinical trials were studied in Ref. 5. The use of block-
chain in creating and conduction reliable clinical trials was the prime
focus of the paper. Finally the importance of the concept of privacy-by-
design and secured and reliable data sharing in community medicine
were also discussed. The authors in Ref. 6 provided a study on the use of
blockchain for achieving a holistic healthcare environment for all the
participating entities in the healthcare domain. The importance of
creating secured electronic health records for easy sharing and access
were explored. A secured yet faster way of medical information ex-
change is the need of the hour and the paper discussed the pros and
cons of the same in terms of issues and challenges of blockchain. In Ref.
7, the authors proposed a new blockchain based supply-chain model for
overcoming the limiting factors of the traditional supply-chain systems.
They introduced the concept of a multi agent system in order to achieve
G. Tripathi, et al. Healthcare 8 (2020) 100391

Fig. 2. Growth in healthcare market.33

a circular economy. They used blockchain approach to store all the

transactional information. The paper concluded by highlighting the
importance of smart handshake contract between the participating
agents using blockchain approach in order to avoid any illegitimate
activity at any level from production to consumption. The concept of
blockchain based data sharing has seen a major adoption in recent
years. The security and privacy promised by blockchain makes it a
preferable technology in healthcare domains. However there are sev-
eral roadblocks with this technology especially in healthcare segment.
The authors in Ref. 9 provided solutions to two of such key limitations
of blockchain in healthcare. They provided a new data-sharing ap-
proach for protecting sensitive medical records and effective installa-
tion of blockchain mechanism across multiple hospitals. They used
customized micro-services architecture to enable transparency, ease of
usage and security at the same time. A concept of cloud based and cost
effective smart healthcare solution framework was provided in Ref. 10.
The paper discussed the challenges faced by healthcare industry and the
Fig. 4. Types of blockchain.
burden of costly infrastructure for providing IT enabled services to the
patients. The proposed framework introduced three key components viz
“business process”, “service-oriented architecture”, and “service-or- underlying security protocols. The process of acquiring data from
iented infrastructure” for need based work and resource management. multiple sources through IoT devices has never been so inclusive that it
The technical knowledge of a person and the adaptability towards using covers all verticals of healthcare. The potential opportunities and
the advantages of the IoT technological also plays an important role in challenges thereof of adopting IoT for providing effective healthcare
the success of IoT enabled healthcare facilities. One such study was system were discussed in Ref. 12. The study in Ref. 13 was focused on
conducted in Ref. 11, which highlighted the patient capabilities in the use of EMR is smaller medical setups and hospitals. The next part of
adopting IoT enabled wearable devices and other IT related services. the study was dedicated to the issues and challenges in successful
The capabilities explored included-user's knowledge of the system and adoption of ICT based medical facilities and the final part highlighted
technology and the ability to effectively use the technology. A theore- the future trends and timelines in ubiquitous adoption of EMR across all
tical model was presented and validated using the feedback of the pa- medial domains. A quality assessment framework was proposed in Ref.
tients in Spain. This has been widely accepted fact that the ubiquitous 15 in Korea. The authors devised a patient centric framework based on
access to medical data in a secured and privacy preserved manner can the expected and perceived QoS. A notion of quality score was provided
been effectively achieved using the concept of IoT with some which signifies the patient's satisfaction level. A concept of patient-

Fig. 3. Blocks forming a chain using hash.

3
G. Tripathi, et al. Healthcare 8 (2020) 100391

driven interoperability was proposed in Ref. 16. The core aim of the
research was to provide a holistic view of a patient-centric interoper-
Third generation Blockchain meets the Artificial ability mechanism using blockchain technology wherein the data and
information linkage is patient mediated. The various issues and chal-
lenges in such complex inter-linkages were also highlighted in the
paper. In Ref. 23, the authors proposed an IoT model using the concept
Intelligence (SOOM, Multiversum)

of Ethereum blockchain platform. In the proposed model, the concept of

blockchain is used in every phase from information sensing, gathering,
and processing. The control and configuration of IoT devices were also
Automated Verification

proposed to be managed by blockchain technology. The study in Ref. 25

Highly Cost Effective

was dedicated to the security vulnerabilities of blockchain technology.

