Blockchain and Smart Contracts in a Decentralized
Health Infrastructure
Sergey P. Novikov1, Oleg D. Kazakov2, Natalya A. Kulagina3, Natalya Yu. Azarenko4
Bryansk State Technological University of Engineering
Bryansk, Russia
1
spnovikov@gmail.com, 2kod8383@mail.ru, 3kulaginana2013@yandex.ru, 4salovanat@mail.ru
Abstract - Today digitalization penetrates into all spheres of
human activity. The volume of digital data is increasing.
Therefore, it is necessary to use innovative methods of
information processing. This is important for the effective
management of socio-economic systems. The urgent task is to
ensure the security of storage of digital assets. System analysis of
blockchain technology is carried out. The authors substantiate
the effectiveness of the use of lockers for the safe storage and
transmission of information. The advantages and prospects of
implementation blockchain in the management of social and
economic systems are presented. The purpose of this study is to
investigate the effectiveness of blockchain in the health care
system. The article presents a model of the decentralized
infrastructure of the health care system. Interaction of
participants within the model provides solutions to existing
problems. The article presents the scheme of the distributed data
register for creation of the electronic medical card of the patient.
An algorithm for the use of smart contracts in the health care
system has been developed. The results of the research prove the
effectiveness of the blockade technology for storing records of
electronic medical records of patients.
Keywords – blockchain; digital register; smart contract;
electronic medical card (EMC); digitalization of medicine; digital
healthcare
I. INTRODUCTION
Nowadays development of information and
telecommunication technologies is at an enormous pace and
covers almost all the aspects of the socio-economic activities of
a person. Digital economy has replaced digitalization, thanks to
which it became possible to create qualitatively new models of
business, trade, production, to change the format of education,
public health, public administration and communication
between people.
The main goal of modernization of domestic health care
system is to improve accessibility and quality of medical care
for a wide range of people [2]. A large-scale reform of
medicine in Russia provides for the solution not only of the
material and technical problems of polyclinics, hospitals and
dispensaries. Intellectual aspects of improving the organization
of medical care are much more important: firstly, the doctor-
patient relationship, And first of all, the relationship of the
This work was supported by the RFBR grant 18-41-320003\18
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doctor and the patient, release from the "paper" work at a
patient's reception, and, ultimately, the liquidation of queues in
medical institutions.
One of the most important tasks of the federal program
"Digital Economy of the Russian Federation" for the period
until 2025 [23] is the development of digital healthcare. The
section "Digital Healthcare" focuses on the organization of
accessible medical care for citizens at where it shall require
meeting the criteria of modern times, personalization,
precautionary, workability and safety. To provide citizens with
continuity in the provision of medical assistance, medical
organizations of all forms of the ownership must be connected
to the IEMK USIHS (integrated electronic medical card of the
unified state information system in the healthcare sector), but
subject to the patient's consent to processing his data
electronically.
In order to achieve the set goals, it is necessary to form a
single digital environment of the healthcare system that allows
a patient to effectively interact with the medical institution. In
conditions when there is a growth in both incomes and the
number of middle class, people start to spend more on health
care and seek to receive better services. Consumers are no
longer passive patients, they are increasingly interested in the
process of providing services, waiting for treatment with the
help of new technologies and demanding better information.
One of the first tasks is almost complete digitization of the
document circulation of the entire health care system. The next
step is the integration of digital technologies into the health
infrastructure management system. In this regard, there are
acute questions about the storage of personal data, providing
professional access to them, security of information. We
believe that the solution of the set tasks is possible only in the
context of creating a decentralized health infrastructure on a
digital basis.
