Technovation 119 (2023) 102557

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Technovation
journal homepage: www.elsevier.com/locate/technovation

Transforming healthcare ecosystems through blockchain: Opportunities

and capabilities for business process innovation
Davide Aloini a, *, Elisabetta Benevento a, Alessandro Stefanini b, Pierluigi Zerbino a
a
Department of Energy, Systems, Territory and Construction Engineering, University of Pisa, Largo Lucio Lazzarino, 56122, Pisa, Italy
b
IN4ACT Chair – School of Economics and Business, Kaunas University of Technology, K. Donelaičio St. 73, 44249, Kaunas, Lithuania

A R T I C L E I N F O A B S T R A C T

Keywords: Blockchain is an unprecedented enabler and booster of business process innovation, especially in the healthcare
Blockchain sector. Nonetheless, its transformational potential has yet to be fully harnessed because of the challenges that
Business process innovation digitalization has posed to Business Process Management (BPM) and the inherent complexity of the healthcare
Healthcare
processes. Accordingly, through the ambidextrous BPM theoretical lenses, this paper investigates what are the
Ambidextrous business process management
(BPM)
main opportunities for Blockchain-driven healthcare process innovation and which BPM capabilities may un­
Digitalization leash them. Two exploratory case studies were conducted to probe the Blockchain-driven process redesign: a case
BPM Capabilities of exploitative BPM, focusing on drug logistics, and a case of explorative BPM, focusing on integrated home care.
Our findings suggest that Blockchain may enable Healthcare innovation opportunities, such as the redesign of the
information flow and the development of new forms of collaboration in the health ecosystem. In addition, the
most relevant BPM capabilities to pursue such innovations were identified. These results integrate the BPM
research stream and enhance the understanding of Blockchain-driven healthcare process innovation.

1. Introduction
In the Healthcare industry, the current digitalization trend has
offered several opportunities for improving the effectiveness of
diagnostic-therapeutic processes (e.g., Artificial Intelligence for diag­
nostic, remote surgery, telemedicine tools for patient advice and
monitoring, etc.) and re-designing more efficient organizational-
administrative processes to deliver cost-effective services (Biancone
et al., 2019; Biancone et al., 2021; Cobianchi et al., 2020b; Dal Mas
et al., 2020; Drago et al., 2021; Garbuio and Lin, 2019; Maddox et al.,
2019; Secinaro et al., 2021; Yoo et al., 2010).
In this technological landscape, Blockchain represents one of the
most promising emerging technologies for improving healthcare orga­
nizational processes (Spanò et al., 2021; Massaro, 2021). Indeed, it may
tackle notorious issues that characterize this sector, such as data security
and privacy (Esposito et al., 2018; Sousa et al., 2019), lack of trust in
sharing information among stakeholders (Tandon et al., 2020), supply
control over cold chain interruption (Singh et al., 2020), drug counter­
feiting and recall (Tseng et al., 2018), cross-institutional and
cross-border data sharing (Omar et al., 2019). Since Blockchain may
enable incremental and radical business process innovation in
Healthcare (Chang et al., 2019; Holotiuk et al., 2019; Mendling and
Weber, 2018; Rosemann, 2014; Secinaro et al., 2021), it amplifies the
innovation potential related to the Business Process Management (BPM)
paradigm.
It is not by chance that the number of academic works on Blockchain
in Healthcare has been growing in the last few years (Abu-Elezz et al.,
2020; Hasselgren et al., 2020; Tandon et al., 2020). Nevertheless, most
contributions address technical challenges (e.g., scalability, interoper­
ability, security concerns) rather than the managerial ones (Agbo et al.,
2019). Thus, a thorough understanding of the Business Process Inno­
vation (BPI) enabled by blockchaining processes in the Healthcare in­
dustry is largely unaddressed. In particular, in the Healthcare context,
two gaps deserve urgent attention. First, reportedly, the BPI opportu­
nities enabled by Blockchain are manifold, but little investigated. A
prominent reason may be that, in light of the digitalization trend, BPM
for incremental and radical process innovation has become increasingly
contingent upon the technology that enables the innovation and on the
ambidexterity of the organizational context (Benner and Tushman,
2003, 2015). This is particularly felt in Blockchain-driven Healthcare
because health processes are inherently complex to innovate (Antonacci
et al., 2018; Cobianchi et al., 2020a; Reed et al., 2018; Secundo et al.,

* Corresponding author.
E-mail addresses: davide.aloini@unipi.it (D. Aloini), elisabetta.benevento@ing.unipi.it (E. Benevento), alessandro.stefanini@ktu.lt (A. Stefanini), pierluigi.
zerbino@unipi.it (P. Zerbino).

