Abstract
Digital transformation of healthcare systems should rely on decentralized computer networks and take advantage of the unique characteristics of blockchain technology. Decentralization ensures process transparency and data transparency for all relevant stakeholders. These values are essential in the realms of populations’ healthcare information communications and processing, control and tracking of medical logistics supply chains, clinical research management, and control of certified healthcare services organizations. Mounting decentralized processes onto a blockchain-based computerized network will endow the values of immutability, improved cybersecurity, and potential for incentivizing stakeholders for relevant, pre-determined activities. One of the most relevant processes that would benefit from a decentralized, blockchain-based architecture is the submission, review, and publishing of scientific manuscripts. Current structures and processes in this world are non-transparent, poorly incentivizing significant stakeholders such as manuscripts’ reviewers, and many are potentially corrupted. In this review, we suggest a blockchain-based architecture for such systems and advocate further research and development in several domains of modern healthcare systems—offering medicine to become “the new guy on the block (chain).”
Introduction
Blockchain technology and its potential applications in the worldwide community of healthcare (patients, physicians, nurses, administrators, and other allied healthcare professionals) as a natural continuation of the worldwide digitization process of medical data and patient management. Blockchain-based computer networks are only presented hereafter as the most mature embodiment of decentralized computation to date. A basic understanding of this technology, as well as familiarity with existing software applications in other realms of data sharing and analysis, will give healthcare specialists a boost toward harnessing the strength of decentralization technology to improve human health. The growing extent of digital transformation of medicine and patient data increases the difficulties of data storage and increases the risk of data loss, leakage, and tampering. 1 In their review of “Emerging technologies revolutionizing universal health coverage,” Babatunde et al. 2 embrace three such technologies: the Internet of Things (IoT), machine learning, and blockchain technology. They have blockchains’ immutability, cybersecurity, and interoperability characteristics as those which would facilitate adequate data privacy, storage, and management at minimal cost and risk. Khatiwada and Yang 3 describe IoMT (Internet of medical things) as promising but potentially susceptible to leakage of patient data and having inadequate security and privacy precautions. Blockchain technology would further transform the realm of IoMT, eliminating most of the above-mentioned concerns.
The basic concept of computerized decentralization
Blockchain is a design of computer communications, organizing information in a computer network, that is equally controlled by all network members. 4 Consensus methods agreed upon by the network members transfer the information in a predictable, non-interruptible fashion. The agreed-upon methods are enforced by a computer code, which is a permanent network feature. Smart contracts are pieces of code added to the network that allow more communication rules to be implemented. Smart contract codes and rules can be added but not changed or deleted. By not relying on a single computer entity to manage and secure the information each member can trust his or her voting power to prevent other members from changing the network and the information within. The information itself can be hidden from the members. All data uploading, all transformations, and all network members’ activities are documented in an immutable manner. Data are documented and secured by assuring continuity of documentation on sequential data blocks, each containing all the data previously recorded in anteceded blocks. The result is a chain of data blocks that cannot be altered, backdated, or deleted. The fact that the information is secure and immutable is the key advantage of a decentralized architecture over single-entity managed data structures. Blockchain infrastructure, as a digital architecture, is an evolution of the pre-internet, internet, and cloud-server era, as described in Figure 1. Blockchain architecture enables both read and write access for all computers in the network, ensuring decentralized access to information while assuring no changes can be made to data within the blockchain network, as shown in Figure 2. The matrix created, in which there are no “master” or “slave” servers, assures full transparency of all network activities referred to as “transactions” in Blockchain language. Pre-determined rules enable incentivizing network participants for their contributions. Such incentives can potentially create a token-based economy that ensures more efficient activities on behalf of the network stakeholders while preserving transparency.
Decentralized computer networks as the evolution of previous architectures.
Blockchain technology as a leading execution mechanism of the decentralized methodology.
Values of encrypted data decentralization in the world of medicine (Box 1)
Note. EMR: electronic medical record; AI: artificial intelligence; IF: impact factor; HI: H-index.
A decentralized approach would significantly improve medical data transfer between patients and their medical providers and will save time and money. 1 Medical data do not relate only to individual patient data, but also to other critical information in the healthcare national, international, and industrial systems. For example, the World Health Organization (WHO) estimates that 1 in 10 drugs are fake or substandard. 11 A decentralized approach will allow for more accurate tracing of original medications as the progress of the medication can be updated by different health providers.