In the framework of the study, we will consider the
possibility of creating such an infrastructure based on
blockchain technology and smart contracts. Such a system will
create an effective mechanism for the exchange of medical
information, improve the integrity of data, reduce transaction
costs and will help to avoid the third-party services involved in
the management of public health. All the organizations that
provide medical services, including insurance companies, and
directly the citizens seeking medical care should be the key
978-1-5386-6757-6/18/$31.00 ©2018 IEEE
players in such a system. Maintaining the proposed system in a
workable state will require the introduction of innovative
technologies for working with digital information. Such
technologies should provide exceptional reliability and security
of information storage, its relevance, reliability, availability
and high speed of network processing. In addition, the creation
of a digital patient-oriented protocol will allow to optimize
relationships between all the concerned parties in the health
sector.
To solve the set tasks and to test the hypothesis about the
possibility of using blockchain technology and smart contracts
in the organization of decentralized infrastructure of the
healthcare system, we will conduct a study of the practice of
using modern digital technologies for reliable and safe storage
of information in public networks and ensure effective
exchange of professional information between all the
participants of the digital environment of the social and
economic system.
II. BLOCKCHAIN-TECHNOLOGY AS A
COMMUNICATIONAL BASIS FOR SOCIO-ECONOMIC
SYSTEMS MANAGEMENT
A. Blockchain technology
Blockchain-technology has made a breakthrough in the
field of reliable storage of information in public networks [6].
Blockchain is a type of distributed database where records are
grouped into blocks. Each block is linked to the previous one
using a hash key [10]. This ensures that the information within
the block can not be changed without changing the information
stored in subsequent blocks. The chain of blocks is stored on
the node computer (Node) of each participant of the system,
forming a distributed data register. When adding a new block,
copies of the entire block chain are updated for each
participant. Consensus on what types of blocks and
transactions can be part of a blockchain is automatically
achieved according to whether most block chain holders agree
with the proposed blocks or not. The novelty of the blockchain
technology is that it becomes possible to install business logic
in the transaction itself. The block contains a set of records and
new blocks are added strictly to the end of the chain. This
distinguishes this technology from the traditional databases
where business logic is installed in the database itself or in
software.
Advantages of the blockchain technology:
1. Decentralization, which minimizes the risk of failure of
work in case of failure of a separate system.
2. Increased security through the use of cryptography in the
implementation of each transaction.
3. Impossibility to change the data of the approved block. This
is achieved by the fact that the hash of the identifier of each
block is calculated on the basis of the cumulative data hash of
the entire block and the hash of the identifier of the previous
block.
4. Transparency, as all actions are documented and available
for all the participants of the system.
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B. Blockchain technology in socio-economic systems
management
Development of the blockchain-technology is associated
with the appearance of a crypto-currency. In 2008, Satoshi
Nakamoto article appeared on the Internet: "Bitcoin: A Peer-to-
Peer Electronic Cash System" [11]. The article presented
principles of building a peer-to-peer payment system with the
ability to make electronic transactions between its participants,
bypassing intermediaries in the form of financial institutions.
Thus, initially the blockchain technology was widely used in
the financial sphere and led to the appearance of crypto-
currencies, the most famous of which is a bitcoin. However,
the obvious advantages of blockchain technology (openness,
transparency, high level of security and security of ongoing
transactions) prompted IT specialists to search for opportunities
for its implementation in various areas of socio-economic
relations of modern society [12].
At the beginning of 2016, the report " Distributed ledger
technology: beyond the Block chain" was published in the UK
[5], which represents a study conducted by the State Science
Administration under the leadership of the UK Government
Chief Scientific Adviser, Sir Mark Wolport. The report, in
particular, notes that the main task of the state is to develop a
clear concept of how distributed ledger technology can
improve business processes of government bodies and how it
can be used to provide services to citizens.
So far blockchain technology has come a long way from
transforming from individual transactions with bitcoin crypto
currency to the base of creating flexible platforms and building
a system around them in order to accumulate the development
of adapted applications for their subsequent implementation in
a wide range of industries. In the book "Blockchain. Blueprint
for a New Economy” researcher and founder of the blockchain
research institute Melanie Swan, identifies three conditional
areas for the application of this technology [22]:
• Blockchain 1.0 - crypto-currency transactions (crypto-
currencies are used in various applications related to
financial transactions, for example, the system of
transfers and digital payments) [9];
• Blockchain 2.0 - smart contracts (applications in the
field of economy, markets and finance working with
various types of instruments - shares, bonds, futures,
mortgages, titles, assets and contracts) [15];
• Blockchain 3.0 - applications, the scope of which goes
beyond financial transactions and markets (extends to
the areas of public administration, health, science, etc.)