https://doi.org/10.1016/j.technovation.2022.102557
Received 31 August 2021; Received in revised form 10 March 2022; Accepted 19 May 2022
Available online 1 June 2022
0166-4972/© 2022 Elsevier Ltd. All rights reserved.
D. Aloini et al.
2019; Shaygan and Daim, 2021) and because the Blockchain innovation
potential is still untapped and little explored (Garcia-Garcia et al.,
2020). Second, the BPM capabilities needed to innovate business pro­
cesses has been reshaped by the changes brought by digitalization
(Chirumalla, 2021; Helbin and Van Looy, 2021). Yet, this shift in BPM
capabilities requires empirical investigation and contextualization in
specific technological settings and industries (Kerpedzhiev et al., 2021),
such as the Blockchain-driven Healthcare.
Accordingly, we aim at answering the following Research Questions
(RQs):
RQ1: “What are the Business Process Innovation opportunities enabled by
Blockchain in Healthcare?"
RQ2: “What are the main BPM capabilities to enable Blockchain-driven
Healthcare Business Process Innovation?"
In responding to the RQs, we focused on the business process (re)
design phase of the BPM life cycle because it is the phase in which
process innovations are designed and formalized (Dumas et al., 2018).
More in detail, we conducted two exploratory case studies in the
Healthcare industry. The first one focused on a national drug logistics
process to investigate a scenario of incremental BPI, meant as more
efficient decision flow. The second one concerned the home care process
to probe a scenario of radical BPI, intended as the development of a new
process choreography hardly achievable by other technologies.
From a scientific perspective, this work may contribute to the
Innovation Management and BPM research streams in the Healthcare
industry in two ways: 1) it sheds light on the BPI opportunities that
Blockchain can open in healthcare ecosystems; 2) it pinpoints the main
BPM capabilities required to innovate the Healthcare business processes
through Blockchain. In doing so, it attempts to empirically advance the
understanding of context-specific factors driving digital innovation by
combining Innovation Management and BPM approaches (Mendling
et al., 2020). From a practitioner perspective, investigating
blockchain-driven BPI into the Healthcare ecosystem may be beneficial
to convey a deeper and actionable understanding of the Blockchain
innovation potential. Therefore, the findings may provide Healthcare
managers with an advanced comprehension of what process compo­
nents may channel latent BPI through Blockchain and with actionable
insights regarding which BPM capabilities should be prioritized in this
regard.
The remainder of this work is as follows: Section 2 presents the
literature background; Section 3 explains the research design; Section 4
and 5 describe the case study evidences; Section 6 discusses the findings;
Section 7 concludes the manuscript.
2. Theoretical background
2.1. Ambidexterity and business process management
Business Process Management (BPM) is a discipline that, across the
whole business process life cycle, aims to fix inefficiencies, bottlenecks,
deviations, and any other issue that may reduce process performance
(Dumas et al., 2018). BPM is intended as a continuous form of incre­
mental Business Process Innovation (BPI) that focuses on increasing
efficiency and reducing variance, but that hampers radical innovation.
Indeed, the innovation potential of BPM is inherently limited by its
inside-out approach, which drives incremental innovation of extant
processes but which is hardly able to access the radical process inno­
vation that lies outside the already-adopted process configurations
(Rosemann, 2014; Mendling et al., 2020). For this reason, the core ca­
pabilities needed to carry on BPM activities fit the exploitative innova­
tion efforts but may plaster up the explorative innovation efforts and
become competency traps in rapidly changing environments that are
rich in innovation opportunities (Benner and Tushman, 2003).
Yet, Benner and Tushman (2003) claim that the effect of BPM on
2
Technovation 119 (2023) 102557
innovation is not fixed and is contingent upon the organizational and
technological contexts. For instance, in ambidextrous organizations,
BPM practices increase exploitative innovation and no longer dampen
exploratory innovation. Furthermore, ceteris paribus, the wider adoption
of BPM practices improves a firm’s responsiveness and performance
during periods of incremental technological change but has no effect on
such factors during periods of technological ferment (Benner and
Tushman, 2003).
However, digitalization has been bringing significant changes in the
innovation domain itself (Benner and Tushman, 2015). The availability
of unprecedented digital technologies has multiplied the BPI potential
(Grisold et al., 2021; Van Looy, 2021; Elia et al., 2020; Nambisan, 2017)
through a significant reduction in communication and collaboration
costs. On one side, this trend has pushed the locus of innovation outside
of firm boundaries, stimulating exploratory innovation (Benner and
Tushman, 2015). On the other side, it has caused BPM to evolve to
embed the ambidexterity notion to fully harness the generative capacity
of digitalization and overcome the BPM inertia over radical innovation.
In this regard, Rosemann (2014) introduced the ambidextrous BPM
concept, conceived as a combination of “exploitative BPM” and
“explorative BPM”. Exploitative BPM is an accurate reflection of the
classical, above-mentioned BPM notion that relies on analytical, formal,
and computational methods. Exploitative BPM pursues reaction-based,
problem-driven enhancement of business processes without being
aware of process redesign possibilities emerging from the external dig­
ital environment. Instead, explorative BPM puts forth an outside-in
perspective that may enable radical BPI through the environmental
scanning of opportunities driven by digital technologies. Explorative
BPM requires recognizing new opportunities and technologies and
assessing their affordance and transformational potential for radical BPI
purposes (Berger et al., 2018; Kohlborn et al., 2014). Therefore, it
complements exploitative BPM by offering “the same, improved, or new
value propositions through reengineering of extant processes or creation of
new ones enabled by the most suitable and innovative digital technologies”
(Grisold et al., 2019, p. 26).
Despite its topicality and the manifold opportunities for future
research that it may provide, ambidextrous BPM is still in its infancy and
needs more attention (Rosemann, 2014). Ambidextrous BPM for deliv­
ering process innovation is a new frontier that deserves further clarity
(Del Giudice et al., 2018; Grisold et al., 2019; Kohlborn et al., 2014). In
particular, the shift from classical BPM to ambidextrous BPM for inno­
vating business processes lays emphasis on two overlooked aspects.
First, ambidextrous BPM paves the way for both radical and incremental
BPI (Del Giudice et al., 2018; Helbin and Van Looy, 2021). However, BPI
opportunities depend on what technology enables them and the orga­
nizational context in which the business processes to innovate are car­
ried on (Benner and Tushman 2003). In this respect, BPM-driven
empirical fieldwork to advance the understanding of digital innovation
opportunities in specific contexts is an open issue (Mendling et al.,
2020). Second, the capabilities required to undertake ambidextrous
BPM may be different from the capabilities needed for classical BPM
because they must enable both explorative and exploitative efforts,
which are often contrasting (Benner and Tushman, 2003). Moreover, the
socio-technical changes brought by digitalization further challenge
these capabilities, calling for new ones and reshaping the known ones
(Kerpedzhiev et al., 2021). Thus, it is not by chance that ambidextrous
BPM capabilities for digitally-enabled BPI have a prominent, albeit
little-investigated spot in current BPM research agendas (cf. Ker­
pedzhiev et al., 2021).
2.2. Blockchain and business process innovation
The digital revolution has expanded the spectrum of digital tech­
nologies that may enable BPI and has reshaped the way to develop and
deliver innovation (cf. Benner and Tushman, 2015). Therefore, it is licit
to assume that digitalization has made ambidextrous BPM innovation
D. Aloini et al.
opportunities and capabilities even more contingent on specific tech­
nological and organizational contexts.
In the digital landscape, Blockchain is one of the most promising
technologies in terms of innovation potential (Pilkington, 2016; Cohen
et al., 2017). It is a tamper-proof database distributed among the nodes
of a network and arranged in blocks that are linked to each other
through cryptographic principles (Yli-Huumo et al., 2016; Rippa and
Secundo, 2019). Blockchain relies on asymmetric cryptography and
distributed consensus algorithms to grant user security and database
consistency, integrity, anonymity, and auditability (Zheng et al., 2017).
In doing so, it aims at establishing trust in the network because no third
party is in control of the data (Werbach, 2018). To grant security,
transparency, and efficiency of the transactions in the network, Block­
chain can rely on Smart contracts, i.e., programs with encoded condi­
tions that automatically execute transactions without the mediation of a
trusted central party (Wang et al., 2019).
Blockchain has largely been proffered as an enabler of incremental
and radical innovation of cross-organizational business processes
(Chang et al., 2019; Holotiuk et al., 2019; Mendling and Weber, 2018).
Although the financial service industry had initially monopolized the
exploration of the Blockchain innovation potential (Swan, 2015), other
industries, , Insurance, Logistics, Agriculture and Food, Energy Man­
agement, have turned their attention to this topic (Al-Jaroodi and
Mohamed, 2019). In this regard, Healthcare is getting the lion’s share
because Blockchain may enable BPI in both administrative and
diagnostic-therapeutic processes and cope with well-known concerns of
the Healthcare industry. Examples of such concerns are data privacy and
cyber-security, lack of trust among stakeholders, control over the supply
of drugs and equipment, and the increasing necessity to share infor­
mation at the regional, national, and European levels (Chukwu and
Garg, 2020; Mettler, 2016; Tandon et al., 2020).
To figure out if and how an ambidextrous approach to BPM enables
Blockchain-driven BPI, especially in the Healthcare context, we
reviewed1 the scientific literature that investigates Blockchain at the
intersection between Innovation Management and BPM. The review
showed that the Blockchain-based BPI literature is at a very early stage
and should be further investigated (Garcia-Garcia et al., 2020; Mendling
and Weber, 2018; Viriyasitavat and Hoonsopon, 2019). For instance, a
frequently addressed subject is the Blockchain-based management of
medical records and patient data (, Electronic Health Record) to prevent
unauthorized access or assure data accountability and reliability (,
Dwivedi et al., 2019; Miyachi and Mackey, 2021, Stafford and Treibl­
maier, 2020; Nguyen et al., 2019). Another quite investigated subject is
drug logistics, where Blockchain is used for monitoring and certifying
the distribution of drugs in the pharmaceutical supply chain (Agbo et al.,
2019; Singh et al., 2020). Noteworthy use cases of Blockchain are
certifying the storage temperature of drugs during transportation,
guaranteeing the authenticity of drugs, or managing drug recalls (,
Khezr et al., 2019; Jamil et al., 2019; Yong et al., 2020; Saxena et al.,
2020; Bamakan et al., 2021).
Yet, almost all of these contributions focused on a Computer Science
standpoint. Technology is a necessary but not sufficient condition to
innovate business processes. In this respect, although significant tech­
nical challenges remain (e.g., privacy, scalability, interoperability), the
technical pull in studying Blockchain-enabled BPI might have been
overemphasized (Agbo et al., 2019; Hu et al., 2020). A major reason may
be that the early research on Blockchain focused on developing novel
algorithms, frameworks, and proofs of concept rather than on
1 results in direct and immediate efficiency gains, , in the case of auto­
