literature review blockchain technology

• Open access
• Published: 04 July 2019

A systematic review of blockchain

• Min Xu   ORCID: orcid.org/0000-0002-3929-7759 1 ,
• Xingtong Chen 1 &
• Gang Kou 1  

Financial Innovation volume  5 , Article number:  27 ( 2019 ) Cite this article

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Blockchain is considered by many to be a disruptive core technology. Although many researchers have realized the importance of blockchain, the research of blockchain is still in its infancy. Consequently, this study reviews the current academic research on blockchain, especially in the subject area of business and economics. Based on a systematic review of the literature retrieved from the Web of Science service, we explore the top-cited articles, most productive countries, and most common keywords. Additionally, we conduct a clustering analysis and identify the following five research themes: “economic benefit,” “blockchain technology,” “initial coin offerings,” “fintech revolution,” and “sharing economy.” Recommendations on future research directions and practical applications are also provided in this paper.

Introduction

The concepts of bitcoin and blockchain were first proposed in 2008 by someone using the pseudonym Satoshi Nakamoto, who described how cryptology and an open distributed ledger can be combined into a digital currency application (Nakamoto 2008 ). At first, the extremely high volatility of bitcoin and the attitudes of many countries toward its complexity restrained its development somewhat, but the advantages of blockchain—which is bitcoin’s underlying technology—attracted increasing attention. Some of the advantages of blockchain include its distributed ledger, decentralization, information transparency, tamper-proof construction, and openness. The evolution of blockchain has been a progressive process. Blockchain is currently delimited to Blockchain 1.0, 2.0, and 3.0, based on their applications. We provide more details on the three generations of blockchain in the Appendix . The application of blockchain technology has extended from digital currency and into finance, and it has even gradually extended into health care, supply chain management, market monitoring, smart energy, and copyright protection (Engelhardt 2017 ; Hyvarinen et al. 2017 ; Kim and Laskowski 2018 ; O'Dair and Beaven 2017 ; Radanovic and Likic 2018 ; Savelyev 2018 ).

Blockchain technology has been studied by a wide variety of academic disciplines. For example, some researchers have studied the underlying technology of blockchain, such as distributed storage, peer-to-peer networking, cryptography, smart contracts, and consensus algorithms (Christidis and Devetsikiotis 2016 ; Cruz et al. 2018 ; Kraft 2016 ). Meanwhile, legal researchers are interested in the regulations and laws governing blockchain-related technology (Kiviat 2015 ; Paech 2017 ). As the old saying goes: scholars in different disciplines have many different analytical perspectives and “speak many different languages.” This paper focuses on analyzing and combing papers in the field of business and economics. We aim to identify the key nodes (e.g., the most influential articles and journals) in the related research and to find the main research themes of blockchain in our discipline. In addition, we hope to offer some recommendations for future research and provide some suggestions for businesses that wish to apply blockchain in practice.

This study will conduct a systematic and objective review that is based on data statistics and analysis. We first describe the overall number and discipline distribution of blockchain-related papers. A total of 756 journal articles were retrieved. Subsequently, we refined the subject area to business and economics, and were able to add 119 articles to our further analysis. We then explored the influential countries, journals, articles, and most common keywords. On the basis of a scientific literature analysis tool, we were able to identify five research themes on blockchain. We believe that this data-driven literature review will be able to more objectively present the status of this research.

The rest of this paper is organized as follows. In the next section, we provided an overview of the existing articles in all of the disciplines. We holistically describe the number of papers related to blockchain and discipline distribution of the literature. We then conduct a further analysis in the subject field of business and economics, where we analyze the countries, publications, highly cited papers, and so on. We also point out the main research themes of this paper, based on CiteSpace. This is followed by recommendations for promising research directions and practical applications. In the last section, we discuss the conclusions and limitations.

Overview of the current research

In our research, we first conducted a search on Web of Science Core Collection (WOS), including four online databases: Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Arts & Humanities Citation Index (A&HCI), and Emerging Sources Citation Index (ESCI). We chose WOS because the papers in these databases can typically reflect scholarly attention towards blockchain. When searching the term “blockchain” as a topic, we found a total of 925 records in these databases. After filtering out the less representative record types, we reduced these papers to 756 articles that were then used for further analysis. We extracted the full bibliographic record of the articles that we identified from WOS, including information on the title, author, keywords, abstract, journal, year, and other publication information. These records were then exported to CiteSpace for subsequent analysis. CiteSpace is a scientific literature analysis tool that enables us to visualize trends and patterns in the scientific literature (Chen 2004 ). In this paper, CiteSpace is used to visually represent complex structures for statistical analysis and to conduct cluster analysis.

Table  1 shows the number of academic papers published per year. We have listed the number of all of the publications in WOS, the number of articles in all of the disciplines, and the number of articles in business and economics subjects. It should be noted that we retrieved the literature on March 25, 2019. Therefore, the number of articles in 2019 is relatively small. The number of papers has continued to grow in recent years, which suggests that there is a growing interest in blockchain. All of the extracted papers in WOS were published after 2015, which is seven years after blockchain and bitcoin was first described by Nakamoto. In these initial seven years, many papers were published online or indexed by other databases. However, we have not discussed these papers here. We only chose WOS, representative high-level literature databases. This is the most common way of doing a literature review (Ipek 2019 ).

In the 756 articles that we managed to retrieve, the three most common keywords besides blockchain are bitcoin, smart contract, and cryptocurrency, with the frequency of 113 times, 72 times, and 61 times, respectively. This shows that the majority of the literature mentions the core technology of blockchain and its most widely known application—bitcoin.

In WOS, each article is assigned to one or more subject categories. Therefore, we use CiteSpace to visualize what research areas are involved in current research on blockchain. Figure  1 shows a network of such subject categories. The most common category is Computer Science, which has the largest circle, followed by Engineering and Telecommunications. Business and Economics is also a common subject area for blockchain. Consequently, in the following session, we will conduct further analysis in this field.

Disciplines in blockchain

Articles in business and economics

Given that the main objective of our research was to understand the research of blockchain in the area of economics and management, we conduct an in-depth analysis on the papers in this field. We refined the research area to Business and Economics, and we finally retrieved 119 articles from WOS. In this session, we analyzed their published journals, research topics, citations, and so on, to depict the research status of blockchain in the field of business and economics more comprehensively.

There are several review papers on blockchain. Each of these paper contains a summary of multiple research topics, instead of a single topic. We do not include these literature reviews in our paper. However, it is undeniable that these articles also play an important role on the study of blockchain. For instance, Wang et al. ( 2019 ) investigate the influence of blockchain on supply chain practices and policies. Zhao et al. ( 2016 ) suggest blockchain will widely adopted in finance and lead to many business innovations and research opportunities.

The United States, the United Kingdom, and Germany are the top three countries by the number of papers published on blockchain; the specific data are shown in Table  2 . The United States released more papers than the other countries and it produced more than one-third of the total articles. As of the time of data collection, China contributed 11 papers, ranking fourth. The 119 papers in total are drawn from 17 countries and regions. In contrast, we searched “big data” and “financial technology” in the same way, and found 286 papers on big data that came from 24 countries, while 779 papers on fintech came from 43 countries. This shows that blockchain is still an emerging research field, and it needs more countries and scholars to join in the research effort.

We counted the journals published in these papers and we found that 44 journals published related papers. Table  3 lists the top 11 journals to have published blockchain research. First is “Strategic Change: Briefings in Entrepreneurial Finance,” followed by “Financial Innovation” and “Asia Pacific Journal of Innovation and Entrepreneurship.” The majority of papers in the journal “Strategic Change” were published in 2017, except for one in 2018 and one in 2019. Papers in the journal “Financial Innovation” were generally published in 2016, with one published in 2017 and one in 2019. All five of the papers in the journal “Asia Pacific Journal of Innovation and Entrepreneurship” were published in 2017.

Cited references

Table  4 presents the top six cited publications, which were cited no less than five times. The list consists of three books and three journal articles. Some of these publications introduce blockchain from a technical perspective and some from an application perspective. Swan’s ( 2015 ) book illustrates the application scenarios of blockchain technology. In this book, the author describes that blockchain is essentially a public ledger with potential as a decentralized digital repository of all assets—not only tangible assets but also intangible assets such as votes, software, health data, and ideas. Tapscott and Tapscott’s ( 2016 ) book explains why blockchain technology will fundamentally change the world. Yermack ( 2017 ) points out that blockchain will have a huge impact and will present many challenges to corporate governance. Böhme et al. ( 2015 ) introduce bitcoin, the first and most famous application of blockchain. Narayanan et al. ( 2016 ) also focus on bitcoin and explain how bitcoin works at a technical level. Lansiti and Lakhani ( 2017 ) argue it will take years to truly transform the blockchain because it is a fundamental rather than destructive technology, which will not drive implementation, and companies will need other incentives to adopt blockchain.