Fourth generation

Proof of Integrity

Very High Speed

Highly Efficient

Highly Scalable

The paper reviewed several existing state-of-the- art mechanisms to

enhance blockchain security. A comprehensive review was conducted
by exploring the existing blockchain systems to come up with potential
threats to blockchain security. Finally the future trends and research
domains of blockchain were highlighted. In Ref. 27, the authors re-
viewed the role of blockchain technology in intrusion detection. Since
blockchain has already been proved to provide much better security
Cardano, IOTA, Nano Comes handy in cases of contracts,

and transparency to the data, the paper explores its potential use in
intrusion detection so that, new intrusion detection systems can be
devised using blockchain technology. A framework for improved supply
chain management using the concept of blockchain technology was
agreement managements, information flow.

proposed in Ref. 35. The authors also provided some use cases showing
the improvement that can be observed using the proposed blockchain
Inbuilt Mechanism for Verification

based supply chain management framework.

3.1. Research gap analysis

Although extensive research is carried out exploring the effective-

Third generation

Energy Efficient

ness of blockchain in various application domains, healthcare domain is

Highly Scalable
Proof of Stake

the one which is lagging behind. The reasons behind this are multi-
High Speed

faceted. The primary reason is the severe shortage of blockchain experts

Cheaper

in medical domain. There are other challenges in adoption of block-

chain for medical domain which includes 18,25,27,29–31:

1. Absence of a standard data collection, sharing and interoperability

Ethereum (Focused on Asset Management)- apt for

Proof of work with some additional capabilities

mechanisms in the existing SHS operations.

2. Smart contracts are not possible in cases where the patients are not
Process Smart Contracts, Maintain dApps

in a state to grant access to their personal medical data (like un-

consciousness, dizziness, under the influence of alcohols, drugs etc.)
Scalability issues (Sharding is used)

3. Data migration issues (from EMR to blockchains).

techniques like crowdsourcing

Cheaper than First generation

4. Lack of knowledge among the participants of the blockchain tech-

nology in healthcare industry.
5. Absence of standard Government policies and Standard protocols
Second generation

defining the rules and regulations of the fair usage of blockchain

technology covering all aspects like data ownerships, legal issues,
types and nature of punishments in case of any misconduct etc.
Moderate

6. With blockchains, the whole system will become data centric (data
Slow

from EMR, wearable devices etc), this however is not acceptable

after a certain limit as human intervention is a must to better un-
derstand the conditions of a patient.
Not scalable (Lightning)
Requires more Energy

Cannot process Smart

After analyzing the above state-of-the-art related works, it can be

Bitcoin, Litecoin
First generation

concluded that even though blockchain has been accepted as a re-

Proof of work

volutionary technology, its adoption in healthcare domain is still not

Contracts

widespread. Also, there are very few literatures available which ex-
Costly

Slow

clusively talks about improving the healthcare facilities for the patients
covering all aspects. Some researches talk about improving the security
Generations of blockchain.

Focus Areas and Examples

of the data while others are focused on providing faster services. Few
Consensus Mechanism

researchers had reviewed the use of blockchain technology in health-

Energy Requirements

care discussing its challenges and opportunities. These reviews were

Smart Contracts

done on the basis of expert interactions and feedback from the users.
Finally the comparison was drawn on the basis of expected and per-
Scalability