[1].
Since the scope of blockchain technology has expanded
significantly, the main trend is not the emergence of new
crypto currency as means of payment but the creation of multi-
functional platforms that act as an infrastructure for a whole
range of business applications [3]. This became possible in the
new version of Blockchain 3.0 based on the Erachain platform,
which for the first time provided an opportunity to work within
the framework of legal norms, taking into account the
provisions of federal laws of the Russian Federation No. 152-
FZ "On Personal Data" and No. 63-FZ "On Electronic
Signatures". Unique protocol and regulatory support of data of electronic medical records of patients.
Erachain made it attractive for commercial enterprises, public Skvortsova emphasized that the system of storing
organizations of any type and government structures. medical cards would be maximally depersonalized, and
that would preserve medical confidentiality. In this case,
C. C. Global experience of using blockchain technology patients will be able to determine for themselves what
and smart contracts in the healthcare industry part of the information from their medical cards they
want to disclose [19]. Previously, Vladimir Demin,
Nowadays digital technologies based on blockchain and
adviser to the chairman of the board of
smart contracts are widely used in the healthcare industry:
Vnesheconombank, announced plans to introduce
- Active researches on the use of distributed ledgers in the
distributed ledger technology into the system of the
healthcare industry are conducted by a Dutch company
Ministry of Health [21]. According to the expert’s
Royal Philips. The company's division, Philips
opinion cards on the blockchain will allow to eliminate
Healthcare, has launched the Blockchain Research Lab,
the paper bureaucratic "red tape" in medical institutions
a research laboratory that investigates the use of
and to focus doctors’ efforts on healthcare delivery.
blockchain in medicine.
The analysis of using the blockchain technology has
- A blockchain-platform, in which patients' medical
revealed that nowadays it’s been defined as a separate
records can be seen in real time operates in Estonia.
technology, which can be used outside the framework of the
Blockchain technology Guardtime and eHealth
crypto-currency. It’s mostly used when it is necessary to
Foundation ensures safety, transparency and integrity of
optimize the relationship between participants in socio-
medical information, protecting data from unforeseen
economic systems. Analysis of the blockchain technology
changes or deletions due to hacker attacks, system
advantages confirms the previously suggested hypothesis that
failures and malicious programs [20].
this technology will allow to solve the issues of reliability and
- A work on the project of placing all the medical records "transparency" of information storage on the relationships of
in the country in the block chain is being held in the subjects of socio-economic systems in public networks.
UAE, in cooperation with the Estonian company However, successful implementation of the blockchain
Guardtime. The idea is to make it easier for doctors to technology will require a combination of public administration
access all the information about the patient and reduce to protect participants in the system and concerned parties and
the need to collect various information [18]. regulation to ensure resilience to system risks as well as
protection against the use in criminal activities.
- In the US, the Ministry of Health calls for the
modernization of medical records system and for III. PECULIARITIES OF IMPLEMENTATION OF
transferring them into a blockchain. [16] The BLOCKCHAIN TECHNOLOGY AND SMART
Department of Health initiated a competition of research CONTRACTS IN THE SYSTEM OF HEALTH CARE
works in the field of applying blockchain technology in
healthcare [17]. The main task is to improve the transfer Need for cooperation with health care providers leads to the
of medical data between states [7]. increasing use of digital technologies. In this case an electronic
environment providing a convenient and effective interaction
- Development of a registry of medical data on the basis between all health facilities and consumers of medical services
of blockchain is conducted by a subsidiary of Google in is needed. Development of such an environment leads to the
the UK [19]. First users of the system called Verifiable creation of medical information storages based on the use of
Data Audit, will be hospitals, the British National the integrated electronic medical record (IEMC). To build an
Health Service (NHS), then patients will join it. The effective health management system, it is advisable to use a
system will be regulated by medical institutions and service model, where the central place is taken by IEMC. An
data operators. approximate scheme for organizing such a model is shown in
- In Germany SAP company uses blockchain-based the Figure 1.