Most influential articles

These 119 papers were cited 314 times in total, and 270 times without self-citations. The number of articles that they cited are 221, of which 197 are non-self-citations. The most influential articles with more than 10 citations are listed in Table  5 . The most popular article in our dataset is Lansiti and Lakhani ( 2017 ), with 49 citations in WOS. This suggests that this article has had a strong influence on the research of blockchain. This paper believes there is still a distance to the real application of the blockchain. The other articles describe how blockchain affects and works in various areas, such as financial services, organizational management, and health care. Since blockchain is an emerging technology, it is particularly necessary to explore how to combine blockchains with various industries and fields.

By comparing the journals in Tables 4 and 5 , we find that some journals appeared in both of the lists, such as Financial Innovation. In other words, papers on blockchain are more welcomed in these journals and the journal’s papers are highly recognized by other scholars. Meanwhile, although journals such as Harvard Business Review have only published a few papers related to blockchain, they are highly cited. Consequently, the journals in both of these lists are of great importance.

Research themes

Addressing research themes is crucial to understanding a research field and exploring future research directions. This paper explored the research topic based on keywords. Keywords are representative and concise descriptions of article content. First, we analyzed the most common keywords used by the papers. We find that the top five most frequently used keywords are “blockchain,” “bitcoin,” “cryptocurrency,” “fintech,” and “smart contract.” Although the potential for blockchain applications goes way beyond digital currencies, bitcoin and other cryptocurrencies—as an important blockchain application scenario in the finance industry—were widely discussed in these articles. Smart contracts allow firms to set up automated transactions in blockchains, thus playing a fundamentally supporting role in blockchain applications. Similar to the literature in all of the subject areas, studies in business and economics also frequently use bitcoin, cryptocurrency, and smart contract as their keywords. The difference is that many researchers have combined blockchain with finance, regarding it as an important financial technology.

After analyzing the frequency of keywords, we conducted a keywords clustering analysis to identify the research themes. As shown in Fig.  2 , five clusters were identified through the log-likelihood ratio (LLR) algorithm in Citespace, they are: cluster #0 “economic benefit,” cluster #1 “blockchain technology,” cluster #2 “initial coin offerings,” cluster #3 “fintech revolution,” and cluster #4 “sharing economy.”

Disciplines and topics

Many researchers have studied the economic benefits of blockchain. They suggest the application of blockchain technology to streamline transactions and settlement processes can effectively reduce the costs associated with manual operations. For instance, in the health care sector, blockchain can play an important role in centralizing research data, avoiding prescription drug fraud, and reducing administrative overheads (Engelhardt 2017 ). In the music industry, blockchain could improve the accuracy and availability of copyright data and significantly improve the transparency of the value chain (O'Dair and Beaven 2017 ). Swan ( 2017 ) expound the economic value of block chain through four typical applications, such as digital asset registries, leapfrog technology, long-tail personalized economic services, and payment channels and peer banking services.

The representative paper for cluster “blockchain technology” was published by Lansiti and Lakhani ( 2017 ), who analyze the inherent features of blockchain and pointed out that we still have a lot to do to apply blockchain extensively. Other researchers have explored the characteristics of blockchain technology from multiple perspectives. For example, Xu ( 2016 ) explores the types of fraud and malicious activities that blockchain technology can prevent and identifies attacks to which blockchain remains vulnerable. Meanwhile, Aune et al. ( 2017 ) propose a cryptographic approach to solve information leakage problems on a blockchain.

Initial coin offering (ICO) is also a research topic of great concern to scholars. Many researchers analyze the determinants of the success of initial coin offerings (Adhami et al. 2018 ; Ante et al. 2018 ). For example, Fisch ( 2019 ) assesses the determinants of the amount raised in ICOs and discusses the role of signaling ventures’ technological capabilities in ICOs. Deng et al. ( 2018 ) argue the outright ban on ICOs might hamper revolutionary technological development and they provided some regulatory reform suggestions on the current ICO ban in China.

Many researchers have explored blockchain’s support for various industries. The fintech revolution brought by the blockchain has received extensive attention (Yang and Li 2018 ). Researchers agree that this nascent technology may transform traditional trading methods and practice in financial industry (Ashta and Biot-Paquerot 2018 ; Chen et al. 2017 ; Kim and Sarin 2018 ). For instance, Gomber et al. ( 2018 ) discuss transformations in four areas of financial services: operations management, payments, lending, and deposit services. Dierksmeier and Seele ( 2018 ) address the impact of blockchain technology on the nature of financial transactions from a business ethics perspective.

Another cluster corresponds to the sharing economy. A handful of researchers have focused on this field and they have discussed the supporting role played by blockchain in the sharing economy. Pazaitis et al. ( 2017 ) describe a conceptual economic model of blockchain-based decentralized cooperation that might better support the dynamics of social sharing. Sun et al. ( 2016 ) discuss the contribution of emerging blockchain technologies to the three major factors of the sharing economy (i.e., human, technology, and organization). They also analyze how blockchain-based sharing services contribute to smart cities.

In this section, we will discuss the following issues: (1) What will be the future research directions for blockchain? (2) How can businesses benefit from blockchain? We hope that our discussions will be able to provide guidance for future academic development and social practice.

What will be the future research directions for blockchain?

In view of the five themes mentioned in this paper, we provide some recommendations for future research in this section.

The economic benefits of blockchain have been extensively studied in previous research. For individual businesses, it is important to understand the effects of blockchain applications on the organizational structure, mode of operation, and management model of the business. For the market as a whole, it is important to determine whether blockchain can resolve the market failures that are brought about by information asymmetry, and whether it can increase market efficiency and social welfare. However, understanding the mechanisms through which blockchain influences corporate and market efficiency will require further academic inquiry.

For researchers of blockchain technology, this paper suggests that we should pay more attention to privacy protection and security issues. Despite the fact that all of the blockchain transactions are anonymous and encrypted, there is still a risk of the data being hacked. In the security sector, there is a view that absolute security can never be guaranteed wherever physical contact exists. Consequently, the question of how to share transaction data while also protecting personal data privacy are particularly vital issues for both academic and social practice.

Initial coin offering and cryptocurrency markets have grown rapidly. They bring many interesting questions, such as how to manage digital currencies. Although the majority of the previous research has focused on the determinants of success of initial coin offerings, we believe that future research will discuss how to regulate cryptocurrency and the ICO market. The success of blockchain technology in digital currency applications prior to 2015 caught the attention of many traditional financial institutions. As blockchain has continued to reinvent itself, in 2019 it is now more than capable of meeting the needs of the finance industry. We believe that blockchain is able to achieve large-scale applications in many areas of finance, such as banking, capital markets, Internet finance, and related fields. The deep integration of blockchain technology and fintech will continue to be a promising research direction.

The sharing economy is often defined as a peer-to-peer based activity of sharing goods and services among individuals. In the future, sharing among enterprises may become an important part of the new sharing economy. Consequently, building the interconnection of blockchains may become a distinct trend. These interconnections will facilitate the linkages between processes of identity authentication, supply chain management, and payments in commercial operations. They will also allow for instantaneous information exchange and data coordination among enterprises and industries.

How can businesses benefit from blockchain?

Businesses can leverage blockchains in a variety of ways to gain an advantage over their competitors. They can streamline their core business, reduce transaction costs, and make intellectual property ownership and payments more transparent and automated (Felin and Lakhani 2018 ). Many researchers have discussed the application of blockchain in business. After analyzing these studies, we believe that enterprises can consider applying blockchain technology in the four aspects that follow.

Accounting settlement and crowdfunding

Bitcoin or another virtual currency supported by blockchain technology can help businesses to solve funding-related problems. For instance, cryptocurrencies support companies who wish to implement non-cash payments and accounting settlement. The automation of electronic transaction management accounting improves the level of control of monetary business execution, both internally and externally (Zadorozhnyi et al. 2018 ). In addition, blockchain technology represents an emerging source of venture capital crowdfunding (O'Dair and Owen 2019 ). Investors or founders of enterprises can obtain alternative entrepreneurial finance through token sales or initial coin offerings. Companies can handle financial-related issues more flexibly by holding, transferring, and issuing digital currencies that are based on blockchain technology.