There are several keywords that deserve attention when addressing the issue of data safety in the world of medical data: Encryption—data stored on a decentralized network such as blockchain can be encrypted, making it more difficult for unauthorized individuals to access and understand. Access controls—access to the blockchain and the data it contains can be restricted to authorized individuals or groups, ensuring that only those with the appropriate permissions can view the data. Access logging—any access to a specific patient record can be logged in order to identify and analyze any future data and to enable a potential business model where patients or database owners are compensated by the number of times machine learning systems access specific records. Pseudonymization—health data can be stored on the blockchain using pseudonyms or pseudonymized identifiers, rather than real names, to help protect the privacy of individuals while making their data available for large-scale analysis. Permissioned blockchain—in permissioned blockchain access is restricted to authorized participants, allowing for greater control over who can view and modify the data. Zero-knowledge proof—is a cryptographic technique that allows two parties to prove the validity of a statement without revealing the content of the statement or any additional information. It can be used to verify the authenticity of the data on the blockchain without revealing the data itself.
Suitable scenarios for decentralized medical data storage and access management
Decentralized network-based electronic medical records (EMR) systems can help improve the accuracy and accessibility of patient medical records while protecting the privacy and security of that data. Such decentralized networks which will be secured yet accessible worldwide, can be used to track and monitor outbreaks of infectious diseases, as well as to track the distribution of vaccines. As an example, for the global effectiveness of such networks, Farooq et al. 12 offered a blockchain-based medical records network that would be dedicated to asthma patients worldwide. They describe the value of easier, smart contract-based, approach to asthma patients’ data by healthcare professionals, and state that the value of timely approaching encrypted patients’ files in times of respiratory distress is potentially lifesaving. Griewing et al. 13 offered a blockchain-based scheme for artificial intelligence (AI) analysis of breast cancer patients’ data as a natural continuation of the process of digitizing these patients’ workflow in different medical centers and community-based clinics. Decentralized, blockchain-based data management will allow real, big data AI analysis of critical patients’ data required for taking critical, clinical decisions.
Estonia was the first country to secure its national medical records using blockchain technology. The WHO and the Estonian government are working on a blockchain-based COVID-19 vaccine certificate that will be used worldwide. 14 This is an example of using blockchain technology for a highly secured, non-backdating database, that has multiple stakeholders and must be available worldwide when potentially non-vaccinated travelers are trying to cross the borders between countries.
With the development of advanced tools such as machine learning, the immutability of decentralized networks serves the additional purpose of producing more accurate results as much less data is lost. 2 In terms of convenience, keeping patients’ medical data organized throughout their lifetime will also reduce the burden on the patients themselves. One study found that in the United States, an average patient sees 18.7 different physicians and has 19 medical records during their lifetime. 3 In terms of data privacy, a method to encrypt patient data before sending it to the blockchain was already proposed. 8
Beyond improving the management of medical records and ensuring the quality and authenticity of pharmaceutical products, blockchain technology can support additional advancements in medicine. Kumar et al. 15 offer a model in which multiple hospitals could share raw medical imaging data in order to apply AI algorithms for clinical interpretation. For this purpose, a decentralized, blockchain-based platform technology enables the large-scale data sharing that is needed to effectively use AI without breaching data privacy. Blockchain can also be used to securely store and share clinical trial data, making it more transparent and easier to access for researchers and regulatory authorities. In terms of research, it is estimated that 10% of clinical data cannot be replicated, most likely due to human error. 16 The immutability of blockchain will allow for better data retention.
Blockchain can further be used to facilitate the recruitment of patients for clinical trials, as well as to track the progress of those trials. It can also be used to store and share data on drug candidates, enabling more efficient and effective collaboration between researchers and pharmaceutical companies.
Toward increased application of IoT (Internet of Things) technologies in clinical laboratories, this arena will also need a solution for mass data transportation with an increasing need to facilitate the processing of multiple stakeholders without endangering data privacy. 17 Blockchain technology has the potential to revolutionize the world of clinical laboratories-generated data, especially with the rise of IoT. As ownership in the blockchain can be unique to a user or a dataset and cannot be duplicated, the data itself may be transported between parties, dependent on a private key only. 5
In an era of increasing patient involvement and patient empowerment, increased data transparency within medical systems is necessary. Transparency is endangered and halted by the worldwide phenomenon of fake information. It seems that only decentralization of computerized networks, such as blockchain technology, bringing its values to medical data management systems, could enable transparency while minimizing the impact of fake information on our healthcare systems. Table 1 presents examples of potential healthcare realms to benefit from decentralized transformation. The references cited were collected in the PubMed network using the following keywords: Blockchain; Healthcare; Computerized network.