The following query was carried out: (Blockchain OR “distributed ledger
technology”) AND (“process innovation” OR “business process management”
OR “business process improvement” OR “business process redesign” OR “busi­
ness process reengineering”). The query was performed in the Scopus, ISI Web
of Science, and Google Scholar databases. No restriction on the time window
and type of contribution was applied.
3
Technovation 119 (2023) 102557
business-process-related aspects (Lacity, 2018; Tandon et al., 2020).
Indeed, Blockchain technical realisations are increasingly facing unan­
ticipated challenges that call for more managerial-oriented research
from the Operations Management, Organizational Science, and Business
Research fields (Mendling and Weber, 2018). The managerial opportu­
nities linked to the Blockchain introduction have attracted less interest
than the Computer Science ones (Agbo et al., 2019). Thus, the exploi­
tation of Blockchain solutions for innovating business processes is a
rather overlooked topic (Sharma et al., 2021). This may be the main
explanation why there are few real-life healthcare applications.
Furthermore, the review brought out twofold evidence. First,
Blockchain-enabled BPI has been gaining momentum (Garcia-Garcia
et al., 2020; Mendling and Weber, 2018), and a few contributions have
been emerging in the BPM literature. For instance, Hu et al. (2020)
proposed a method for process re-engineering based on Blockchain
technology. Johng et al. (2020) presented a framework to enhance and
redesign business processes by leveraging the trustworthiness provided
by the Blockchain. Kirss and Milani (2020) conducted a case study to
examine how Blockchain may enable process redesign in the banking
industry. Despite this, to the best of our knowledge, the contingent effect
of Blockchain on possible BPI opportunities enabled through an ambi­
dextrous BPM approach is an unaddressed topic, particularly in the
Healthcare industry. Shedding light on this gap may improve the un­
derstanding of the Blockchain innovation potential through ambidex­
trous BPM. Thus, drawing on Benner and Tushman (2003, 2015) and
Rosemann (2014), we advance the following proposition:
Proposition 1. “Blockchain may offer opportunities for incremental and
radical business process innovation in Healthcare through an ambidextrous
BPM approach”
Second, the way Blockchain works and the advantages it entails in
terms of security, trust, and transparency make such a technology
unique in the current digitalization context (Swan, 2015). Thus, it is no
coincidence that BPM capabilities for Blockchain-driven process inno­
vation are advocated as a topic that deserves specific and urgent
research efforts, especially in cross-organizational settings such as the
Healthcare one (Mendling and Weber, 2018; Al-Rakhami and
Al-Mashari, 2020). Nevertheless, surprisingly, no attention has been
devoted to how an ambidextrous approach to BPM may reshape such
capabilities in a Blockchain-driven Healthcare context. Getting a grasp
on this subject would clarify what firms should need to enhance their
readiness towards Blockchain-based process innovation in the Health­
care multi-stakeholder environment. Accordingly, we suggest the
following proposition:
Proposition 2. “Blockchain-enabled business process innovation in
Healthcare may require developing new BPM capabilities and reshaping
existing ones”
2.3. Theoretical framework
To provide a theoretical reference to steer our inquiry and identify
and arrange the BPI opportunities and the BPM capabilities, we adopted
two conceptual models – one for each proposition. Section 2.3.1 details
the model regarding Blockchain-enabled BPI opportunities, while Sec­
tion 2.3.2 specifies the model concerning the BPM capabilities in light of
digitalization.
2.3.1. Blockchain-driven business process innovation categories
The introduction of technologies to support business processes rarely
mation technologies. Generally, to fully exploit the potential of the
technology it is often advisable to redesign the business processes
(Brynjolfsson and McAfee, 2014). Since Blockchain is a transformational
technology, i.e., a technology that changes the way people work and
even the nature of the business enterprises (Tapscott and Tapscott,
D. Aloini et al.
2016), it may enable both incremental and radical business process
redesign (cf. Dumas et al., 2018). In this respect, Milani et al. (2020)
adapted known business process redesign best practices into heuristics
for redesigning processes supported by Blockchain. Considering the
Blockchain technical characteristics, they propose a set of fourteen
heuristics arranged in four categories:
1. Collaboration of Entities: redesign heuristics that leverage the Block­
chain shared data storage to consider the entities participating in a
cross-organizational process as they are centralized and integrated.
2. Case Management Structure: redesign heuristics to reorganize the
work of cross-organizational process through smart contracts, : using
smart contracts for task execution to reduce coordination efforts;
eliminating tasks or automating them; using different smart con­
tracts for separated process variants; optimizing sequence or paral­
leling of the tasks executed by smart contracts.
3. Data Management: redesign heuristics enabled by how Blockchain
stores data and makes them available to the stakeholders partici­
pating in the network, : moving data controls closer to the data entry;
storing in the distributed ledger data from sources external to the
Blockchain network in the distributed ledger to streamline the acti­
vation of the smart contracts.
4. Tokenization: redesign heuristics that leverage the Blockchain capa­
bilities for asset management. The Blockchain architecture allows
smart contracts to manage tokens, i.e., digital representations of
tangible and intangible assets. Tokenization is the process through
which such assets are digitalized so that they can be recorded, stored,
shared, or transferred on a Blockchain. Through tokenization,
physical objects can be tracked, and the status of intangible objects, ,
a smart contract, can be monitored. An example of redesign heuris­
tics is to use tokenization to represent assets in cross-organizational
processes.
These categories were used as a reference to drive the identification
and discussion of the Blockchain-enabled BPI opportunities.
2.3.2. BPM capabilities for digitally-enabled business process innovation
BPM is structured not only through life cycle models but also through
capability frameworks that encompass the most relevant capabilities for
successfully implementing process orientation in organizations
(Pöppelbuß et al., 2015). The impact of digitalization on behavioural
aspects and intra- and cross-organizational communication and collab­
oration has been transforming existing processes and enabling new ones,
questioning the ability of the known BPM capabilities to steer a
process-oriented organization. Thus, to execute business processes and
implement incremental and radical process innovation in the current
digital context, the required BPM capabilities should reflect such
transformation and be able to lead organizations to successful digitally
enabled process-driven management. Kerpedzhiev et al. (2021) took up
this challenge and developed a BPM capability framework in view of
digitalization. The framework includes a set of thirty BPM capabilities
areas arranged in five categories, which are briefly described in the
following:
• Strategic alignment: consistency between organizational priorities and
enterprise processes to enable the achievement of business goals.
• Governance: transparent accountability and decision-making pro­
cesses to align rewards and steer actions.
• Methods and Information Technology: approaches, methodologies,
techniques, and process-oriented software and hardware technolo­
gies that enable consistent process actions and outcomes.
• People: human resources that apply and improve their process-
related know-how.
• Culture: set of shared assumptions that shape process-related atti­
tudes and behaviors.
4
Technovation 119 (2023) 102557
These categories were steered the identification and analysis of the
Blockchain-related BPM capabilities in light of digitalization.
3. Research design
To answer the RQs, two exploratory, single-case studies were
developed according to the guidelines by Pan and Tan (2011). In the
following, this section provides the justification for using the case
research method (3.1), and details the data collection (3.2) and analysis
(3.3).
3.1. Justification for the case research method
The case study research method was chosen because it is suitable for
studying a phenomenon in real-life settings when no control over
behavioral events is required, the phenomenon focuses on contemporary
events, and when capturing the context of the phenomenon is of para­
mount importance (Cavaye, 1996; Yin, 2013). The selected case type
was exploratory because it fits the exploratory form of research ques­
tions (Tellis, 1997). Furthermore, it fits the situations in which a phe­
nomenon – the Blockchain-enabled BPI – has multiple and unclear
outcomes (Baxter and Jack, 2008; Yin, 2013). We opted for a single-case
design because our inquiry is revelatory in nature, i.e., it investigates a
rather unexplored phenomenon and aims to be an unprecedented source
of insight (Yin, 2013). Indeed, the BPI opportunities and the BPM ca­
pabilities for digital innovation have been more theorized rather than
being actually explored. In addition, single cases may lead to a deeper
understanding of the subject under investigation (Dyer and Wilkins,
1991).
Since our study is framed within the ambidextrous BPM research
stream, we carried out two case studies: one for an exploitative BPM
scenario and one for an explorative BPM scenario. In line with the RQs,
the Blockchain initiatives to select have to be developed in the Health­
care industry and be consistent with the explorative/exploitative BPM
paradigm (e.g., purely technology-driven initiatives were overlooked).
In both cases, the unit of analysis was the business process to innovate,
including the innovation goals and the information and resource needs.
The first case investigated an Italian project that aims at innovating a
national drug logistics process through Blockchain to cope with the
insufficient information sharing and traceability across the supply chain.
The pharmaceutical supply chain is critical to the performance and
sustainability of the Italian National Health System. Expired products,
waste, and logistics inefficiencies account for about 13% of the phar­
maceutical expenditure each year (AIFA, 2020), which was €30,5 billion
in 2020 in Italy. Furthermore, almost 1.3 billion packs of medicines were
dispensed by the Italian National Health System in 2020 to guarantee
the supply to hospitals and more than 19,000 pharmacies (FEDER­
FARMA, 2020). This is a case of exploitative BPM because is
problem-driven and seeks to improve an existing business process for
offering an enhanced value proposition (Grisold et al., 2019). We chose
this initiative because carrying drug logistics out in the best possible way
is critical to healthcare ecosystems for three reasons. First, it guarantees
drug supply continuity to avoid supply starvation. Second, it is essential
to preserve the quality of the drugs until their storage in their final
destination. Third, it may tackle the well-known inefficiency of phar­
maceutical supply chains (Papalexi et al., 2020).
The second case explored the opportunity to innovate the Italian
Integrated Home Care process by means of Blockchain to improve the
service level offered to patients. This is a case of explorative BPM
because it is opportunity-driven and aims at redesigning existing pro­
cesses for proposing an enhanced value proposition (Chen et al., 2014;
Grisold et al., 2019). We chose this process because in Italy there is a
progressive increase in the request and provision of home care to the
elderly due to population aging and growing in chronic pathologies
(Matta et al., 2014). The percentage of assisted people over 65 years old
has risen from 1,8% in 2014 to 3,2% in 2017. In 2017, about 779,000
D. Aloini et al. Technovation 119 (2023) 102557