Data storage and sharing

As the most valuable resource, data plays a vital role in every enterprise. Blockchain provide a reliable storage and efficient use of data (Novikov et al. 2018 ). As a decentralized and secure ledger, blockchain can be used to manage digital asset for many kinds of companies (Dutra et al. 2018 ). Decentralized data storage means you do not give the data to a centralized agency but give it instead to people around the world because no one can tamper with the data on the blockchain. Businesses can use blockchain to store data, improve the transparency and security of the data, and prevent the data from being tampered with. At the same time, blockchain also supports data sharing. For instance, all of the key parties in the accounting profession leverage an accountancy blockchain to aggregate and share instances of practitioner misconduct across the country on a nearly real-time basis (Sheldon 2018 ).

Supply chain management

Blockchain technology has the potential to significantly change supply chain management (SCM) (Treiblmaier 2018 ). Recent adoptions of the Internet of Things and blockchain technologies support better supply-chain provenance (Kim and Laskowski 2018 ). When the product goes from the manufacturer to the customer, important data are recorded in the blockchain. Companies can trace products and raw materials to effectively monitor product quality.

Smart trading

Businesses can build smart contracts on blockchain, which is widely used to implement business collaborations in general and inter-organizational business processes in particular. Enterprises can automate transactions based on smart contracts on block chains without manual confirmation. For instance, businesses can file taxes automatically under smart contracts (Vishnevsky and Chekina 2018 ).

Conclusions

This paper reviews 756 articles related to blockchain on the Web of Science Core Collection. It shows that the most common subject area is Computer Science, followed by Engineering, Telecommunications, and Business and Economics. In the research of Business and Economics, several key nodes are identified in the literature, such as the top-cited articles, most productive countries, and most common keywords. After a cluster analysis of the keywords, we identified the five most popular research themes: “economic benefit,” “blockchain technology,” “initial coin offerings,” “fintech revolution,” and “sharing economy.”

As an important emerging technology, blockchain will play a role in many fields. Therefore, we believe that the issues related to commercial applications of blockchain are critical for both academic and social practice. We propose several promising research directions. The first important research direction is understanding the mechanisms through which blockchain influences corporate and market efficiency. The second potential research direction is privacy protection and security issues. The third relates to how to manage digital currencies and how to regulate the cryptocurrency market. The fourth potential research direction is how to deeply integrate blockchain technology and fintech. The final topic is cross-chain technology—if each industry has its own blockchain system, then researchers and developers must discover new ways to exchange data. This is the key to achieving the Internet of Value. Thus, cross-chain technology will become an increasingly important topic as time goes on.

Businesses can benefit considerably from blockchain technology. Therefore, we suggest that the application of blockchain be taken into consideration when businesses have the following requirements: accounting settlement and crowdfunding, data storage and sharing, supply chain management, and smart trading.

Our study has recognized some limitations. First, this paper only analyzes the literature in Web of Science Core Collection databases (WOS), which may lead to the incompleteness of the relevant literature. Second, we filter our literature base on the subject category in WOS. In this process, we may have omitted some relevant research. Third, our recommendations have subjective limitations. We hope to initiate more research and discussions to address these points in the future.

Availability of data and materials

Data used in this paper were collected from Web of Science Core Collection.

Abbreviations

Initial coin offering

Web of Science Core Collection

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Acknowledgements

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This research is supported by grants from National Natural Science Foundation of China (Nos. 71701168 and 71701034).

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Min Xu, Xingtong Chen & Gang Kou

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Three generations of blockchain

The scope of blockchain applications has increased from virtual currencies to financial applications to the entire social realm. Based on its applications, blockchain is delimited to Blockchain 1.0, 2.0, and 3.0.

Blockchain 1.0

Blockchain 1.0 was related to virtual currencies, such as bitcoin, which was not only the first and most widely used digital currency but it was also the first application of blockchain technology (Mainelli and Smith 2015 ). Digital currencies can reduce many of the costs associated with traditional physical currencies, such as the costs of circulation. Blockchain 1.0 produced a great many applications, one of which was Bitcoin. Most of these applications were digital currencies and tended to be used commercially for small-value payments, foreign exchange, gambling, and money laundering. At this stage, blockchain technology was generally used as a cryptocurrency and for payment systems that relied on cryptocurrency ecosystems.

Blockchain 2.0

Broadly speaking, Blockchain 2.0 includes Bitcoin 2.0, smart-contracts, smart-property, decentralized applications (Dapps), decentralized autonomous organizations (DAOs), and decentralized autonomous corporations (DACs) (Swan 2015 ). However, most people understand Blockchain 2.0 as applications in other areas of finance, where it is mainly used in securities trading, supply chain finance, banking instruments, payment clearing, anti-counterfeiting, establishing credit systems, and mutual insurance. The financial sector requires high levels of security and data integrity, and thus blockchain applications have some inherent advantages. The greatest contribution of Blockchain 2.0 was the idea of using smart-contracts to disrupt traditional currency and payment systems. Recently, the integration of blockchain and smart contract technology has become a popular research topic in problem resolution. For example, Ethereum, Codius, and Hyperledger have established programmable contract language and executable infrastructure to implement smart contracts.

Blockchain 3.0

In ‘Blockchain: Blueprint for a New Economy’, Blockchain 3.0 is described as the application of blockchain in areas other than currency and finance, such as in government, health, science, culture, and the arts (Swan 2015 ). Blockchain 3.0 aims to popularize the technology, and it focuses on the regulation and governance of its decentralization in society. The scope of this type of blockchain and its potential applications suggests that blockchain technology is a moving target (Crosby et al. 2016 ). Blockchain 3.0 envisions a more advanced form of “smart contracts” to establish a distributed organizational unit that makes and is subject to its own laws and which operates with a high degree of autonomy (Pieroni et al. 2018 ).

The integration of blockchain with tokens is an important combination of Blockchain 3.0. Tokens are proofs of digital rights, and blockchain tokens are widely recognized thanks to Ethereum and its ERC20 standard. Based on this standard, anyone can issue a custom token on Ethereum and this token can represent any right or value. Tokens refer to economic activities generated through the creation of encrypted tokens, which are principally but not exclusively based on the ERC20 standard. Tokens can serve as a form of validation of any right, including personal identity, academic diplomas, currency, receipts, keys, event tickets, rebate points, coupons, stocks, and bonds. Consequently, tokens can validate virtually any right that exists within a society. Blockchain is the back-end technology of the new era, while tokens are its front-end economic face. The combination of the two will bring about major societal transformation. Meanwhile, Blockchain 3.0 and its token economy continue to evolve.

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Xu, M., Chen, X. & Kou, G. A systematic review of blockchain. Financ Innov 5 , 27 (2019). https://doi.org/10.1186/s40854-019-0147-z

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Blockchain technology in healthcare: A systematic review

Hassaan malik, umair bashir, aiesha ahmad, shafia riaz, maheen ilyas, wajahat anwaar bukhari, muhammad imran ali khan.

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Received 2021 Nov 8; Accepted 2022 Mar 21; Collection date 2022.

This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Blockchain technology (BCT) has emerged in the last decade and added a lot of interest in the healthcare sector. The purpose of this systematic literature review (SLR) is to explore the potential paradigm shift in healthcare utilizing BCT. The study is compiled by reviewing research articles published in nine well-reputed venues such as IEEE Xplore, ACM Digital Library, Springs Link, Scopus, Taylor & Francis, Science Direct, PsycINFO, Ovid Medline, and MDPI between January 2016 to August 2021. A total of 1,192 research studies were identified out of which 51 articles were selected based on inclusion criteria for this SLR that presents the modern information on the recent implications and gaps in the use of BCT for enhancing the healthcare procedures. According to the outcomes, BCT is being applied to design the novel and advanced interventions to enrich the current protocol of managing, distributing, and processing clinical records and personal medical information. BCT is enduring the conceptual development in the healthcare domain, where it has summed up the substantial elements through better and enhanced efficiency, technological innovation, access control, data privacy, and security. A framework is developed to address the probable field where future researchers can add considerable value, such as data protection, system architecture, and regulatory compliance. Finally, this SLR concludes that the upcoming research can support the pervasive implementation of BCT to address the critical dilemmas related to health diagnostics, enhancing the patient healthcare process in remote monitoring or emergencies, data integrity, and avoiding fraud.

Introduction

Healthcare is a system that includes 3 main components: (i) Main suppliers of services for medical treatment, For instance, doctors, nurses, technicians, and hospital administrations (ii) Emergency related services [ 1 – 4 ], and (iii) Health and health-oriented service users, specific patients. In the current study, to encourage, preserve or restore the health of beneficiaries, we examine the health maintenance to include technology-based remotely controlling services increased by constituent service providers [ 5 – 9 ]. In the medical field, every year, there are more security and privacy breaches, in 2017, more than 300 breaches were reported, and up to 37 million records were affected during 2010–2017 [ 10 , 11 ]. The growing digitization of medical care has advanced the acknowledgment of issues about secure storage, accessing of patients’ medical records, ownership, and medical data from associated sources [ 12 – 16 ]. Blockchain is recommended as a method of addressing critical issues faced by healthcare, for instance, protected sharing of health records and adherence to data privacy laws [ 17 – 19 ].