software to establish interaction between patients and
physicians [17]. The SAP Health Engagement system
allows patients to maintain direct communication with
doctors and health facility managers, and medical
institutions.
- To develop better treatment of chronic diseases.
- The MedRec project in Israel is working on a system of
smart contracts for the exchange of medical cards
between different clinics [14].
- In Russia, the idea of transferring medical cards to
blockchain was also proposed. On Sept. 6, 2017, during
the Health Forum at the Eastern Economic Forum
(EEF), Health Minister Veronika Skvortsova said that
the blockchain technology could be used to store the Fig 1. E-health system model based on IEMC

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 The main task of the IEMC is to provide collection of the
largest possible amount of medical information about a specific
patient in an electronic form. Technically, this information is a
block of electronic personal medical records (EPMR) relating
to one person, collected and used by several medical
organizations. The IEMC can be established by a group of
medical organizations or a health management authority. The
management way of the IEMC, information storage, access
rights and information exchange standards should be
determined by the organizations creating the IEMC. General
requirements for the IEMC must be formulated in a separate
national standard.
Thus, the IEMC is a properly organized electronic archive
that provides reliable storage and operative regulated
information exchange, as well as the fastest and the most
convenient way to delivery information about a patient to an
authorized physician wherever and whenever it is detected.
When designing the IEMC, various information tasks will
arise: organization and standardization of information flows
and formats of the information exchange, strict delineation of
access rights, creation of a patient identification system, etc.
The concept of creating a unified information environment in
the healthcare sector is not feasible until they are solved.
Filling the IEMC is a separate task. In addition to
information about the services provided and the medical
history, the IEMC should contain the results of laboratory
studies and other medical documents. In accordance with a new
law it is planned to introduce electronic medical certificates of
incapacity for work, which will be transferred from polyclinics
and hospitals. Exchange of the information about electronic
medical certificates can be arranged through the IEMC, that
will combine information on the disability of citizens and
further to analyze the loss of economic potential due to
morbidity.
Thus, the main advantages of using the IEMC are:
1. Keeping medical history in an electronic form, for
example, if the original is lost.
2. Chance to quickly exchange information between
doctors from different health facilities within a single
information system.
In Russia, the work on creation of the electronic medical
cards within the framework of the EGIS is conducted for a long
time. More often in commercial medical organizations the tests
are delivered to a doctor electronically. Issues of connecting
the information systems of commercial laboratories and private
medical institutions to the regional segment of the integration
bus of the UGISZ are actively discussed, and a patient is given
full access to his data. However, the question arises - how to
guarantee the unchanged data in such electronic cards? There
are situations when an incorrect diagnosis is made, the course
of treatment is incorrectly assigned and a patient dies. In this
case, there is a possibility of fraud related to the correction of
the data in the IEMC in order to avoid claims from relatives of
the deceased. To prevent such a scenario, it is necessary to
ensure security of personal medical data and their
"transparency" for all participants in the digital healthcare
system.
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In this case, a distributed ledger based on the blockchain
technology is ideally suited for storing electronic medical
record data. The consistency of the data entered in such a
register is one of the main advantages of using the blockchain
technology.
In addition, the creation of such a system will allow the
main providers of health services to actively communicate and
cooperate with other specialists and auxiliary medical
organizations, such as laboratories and pharmacies. In addition,
on the basis of the decentralized data storage system of the
IEMC, an effective communication between a health care
provider and a patient can be organized. Given that many
doctors do not want patients to have access to electronic
medical records, patients play a passive role in monitoring their
health. Implementing the blockchain infrastructure of the
healthcare system, health care providers receive new channels
for simplified coordination of patient’s care and overall
improvement of health interventions results.