elderly people (about 3% of the over 65s) benefited from the IHC ser­ as recommended by McIntosh and Morse (2015). First, the domain of the
vice, for a total of 12,400,000 h delivered (OASI, 2019). However, the topic under investigation was defined and bound by analyzing the
IHC process lacks coordination and integration of care delivery (Russo pertinent BPM and BPI literature (Rabionet, 2011). Second, in line with
et al., 2015). the case objectives, two categories were identified to develop the
questions: “BPI opportunities” and “BPM capabilities”. The “BPI op­
3.2. Data collection portunities” category includes all the main components of a business
process, i.e., activities, relations among activities, resources, informa­
The objectives of the case studies are to collect context information tion flow, boundaries, and procedures (Dumas et al., 2018), that may be
and the necessary data to: involved in innovating a business process according to the model by
Milani et al. (2020). The “BPM capabilities” category covers the BPM
1. Model the business processes prior to the Blockchain implementation capability areas specified in the framework by Kerpedzhiev et al. (2021).
(as-is process models) and re-designed processes to introduce the Third, the question stems were developed for both the categories. The
Blockchain (to-be process models). Two use cases were considered questions were refined by a pilot test (Adams, 2015) conducted with the
for the drug logistics process, while three use cases were taken into Project Manager for the drug logistics case and with the Head of the
account for the Integrated Home Care process. All the process models Process Innovation Area of the Local Health Authority for the integrated
were jointly reviewed by the authors and the informants to guarantee home care case.
their consistency, completeness, and comprehensiveness. The interviews were conducted from January to July 2021 and were
2. Identify Blockchain-enabled BPI opportunities and which BPM ca­ recorded, transcribed, and enriched by field notes. The main case evi­
pabilities are needed to enable the BPI through Blockchain. dence was reviewed with the key informants. The interview data were
complemented by the analysis of documentation and archival records
The case data were collected by semi-structured interviews (Koch, regarding performance reports, project documents, and process blue­
2004; Li, 2020; Secinaro et al., 2020). The data collection started with a prints. All the case data were arranged in a case archive (Yin, 2013).
kickoff meeting. In the drug logistics case, this meeting was carried out
with the Project Manager to obtain an overview of the whole initiative 3.3. Data analysis
and its objectives, phases, milestones, and challenges. In the IHC case,
the meeting was conducted with the Head of the Process Innovation To conduct a qualitative content analysis of the case archive data, the
Office of a Local Health Authority to collect information on the current three-column approach by Saldaña (2015) was adopted. This approach
status of home care in Italy, how such a process is structured, and which aimed to analyze, synthesize and code the case data through a pro­
are its main inefficiencies. In these meetings, the key informants were gressive procedure for making inference from the data. The coding
jointly identified according to: representativeness of the main stake­ procedure was driven by the research questions, considering the in­
holders; commitment to and sponsorship of the project/process; formants’ responsibilities, project and process drivers and objectives,
knowledge about the process under investigation, the requirements for performance indicators, Supply Chain configuration, technological
re-designing the process, and the resource and information needs. The context, and resource needs (cf. Saldaña, 2015). The authors were split
interviews with the key informants (Table 1) were carried out until into two groups that concurrently carried out the coding procedure
saturation, for a total of 50 interviews with 37 informants. Further minor manually in two steps as follows:
details on quantitative aspects were collated by additional video con­
ferences and phone calls. • From raw data to preliminary codes. The raw data chunks were
The questions were designed and developed by following three steps, explored to identify the “preliminary codes”. A preliminary code is
the conceptual unit summarizing the main concepts expressed in one
or more consecutive sentences.
Table 1
Detail of the semi-structured interviews. • From preliminary codes to final codes. The preliminary codes were
gathered and synthesized into analytical categories (Schmidt, 2004),
Key informant Duration
called “final codes”. This was carried out according to a conceptual
Drug logistics Project Manager A first 2-h meeting; a homogeneity criterion. The final codes were compared to each other
(exploitative BPM) second 1-h meeting
to refine their formulation and removing any duplication.
IT manager of the project Two 2-h meetings
One international primary One 1.5-h meeting
distributor After each step, the outcomes from the two groups were discussed
Two national primary distributors Three 1-h meetings jointly until a consensus was reached. The synthesized data were ar­
per person ranged into the “BPI opportunities” and “BPM capabilities” categories
Supply Chain manager from three One 1.5-h meeting
and reviewed with the support of the informants to fix any inconsistency
different regional purchasing per person
bodies and fill incomplete concepts. The analysis of the case data and the
One pharmacist from ten hospitals One 1.5-h meeting iterative comparison between the as-is and to-be process models allowed
per person us to identify the most relevant Blockchain-driven BPI opportunities and
Integrated home care One ICT Partner One 1-h meeting the main BPM capabilities.
(explorative BPM) Three Responsible for the IHC A first 1-h meeting; a
processes in a Local Health second 1.5-h 4. The drug logistics process
Authority meeting
One Head of the Process Two 1-h meetings
Innovation Area of a Local Health Pharmaceutical supply chains are complex because of several rea­
Authority sons: numerous involved stakeholders, high level of service required,
Three General practitioners Two 1-h meetings high variability and low predictability of the demand, high drug costs,
per person
perishability of some drugs. Although an efficient supply chain should
Four patients/caregivers One 1-h meetings per
person guarantee drug visibility, provenance, and tracking (Hasan et al., 2019),
Two Physiotherapists One 1-h meeting the current pharmaceutical supply chain is not continuously monitored,
Three Social Workers One 1-h meetings per and its information is fragmented and not shared appropriately (Privett
person and Gonsalvez, 2014). In this regard, Blockchain can provide trans­
Two Head Nurses One 1-h meeting
parency and end-to-end tracking capability in supply chain operations