Blockchain is a particular type of database that can be managed by the network of authenticated members or nodes [ 13 ] and stores immutable information blocks that can be strongly exchanged without interference by third parties [ 10 ]. With cryptographic signatures and the use of consensus algorithms which are implemented as key enablers in their application, data is stored and registered [ 20 ]. The capability of preserving data is a major aim for using the BCT particularly in healthcare [ 21 ], which is subject to massive sharing and dissemination of a significant amount of data [ 7 ]. In different stages, the development of blockchain technology, as well as its application in various contexts, had been materialized. The first phase of blockchain development was focused on cryptocurrencies, while the second focused on the use of smart contracts in industries like real estate and finance [ 11 , 22 ]. The 3rd generation of evolution concentrated on employing blockchain in non-financial areas including government, culture [ 23 ], and healthcare space [ 22 , 24 ]. Also, powered by revolutionary technical features such as data immutability [ 25 ], with the introduction of artificial intelligence, blockchain technology is having its 4th generation of evolution [ 26 ]. This asserted diversity in Blockchain’s application spectrum can be attributed to its ability to build decentralized [ 27 ] and trustless transaction environments [ 28 ]. As blockchain can tackle serious issues, such as automated claim authentication [ 9 ] and public health management [ 29 ], the healthcare sector is a prime choice for the application of blockchain technology [ 30 – 32 ]. This technology allows patients to keep personal data and determine with whom this can be shared, thus resolving current data ownership, and sharing issues [ 28 , 33 ]. At the same time, it allows recorded data to be integrated, modified, shared safely, and retrieved on time by relevant authorities using consensus protocols [ 31 ]. This is a significant benefit of the use of this technology in the healthcare system, as existing procedures need third parties to store the data [ 10 ]. Finally, because of possible human error, blockchain could potentially add accountability to data management processes [ 34 ] further decreasing the risks of mishandling or misusing recorded data [ 31 ]. Given the optimistic connotations of the effects of blockchain on social and business change, in contrast to previously defined expectations, it appears to be a discussion regarding its basic and derived advantages. A recent study indicates that while organizations will make substantial investments in the future in adopting blockchain-based technology due to a widespread perception that the advantages could be over-hype, they will probably accept a cautiously pragmatic approach [ 35 ]. It can be said that this technology has yet to fulfill its expectations [ 36 ], a fact that can be due to the prevalent adoption of block chain, particularly about regulatory barriers, to certain challenges [ 31 ]. The general public and specific users, for instance, patients or physicians are not acquainted with the way blockchain works, the technological features, or its advantages for data processing is another significant obstacle in promulgating the implementation of blockchain [ 35 ]. Suggest that it may take a considerable time for this technology to establish all anticipated stages of business transformation mainly because of the organizational, social, and implementation challenges, for example, security issues or governance reasons [ 22 , 31 ]. This could also be exacerbated by general confusion regarding the use of blockchain regarding legal enforcement and regulations of the government. Current research focuses on supporting blockchain operational growth and speed-up its prevalence by overcoming these barriers.

However, previous studies have made little attempt to comprehensively summarize the existing knowledge by using SLRs [ 9 – 13 ]. For example, bibliometric techniques were used by [ 10 ] to provide a summary of blockchain research patterns and components related to the implementation of blockchain in the field of healthcare. In [ 9 ] the different blockchain platforms have been developed to deploy blockchain in healthcare. The study [ 11 ] addressed different examples of the implementation in the healthcare of blockchain technology, the problems, and their potential solutions. In diverse contexts where this technology was implemented [ 12 ], addressed design choices and tradeoffs made by the researchers. The research studies of [ 13 , 14 ] have discussed the Blockchain-based applications throughout numerous industries and addressed many contexts of use for this technology in a broad manner. Recently [ 14 ] reviewed 39 studies to present an overview on common channels and other areas where blockchain technology is utilized for healthcare enhancement. Although these systematic literature reviews have a contribution to the extent of knowledge, their emphasis has been mainly on synthesizing or delineating blockchain technology patterns and areas [ 10 , 11 , 13 , 14 , 16 ]. However, researchers will get benefit from a concentrated discussion on the implications of its adoption [ 15 ], along with concrete obstacles and areas for progress for advancing the field, due to the reach and diversity of previous blockchain studies [ 11 ]. Through assimilating existing information and describing focus areas that require considerable academic attention, review-based research will assist in meeting these needs [ 11 , 16 – 19 ]. As a result of this necessity, we perform an SLR on the blockchain technology application. This SLR presents a valuable overview of ongoing research, gaps in current knowledge, and future avenues of research as well. The contribution of this study is in two ways, this research adds to the emerging blockchain literature in healthcare. First regarding their implementation areas, restrictions, and recommendations, it offers an advanced and thematically ordered classification of previous literature. Second, we propose a synthesizing process according to the results of the SLR to detail possible topics that need academic attention to further update the existing body of literature.

The present study is organized as follows: In Section 2, we provide a thorough description of the research method utilized to search, screen, and select the literature. In Section 3, we present relevant review works that have been conducted in the field of health care using blockchain technology and discuss all the papers that have been selected, focusing on their main findings, and highlighting research gaps for future research. Finally, in Section 4we conclude this study.

Methodology

SLRs always provide a thorough understanding of literature as it presents a complete and systematized review meeting all standard protocols in it [ 18 , 37 – 39 ]. SLRs also help in the understanding of current information gaps and, as a result, the discovery of potential research avenues [ 19 ].

Research questions

We conduct this SLR by addressing the following research questions (RQs).

RQ1 : What is the advanced profile used for the employment of blockchain in the healthcare domain?

The purpose of this research question is to identify the number of research papers issued every year, the average citation received on research papers yearly, and academic contribution on the subject by Journals, publishing houses, and community.

RQ2 : What are the major healthcare domains where blockchain technology has been implemented?

The purpose of this question is to identify the contexts in which blockchain technology has shown significant outcomes in healthcare.

RQ3 : What are the existing problems and constraints raised by the previous studies in the healthcare field using blockchain technology?

The motivation behind this question is to identify existing problems and issues of blockchain technology in the healthcare field based on results, limitations, and conclusions of previous research studies.

RQ4 : What are the potential healthcare avenues that would benefit from blockchain technology implementation?

The purpose of this question is to identify growing gaps and prospects of the future research agenda

Research objectives

The research objectives (ROs) of the article herein presented are the following:

RO1 : Establishing an archive of work that relates a wide topic about Blockchain in healthcare and offers an open dataset about Blockchain for all other researchers.

RO2 : Identify a more focused set of studies that have used blockchain technology in healthcare applications.

RO3 : Identify problems and constraints discussed in the healthcare field using blockchain technology.

RO4 : Characterize existing solutions in the field of blockchain in healthcare and clarify the similarities and differences between them using a characterization framework.

Research strategy

Nine databases—IEEE Xplore, ACM Digital Library, Springs Link, Scopus, Taylor & Francis, Science Direct, PsycINFO, Ovid Medline, MDPI—are recognized by previous studies as standard data sources of research papers about health informatics [ 40 ]. Reviewed papers have been outlined for understanding the research status of applying blockchain in health care. For the right database search the three keyword combinations existed as—“blockchain and Healthcare”, or “medical Health” or Medical Management or Health Management. The above keywords were extracted from an article of previous literature i.e. SLRs) using similar keywords such as blockchain and medical healthcare.

Study selection

The selection process aimed to find the articles that are the most relevant to the objective of this SLR. If there was the same paper in more than one source, as per our research, it was considered only once. The content of the papers chosen for the final sample was evaluated [ 39 , 41 ] to make sure that the findings of the present SLR produced clear results and that is not biased. For reaching a consensus of final inclusion or exclusion, two of the researchers finalized the evaluation. After completing this, the discrepancies of individual assessments were addressed through discussion. A third author was engaged in analysis and debate in situations where the two writers did not find consensus. After the papers were found, the first move was to delete redundant titles and those which are not connected in scrutiny. The standards for inclusion were limited to the hunt for String, and a study conducted by at least one of the following criteria for exclusion (EC) is omitted:

Inclusion criteria (IC`s)

IC1 : Studies are released any time on or before August 2021.

IC2 : Studies are limited to the journal, conference, report, workshop, and symposium articles only.

IC3 : Availability of complete texts in digital databases.

IC4 : Proposed models or frameworks present.

Exclusion criteria (EC)

EC1 : Exclude duplicated studies.