A call for action in the realm of scientific data and results, dissemination, and publication
The first academic journal ever published was “Journal des sçavans,” which came out in 1665. 18 The main principles of scientific publishing have changed little since then. One of the most important potential applications of Blockchain, as a decentralized technology, in the eyes of the authors, are the expected values from conversion of the worldwide ecosystem of scientific publishing to a blockchain-based, token economy-driven system. We foresee this as the cornerstone of this ecosystem’s essential digital transformation in the coming years.
Important benefits are exchanged within this system, which could translate to significant amounts of money and prestige. The most dominant and measurable parameter in this world is the IF, impact factor, and the quantitative value of scientific journals which are incorporated under a small number of international publishers. This specified journal parameter stands for the mean number of times its articles have been cited in the previous year, 3 years, or 5 years period. The higher the number of citations, the higher the value of the author in the eyes of the academy to whom he or she is affiliated, and the higher the value of the journal in the eyes of the readers and potential future article authors. The IF is the main parameter affecting authors’ decisions regarding the journal to which they submit their manuscripts. Parallel to the journal value, measured and displayed as the IF, the value of the author is presented as H-index (HI). The HI represents the number of yearly citations of that author in published, formally indexed, IF-carrying journals.
Both values, IF and HI, carry immense importance for both authors and journals and are calculated according to the accepted published citations of their publications. Nevertheless, the process of calculating IF and HI is only partially transparent: only selected journals are counted (should be those that are peer-reviewed and indexed in accepted, international websites such as PubMed) and self-citations of authors and journals should be subtracted. The fact that these calculations are not “out in the open,” and the fact that huge amounts of money are at stake, set the stage for “predator journals” and unreliable publishers to present IFs that are fake. Only a few international organizations are considered today to be reliable in supplying IF and HI data. Academic and clinical institutions are dependent upon these organizations and pay them very high annual fees. These fees are paid only as a result of the fact that the data are not decentralized, and the rules for its transfer and management are obscure.
Scientific indexed journals are separated by their field of research and are stratified in that same field. For example, all journals dedicated to internal medicine are compared to each other according to their IF. Many academic institutions will consider researchers’ publications only if these are published in the Q1 or Q2 (higher two quartiles) of their IF list. As a result, the values of IF and HI have an immense impact: relating to researchers/authors, these values are the most predominant parameters influencing their academic prestige and promotion. These will determine the author's salary from academy and clinical placements, and influence potential payments in the private sector. The academic institutions to whom these researchers/authors are affiliated are also significantly influenced by the publication ratings. The national and academic grants for each academic institution are determined, predominantly, by their authors’ HI and the IF of the journals accepting their faculty publications. Both national and international prestige and budgets of academic institutions and universities are influenced by these parameters.
This dynamic explains why the global market for scientific publication ratings is flourishing, but since this market lacks transparency it creates the potential for corruption and fraud. Thus, the whole ecosystem of medical scientific research and publications is harmed: low-quality publications which might earn high visibility and impact, have a negative influence on clinical practice and further research, and authors who might spend significant funds (from their personal and institutional budgets) on so-called “free-access” journals that frequently do not contribute to their academic promotions. This occult economy is the basis for market inefficiencies and failures.
When summarizing the main maladies of this economy we point to two principles: the absence of transparency and minimal incentives for the true promotion of the authors’ rights and privileges. The whole process of manuscript submission is non-transparent. The author has no means of truly following his manuscript down the road of editorial processing. Most, so-called, peer-reviewed journals reject manuscripts without review, by their editorial board members. The most common justification is that this practice would save time for the author in cases where the editorial board does not foresee a realistic chance for publication. This process centralizes the power in the hands of a few individuals, without visibility of their motives or the pressures influencing them. It is important to note that all journals deny authors from submitting their manuscripts to more than one journal in parallel. This fact, unconditionally imposed on researchers worldwide, dramatically slows the rate of research outcome dissemination and is the direct result of publishers’ dominance and fear of data leakage during the editorial assessment process.