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D. Aloini et al.
and can enable decentralized coordination without the involvement of
intermediaries (Hasan et al., 2019).
The Italian pharmaceutical supply chain (Fig. 1) involves several
stakeholders, described in Table 2. The downstream part of the supply
chain involves the actors that are part of the Italian National Health
System, while the upstream part involves the actors that feed the health
system.
The following sections (Sections 4.1 and 4.2) illustrate the as-is and
to-be models of two specific processes taking place in the pharmaceu­
tical supply chain, i.e., the drug shipment and the drug stocks
monitoring.
4.1. Drug shipment
The pharmaceutical supply chain is generally a cold chain (Sunny
et al., 2020). As such, it is inherently vulnerable. Specifically, the tem­
perature and humidity of the medicines should be maintained between
specific values both in the storage areas of the warehouse and during the
transit as per the specifications. However, the shipment process is
currently not monitored in real time, and it is thus difficult to trace and
certify the party who potentially violated the specifications. Therefore,
any non-conformance may only be detected at the time of delivery or
may not be detected at all.
4.1.1. Drug shipment as-is process
The drug logistics process starts with a distributor that packages the
drugs and delivers them to the carrier. The drug container is equipped
with a data logger that collects data on the status of the delivery (e.g.,
localisation, temperature, humidity, light exposure). Before the depar­
ture, the carrier checks that the truck refrigerators are working properly.
Once arrived at destination, the recipient verifies the consistency among
the package, the purchase order, and the delivery note. In addition, s/he
checks the integrity of the package and the compliance with re­
quirements through the data recorded on the data logger. In case of non-
compliance, the shipment is refused. Therefore, delivery control is
generally considered tedious and costly by pharmacists and healthcare
professionals, e.g.:
“[Talking about incoming delivery control] … This is a time-consuming
activity and often the information recorded is incomplete. Unfortu­
nately, since we have no visibility of delivery status and distributor
availability, we only find out if something is wrong or missing at the end.
Very often we have to re-order from scratch.” (Pharmacist)
Fig. 1. The Italian pharmaceutical supply chain.
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Technovation 119 (2023) 102557
Table 2
Stakeholders of the Italian pharmaceutical supply chain.
Stakeholder Description
Manufacturer It purchases the drug raw materials (active ingredients) and
processes them to produce drugs, which are sold or delivered
to the distributors.
Primary Distributor On behalf of the manufacturers, it stocks and distributes
medicinal products to the secondary distributors and to the
hospitals and territorial retailers, such as pharmacies. It does
not own the medicinal products. It also offers specialized
services, such as specialty drug distribution, packing, and
repackaging.
Secondary It purchases medicines from the manufacturers and resells
Distributor them to the hospitals and territorial retailers. It owns the
medicines that it distributes.
Hospital System In Italy, the hospital systems are managed centrally or in a
decentralised manner depending on the geographical region
in which they operate. In the centralized management,
manufacturers and/or secondary distributors ship their
products directly to a central hub. In this hub, shipments are
broken down into smaller units, repackaged, stored, and then
delivered to the hospital wards. In the decentralized
management, manufacturers and/or secondary distributors
ship their products to the hospitals’ warehouses directly or
through intermediaries.
Territorial Pharmacy It purchases drugs from manufacturers and/or secondary
distributors and sells them to end consumers (patients).
Patient S/he buys medicines from pharmacies or receives them
during hospitalization.
Drug Regulatory It checks the quality, safety, efficacy, and availability of
Authority pharmaceutical products.
4.1.2. Drug shipment to-be process
The use of Internet of Things (IoT) sensors embedded in the container
allows to constantly check that any relevant parameters – e.g., tem­
perature and humidity – remain within the threshold values throughout
the shipment. The blockchain-based logistics platform uses the data
extracted from the sensors, to enable an end-to-end tracking and a real-
time monitoring of the shipment process. In addition, it allows to certify
the responsibility for possible violations. Fig. 2 shows the proposed to-be
model, depicted in Unified Modeling Language (UML) sequence diagram
(Rumpe, 2016). The control-flow of the shipment process remains un­
changed, while the information flow has improved. Indeed, information
exchange is faster and based on certified information.
In the to-be model (Fig. 2), the distributor enters the shipment in­
formation on the platform. This information includes the drugs to be
delivered (e.g., type, lot number, expiration date, quantities, etc.), the
D. Aloini et al. Technovation 119 (2023) 102557

Fig. 2. To-be model of the drug shipment process.

place of departure and delivery, the recipient, and the shipment condi­ recipient (see alternatives 3.1 and 3.2), and the shipment is aborted. In
tions (temperature, humidity, etc.). The IoT sensors measure and record doing so, the blockchain-based platform allows the shipment to be
all the relevant parameters (temperature, geographic location, unex­ stopped as soon as an anomaly occurs, without necessarily waiting for
pected container opening, etc.) in real time and continuously submit the completion of the delivery. Thus, the Blockchain enables and auto­
them to the platform from the storage until the end of the shipment. This mates the real-time monitoring of the shipment. This aspect is particu­
allows the recipient to figure out whether the shipment conditions larly appreciated by distributors and manufacturers, e.g.:
established for the transport were met. At this point, the shipment starts,
“I think it would be important to know the status of the delivery through
and the carrier notifies it to the platform. If no anomaly was detected
the platform. That way, I can find out immediately about any problems
(see alternative 1), the shipment is accepted by the recipient. In case of
and I can try to solve them. At present, I only encounter problems in the
anomaly, the acceptance of the shipment depends on the type of the
shipment after delivery, when the carrier returns the transport document,
problem. When a partially serious but solvable problem occurs, which
or when I receive a complaint from the pharmacy.” (International Pri­
has not affected the status of the shipment, the blockchain-based plat­
mary Distributor)
form alerts the carrier, which tries to solve the issue before the arrival of
the shipment (see alternative 2). If the anomaly is serious and cannot be
corrected, the platform notifies the situation to the carrier or to the