EC2 : Eliminate preview, book chapters, magazines, thesis, monographs, and interview-based articles.

EC3 : Exclude studies based on quality evaluation criteria.

EC4 : Studies written in a language other than English.

The choice of papers was based on clear above discussed criteria for inclusion and exclusion. Below Fig 1 has been developed through the aspiration from the PRISMA diagram [ 42 ]. Fig 1 shows the study selection process.

Fig 1. PRISMA flow chart-based studies selection process.

Results and discussion

This section describes the outcomes related to the systematic study RQs discussed above. 51 research studies have been selected to illustrate the outcomes of each RQs. Publication and other selection biases are a potential threat to validity in all SLR and we cannot exclude the possibility that some research studies were missed resulting in reduced precision and the potential for bias. Therefore, we made significant efforts in finding all eligible research articles, and conference proceedings from different well-reputed databases and by contacting experts in the BCT area through social media platforms. We believe that our work provides a significant contribution to the role of blockchain technology in health care.

Selection results

Our search identified 1177 records, of which 1126 were screened as shown in Fig 1 . 51 research articles were included in this SLR. The list of selected papers with descriptions of the overall classification results are discussed below.

RQ1: What is the advanced profile used for the employment of blockchain in the healthcare domain?

This SLR addresses the achieved descriptive records about the number of articles that have been published each year, publication source, the average citation received on research papers yearly (see Table 1 ). To complete this SLR, we have examined published surveys, systematic literature review (SLR), systematic reviews (SR), and research papers related to blockchain in healthcare, and published in the field of blockchain from 2018 to 2021. The number of highest citation research articles with the most citations is shown in Table 1 .

Table 1. List of the selected papers with details of QE, publication channel, year, H-index, and citation per year.

Fig 2 demonstrates the number of articles published each year from 2018–2021. The four obvious outliers are existing from 2018 to 2021. In 2018, 24 articles were published, 16 articles were published in 2019, 9 articles were published in 2020 and 2 articles were published in 2021.

Fig 2. Number of articles published per year.

The authors of the reviewed articles were found to be affiliated with institutes located across 17 countries. Five countries, China (number of articles = 12), USA (number of articles = 6), South Korea (number of articles = 4), Brazil (number of articles = 3) and India (number of articles = 3), cumulatively represented 65% of the sample (see Fig 3 ).

Fig 3. Country-wise publications of selected research studies.

In addition, the analysis of author indexed keywords conducted by using word cloud showed that the main emphasis of article related to “blockchain”, “technology”, “data”, “healthcare”, “sharing”, and “medical” which are graphically illustrated in Fig 4 .

Fig 4. Constructs key framework.

RQ2: What are the major healthcare domains where blockchain technology has been implemented?

In this part, we will discuss a review of the fundamental principles of blockchain. BCT is used in medicine, especially in managing the information in healthcare that particularly is important in the healthcare area as this technology involves the sensitive data of patients. This sector is important to society because innovations in this field will enhance the quality of people’s life. Following this logic, the computation can help to mitigate the effects of certain problems in this field. Informatics, for example, helps in the automation of medical records by ensuring more reliable data sharing, log management, and other applications. One of the first and most popular blockchain applications in healthcare is the exchange of health records. Information related to health is difficult to disclose because it is labeled as confidential information and includes patients’ details. Among the key works in the literature that discuss this application of blockchain technology are: [ 85 , 86 ]. The characteristics of blockchain-based architectures for the sharing of electronic healthcare records can vary. The features of blockchain-based systems for the exchange of electronic healthcare records may vary. One of the most well-known structures in the literature is discussed in the work of Azaria et al. [ 86 ]. Several recent papers in the literature have cited this as a framework for the development of other similar architectures. Some of these systems are inspired by Azaria et al. [ 86 ] cited in [ 30 , 79 , 87 , 88 ]. Voting is a formal statement of an individual’s or a group’s opinion or choice, whether positive or negative. Traditional voting methods, on the other hand, are centralized and are known to have security and efficiency flaws. The study [ 89 ] examines blockchain-based voting systems in depth and categorizes them based on a variety of characteristics e.g., the types of blockchain used, the consensus approaches used, and the scale of participants. Artificial intelligence (AI) is now the core technology for a wide range of applications, from self-driving cars to smart cities. One of the most crucial pillars of social and economic stability is smart healthcare, which is an integral part of smart cities. The research study [ 90 ] focused on designing a human-in-the-loop-aided (HitL-aided) scheme to protect patient privacy in smart healthcare. Profile matching technology can facilitate the sharing of medical information across patients by matching similar symptom traits. However, because the symptom attributes are linked to sensitive information about patients, their privacy will be compromised during the IoMT matching process. To accomplish fine-grained profile matching, the study [ 91 ] provides a verifiable private set intersection scheme and used a re-encryption technique to preserve patients’ privacy. Technologically advanced countries are exploring or implementing smart homes, it is convenient but risky. Most of the existing solutions are generally based on a single-server architecture, which has limitations in terms of privacy, integrity, and confidentiality. While blockchain-based solutions may alleviate some of these problems, they still face some significant obstacles. Lin et al. [ 92 ] developed a revolutionary safe mutual authentication method for use in smart homes and other applications. MedRec will be the first sharing architecture to be discussed, which uses a blockchain-based system to store electronic medical records. The MedRec considers resolving issues as data access response time, interoperability, and increased data quality in healthcare research [ 86 ]. It is worth looking into the resources that were used to create MedRec’s architecture, since it implements a private P2P network (Permission block chain), as well as using Ethereum’s smart contract platform, to make it easier to monitor and track network state transitions. One of the MedRec architecture’s hallmarks is that it provides patients with a consulting agency that has records of their healthcare background, enabling them to remain informed about health decisions. Another difference is that they enable the standardization of health data since they are adaptable and provide open data standards in a variety of formats. This architecture takes a novel approach to the use of health data management systems by enhancing security and establishing a common language for data exchange for research purposes [ 86 ]. While Azaria et al. [ 86 ] also plan to perform experiments and analyses with a diverse community of users. In summary, MedRec is a realistic choice for exchanging healthcare information that can be used to combine patient care, hospital care, and physician care. As a consequence, the reported data can help to minimize discrepancies among different systems of hospitals. As stated by [ 85 ], the method introduces the topic of cloud computing, which could help in creating new architectures for sharing healthcare records via blockchain, resulting in safer and more secure healthcare systems for clinical use. The authors propose a cloud-based architecture that uses a blockchain-based data system to connect a network of communication nodes. The paper [ 85 ] shows how to handle the exchange of healthcare information using a blockchain architecture, which employs the principles of intelligent contracts and, immutable bookkeeping. The major roles of BCT in sharing health information, remote care with IoT, security, and privacy, and supply chain are depicted in Fig 5 .

Fig 5. Major healthcare domains where BCT has been used.

The list of blockchain-based healthcare methods is discussed in Table 2 .

Table 2. Blockchain-based healthcare methods.

Rq3: what are the existing problems and constraints raised by the previous studies in the healthcare field using blockchain technology.

Even though blockchain is a multidisciplinary concept with challenges and limitations, it can be applied to a variety of areas [ 88 ]. Researchers in this field are working to overcome or mitigate the negative effects of these factors. The following are some of the problems (i.e. technological challenges) that blockchain technology faces when used in healthcare [ 22 , 88 , 97 , 98 ].

1) Throughput

If the number of transactions and nodes in the network grows, more checks will need to be performed, possibly causing a network bottleneck. When dealing with healthcare systems, high throughput is a challenge because unless there is fast access, it might adversely affect a diagnosis which could save someone’s life [ 64 ], correspondingly recognizing that the suggested framework focuses on identifying inconsistencies will possibly not perform well when datasets are unlabeled. Issues including specifications for continuous updates by the used system [ 59 ], keyword set size [ 75 ], network set-up and disk space needed based on the blockchain type, such as Ethereum software, employed to the framework can all affect a framework’s scalability and performance quality [ 25 , 99 ]. Similarly [ 48 ], suggests that integrating certain features into established systems, e.g. making global smart deals, can offset higher performance-related costs. Furthermore, a small number of studies have suggested that performance-related problems can be connected to the node management in a suggested system.

Validating a block takes about 10 minutes; this can be harmful to system security services since successful attacks may occur during that time. Healthcare networks are complex and should be accessed at all times, as any delay may negatively affect the analysis of an exam.

3) Security

When a party has control of 51 percent of the voting power, this can adversely affect the computing power of the network. This is a serious issue that needs to be addressed because a harmed healthcare system will lead to healthcare organizations losing their reputation.