ceived functionalities and facilities. The proposed S2HS framework

Table 1

Speed
Cost

provides an overall conceptual model which covers all aspects of

healthcare domain including the security and privacy of the patients,

4
G. Tripathi, et al.
transparency of the transactions, easy migration and record standardi-
zations, secured and consistent information linkages, easier collabora-
tion and communication among all the participating entities like pa-
tients, doctors, clinicians, pharmacists, insurance companies etc.
4. Smart healthcare system
The healthcare industry today is not the ostracized zone untouched
by the miracles of modern technological developments. With the
technological advancements and the convergence of the area of com-
puter science, electronics and related technologies, it has become pos-
sible to create a smart healthcare environment where all medical en-
tities are connected together and can communicate with each other.
This concept is furthered by the current trends in the healthcare market.
Today with technologies like “Internet of Things (IoT)”, “Artificial
Intelligence (AI)”, “Machine Learning (ML)”, “cloud computing”,
“Robotics”, “WAN” and “Big Data Analytics (BDA)”, the SHSs are a
reality. Many nations are realizing the potential of adopting modern
ways of catering the medical industry and are successfully working
towards it. 30,31,36
4.1. Pillars of SHS
The rapidly growing technologies has enabled the healthcare sector
to implement modern technologies like IoT, AI, Robotics etc to its
benefit and bring reforms to its traditional ways of functioning. Fig. 5
presents the pillars of SHS which enables them to provide state-of-the-
art diagnosis and treatments facilities and take better and informed
decisions like never before. 30,31,36
Internet of Things and wireless sensor network allows all entities of
a healthcare system (like monitoring devices, medical equipments,
wearable devices etc.) to connect to a network and communicate with
each other. The wearable devices can be used to monitor the real time
conditions of the patients and any deviation in vitals can be reported in
real time. The volumes of data generated through these devices can be
stored on a cloud which can be accessed and analyzed using big data
analytic techniques to provide deep insights about the patient's condi-
tions so that better and informed decisions about the diagnosis and
treatments can be taken. The archived data can also be used to provide
use cases for research and development and with the AI and ML tech-
niques systems can be trained to predict diseases and recommend
possible treatments and prescriptions. Such predictive healthcare is
already a reality now. This data can also help in assisting robotic sur-
geries and other automated facilities. Thus the modern technologies
work in a symbiotic relationship and forms the pillars of a smart
healthcare system 18,30,31,36 Fig. 6 presents the architecture of a typical
SHS.
Fig. 5. Pillars of smart healthcare system.
5
Healthcare 8 (2020) 100391
4.2. Barriers and challenges in existing SHS
Despite of providing the state of the art services to the stakeholders
across the globe, the smart healthcare systems are still lacking in terms
of tackling its vulnerabilities. With such large volumes of sensitive
medical data, the connected devices are the most sought after target of
the cybercriminals. In such situations the personal data of the patients
can be easily compromised. In worst cases the hackers can gain full
control of the wearable IoT devices and can misuse it. In one such case,
Johnson & Johnson had earlier warned the patients of the vulnerability
of one of its insulin pumps that could be exported by the hackers to
overdose the patients.22,19,29,34,36 These compromised devices can fur-
ther be used as a passport to enter the otherwise secured network. In a
report by the “European Union Agency for Network and Information
Security (ENISA)”, it is highlighted that the smart healthcare systems
are prone to malware resulting in data thefts.19 Figs. 7 and 8, below
gives the technological and social barriers and challenges faced by
smart healthcare systems.
System failures are the most common type of challenge faced by
SHS. Whenever the system fails, the whole data and information stored
in the system becomes inaccessible. Since it is controlled by centralized
monitoring unit, there is a high probability of data loss or data cor-
ruption. SHS are prone to virus attacks, once the system is infected, it
make it vulnerable against all types of cybercrimes including data
thefts, impersonation, eavesdropping etc. It is very difficult to maintain
synchronization among different entities of the SHS, the primary reason
for this is that, all the units work independent of each other. Each of
them has their own data standards and formats and thus integrating
these data is a huge challenge. Without the presence of proper audit
trails and verification, the patients often get billed for services and
treatment procedures never availed by them. The absence of proper
coordination among different departments creates inconsistency in
providing proper care to the patients (especially in cases of chronic
ailments). In classical SHS there is no provision to store clinical trials in
a secured and privacy preserved manner and therefore, the archived
clinical trials are rarely used. Thus, in order to conduct research and
other analysis, these clinical trials needs to be conducted afresh which
involve huge amount of cost, infrastructure, time and human resources.
Data ownership is again a vital challenges posed by the existing SHS.
The questions like “who owns what data at what time” are not an-
swered in the existing SHS especially during data transfer and in-
formation linkage phases.36–39 SHS still lacks proper inventory man-
agement and thus there are several gaps in supply-chain management of
the healthcare industry.35,36
4.3. Role of sensors used in smart healthcare systems (SHS)
Health monitoring is witnessing a complete transformation with the
advent of IoT based wearable sensors which are miniature devices
generally non-invasive and has the ability to monitor the physiological
conditions and vital health parameters of the patients with minimum or
no intervention of hospital staffs (nurses, ward boys). The IoT based
healthcare system has proved to be imperative in several contexts such
as facilitating the remote monitoring of elderly for health related issues,
allowing people to take treatment at their homes instead of in-hospital