These characteristics of medical research and publishing make it a good target for transformation into a decentralized/blockchain-based, token economy-based market. A market that stands to gain efficiency and fairness based on the immutability, cybersecurity, and interoperability characteristics of blockchain.
Methods
A proposed blockchain system for scientific medical research results dissemination and scientific publication
In the current legacy systems, the original author uploads manuscripts onto an editorial, cloud-based management system. The choice of target journal/editorial system is solely determined by the author's decision according to the published IF of the journal and its quartile grading in his field of expertise. The IF is presented by the journal/publisher but there are only a few, expensive services through which authors can authenticate the IF. Most authors do not authenticate the reported IF and are potentially deceived. The manuscript goes through an “administrative control” that checks the suitability of the manuscript to the editorial guidelines of that specific journal. This is a time-consuming process and there are no regulations relating to the maximal time allotted for this process. As mentioned earlier, it should be emphasized that all journals deny the option of parallel submissions, which means that from the moment of submission, the process of advancing the manuscript is only dependent on the editorial rate of document handling, with zero transparency. As long as a manuscript is evaluated by one journal, the author is forbidden to submit it to other journals! Following the administrative processing, the manuscript is forwarded to the editorial staff for initial review. Most editors will then decide whether the manuscript will proceed to the phase of peer review. More than 50% of manuscripts are rejected in this phase at the editors’ discretion. The rules and regulations determining editorial decisions in this phase are not transparent to the authors, and the manuscript is not peer-reviewed. This process is, once again, executed without transparency, with all decisions made by the editorial staff with no accountability for their decision or for how long they take to make it. Only a few journals allow follow-up of an open-review process, and the authors have no influence on this process. The review process might take several months, during which the authors are banned from submitting their work to other journals. This is the most prolonged period of this process, slowing the rate of manuscript proceeding for a painfully time. One explanation for this pace is the fact that reviewers have no incentive to expedite this process. Moreover, there are no mechanisms to ensure that reviewers will keep the manuscripts private and not adopt ideas, facts, and figures from the original manuscripts they review. After accepting the reviewers’ comments (the number of reviewers is an editorial, non-transparent decision) the editors should reach a decision if the manuscript is rejected or necessitates a minor/major review. The process of reviewing these revisions will further elongate the process and might take many months, ending with either rejection or acceptance. Accepted manuscripts will go through a prolonged process of editing and authors’ approvals, and after the authors pay for gaining the rights for publishing (in the open access journals) they will wait for their work to be published. The process described is depicted in Box 2. This process is a major obstacle for researchers, authors, and publishers in their quest for a timely, efficient, and cost-effective process. It also imposes a slow progression of disseminating essential, research-derived scientific and medical information.
Current steps in legacy pathways for manuscripts review and processing.
Administrative processing
Editorial assignment
Preliminary editorial assessment
First editorial decision (with potential “Immediate rejection”)
Reviewers’ selection and assignment
Separate review by all selected reviewers
Collection of reviews
Second editorial assessment
Second editorial decision (“accept as is”/“minor revision”/“major revision”/“rejection”)
Authors’ submission of revised manuscript accompanied by a rebuttal letter (“point-by-point” answer letter to reviewers)
Administrative processing
Editorial assignment
Second editorial assessment
Second editorial decision
Authors’ submission of revised manuscript accompanied by a rebuttal letter (“point-by-point” answer letter to reviewers)
Administrative processing
Editorial assignment
Next possible editorial assessment
Next possible editorial decision
In case of manuscript acceptance:
Manuscript editing
Authors’ approval and acceptance of the final manuscript
“Galley proof stage”
Authors’ payment of publication fees
Authors’ signing of publication contract (with various models of copyright agreements)
Preprint publication
Article publication
Following publication, authors have to pay for a third-party service to perform private research and check which authors cited them. There is no standard of citation tracking, which can also promote the option of errors and fraud.
The process described above has several significant disadvantages: awkward, ill-defined progression of a global process, lack of transparency, lack of incentives for efficiency, and high potential for corruption and abuse. All these are potentially cured by the suggested model of transforming this system to a blockchain-based, token-based global economy. Such transformation will bring transparency and incentives while minimizing the potential for corruption.