4) Resource Consumption

Since the mining process consumes a lot of energy, using this technology could result in a significant loss of resources. Since multiple devices are required to track patients in a healthcare setting, energy costs are high; however, the use of blockchain may result in high computing and energy costs. Managing these expenses is a challenge for businesses.

5) Usability

Since these systems are so complicated, usability is a challenge as well to deal with. Additionally, an API must be developed (Application Programming Interface) Users would enjoy the user-friendly features. Since not all health practitioners have the same level of education, As IT professionals, we should be able to use frameworks that are easy and effective.

6) Centralization

Even though blockchain has a decentralized design, certain implementations tend to concentrate the miner, which decreases network stability. Because this central node is insecure and may be hacked, hostile attackers can get access to the data it holds [ 25 ].

It is common to suppose that the Bitcoin framework allows blockchain to make sure the privacy of its nodes. The results of [ 25 ], on the other hand, contradict this assumption. Furthermore, strategies to provide this functionality to blockchain-based systems are needed [ 25 ]. Due to privacy laws and regulations, blockchain-based systems have to conform to the General Data Protection Regulation (GDPR). Our research also indicates those users’ reservations about the safe and ethical utilization of data could be a major barrier to blockchain adoption in healthcare systems. The existing issues are primarily associated with blockchain technology’s technological limitations, such as the protection of individual nodes [ 53 ], the degree of safety permitted through cryptographic elements implemented with the system [ 70 ], besides the preservation of confidential data whereas requesters complete their computations [ 100 ]. However, certain research has drawn attention to more socially relevant issues regarding sharing of public data [ 73 ] and users’ confidence in governments [ 49 , 74 ]. Such issues may also be linked to the suggested framework protection from the perspective of users for example users’ management and misuse of permitted personal keys/codes [ 46 ].

8) Constraint

Prior studies have identified constraints, which can be divided into four categories. These dimensions mean that such constraints extend beyond technical boundaries (costs of designing, implementing blockchain systems, data analysis for system assessment, and framework constituent elements) to include certain social facets also such as trust in the administration, infrastructure of technology in a country.

This set of constraints is specifically concerned with the time, capital, and economic expenses of putting a system of blockchain into action. For example [ 50 ], discuss resource constraints in IoT, while [ 28 ] discuss the costs of arranging dispersed app in the deployment of blockchain. Additional expenses that have been established as constraints and limitations in previous research include the linear increase in protocol costs based on the characteristics and attributes of the entities involved, such as patients [ 54 ], increased operational overhead for the patient, and access latency for the requester [ 69 ], the exchange and implementation costs depend upon inconstant inputs in size and length of a string [ 67 ]. The issues related to time are further listed as one of the limitations, i.e. the spent time in finding smart contracts globally [ 48 ], increased time consumption [ 57 ], transmission timing [ 53 ], the time needed for the data receiver to seek the required data in shared storage [ 68 ], and higher overall execution time [ 21 ].

RQ4: What are the potential healthcare avenues that would benefit from blockchain technology implementation?

Blockchain consists of a sequence of blocks connected with cryptographic techniques. The immutability of this is one of the most attractive characteristics to many industries. The data that is added to the blockchain is irreversible, consequently, allowing for the creation of a consensus-based, verifiable, and accurate data ledger. That creates blockchain especially well-suited to tasks wherever integrity of data is critical; ProvChain [ 101 ], an infrastructure based on this technology in giving chain-of-custody to the database, is a functional example of this immutability. There are many blockchain implementations, including Bitcoin, a cryptocurrency token based on the blockchain; and Ethereum, a cryptocurrency token based on blockchain. Ethereum [ 102 ], a blockchain ledger with Turing-complete computer-generated device that allows smart contracts to implement code on this; and JP Morgan’s Juno [ 103 ], an Ethereum fork that uses the particular consensus mechanism called Quorum, along with several other blockchain implementations. The execution of blockchain varies due to ways in their consensus approaches. Bitcoin, for example, employs the HashCash [ 104 ] Proof-Of-Work algorithm, which is a deliberately slow system intended to avoid denial-of-service attacks. As a vote against the blockchain’s agreement, every Bitcoin miner authenticates this blockchain system by conducting that algorithm. Ethereum includes Ethash, which is an algorithm called Proof-of-work based on the Dagger-Hashimoto algorithm, as described in the Ethereum Yellow Paper [ 103 ]. However, shortly Ethereum is likely to advance in an algorithm named Casper. It will consider the excess requirement of energy in Proof-of-work [ 105 ]. The implementation of smart contracts separates Ethereum from Bitcoin. The smart contract is one of the snippets of code that run on each blockchain node. These are self-executing contracts in which all members of the blockchain are bound by the agreement. In the same way, as a standard contract does, they influence advantages, responsibilities, also punishments related to contract-related conduct. It could be utilized to model the HIPAA healthcare personal health information (PHI) workflow to satisfy audit and regulatory standards, likewise, done inside Patientory since they resemble conventional paper contracts and rules [ 106 ]. A new type of blockchain trust model, trust in the consortium, is also emerging. Microsoft recently released the Coco framework, which enables the creation of blockchain-agnostic consortiums [ 107 ]. Above mentioned models are based on a pre-defined group of trustworthy parties. It can be among various clinics or in the UK, NHS Trusts, third parties, and manufacturers of devices. By implementing smart contracts only on the hardware of trusted partners, without requiring miners, a consensus can be generated. It turned out in remarkably improved results, through a Coco-optimized blockchain case capable of processing 1600 transactions in a second, taking the blockchain system very close to the major payment processors. Coco also supports a variety of trusted execution environments, including Windows Virtual Secure Mode, Arm Trust Zone, and Intel Guard Extensions to name a few.

1) Clinical trials

Managing trial subject consent and clinical trials itself is an area in which blockchain can potentially improve the accountability, audit ability, and transparency of researchers and practitioners in the medical field. By keeping the unchangeable log of a patient’s approval, officials could control the standard of clinical trials easily, making sure it complies with informed consent regulations of the country. It is especially important because a forged informed consent form is one of the common types of clinical fraud. It involves falsifying patient consent and editing records, implying that authentication of trial subjects is essential for avoiding it. That kind of setup may be improved by implementing a smart contract system that stops clinicians to use the data of patients unless a key is issued by the end of an auditable process of smart contract that requires permission in each step in the trial, as proposed by Benchoufi, Porcher, and Ravaud. This procedure should also allow the patient’s consent to be revoked. Executing the clinical trial of blockchain consent log provides the subjects with data ownership while also having a trail of audit for regulators, medical professionals, and researchers. The role of BCT in clinical trials is graphically represented in Fig 6 .

Fig 6. Role of blockchain in clinical trials.

2) Sharing the data

Sharing information is regarded as the most significant opportunity for improvement in healthcare; however, it too poses a significant challenge in privacy. Sharing the data using BCT is presented in Fig 7 . Powles and Hodson [ 108 ] use DeepMind’s case study teamwork with the Royal Free London NHS Foundation Trust to address the need for transparency in how patient data is being shared with third parties. Regardless of the good impact on diagnosis/treatment of patients by the product suite of Google, one of the significant issues addressed in the previous case study was a lack of patient consent. On the other hand, Sleep Apnea American Association, and IBM [ 109 ] were collaborating to solve major healthcare challenges to examine sleep apnea (with IBM’s Watson supercomputer at home) in thousands of Americans, with informed and clear patient consent. That was critical to implementing the national standard for interoperability in the healthcare system of IT. Which was emphasized by Wachter and Hafter through a white paper in UK NHS in comparison to the US healthcare sector that emphasized the significance of interoperability in permitting patient Electronic Health Records (EHRs) over various clinics, such as various trusts that do not maintain a separate system to get access on these records built by different vendors.

Fig 7. Sharing health information using BCT.

In a report of Harland Simon on a project justifying RFID tagging in NHS Cambridge shire, about 15% loss of assets annually, resulting in a substantial cost to repurchase the items that hospitals previously have. Furthermore, as per GE Healthcare [ 110 ] report, nurses spend an average of 21 minutes per shift searching for misplaced devices as stated by, defining any device under $5000 as consumable and to again purchase if any device is lost, suggesting significant cost in the sector. Published by Harland Simon, another study reported that [ 111 ], by adopting radio frequency identification (RFID) standards for tracking of medical devices, NHS Forth Valley in Scotland had saved nearly £400,000 in cost avoidance by not having to buy the important devices which would have been lost by the medical system. Tracking of Drugs has been a completely different issue than tracking of devices because a major concern is counterfeits of drugs here. According to WHO’s report, In the US up to 10% supply of Pharmaceutical products is counterfeit. In the United States, the Food and Drug Administration (FDA) recently approved the utilizing the RFID to track pharmaceuticals between the supply side to the patient. It enables the whole sequence kept supervised, to make sure that pharmaceuticals were purchased from a legitimate source. Pfizer was the first pharmaceutical company to use RFID “e-pedigree” to ensure that patients and doctors could trust the source and capabilities of their flagship medicine, Viagra, after identifying it as one of their most counterfeited drugs. Because of the use of low-cost passive RFID tags and barcodes, the system enabled the pharmacists and wholesalers to check the authenticity of their Viagra through a simple RFID scanner at a low rate than Pfizer.