treatment. IoT technology allows the care providers (doctors, nurses
etc) to remotely monitor, diagnose and suggest treatments or provide
urgent care (in case it is needed).44,45 The data and information cap-
tured by the IoT based healthcare devices can be used to provide de-
tailed analysis of the different physiological, cognitive, and physical
conditions of the patients to provide better healthcare facilities like
predictive healthcare, non-invasive treatments and clinical trails, round
the clock monitoring etc.47 The increasing importance of sensors for
these purposes generate a variety of applications and frameworks pro-
posed in the literature.46 Also, according to a “Allied Market Research”,
there will be an exponential growth in wearable sensors market by the
G. Tripathi, et al.
Fig. 6. A typical Smart Healthcare Model.
Fig. 7. Technological barriers and challenges of classical SHS.
end of 2022. Depending upon the type and nature of the data to be
captured and analyzed, there exists a variety of sensors in the market
with specific functionality and usage. Fig. 1 shows the core constituents
of a typical wearable sensor. A sensor is a miniature device capable of
sensing the environment when an event of interest occurs. The data
sensed by the sensors is first converted into the electrical signals. Fi-
nally these electrical signals need to be transferred to the storage device
on the cloud. This means that the sensors/devices needs to be con-
nected via some medium. This medium is generally Wireless, like
Bluetooth, low power wide area networks, cellular, WiFi etc. Now the
use of specific connecting medium is directly depended on the type of
sensing activity the sensor or device is performing.45–47 Fig. 9 provides
6
Healthcare 8 (2020) 100391
the constituents of a typical sensor.
There are several types of sensors which have their specific prop-
erties and usage. Table 2 provides the different types of sensors and
their corresponding functionalities.43,45–47
In order to conveniently monitor the vitals of the patients, they are
made to wear the respective IoT devices. The sensors embedded in these
IoT devices capture the specific phenomenon and transfer it to the
mobile device which is then transferred to the central server for storage
and analysis. There can be interconnection between the various IoT
devices worn by the patient. Such a network is called as body area
network (BAN).46,47 Fig. 10 present a typical BAN with wearable sen-
sors.
5. S2HS (Secured and Smart Healthcare System)-The proposed
framework
This paper proposes a system to overcome the issues and challenges
faced by the classical SHS. At the core, the proposed Secured and Smart
Healthcare System (S2HS) works by deploying blockchain technology
in the SHSs. The private and sensitive data and information of the pa-
tients, clinical trials data and electronic health records which are cap-
tured by the variety of sensors are encrypted using blockchain me-
chanism and are stored in a distributed manner rather than the
centralized cloud storage. These data can be accessed only by any le-
gitimate person (care providers, insurance companies, pharmaceutical
companies etc) with the consent of the patients. Whenever the doctor or
clinician wants to access the data of the patient, a real time notification
is sent to the patients and only when the patients agree to share the data
it is allowed to be accessed by the doctors or clinicians. In the S2HS
system all the entities are connected together through a WSN. Fig. 11
G. Tripathi, et al.
Fig. 8. Social barriers and challenges in SHS.
Fig. 9. Constituents of a typical Sensor.
presents the proposed S2HS framework model. There are five prime
entities in S2HS. The role of each entity is given below:
IoT based Wearable Devices: These devices are used by the doc-
tors to monitor the conditions of the patients in real time. These are
simply a form of wrist bands and watches which can be easily worn on
the body. These wearable devices consists of miniature sensors which
senses the environment and the vitals of the patients (like blood pres-
sure, heart rate, pulse rate, ECG, humidity, temperature etc). When
there is a deviation in these parameters (from the permissible limits),
the doctors and clinicians are notified in real time. The notification
arrives on the smart devices as well as in the form of a SMS to the
concerned doctor(s).
Electronic Health Records/Clinical Data: The continuous mon-
itoring of the patient generates massive amount of data. This data is not
always useful in real time but can provide valuable insights when it is
analyzed intelligently. Thus all the data captured by the smart wearable
device and other monitoring units gets stored on the cloud. Before
storing the data, it is encrypted using the blockchain mechanism sop
that it can be prevented from any data theft and eavesdropping.
Encryption/Decryption and Standardization: This is the most
critical unit of the proposed SHS. The data and information collected
7
Healthcare 8 (2020) 100391
through different sensors are largely in different formats. In order to
perform effective analytics, it is necessary to transform this information
in a common standard format. This unit also performs the task of en-
crypting the data and information using blockchain mechanism. Under
this, smart contracts are being developed and digitally signed by all the
stake holders of the system. Since blockchain provides an immutable
structure, it is considered to be tamper proof thus is provides complete
security, consistency, and transparency along with the user privacy.
Blockchain Mechanism: The transactional data gets stored in the
form of immutable storage blocks. Only legitimate users are allowed to
access the data. Blockchain technology allow us to create privacy-pre-
served and intrinsically secured data exchange systems which facilitates
easy access of archived as well as real-time patient data to the parti-
cipating entities using smart contracts which totally eliminates the
overhead of data reconciliation. Fig. 12 shows the brief working me-
chanism of smart contracts in blockchain. A typical blockchain is a
decentralized control and access mechanism wherein each participant
has some interest, but there is no single administrator. Everyone shares
equal rights and authority.
End Users: End users are the person who will use the system
through smart devices or web interface. These include patients, doctors,
G. Tripathi, et al. Healthcare 8 (2020) 100391