Blockchain technology allows you to accumulate
information for the entire patient's life while ensuring a high
level of safety. In this case, patients will completely dispose of
their data and will be able to easily search for their records,
which are encrypted and stored in a blockchain. Thanks to
encryption with several keys a blockchain-based system will
grant access to data only if the person concerned signs the
corresponding permission [4].
In order to optimize relationships between health care
providers, insurance companies and patients, it is advisable to
use smart contracts in conjunction with blockchain technology.
Such an opportunity is provided, for example, by the universal
blockchain-platform Ethereum.
Ethereum is the second most popular blockchain project in
the world after Bitcoin [13]. In our opinion, this project is most
convenient since it allows to solve a wider class of tasks,
providing conditions for performing transactions based on
technology of smart contracts.
At the same time this project:
• Allows you to maintain an optimal level of security due
to a large deployment and its irreversibility;
• Ensures transparency of the public blockchain,
especially through open source franchising contracts;
• Has many improvements, especially with regard to
scalability.
Thus, the blockchain-platform Ethereum provides an
opportunity not only to create a secure and transparent publicly
accessible IEMC register, but also to ensure efficient exchange.
Below there is a schematic description of the blockchain of the
health system infrastructure based on the IEMC (Figure 2)
The proposed scheme of the blockchain of the health
infrastructure assumes effective interaction of the patient with
all participants of the healthcare system.
The algorithm of the proposed system in case a patient
visits of a medical institution is as follows:
1. A patient gives a temporary access to his/her data.
 2. A smart contract will temporarily unlock the patient's
IEMC for making changes, while the medical institution
uses its identifier to access the required data.
3. Patient’s IEMC records are updated. Smart contract
automatically informs the patient and the doctor about
it:
- the patient is informed of changes in the IEMC records.
-the physician receives information about the services
received by the patient during his visit to the medical
institution.
4. The patient confirms changes of the IEMC, and the
doctor - the services rendered to the patient.
Other participants of the system and a personal IEMC
cooperate with a direct participation of the patient:
Healthcare
Services
Public Service IEMC
Delivery Systems
Insurance
companies
Fig 2. Blockchain of the healthcare system infrastructure based on the IEMC
IV.DISCUSSION OF RESEARCH FINDINGS
Within the study, the possibility of successful use of the
blockchain technologes and smart contracts in the healthcare
sphere was proved. The suggested hypothesis that this
technology will solve the issues of reliability and
"transparency" of the storage of the information concerning the
relationships between subjects of socio-economic systems in
public networks has been confirmed by the system analysis of
the blockchain technology and by the study of the practice of
its usage.
A single approach based on the blockchain will allow
personal medical information to be always with a patient when
visiting a new doctor or a new medical institution, which is
safe and reliable. In this case information can be instantly
updated after visiting a medical institution and will be
immediately available to all the doctors who has a right to view
it upon patient’s permission.
Thus, blockchain technology provides trust, which is very
important in medicine. For example, the Medichain platform
1. The patient provides access to the records of his IEMC
for other participants of the system.
2. A smart contract defines the mechanism of interaction
with unlocked patient data.
3. The patient can at any time get an access to his IEMC
through a single portal of public services.
4. The independent commission monitors the current
processes in the blockchain and provides access to the
data in case of emergency.
The use of blockchain technology to store IEMC will
allow a patient to view and to provide his medical record to
state and commercial medical organizations for recording the
results of analyzes and treatment without being tied to a
specific medical institution.
Patient
Pharmacies
BLOCKCHAIN
Research organizations
Supervisory bodies
Doctor
developed at Oxford University is positioned as a system that
allows patients to safely store their data and provide access to
specialists anywhere in the world, regardless of the medical
network or the electronic medical record used. Created in the
laboratory of the Massachusetts Institute of Technology on the
Etherium platform, MedRec provides an ability to view and to
edit information about the medications that a patient receives
and to combine data from medical records in different medical
institutions.