Results
The proposed blockchain system is focused on hosting and updating all relevant data (from manuscript drafts, through peer review process, publication of manuscripts, citation verification and tracking, and calculating both HI and IF to be automatically disseminated among all stakeholders). The authors will submit their draft manuscripts for a pre-determined sum of tokens, accepted by all stakeholders as the marketable gear for the project. Potential editors and reviewers, already declared eligible for their roles will be incentivized by token payments to commit to their chores and perform them promptly. Speed and efficiency will be similarly incentivized. Information regarding author identity, transfer of intellectual properties, qualitative and quantitative parameters, and eventually, citation tracking, HI and IF calculations—all these will be immutable as blockchain-based calculations. Blockchain will enable stakeholders to track back each step in the process in a clear and accessible manner. Real-world payments, outside the blockchain realm, could still take place between authors and publishers, relying on information generated within the blockchain sequences. We do not propose a change in the market forces as currently operating, and we do not suggest that publishers will be circumvented. A blockchain-based process can allow the trusted collection of additional data during the publication review process. Thus, allowing for measurement and sharing of key performance indicators (KPIs) for the review process. For example, the average time of each step in the publication review process (e.g., administrative decision, peer review, etc.) can be calculated and openly shared as a KPI for each journal and each reviewer. The fact that this information will become public will incentivize journals to speed up their processes and choose more efficient reviewers and will give authors better control by knowing the expected timeline in each journal prior to making their submission choices. We anticipate the results of the suggested architecture and KPI sharing (as suggested in Figure 3) to be transparent, efficient, and immutability and eliminate potential errors and fraud administration in this realm. Moreover, the whole process of scientific research and publishing is expected to gain more credibility among the general public which currently does not relate high readability to this world. Increasing the speed of scientific publication by reducing the time between discovery and sharing in the public domain will accelerate the global knowledge exchange and is likely to accelerate the rate of global discovery and collaboration. Decentralized process should also enable parallel manuscript submission to several journals at the same time. Editors could bid for the best manuscripts and hasten their editorial team members to win them as theirs. This is anticipated to dramatically shorten the time from submission to publication of eligible manuscripts and ensure timely global dissemination of peer-reviewed scientific findings.
Suggested architecture for a manuscript processing and publishing system (legacy system), 24 and mounted on blockchain technology infrastructure (blockchain-based).
Several other endeavors tried to create similar decentralized publication systems. Some failed because of a complicated mechanism of participant roles,19,20 and some because they failed to focus on the main pain points in the current system which is the lack of a clear mechanism for monitoring, calculation, and dissemination of the HI and IF. 21 Previous research shows there is a positive attitude among authors, reviewers, and editors toward a system that will improve fairness and transparency. 22 The authors of this article believe that solutions should be based on existing large-scale blockchains rather than on a new blockchain infrastructure which will lack the fiscal incentive of current blockchains, although such methods have been tried in the past. 23
Discussion
Imagine a world in which essential patient data could be handed over for analysis by specialists without restrictions of time and space. Imagine a setting in which such data could be transmitted for fast-track support of experts worldwide without breaching document safety and individual privacy. Imagine a time in which encryption, data security, and data immutability will enable decentralization of essential data saving, unwinding dependence of, and commitment to, one centralized data owner, enabling multiple stakeholders (primarily patients followed by healthcare organizations and governments) to contribute their capabilities for one shared goal. Above all other missions, deserving this utopic scenario stands the mission of healthcare data communication and analysis in the service of modern medicine.
Digital transformation of healthcare services necessitates information technologies that would enable endowing healthcare with the needed values of transparency, cybersecurity, immutability, incitive-based economy for healthcare professionals, rapid communication, and fast-track execution of complex procedures. Blockchain technology as a decentralized computer network methodology, represents an evolution of computerized network architecture and holds promise for all of the above. In the current review, we detailed a specific application in the realm of medical scientific manuscript evaluation and dissemination. This should serve as a call for action to all personnel in the worldwide healthcare systems environment.
In the Chaim Sheba Medical Center in Israel, we established a research and development center focused on decentralized computer networks. We intend to investigate decentralized architectures and token-based infrastructures to help identify the options that could bring the message of tomorrow to the global healthcare system.
Conclusion
A decentralized, blockchain-based computer infrastructure is a viable alternative to the current practices of calculating IF and HI values for the global research and academic community. This should be a pivotal step in further decentralizing other realms of critical information processing in the healthcare ecosystem, worldwide.
Footnotes
Contributorship
All authors contributed equally to this review.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