nurses, chemists, clinicians, insurance companies, pharmacists and re-

Smart phones, Smart watches, fitness

searchers.
Smart Watches, Fitness bands, Chest

Standalone devices, Fitness bands,

We proposed to apply two level blockchain mechanisms in S2HS. A

Hand Gloves, Finger Strips etc

private blockchain is used for the internal entities of the healthcare

Fitness Band, Smart Watches

Gadgets, Vests, Apparels etc
ecosystem like care providers, clinicians, inventory and other internal

Headbands, Headphones
stakeholders. A public blockchain is used to interact with external en-
Band-aid like Straps

Standalone devices
tities like patients, pharmacists, insurance companies etc. The use of

Standalone device
Wearable Device

Shoes, Apparels

Smart Watches
two-level blockchain implementation provides isolation among dif-
ferent entities and thus provides a consistent and transparent workflow
in a secured and privacy preserved manner.
Straps

bands
5.1. Significance of blockchain in S2HS

The healthcare industry is seeing the transition from the traditional

Galvanic skin response (GSR) technology to measure sweat gland activity

Measurement of Strain in the form of electrical signals due to change in

methods of healthcare to a new smart healthcare system. With myriads

of challenges on its way the healthcare sector continues to pave its way
through this transition phase. As already discussed in section 2, the
Strain Measurements using piezo-resistive sensor technology

present day smart healthcare systems are vulnerable to a number of

threats like data theft, compromised security and privacy, ownership
control etc. Blockchain can assist the current modern day technologies
to provide better healthcare solutions in a much secured and privacy
preserved manner. The different features of blockchain technology can
help the modern day smart healthcare systems to address most of the
challenges that they are facing. The built in features of the blockchain
Thermostat, Infrared, Silicon based

technology like distributed ledger, decentralized storage, authentica-

Uses the concept of Sound waves

Phonocardiogram (or PCG) plot

Based on the concept of Inertia
temperature, pressure or force.

tion, security, and immutability has made it a digital backbone for most
photoplethysmography (PPG)

research areas including healthcare.30,31,41-42 Despite of the numerous

Photo Phlethysmography

Non-invasive electrodes

Non-invasive electrodes

researches in the field of healthcare there is still no universally re-

cognized identifier for patients. It may result in the mismatching of the
Technology Used

electronic health records. Moving the patient's data on the blockchain

helps to overcome this issue by generating a unique hashID value ex-
clusive to every patient. This hashID can be used to identify a patient
without revealing his true identity. Thus, data transparency is achieved
while maintaining the patient privacy. It also helps to resolve the data
ownership issues as no hospitals or medical institutes can own the
Used to measure strains on the surface of the body for example to detect body
Can be used to visualize internal conditions of human body like tissue biopsy,

medical data rather the entire record belongs to the blockchain. This
feature will check the unreasonable constraints imposed on the ex-
change of patient's electronic health record. The decentralized nature of
Used to measure temperature of the subject, area or surroundings

the blockchain removes the possibility of a single point of failure as the

entire medical records are distributed. The possibility of human error
while entering data in the traditional data base systems is removed as
Used for measuring the electrical activity of the heart

adding any block to the existing blockchain requires executing a con-

Can be used to measure degree of emotions arousal

sensus protocol. Blockchain technology also helps the other stake-

Used to measure number of breaths per minute

Used to measure electrical activities of brain

holders in the healthcare market like insurance companies, pharma-

Used to measure pulse rate, Anxiety, Sleep

ceutical companies, healthcare supply chain etc.36–39 It can be observed

Used in navigation and motion detection
postures, falling possibility, weight etc