Despite the fact that blockchain technology has a number of
undeniable advantages over other technologies, a number of
issues remain unresolved:
1. Information quality. The technology does not allow to
determine if the diagnosis is accurate and a suitable list of
services was provided to a patient.
2. Information unification and standardization of medical
records. You will need the tools to manage data quality and to
create so-called "gold" records about patients: you will need to
701
identify everyone, remove duplicate records. Without the tools
that automate this process it can take years.
3. Change of work processes inside the medical institution.
A new principle of collecting and using information will entail
changes in the order of work of doctors and administration. In
particular, a system of medical cards will need to be integrated
with a settlement system. Here, qualitatively formed smart
contracts and technologies for crypto-currency settlements can
come to the rescue. It is also necessary to establish an
exchange of the information between institutions, to create and
to implement a process of providing and accessing the
patient's card. Additional costs will be required for training
medical personnel to work with electronic platforms, as well
as equipping with necessary equipment.
V. CONCLUSIONS
Within the framework of this research, the expediency of
using blockchain technology in the healthcare sphere has been
proved. System analysis showed that solutions based on this
technology form a safe and naturally decentralized framework
for effective digital interaction. One of the main advantages of
blockchain in comparison with other models of distributed
databases is the integration of data processing, ensuring
correctness and security in a single protocol, implemented
algorithmically and minimizing the human factor. Thus, the
main characteristics of the blockchain technology is
availability and stability of the information that allow it to be
introduced into the healthcare sphere.
We highlight the main advantages of the blockchain
platform as a key element of the health information system:
1. Entered in the blockchain data remains unchanged. A
doctor making any new entries in the medical history will not
be able to remove already available information about a
patient, as it will always remain in the system and will be
identified and tied to the particular person who entered it.
2. The blockchain technology will not allow you to
manipulate data about the patient's medical history for
obtaining positive medical conclusions. Data on the diseases
cannot be deleted or unauthorizedly made without letting
know someone who has the right to adjust or to enter such
data. Thus, the system reduces corruption risks associated with
issuing medical certificates.
3. Blockchain will help to avoid fraud with prescriptions
by implementing the following scheme. A patient visits a
doctor and he establishes a definite diagnosis that requires
prescribed medicines. The doctor opens a system and makes
necessary preparation for making a record into the patient's
medical history. The patient can immediately go to the
pharmacy where the pharmacist when opening the patient’s
electronic card has an opportunity to make sure what medicine
was prescribed or if was prescribed or not. Based of this, the
pharmacist gives prescribed medicine to the patient and
immediately makes a note that the patient has received the
necessary medicines.
4. Blockchain will help to avoid misappropriation of
budget funds and funds paid by CHI (Compulsory Health
702
Insurance) or by VHI (Voluntary Health Insurance) because
an insurance company will not need to make written inquiries
to a medical institution to check the patient's medical history.
The insurance company that will have access to viewing
patients' medical cards can directly see what medical services
have been provided and what medications have been
prescribed for a particular patient. As a result, insurance
companies will always be aware of the appropriateness of
using the funds allocated to the medical institution.
Thus, the use of blockchain technology to store IEMC will
improve safety and security of patient data and will help to link
disparate bases into a single one making the interaction
between patients, doctors, medical institutions and insurance
companies more transparent. The use of blockchain makes it
possible to switch to personalized medicine since all the
episodes of patient interaction with medical institutions,
analyzes, physiotherapeutic procedures, chronicle, heredity,
reaction to various drugs, etc. will be stored in the database. It
will be much easier to audit the quality of care provided and to
rank medical institutions, as well as to monitor their work.
The main difficulty in using the blockchain technology in
healthcare is to achieve a balance between protecting interests
of participants in the system and to satisfy broader interests and
needs of the society.
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