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D. Aloini et al. Technovation 119 (2023) 102557

4.2. Drug stocks monitoring “I don’t know the availability of the drugs at the distributors’ or manu­
facturers’ warehouses. As a result, when I place a new order, I have to
The unavailability of medicines is a critical issue involving all actors hope that the amount of drugs I need is available, otherwise I have to wait
in the pharmaceutical supply chain. This is aggravated by the current for a restock. Maybe the drug is expiring somewhere but I don’t know.”
lack of information sharing on stock levels between them. In fact, if there (Pharmacist)
was visibility between the nodes of the supply chain, they could cope
with shortages by exploiting the availability of their neighbours.
4.2.2. Drug stock monitoring to-be process
Fig. 3 shows the proposed to-be model. The control-flow of the
4.2.1. Drug stock monitoring as-is process
monitoring process remains unchanged. Yet, thanks to the Blockchain,
The as-is drug stocks monitoring process starts with a drug/refill
the stakeholders can know the actual availability of drugs in each area
request. Once it is received, the package is prepared and delivered to the
(regions or sub-regions) and may react promptly to any emergency or
carrier, who will hand it over to the recipient. At the end of the delivery,
unexpected shortage situations.
the recipient may accept or, in case of non-compliance, reject it. Dis­
Once a drug request or a refill request is received, the package is
tributors and logistics hubs can access the up-to-date stock information
prepared and delivered to the carrier. At the same time, stock updates
to manage the warehouse and plan orders. Yet, such information is not
are sent to the blockchain platform, which verifies that the required
shared among the other actors. The lack of stock visibility is considered
information is entered on time by the authorised actors. Once this in­
problematic especially by pharmacists and supply chain managers, e.g.:
formation is received, the platform anonymises and aggregates it ac­
cording to predefined criteria (e.g., by geographical area). Then, the

Fig. 3. To-be models of the drug stock monitoring process.

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D. Aloini et al.
platform shares such anonymised stocks information with the other
actors in the supply chain, with different read permissions. The security
and anonymity of the data is particularly relevant for distributors, e.g.:
“Our concern was having to disclose sensitive information. Thanks to this
platform, we could share inventory data without having to disclose
confidential information about our warehouses.” (National Primary
Distributor)
For example, as shown in Fig. 3a, manufacturers, distributors, and
the drug regulatory authority can know actual stock levels and ware­
house information in the different areas. Instead, as shown in Fig. 3b,
central hubs downstream in the supply chain have visibility on the stock
levels and on the availability of expiring drugs in the national territory.
In so doing, they can be able to cope with stock-outs and/or unavail­
ability of drugs (e.g., expensive or rarely used), knowing the availability
of the other nodes in the supply chain. Once the information has been
uploaded, as in the as-is scenario, the carrier delivers the package to the
recipient/hospital ward, which verifies its quality and compliance with
the order. In case of non-conformity, the delivery is refused.
4.3. Blockchain-enabled BPI opportunities and BPM capabilities in the
drug logistics case
As regards Proposition 1, Blockchain drives incremental improve­
ments into the drug supply chain at information flow level, without
disrupting the process workflow.
Indeed, as shown by the drug shipment and drug stocks monitoring
process models above, the information flow has improved, favouring
trustworthy data sharing and visibility among the stakeholders of the
supply chain. For example, the Blockchain-based platform allows the
supply chain actors to be constantly updated about the state of the
shipment and to immediately interact in case of non-compliance. The
possibility to share data reliably, guaranteeing anonymity and security,
is particularly appreciated by distributors and manufacturers; whereas
the visibility of stock information is a need that has emerged in most
cases among pharmacists and supply chain managers.
On the contrary, the drug logistics process and the work practices
carried out by the operators remain substantially unchanged. Indeed,
Blockchain allows the automation of some monitoring actions – e.g.,
control of transport parameters or stock levels - without burdening re­
sources in terms of effort. This aspect is appreciated by all stakeholders
because it would allow them to limit time consuming activities and the
risk of error.
As concerns Proposition 2, the evidence obtained from the interviews
highlighted that three capability areas are of the greatest importance in
pursuing Blockchain-enabled BPI: Process Portfolio Management, Process
Data Governance, and BPM Platform Integration, which belong respec­
tively to the Strategic Alignment, Governance, and Methods & Infor­
mation Technology clusters, respectively.
The Process Portfolio Management capability area (Strategic Align­
ment cluster) permits to identify the interdependencies between the sub-
processes that are the subject of improvement activities, keeping into
account the final purpose. Process Portfolio Management allowed the
project team to take into account effectively the dependencies among
inter and intra-organizational processes in the design of the Blockchain-
based Logistics Platform. This was crucial to the planning of the
Blockchain initiative because drug logistics processes involve a high
number of heterogeneous subjects (i.e., manufacturers, primary dis­
tributors, pharmacies, drug regulatory authority, carriers, etc.). This
entails the need to handle manifold informative interactions among
them. For this reason, the capability to design a correct process
orchestration among different actors turned out to be fundamental to
guarantee the alignment between the business processes and the
Blockchain.
The Process Data Governance capability area (Governance cluster)
regards the definition of standards and guidelines for managing
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Technovation 119 (2023) 102557
structured and unstructured process data. The importance of Process
Data Governance capability in this case study relates to both the process
characteristics and the nature of the technology exploited. Given the
clinical relevance of the drug logistics and the severe legal requirements
it has to meet, drug logistics process data need to be strongly reliable.
Blockchain can fulfil this requirement. Yet, it required the formalization
of standards and guidelines for generating, updating, and accessing, and
using these process data, e.g., the unambiguous identification of the data
sources and permissions for access, reading, and writing. In particular,
the interviews with the Project Manager and the IT manager showed
that the definition of privacy and cybersecurity guidelines strongly
affected the design of the Blockchain-based platform.
BPM Platform Integration (Methods & Information Technology clus­
ter) is the capability to establish the components and the standardized
interfaces for integrating any new BPM platform with other platforms
and information systems. IT manager and his staff revealed that this
capability area was essential to steer the most operative activities of the
redesign phase – e.g., the definition of specific requirements for assuring
the integration between the existing information systems and the new
Blockchain system. Indeed, the Blockchain-based Logistics Platform
aims to integrate and consolidate the data from numerous information
systems belonging to different organizations without modifying the
operational practices and information systems.
In addition to the previous three capabilities, the case study under­
lined a further essential capability area that we labelled as Process Risk
Analysis. Process Risk Analysis permits the project team to identify and
analyse potential negative issues that may affect key activities and/or
information flows of business processes. This capability area, which does
not explicitly appear in the framework by Kerpedzhiev et al. (2021), was
of the utmost importance because it involved a Blockchain-oriented
analysis of the main critical points of the drug logistics process, such
as internal controls, handovers, data security and privacy. In our case
study, this capability area was rather relevant because of the potential
serious side effects on patients in case of incorrect information. The
presence of several heterogeneous organizations in the supply chain,
some of which may be competitors or involved into buyer-supplier re­
lationships, contributes to raise the importance of this capability area.
5. The integrated home care process
The Integrated Home Care (IHC) process aims to satisfy the health
and social needs of people by providing appropriate and high-quality
services within a balanced and affordable continuum of care delivered
directly at home (WHO 2000; Matta et al., 2014). In detail, IHC consists
of a suite of services and treatments, both clinical and social, to care for
patients in their homes. Clinical services include specialist medical ex­
aminations, rehabilitation physiotherapy and even more complex and
delicate operations. Social services consist of a variety of home services,
including personal care, activities of daily living, and more. IHC con­
stitutes one of the core services of the Italian National Health System for
the elderly and the frail. It is generally provided to people suffering from
acute or chronic disabling diseases, not self-sufficient elderly, and
terminally ill people. Its deliver involves several stakeholders with
different specialisations, which are detailed in Table 3.
The IHC process is not formalised as a stand-alone process, but it is a
combination of fragments of sub-processes. Therefore, its information
flow is neither continuous nor complete, as illustrated in Fig. 4.
The main sub-processes of which the IHC process is composed are:
• The assessment of the patient’s eligibility, performed by the Local
Health Unit (LHU) with the support of social workers and other
specialists.
• The definition of the patient care plan and the designation of the
team members in charge of the patient care. The care plan consists of
a set of planned and interrelated care activities to achieve predefined
therapeutic objectives.
D. Aloini et al. Technovation 119 (2023) 102557