3) Records of patients

Blockchain is having the potential to significantly disrupt health services and place data in the patient’s hand. The specific intriguing steps are in MedRec [ 86 ], which provides doctors and patients with an immutable log of a health record as shown in Fig 8 . That has a different approach to incentivize miners by providing access to anonymized data about health in exchange for network maintenance. MedRec maps Patient-Provider Relationships (PPRs) using Smart Contracts when the contract displays a reference list having relationships between nodes on the Blockchain-system. This too places PPRs in the patient’s hand, empowering them in accepting, rejecting, or modifying relations with health service providers for example doctors, insurers, and hospitals, etc. Blockchain-system allows for interoperability in the health system by providing a decentralized ledger of accepted facts in healthcare records to which all health service providers are having access. It implies that while user interfaces may differ, the central ledger would be the same across all service suppliers. A challenge that exists relates to the current state of health records across providers, which contain significant amounts of the same information under different identifiers that may not be linked. This causes replication, and as the blockchain system increases in size, it is reduced in performance. The level of data duplication in all records will necessitate replication to maintain a reasonably performant system with unique, anonymized identifiers to identify the patient in all kinds of service. Adopting the blockchain health record is a business challenge in and of itself. The important thing is that medical records will not start from zero because they would have to replace the current setup, and that is challenging. Furthermore, the sheer volume of data generated in the healthcare sector is ever-growing, with Kaiser Permanente estimated to have between 26 and 44 petabytes of data on its 9 million members from EHRs and other medical data in 2014. The data volume which is logged and referenced would mainly exacerbate the scalability issue.

Fig 8. Records of patients.

4) Drug tracking

Another opportunity is tracking the drugs using a blockchain system as shown in Fig 9 , which takes advantage of its immutability in the development of tracking and a chain of custody from manufacturer to patient. Chronicled is a technology startup company that is working on its product, Discover, that develops a chain of custody model that shows the manufacturing place of a drug, the places it had been since then, and when it was disbursed to patients, hence reducing the pharmaceutical theft and fraud. That enables the health professionals in meeting existing standards of the pharmaceutical supply chain, along with focusing on interoperability among healthcare professionals. The Counterfeit Medicines Project has been launched by Hyperledger, the Open-Source Blockchain Working Group, to address the issue of counterfeits of medicines. The origins of counterfeit medicines would have been tracked and thus eliminated from the chain of supply. One benefit of tracking drugs by blockchain-system over conventional methods is the inherent decentralization of trust and authority in the technology’s principles; whereas chief authorities could have bribed or faked, it is much more difficult to bribe a consensus of those on the blockchain. As a result, an existing standard in pharmaceuticals tracking in industry, ePedigree, which already employs RFID and a traditional database, is transitioning to its blockchain application. If medicines/drugs could be tracked and developed at the point of manufacture using blockchain’s inherent anti-tampering capabilities, that will remove the counterfeited pharma products engaging in the supply chain.

Fig 9. Drug tracking.

5) Device tracking

Tracking of medical devices is one aspect of Block chain in disrupting healthcare, from manufacturing to decommissioning. The monetary benefit generated through tracking of assets is clear; NHS East Kent Hospital discovered 98 infusion pumps they had no idea they still owned across three sites as concluded through the case study of Harland Simon [ 111 ] in which active RFID trackers were implanted. Because of this single case study, they saved $147,000 at $1,500 per person. The use of blockchain in conjunction with this technology allows for an immutable ledger that not only shows the current location of the device, also the location of the lifecycle, along with the serial number, distributors, and the manufacturer linked with the device, assisting with regulatory compliance. Deloitte identified the competency among the potential game-changers for blockchain in the domain of healthcare in a white paper. According to an IBM study, 60 percent of government stakeholders in healthcare believed the integration of medical devices and asset management as the most likely area of disturbance in industry. The blockchain-based system has various advantages above conventional products of location tracking. This immutability and tamper-proof properties of the Blockchain are the most obvious. This prevents a malicious user from changing or deleting a device’s location history. This is especially important given that theft of devices and shrinkage has been a major issue in the United States and the United Kingdom. This immutability, in addition to preventing traditional theft, also protect devices from being lost and reordered, that have incurred high cost in terms of both actual equipment cost and care provided. The setup must not add significantly to the workload of staff, nurses, or workers because that requires tapping the device only using a mobile phone and further entering the device location. Whereas the use of blockchain on the Internet of Things (IoT) is still in its early stages, Huh states a method to communicate the devices using an Ethereum blockchain and public key system of RSA. Likewise, the device while it stores on blockchain its public key also stores the associated private key on the device.

This study aimed to conduct an organized analysis of previous literature about the employment blockchain in healthcare for a better understanding of their current and probable state. The four key research problems are defined for this reason. RQ1 was presented with summing up top writers, publishers, publication houses, and designs of publication patterns of this subject. Furthermore, it included an existing outline of research about employing blockchain in the healthcare space. The comprehensive description of the reviewed articles is discussed in Table 3 . RQ2 was designed to help researchers better understand how blockchain can be used, it is responded by defining particular themes and sub-themes that reflect key aspects in employing blockchain in this sector. RQ3 further discussed its shortcomings and obstacles that previous researchers had encountered. We were able to recognize the research gap in the existing literature and responded to this question by summarizing its main research themes and existing limitations. RQ4 concentrated on the key aspects where future investigation can provide valuable insight. The fourth research question is addressed by combining findings through emerging differences, shortcomings, and previously proposed guidelines.

Table 3. Comprehensive description of reviewed studies.

Conceptual evolution.

According to the findings of the study, research in healthcare’s blockchain was largely focused on enhancing more creating new ideas and concepts that help researchers to derive multi-domain [ 59 ] also practicable blockchain in healthcare implementations. The viability of employment [ 99 ] is being established and evaluated across three sub-themes of research: design creation, applications on benefit-based, and developing predictive competencies.

Concept development

The findings of the analysis indicate that new proofs and algorithms have received a lot of attention, such as proof of data primitiveness [ 62 , 112 ], proof of familiarity [ 74 ], and simpler workload for proof of work; [ 54 ]. Studies have also focused on testing new variables and components in architecture systems, as well as improving frameworks that enable blockchain execution by including them. Consider cryptosystems based on attribute [ 72 ], approach the Stackelberg game [ 63 ], sibling intractable functions [ 70 ], and homomorphic computations for more efficient frameworks [ 77 ]. Further [ 113 ], suggested a new scheme (BBDS) based on blockchain to protect data transactions and maintain privacy [ 57 ]. Used fog computing estimation efficiency as well as reliable models for human pursuit acknowledgment to support remote e-health controlling [ 51 ]. To eliminate a single point of failure, they are focused on incorporating several time sources into their technique. Finally, this research has centered on how to boost the efficiency of already established algorithms and structures based on the blockchain.

Benefit-based application

Blockchain has been used in healthcare research to extract concrete benefits by identifying and testing new technology avenues. It involves work in upgrading the technical advantages of employing blockchains, such as advanced image processing [ 60 ], effective behavior recognition [ 57 ], and Internet-of-Things synchronization (IoT) devices [ 51 ]. Furthermore, the majority of studies in this category have centered on the use of blockchain technology to establish specific benefits of healthcare, e.g. mutual decision making in the medical field [ 74 ]. Blockchain adoption, for example, is being suggested to have positive implications while managing clinical trials [ 73 ], DNA data transmission [ 61 ], preventive healthcare, biomarker growth, and discovery of drugs are all examples of remote patient monitoring [ 50 , 53 , 64 ].

Advancing decentralization

Existing research is also considering promoting key advantages of blockchain technology throughout healthcare environments for encouraging justice and also efficient decentralization [ 76 , 114 ]. For instance [ 63 ], produced an efficient framework for promoting maximization of revenue maximization along with fair decentralized trade, considering that [ 48 ] stated the need for trade-offs for mining benefits. Researchers in previous literature already described blockchain’s prospects in developing transparency in exchanging the data [ 56 ], such as utilizing upright client roles [ 21 , 30 ]. By doing this, we can say that previous research about the increasing use of blockchain-based technology in the medical space is focused on spreading decentralization along with its related advantages.