in Fig. 8 that in the blockchain based smart healthcare system the un-
Used to measure or record heart rate

derlying technologies are mostly the same except the concept of

Used to monitor sound of heart

blockchain is introduced to handle the security and privacy of the

medical data and records. Blockchain unlike the centralized cloud
prenatal examination etc

storage and monitoring provides a distributed and decentralized ap-

proach for data storage depending on the type of blockchain used. It
adds a unique feature of maintaining data transparency while main-
taining the privacy of the patient's personal and medical data. The
Function

authorization and access to data can be efficiently managed on the

blockchain with the patient being the primary delegator using the
concept of smart contracts. A transaction once recorded cannot be
hacked, thus adding a permanence feature to the personal and medical
Phonocardiograph sensor
Skin conductance sensor
Respiration rate sensor

data. The data once stored through a blockchain remain there for future
Strain Gauge Sensor
Heart rates sensor

studies and research. It also facilitates the tracking and tracing of drugs
Ultrasonic sensor

Pulse rate sensor

Thermal Sensor

Inertial sensors

and other medical entities in the supply chain. The immutable nature of
EEG Sensors
Sensor Type

ECG Sensor

blockchain makes it easier to audit and provide compliance. With its

Type of sensors.

unique features blockchain has huge potential in the healthcare sector.

5.2. Benefits of blockchain in healthcare

Table 2

S.No

10

11
1

2
3

4
5
6
7

Blockchain technology is slowly considered as a blessing of modern

8
G. Tripathi, et al. Healthcare 8 (2020) 100391

Fig. 10. Body area network with wearable sensors.

Fig. 11. S2HS-Proposed Blockchain based Smart Healthcare System.

9
G. Tripathi, et al.
Fig. 12. Smart Contracts using Blockchain.
day computing providing impeccable use cases in several technological
and societal domains. Healthcare industry is considered as an ex-
ponentially growing economy with a huge scope of improvements.
There are several direct and indirect benefits of using blockchain
technology in healthcare ecosystem. Some of them are given below
8–12,14,28,32,40
• Distributed and Secured Storage of patient's medical and clinical
Data.
• Enable Patient Centric System.
• Transparency in Audit Trials.
• Holistic Quality Management and tracking of facilities and services.
• Secured and Transparent Supply Chain Management.
• Trusted and Immutable Control and Management System.
• Promotes patient mediated communication, information sharing
and exchange.
• Data is encrypted using immutable blocks forming a chain like
structure.
• Remove central node dependency (everyone shares equal rights and
privileges)
• Better engagement of patients in every aspect from diagnosis to
treatment and cure.
6. Conclusion and future research directions
Blockchain technology in combination with the other modern
technologies has the power to transform the existing smart healthcare
systems from a centralized and vulnerable system to a distributed, de-
centralized and secure system that can help in improving the quality of
medical and other related services. The rationale behind considering
blockchain as a means to improve the healthcare system is multifold.
Firstly, it helps to provide transparent data to all stakeholders while
maintaining the privacy of the patients. Secondly, it becomes im-
possible for the malicious attackers to tamper the valuable medical
records and also preventing it against any kind of data thefts and
eavesdropping. It also puts a check on the expensive manual in-
efficiencies. Blockchain based healthcare systems can further provide
inexpensive and secure services to insurance companies, drug supply
chain, pharmaceutical companies and medical researchers. In future,
the research can be directed towards achieving scalability in the S2SH.
Also there is a need for the development of universal standards for the
adoption of blockchain healthcare. The future of blockchain in
healthcare further requires the development of infrastructure and in-
terconnection for easy adoption of the technology. Furthermore the
issues related to network bottlenecks, scalability and widespread
adoption of blockchain system needs to be resolved. One of the major
hurdles in the adoption of blockchain is the lack of awareness amongst
the stakeholders which needs to be addressed in future. Since its in-
ception in 2008 blockchain has seen multifold growth across all sectors.
The applications of blockchain in healthcare are still at an embryonic
stage of study but it has a great potential to transform the healthcare
10
Healthcare 8 (2020) 100391
sector. There is a need to bring together the healthcare leaders, gov-
ernments, technology innovators and other stakeholders to join hands
to confront the numerous challenges that have vexed the healthcare
sector for decades.
Declaration of competing interest
The authors declare that there is “No Conflict of Interest” in the
current manuscript.
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