Table 3 Once the patient/caregiver has collected all the documents, s/he
The Integrated Home Care stakeholders. sends them to the LHU, which assesses his/her eligibility for the IHC
Actors Description service. The LHU analyses the documents and acquires the information
on the patient’s medical history from the hospital database. At the same
Patient A person needing the IHC service due to diseases and disabilities
that limit his/her cognitive and physical capabilities. time, the LHU asks the SWs to carry out an interview with the patient to
General The care professional who is in charge of the patient. S/he gather further information. According to the outcome of the assessment,
Practitioner provides primary contact and prescribes the IHC service to the the patient can be admitted or rejected.
patient.
Local Health Unit The Local Health Unit is operational unit, composed of doctors,
in charge of the home care process., i.e., of assessing the
5.1.2. Patient eligibility to-be process
patient’s eligibility, defining the patient care plan, appointing Fig. 5 displays a to-be model of the patient eligibility sub-process.
the members of the team that will take care of the patient, and The patient directly sends a request for admission to the IHC. There­
monitoring the progress of the IHC service. fore, s/he is registered in the blockchain-based home care platform by
Doctors and Local Health Unit specialized employees that provide the direct
the LHU.
Nurses treatment to the patient.
Specialist A specialized medical doctor that treats patients and, if needed, In doing so, the introduction of the blockchain may drastically
Physician acts as a consultant for the Local Health Unit. reduce the number of involved actors and checking/control activities.
Social Worker A licensed professional that takes care of social services, such as Indeed, the patient information is already available at the moment of
home help services (e.g., housekeeping activities and shopping registration in the platform. Thus, all the stakeholders, even those
for daily needs) and personal care of the patient (e.g., assistance
with washing, dressing, and eating).
involved in other processes, can benefit in real time from qualified and
Physiotherapist A healthcare professional who restores or enhances the abilities protected information on the patient.
of the patient.
Territorial It is responsible for providing the medicines needed to treat and
Pharmacy maintain the patient condition. 5.2. Care provision
Supplier A provider of medical instruments and equipment for treatment
and patient care. 5.2.1. Care provision as-is process
Hospital It provides information on the patient’s health history, e.g.,
examinations performed, surgery undergone, etc.
The as-is care provision sub-process starts when the LHU designates
Caregiver A person in charge of the continuous care of the patient, usually the members of the team that is in charge of caring for the patient.
24 h a day. Generally, this team consists of internal staff (doctors and nurses) and
external suppliers (medical devices suppliers, physiotherapists, social
workers, pharmacies). In this case, each member receives an assignment
• The care provision by team members: doctors and nurses from the
and confirms his/her participation in the programme. The patient may
LHU and external suppliers (physiotherapists, social workers, phar­
propose that independent suppliers and/or specialists can be included in
macies, medical device suppliers).
the team. In this case, these independent entities can only be appointed
• The monitoring of the various treatment activities and the IHC
after the favourable opinion of the LHU.
payment performed by the LHU.
Once the team is formed, the LHU arranges the care activities and
shares the intervention scheduling with the whole team. Each team
The delivery of the IHC process is done by coordinating these process
member performs his/her interventions and records them on the patient
fragments and thus it can be inefficient, leading to several issues, like
diary. The diary is paper based. Therefore, it is not possible for the other
misaligned and outdated information, cumbersome and time-consuming
team members to access information about the patient’s status in real
information exchanges, repetitive activities.
time. After filling the patient diary, each team member compiles the
Blockchain can cope with these weaknesses, enhancing efficiency,
electronic patient record. Although updating the patient record must be
coordination, and integration of the home care delivery (Russo et al.,
done at the end of the treatment, this does not always happen. Indeed,
2015). Furthermore, it may enable the creation of a collaborative
the treatment is usually recorded at the end of the day or in the following
ecosystem that integrates all the IHC process fragments into a shared
days. Late registration of the service often results in inaccuracies, for
process choreography. This ecosystem is characterized by a
example in the date or time of service provision or in some clinical/
privacy-preserving information exchange that guarantees the quality
treatment parameters.
and reliability of the data flow.
The following sections illustrate and discuss the as-is and possible to-
5.2.2. Care provision to-be process
be models of the patient eligibility (5.1), care provision (5.2), and ser­
Fig. 6 depicts the proposed to-be model of the care provision sub-
vice payment and monitoring (5.3) IHC subprocesses.
process. According to the to-be model in Fig. 6, the LHU registers the
suppliers on the platform. The Blockchain then certifies the validity of
5.1. Patient eligibility
the supplier’s information, making him/her a qualified supplier. Once
the suppliers have been registered, the LHU and all the team members
5.1.1. Patient eligibility as-is process
are required to sign the attested terms and conditions agreement form.
The as-is eligibility sub-process encompasses all the activities
After this, the LHU uploads the patient’s programme onto the plat­
necessary to assess whether a patient can be admitted to IHC. More in
form, so that it can be easily accessed by the team members in real time.
detail, to apply for IHC, a patient/caregiver must collect a series of
On the day of treatment, each team member carries out his/her services
documents: the prescription from the General Practitioner, the medical
and records it on the platform. The patient countersigns the actual
record from the hospital where the patient was previously admitted, and
execution of the treatment on the platform. Therefore, the blockchain-
his/her financial situation at the Income Revenue Authority. According
based platform can certify that a task was actually performed by the
to the caregiver/patient, this is a time-consuming task because s/he has
supplier within the terms of the agreement. Moreover, each treatment is
to interact with different actors to gather the necessary information, e.g.:
easily accessible in real time to the LHU and to all authorised team
“Gathering all the documents required by the LHU is time-consuming: members. This aspect is particularly appreciated by LHU and all the
very often I don’t know who to turn to or I don’t get a reply. However, suppliers, e.g.:
without this information I cannot apply for home care for my mother.”
“I think it would be very important to have access to the electronic patient
(Caregiver)
record at all times. In this way, I could be constantly updated on the
patient’s state of health and the treatments carried out so far. Currently, it

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D. Aloini et al.
Fig. 4. The Integrated Home Care process.
often occurs to me that the first part of the visit is dedicated to a summary
of the services performed on the patient.” (Head Nurse)
5.3. Service monitoring and payment
5.3.1. Service monitoring and payment as-is process
The as-is service monitoring and payment sub-process includes all
the necessary to monitor the IHC service and to carry out the payment of
the treatments. More in detail, the process begins when the LHU com­
pares the patient diary with the electronic patient record. This is a time-
consuming activity that involves the patients and requires to check
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Technovation 119 (2023) 102557
several, often out-of-date, documents. If the check is successfully
completed, the LHU executes the payment of the service(s), according to
the agreed terms. On the contrary, the LHU notifies the anomaly to the
supplier.
5.3.2. Service monitoring and payment to-be process
Fig. 7 displays the proposed to-be model of the service monitoring
and payment sub-process. The recording of the treatment on the
blockchain-based platform guarantees that the treatment fulfils the
agreed terms. In this way, the platform can execute the payment
immediately, without the need for a prior check by the LHU. This
D. Aloini et al. Technovation 119 (2023) 102557

Fig. 5. To-be model of the patient eligibility sub-process.

reduces the number of checks to be made and the time spent on them. transparency among all the parties involved in the IHC service, allowing
Thus, the resulting process is more streamlined and effective. This aspect simple and efficient visibility of information via the new shared plat­
is welcomed by the LHU, e.g.: form, instead of having information stored in multiple systems
belonging to different organizations. In so doing, all IHC participants
“Thanks to the platform, I would be able to avoid countless checks to
can interact and have secure access to data. The timely access to data
ensure that the supplier’s service was performed correctly and to approve
was particularly appreciated by both the suppliers who would have up-
payment. Currently, there are some specialists who tend to fill in the
to-date information on the patient’s conditions and activities provided,
electronic patient record at the end of the day, others who wait a few days.
and the LHU who would have assurance that treatments were carried out
As a result, I have no guarantee that the treatment has been carried out on
on the agreed schedule. On the contrary, patients/caregivers would
time.” (LHU)
mainly value the possibility to easily share personal information (health
In addition, the use of the blockchain allows to certify the supplier’s conditions, financial conditions, etc.) in an anonymised and secure way.
performance in providing the service. This facilitates the LHU’s peri­ As concerns Proposition 2, seven capability areas resulted to be of the
odical evaluation of the supplier. greatest importance to the explorative Blockchain initiative. Four ca­
pabilities areas are the same found in the drug logistics case study –
Process Portfolio Management, Process Data Governance, BPM Platform
5.4. Blockchain-driven BPI opportunities and BPM capabilities in the
Integration, and Process Risk Analysis. Furthermore, three additional
integrated home care case
capability areas emerged as critical: Multi-purpose Process Design, Digital
Literacy, and Customer Centricity – belonging respectively to Methods &
With respect to Proposition 1, the introduction of the Blockchain-
Information Technology, People, and Culture clusters.
based home care platform affects both operational practices and infor­
In analogy with what observed for the drug logistics case, Process
mation flows. The platform allows socio-health professionals and pa­
Portfolio Management, Process Data Governance, and BPM Platform Inte­
tients/caregivers to remain constantly updated on health conditions and
gration were critical in the IHC case study because the IHC process: in­
the service provided/expected, facilitating the planning and imple­
volves a high number of dependencies between inter and intra-
mentation of personalised healthcare programs accompanied by a
organizational sub-processes executed by heterogenous subjects;
steady pipeline of medical data.
should have a high reliability in the data produced and exploited for
Blockchain, in this case, creates an interoperable and trusted
providing an adequate service to the patient; is supported by several
collaboration ecosystem where the various sub-processes composing the
information systems with which the Blockchain-based home care plat­
IHC service can be managed in an organic way, developing an unprec­
form must communicate. The Process Risk Analysis remain also critical as
edented form of process choreography hardly achievable by other
the Blockchain technology is applied to certify the correctness of the
technologies. This strongly affects how the process actors carry out their
information and, thus, an effective identification and quantification of
activities and interact – e.g., treatment registration or team nomination
uncertainties and risks related to the information flows is still highly
– and permits to face the process fragmentation which typically harms
necessary. The presence of more heterogeneous organizations and of
the IHC service.
extensive information relating to patients even increases, compared to
The Blockchain-based home care platform also increases the

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D. Aloini et al. Technovation 119 (2023) 102557

Fig. 6. To-be model of the care provision sub-process.

Fig. 7. To-be model of the service monitoring and payment sub-process.

the drug logistics case, the relevance of this capability area. In addition, this case study also the process flows and work practices are redesigned.
Process Risk Analysis capabilities are here applied also to identify and The Multi-purpose Process Design capability area belongs to the
analyse the potential negative issue related to business processes, as in Methods & Information Technology cluster and involves the

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D. Aloini et al.
collaborative design of business processes, including all the sub-
processes and process fragments as well as the needs of individual
process participants. This capability area facilitated the creation of a
unified process design that accounts for the main IHC decision points
and the operational needs of all the subjects involved. In doing so, it
permitted the project team to manage the several sub-processes of which
the IHC process consists of. This is particularly relevant because of the
lack of coordination among the manifold IHC activities and actors.
Digital literacy (People cluster) considers the knowledge and aware­
ness about the opportunities associated with emerging technologies
under the employees’ perspective. Given the explorative nature of this
BPM initiative, the prospects offered by the Blockchain technology (e.g.,
service integration, increased coordination, automatic and certified
processing) were in-depth investigated in light of the IHC service char­
acteristics and weaknesses. This made the digital literacy capability
relevant for steering and addressing the exploration of the external
technologies to redesign the IHC process and enabling enhancements in
its value proposition.
Finally, Customer centricity (Culture cluster) refers to the capability of
putting the customer perspective and needs at the centre of the business
process design. This capability turned out to be strongly critical because
IHC customers are particularly frail, have reduced motor skills or suffer
from chronic diseases. Thus, the IHC process redesign has to consider
additional, strong customer-related boundaries and requirements ac­
cording to which the IHC redesign has to be carried out. In addition, the
needs of the customers’ relatives and caregivers have to be considered
within the Customer centricity scope because such actors accompany and
support the patient continuously. The analysis of all these needs con­
tributes to defining the design of the Blockchain platform for providing a
more effective and efficient service (e.g., simpler procedures for
accessing the service, better care coordination between professionals,
quicker response to changes in care needs).
6. Discussion
The discussion section is structured in four parts: Section 6.1 answers
the first RQ, discussing the most relevant BPI opportunities enabled by
Blockchain technology in the healthcare context; Section 6.2 responds to
the second RQ, illustrating the most important BPM capabilities; Section
6.3 underlines the theoretical contributions, while Section 6.4 provides
the practical implications of the research.
6.1. Opportunities in blockchain-driven healthcare BPI
The case evidence suggests that Blockchain technology can be inte­
grated into BPM solutions to address the need of security, distribution,
openness, and cost effectiveness that characterize emergent health dig­
ital ecosystems. The Blockchain characteristics (i.e., decentralization,
immutability, transparency, integrity, security, and scalability) enabled
two BPI opportunities: Information Flow Redesign and Trusted Process
Interoperability.
The Information Flow Redesign opportunity refers to the redesign of
the information flow without modifying the process workflow and
related work practices. This may limit possible resistance to change,
which typically occurs during process improvement and re-engineering
projects. Thus, it can facilitate the adoption of new technologies and
business practices. This opportunity mainly emerged from the Drug
Logistics case (problem-driven BPI). Indeed, as shown in Section 4, the
implementation of the Blockchain has improved the information flow,
favouring a streamlined, less time-consuming, and trustworthy data
sharing. Interestingly, the main process activities were almost un­
changed. On the one side, drug supply chain actors are not called to
modify their way of working. On the other side, critical information is
made available to all the players, and some monitoring actions are
automated. A similar opportunity emerged also from the IHC case (op­
portunity-driven BPI), where the introduction of the Blockchain system
14
Technovation 119 (2023) 102557
drastically reduced the number of manual controls of the supplier ac­
tivities. Indeed, the Blockchain capability to certify transactions pro­
vides organizations with a high degree of trust in the distributed data
systems on the supply network, opening the way to more intense data
sharing (Werbach, 2018). This is particularly valuable in the healthcare
context because of two reasons. First, it is characterized by data security
issues, lack of trust in sharing information among stakeholders, and lack
of visibility and traceability, fraud and counterfeiting (Esposito et al.,
2018; Tandon et al., 2020; Dutta et al., 2020). Second, most healthcare
industries still rely on loosely integrated information systems, where
data belongs to many different sources and is not shared among
authorized parties (Viriyasitavat et al., 2019). This leads to duplicate or
outdated information and process inefficiency.
The Trusted Process Interoperability opportunity refers to the creation
of a trusted and interoperable collaboration ecosystem where different
sub-processes can be managed and controlled in a distributed and
effective way. This opportunity changes the way the actors work and
communicate, and permits to face the typical process fragmentation of
the healthcare context (Mans et al., 2015). Trusted Process Interoperability
emerged only from the IHC case study, in which Blockchain is proposed
to design a new agile process choreography available to all the stake­
holders (cf. Mendling and Weber, 2018). Indeed, as shown in Section 5,
the Blockchain characteristics allows process participants to interact
with each other and to access data in a seamless, secure, and instant
fashion. Blockchain-based distributed systems can contribute to over­
come the typical trade-offs of centralized BPM contexts, i.e., security vs
openness and cost vs flexibility. Decentralized processes are built on
flexible process choreographies in an open environment that is generally
inclined to intense collaboration, service sharing, and collective
decision-making (Da Xu and Viriyasitavat, 2019). The Blockchain-based
system, in fact, enables automated data exchange to certify process
transaction (e.g., by smart contracts). Hence, business players have not
to know and trust each other to engage in such transactions but they can
simply and directly interact. In addition, being decentralized in nature
with no single point of failure into the network, blockchain can also
boost ecosystem resilience. This may be a key aspect in healthcare where
continuity of care is required.
Table 4 summarizes the main Blockchain characteristics and the
contributions to business process value that underlies the two BPI op­
portunities identified.
6.2. BPM capabilities for blockchain-driven healthcare BPI
The analysis of the case studies pinpoints six capability areas
deriving from the framework of Kerpedzhiev et al. (2021): Process
Portfolio Management, Process Data Governance, BPM Platform Integration,
Multi-purpose Process Design, Digital Literacy, and Customer Centricity. In
Table 4
Blockchain characteristics and BPI opportunities.
Blockchain Business Process Value BPI opportunity
Characteristics
- Shared data Trustworthy and automated data
storage sharing
- Privacy and
anonymity
- Transparency Access to critical data in a seamless, Information Flow
- Security secure, and instant fashion Redesign
- Smart contract Certification of transactions &
- Security Trusted Process
- Immutability Data security Interoperability
- Integrity
- Smart contract Automation of monitoring activities
- Security and reduction in the number of
manual controls
- Decentralisation Trusted and interoperable Trusted Process
- Scalability collaboration ecosystem Interoperability
D. Aloini et al.
addition, a new seventh capability area - Process Risk Analysis - appears
to be strongly relevant for the design phase of Blockchain-based BPI
project in healthcare sector (Fig. 8).
The inclusion of Process Risk Analysis seems to be linked to the spe­
cific capacities of the Blockchain technology, i.e., to certify the cor­
rectness of information flows and to automate process transactions in
the most critical parts of the process orchestration. Process Risk Analysis
may assume a greater relevance in the healthcare field given the utmost
importance of certifying the accuracy of information and of verifying the
coherence of decision-making.
With respect to the digital capability innovation framework by Ker­
pedzhiev et al. (2021), it is interesting to note that the context and the
specific properties of the Blockchain influence the BPM capability
configuration. Furthermore, some differences between the exploitative
and explorative nature of the BPI patterns emerge (Rosemann, 2014).
While Process Portfolio Management, Process Data Governance, BPM
Platform Integration, and Process Risk Analysis were very significant for
both the BPI cases, Multi-purpose Process Design, Digital Literacy, and
Customer Centricity appeared to be particularly critical only in the
explorative scenario.
In the exploitative case, Process Portfolio Management, Process Data
Governance, BPM Platform Integration, and Process Risk Analysis were
crucial for redesigning the information flows considering the inter-
organizational structure of the process and for defining data manage­
ment rules and system interfaces. On the contrary, the capabilities in the
Culture and People clusters appeared to be less important in the problem-
driven BPI, i.e., when the process redesign just slightly affects the
operational practices and the need to consider the view, skills and ex­
pectations of both employees and customers is less compelling.
In the explorative BPM initiative, the opportunity-driven BPI aims to
enhance the value of the home care service provided to the customers.
Therefore, Customer Centricity (in Culture cluster) assumed an important
role to effectively consider the customer perspective during the design
phases.
Furthermore, since Blockchain modifies the process flow and the
work practices, the skills and expectations of employees should be kept
in mind with priority. In this regard, Digital Literacy (in People cluster)
supports the process re-design to account for the knowledge and
awareness of employees about the Blockchain technology. This may
facilitate the introduction of the process innovation and the adoption of
the technology (Khodadad-Saryazdi, 2021).
Finally, Multi-purpose Process Design (in Methods/IT cluster) also
Fig. 8. The proposed BPM capability configuration for BPI in Healthcare.
15
Technovation 119 (2023) 102557
resulted critical in the opportunity-driven BPI case to properly design
the process choreography integrating all home care sub-processes. This
capability area in fact provides knowledge and tools for unifying the
process fragments belonging to an inter-organizational macro-process.
This is relevant for two reasons. First, Blockchain can enable process
interoperability among different organizations. Second, healthcare
processes are often fragmented and managed by heterogenous, some­
times competing, actors.
6.3. Theoretical contributions
Our work is one of the first attempts to complement Innovation
Management and BPM research streams with empirical fieldwork
(Mendling et al., 2020), addressing the gaps highlighted by Mendling
and Weber (2018) for further research on the Blockchain-driven re-de­
sign of business processes. Answering the two RQs, this paper provides
two main contributions to the BPM stream of literature.
First, we identified and discussed two innovation opportunities –
Information Flow Redesign and Trusted Process Interoperability – that the
Blockchain opens up for business processes considering both the
exploitative and explorative BPM perspectives (Mendling and Weber,
2018; Chang et al., 2019; Grisold et al., 2019). The Information Flow
Redesign opportunity relates to the Data Management redesign category
by Milani et al. (2020) and consists in the chance to leverage Blockchain
to reorganise the information flow without necessarily affecting work
practices. Indeed, Blockchain characteristics may enable the automatic
visibility and sharing of trusted information between all actors in the
health ecosystem and supply chain. The Trusted Process Interoperability
opportunity falls into the Collaboration of Entities redesign category by
Milani et al. (2020) and allows the process participants to interact in a
reliable way through a shared and certified data ledger. In this respect,
Blockchain enables interoperability among different process actors
belonging to different nodes of the Supply Chain, guaranteeing the
safety and reliability of process transactions. Accordingly, our research
is a first attempt to identify and systematize some promising
Blockchain-based BPI opportunities in the healthcare context. In addi­
tion, by integrating the BPM research stream with empirical in­
vestigations, our paper also provides evidence about the actual benefits
potentially associated with the Blockchain technology (Garcia-Garcia
et al., 2020; Viriyasitavat and Hoonsopon, 2019).
Second, our work sheds light on the BPM capabilities needed for
Blockchain-enabled BPI, with particular emphasis on the healthcare
D. Aloini et al.
context (Pöppelbuß et al., 2015; Kerpedzhiev et al., 2021). Thus, this
work is a first attempt to answer the call by Al-Rakhami and Al-Mashari
(2020) for further research on BPM capabilities in cross-organizational
settings. We found that not all the BPM capabilities have the same
relevance in exploitative and explorative BPM projects. In particular, the
opportunity-driven BPI may be more demanding in terms of BPM ca­
pabilities with respect to the problem-driven BPI. For instance,
Blockchain-enabled cross-organizational process interoperability may
require additional efforts in the “Methods & IT”, “People”, and “Culture”
BPM capability clusters. A prominent reason is that the
opportunity-driven BPI often modifies the process flow and the opera­
tions practices. This is particularly evident in the IHC case study, where
the integration of different process fragments entailed considerable
changes, especially at the process interfaces. Thus, our findings suggest
that the scope, context, and nature (problem-driven Vs
opportunity-driven) of the digital innovation project may strongly shape
the necessary BPM capabilities.
Furthermore, we propose Process Risk Analysis as a new BPM
capability area. The need for the Process Risk Analysis capability de­
pends on both the context in which Blockchain is going to be applied and
the characteristics of the technology itself (Drljevic et al., 2020; Lim
et al., 2021). Indeed, in the healthcare contexts we analysed, Blockchain
aimed at certifying an inter-organizational and cross-process informa­
tion flow. Without appropriate risk analysis actions, the definition of the
information flow may result incomplete in terms of involved stake­
holders, data attributes, and process controls, affecting the appropriate
design of the desirable solution. Accordingly, we claim that the Process
Risk Analysis area may enrich the “Methods & IT” BPM capability
cluster with context and technology-specific knowledge, as suggested by
Kerpedzhiev et al. (2021).
6.4. Practical implications
This research provides health organizations with practical directions
to enable Blockchain-driven innovation of healthcare processes. The two
case studies contribute to increase the awareness of healthcare managers
about the prospects that Blockchain concretely opens up, underlining
the presence of two BPI opportunities – Information Flow Redesign and
Trusted Process Interoperability. Interestingly, Blockchain allows health­
care ecosystems to redesign the information flow preserving the current
process workflow and with limited modifications to the work practices.
Indeed, Blockchain enhances data sharing – addressing the fragmenta­
tion of information, one of the most relevant challenges in this envi­
ronment – without the need to converge on common practices and
standards. Given the resistance to change that usually affects the
healthcare sector, this aspect may encourage healthcare managers to
undertake Blockchain-driven BPI projects throughout the health value
chain.
In particular, as regards Trusted Process Interoperability, Blockchain
may favor the creation an interoperable collaboration ecosystem in
which the distributed management of the different sub-processes tackles
effectively the notorious process fragmentation of the healthcare sector.
Indeed, the problem of handling complex process choreographies,
spreading across numerous organizations/departments, is common in
the healthcare domain. Therefore, Blockchain-based systems offer
healthcare organizations a solution to improve the process interactions,
increasing the value provided to the patient. Hence, Healthcare man­
agers should grasp the BPI opportunities offered by Blockchain to solve,
or at least mitigate, the above-mentioned process idiosyncrasies.
In addition, the empirical evidences found in the case studies may
provide healthcare managers with useful insights on how to approach
blockchain-based process re-design from a cross-organizational
perspective. The case studies show manifold examples of how Block­
chain can be exploited for BPI, solving critical points across the overall
collaboration ecosystems and supply chain. This knowledge may be
valuable to better understand how the Blockchain technology may
16
Technovation 119 (2023) 102557
create a competitive advantage.
Finally, the BPM capability configurations that we developed may
inform health managers about the capability needs to conduct an
explorative or exploitative Blockchain initiative. A project team with
expertise in process analysis, data governance, and IT integration is
desirable for (re)designing information flows between different process
and sub-process actors. Thus, managers should either provide team
members with adequate training or consider such specific requirements
for hiring qualified employees or selecting external partners. Further­
more, the project team should be able to carry out a Process Risk
Analysis. This capability is crucial because any Blockchain-driven BPI
project requires identifying and addressing the riskiest spots of the
process to innovate to avoid any gap between the re-designed process
and the support offered by the Blockchain.
7. Conclusions
To shed light on the potential of Blockchain for BPI in Healthcare and
on the BPM capabilities that may unleash such a potential, this manu­
script aims to answer the following RQs: “What are the Business Process
Innovation opportunities enabled by Blockchain in Healthcare?” and “What
are the main BPM capabilities to enable Blockchain-driven Healthcare
Business Process Innovation?”. Accordingly, we carried out two explor­
atory case studies in the Italian healthcare context. The first one was a
case of problem-driven BPI regarding the national drug logistics process.
The second one was a case of opportunity-driven BPI concerning the
Integrated Home Care process.
Our evidence contributes to the Innovation Management and BPM
research streams and points out that Blockchain may enable two broad
categories of BPI opportunities in the healthcare context: Information
Flow Redesign and Trusted Process Interoperability. In addition, it
suggests that Blockchain-enabled BPI in the healthcare context may
require specific BPM capability configurations. Among the two cate­
gories of innovation opportunities, Information Flow Redesign is char­
acterized by a lower transformational potential on the business
processes. Yet, the main BPM capabilities to plan and design it are
limited to the Strategic Alignment, Governance, and Methods & IT
capability clusters. Trusted Process Interoperability exhibits a higher
transformational potential. Nonetheless, it is more demanding in terms
of BPM capabilities, which encompass the whole spectrum of the BPM
capability clusters. However, in both exploitative BPM initiative and the
explorative one, Process Risk Analysis emerged as a new, essential BPM
capability area.
This research is not exempt from limitations, which point out di­
rections for future research. Specifically, the results obtained are
contingent upon the industry and technology that enables the innova­
tion and hardly generalizable. Drawing on two case studies, the op­
portunities for process redesign we found are affected by the specific
applications. This is consistent with the exploratory nature of this
research, but it limits the external validity of our findings. Other sig­
nificant BPI opportunities may be discovered by investigating different
healthcare processes and settings.
In addition, the BPM capability configurations proposed are also
strongly linked to the nature of the healthcare field, to Blockchain
Technology, and to the exploitative or explorative nature of the BPI
initiative. This makes the evidence obtained mostly useful when this
technology and/or such environment are involved. The assessment of
BPM capability configurations in other business and technology contexts
is therefore desirable.
Finally, we focused our inquiry only on the (re)design phase of the
BPM life cycle, while additional BPI opportunities and capabilities may
emerge in other life cycle phases. Accordingly, future developments of
this work may consist in carrying on longitudinal case studies in
healthcare settings to figure out if the BPI opportunities and capability
configuration hold true in the process monitoring and controlling phase
of the BPM life cycle, both in explorative and exploitative initiatives.
D. Aloini et al. Technovation 119 (2023) 102557

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