Advancement in technology

Current studies have contributed substantial progress in terms of advancement and refinement of blockchain for the development of targeted deployment, particularly in the healthcare space. We suggested previous research that is classified in this theme be directed regarding the three main topical issues based on our review:

Developing intelligent healthcare ecosystems

The introduction of blockchain technology programs into healthcare environments has piqued the interest of some academics [ 45 ]. Such integrations can pave the way for the development of intelligent healthcare systems [ 100 ]. For example [ 47 ], argues that blockchain adoption will aid in the development of a more efficient e-health ecosystem. Prior research has also suggested frameworks for developing blockchain-based e-health [ 56 ] and telemedical information systems [ 33 ], which could help healthcare providers, expand the scope of their services in the future.

Improvements to the blockchain architecture on a technical level

The majority of this field’s study has concentrated on improving the efficiency of architectures and developed systems by technological improvements for example utilizing smaller data block sizes [ 74 ] and reducing transaction propagation delay [ 68 , 74 ]. Some attention has also been given to problems that have previously been described as possible roadblocks to the successful implementation of blockchain architectures. Memory and CPU specifications [ 77 ], as well as accurate node recognition, are among the problems considered in research, grouped under this theme [ 71 ]. The efficacy of potential solutions to the above problems has been illustrated in several cases by network and algorithm comparison studies [ 21 , 30 , 74 ]. However, we believe that this theme will continue to progress in the future, necessitating a parallel emphasis on comparative analyses to determine the most powerful networks and algorithms.

Building predictive capabilities

A similar pattern can be seen in blockchain technology’s use in healthcare as it enters the fourth step in development with the rising integration of AI [ 26 ]. IoT [ 50 ], sensors [ 47 ], wireless body area networks [ 53 , 64 ], big data [ 49 ], edge computing [ 76 ], and cloud technology have all recently been incorporated through blockchain-based device architecture [ 59 ]. Researchers are using such technologies to help them develop systems based on blockchain having predictive capacities for enhancing medical information systems and diagnostics [ 61 , 75 ]. Prescription fraud avoidance [ 47 ], verifiable data generation [ 77 ], and automatic claim resolution [ 47 ] have all been investigated previously using such frameworks [ 72 ]. Furthermore, studies have centered on using blockchain-based technology in supporting providers of health care services with other tasks, e.g data collection on population-level [ 46 ] and user identity description [ 28 ].

Enhancement of efficiency

Several researchers in previous literature have attempted to determine how blockchain-based implementation would improve the efficiency of healthcare processes [ 34 , 59 , 79 , 82 ]. According to this study, scholars’ attention has been drawn to two facets of performance improvement: structures and processes.

Prior research has focused on improving the efficiency of technological aspects of the processes that are needed to run a blockchain-based healthcare system. Prior research has also focused on developing systems for timely alerts [ 72 ] and adverse event reporting [ 73 ]. Some research has centered on increasing the computational processes efficiency [ 57 ] and thorough evaluation of suggested architectures [ 60 ] to ensure that its architecture gives far efficient processing as compared to conventional architectures [ 71 ]. Furthermore, studies have proposed changes in blockchain systems to resolve the alleged risks related to time management, data management, and managing related costs. For example, reviewed research has established mechanisms for reducing the cost of implementation after setting up initially [ 74 ], lowering storage costs [ 65 ], and making maintenance and storing files of any size is easier [ 62 , 112 ].

According to our analysis of the current literature, several steps have been applied to enhance the blockchain-based healthcare framework holistically. For example, research has focused on improving system interoperability [ 27 , 49 ], managing inter-institutional access rights [ 63 , 99 ], and data management [ 28 , 46 , 63 , 64 , 99 ]. Enhancing machine scalability [ 113 ] and efficiency have also received scholarly attention [ 60 , 65 ]. Researchers have concentrated their efforts on designing integrated service-oriented architectures [ 56 ] and enhancing the generalizability and flexibility of blockchain systems that have been implemented [ 21 , 27 , 30 ].

Management of data

According to the results, we can conclude that managing the data and medical records is getting more scholarly attention. Existing research has endorsed the blockchain’s utilization for medical data management [ 27 , 48 , 54 , 55 , 69 , 70 , 99 , 115 ]. Furthermore, by integrating heterogeneous forms of data [ 27 , 69 , 100 ], blockchain can aid in the development of an application system of information to manage such PHRs [ 59 , 64 ]. We define three main aspects of current research in this field based on the SLR.

Data privacy

Previous research about data security implications of this technology in medical care has focused on handling the privacy of data by maintaining permitted access to the data. According to the study, access control management [ 76 ] has gotten a lot of attention [ 45 , 46 ]. Because of the requirement of protecting the privacy of confidential data by greater transparency, access control, and immutability, this problem is particularly important in healthcare [ 55 ]. Prior research has developed a framework based on blockchain to guarantee the delivery of effective services [ 115 ], user-centric [ 114 ], and access to patient PHRs and other medical data that is safe and encrypted in response to this vital need e.g. [ 45 , 50 , 54 ].

Data protection

Another main concern discussed in studies on the blockchain aspects of data management in healthcare is the avoidance of unauthorized access and the preservation of data confidentiality to ensure data safety. The majority of the studies that were examined focused on preventing unauthorized access [ 66 ] and preventing eavesdropping [ 71 ]. Several methods have been proposed to achieve this aim, including efficient authentication [ 65 ], biometric authentication [ 49 ], user verification [ 55 ], and the use of dual signatures [ 63 ].

Data handling

Prior research has addressed the need for legally and legally compliant collection, sharing, and controlling of healthcare data to some extent. According to our findings, few research studies have recognized the importance of monitoring enforcement [ 100 ], let alone the criteria and targets for compliance [ 63 , 67 , 75 ]. However, the importance of data integrity has received a lot of attention [ 56 , 69 , 70 ]. Prior research has looked at issues like authentic data mobilization [ 46 , 77 ], double storage expenditure [ 68 ], and eternal data protection [ 68 , 112 , 116 , 117 ]. Along with the growing inter-institutional adoption of blockchain, researchers have transformed their attention to the issue of storing and maintaining sensitive data [ 67 ] from a variety of sources, including medical devices [ 52 ] and health insurance [ 77 ]. A few studies have concentrated on the assistance of cross-institutional sharing of data [ 67 ], as well as changes in data sharing quality and flexibility [ 69 ]. Additionally, previous studies have addressed the need for data processing improvements (e.g. [ 77 ]). Some steps for inducing these changes have been suggested in the reviewed studies, such as the successful incorporation of diverse data from various sources of data [ 99 ] and the integration of smart contracts [ 48 ]. These themes specify that past studies in that area have focused on (i) improving technological features, (ii) managing medical databases, also (iii) identifying unique capabilities in the medical field, where blockchain could make remarkable contributions. Based on emerging trends, it can be said that scholarship in this field is still transforming, with existing facets of healthcare being recognized as possible recipients of using blockchain as a result of technological advancements.

Research framework for future synthesis

This analysis and review helped in the framework development which was created with the research gaps identified in existing recommendations suggested in previous research. The research model includes 5components that would aid in the development of the healthcare ecosystem based on blockchain, for future research. The research framework for the BCT-based healthcare system is depicted in Fig 10 .

Fig 10. Research framework.

Data sources

Personal and medical health records are created and managed by the patients using mobile devices, healthcare service suppliers, and pharmaceutics is one of these associated industries., research and insurance [ 32 , 47 , 70 ]. These serve as the foundation of the blockchain architecture and need management by legitimate and regulatory rules. This technology might aid in the development of authorized databases that information can be retrieved by inter-institutional authorities in collaboration with the required agencies to aid in patient treatment and medical decision-making [ 21 , 30 ]. Because of the incorporation of newer technologies, such as smart patient tracking devices [ 53 ], to increase the comprehensiveness of medical databases, future research should concentrate on handling those data sources.

System architecture

With advances in blockchain technology, the system’s architecture will undergo important changes and refinement in terms of the components incorporated into the system of blockchain. Such as using Permissioned consortium blockchain [ 28 ] or platforms other than Ethereum [ 68 , 77 ], could improve current blockchain deployment architectures in the healthcare ecosystem. Also, future research should concentrate on creating techniques for managing system architectures that have been established, particularly the challenging circumstances that can have an impact on the performance and efficiency, for instance, node management [ 74 ] and techniques of key distribution [ 67 ].

Blockchain technology strategic implementation

In the case of increasing integration of information and communication technology and blockchain over healthcare ecosystems, researchers should have focused on the elements which could impede and assist in the widespread application of blockchain technology. According to our findings, we believe that organizations should think about whether or not, by identifying the key issues throughout this study, blockchain technology might prove a potential source of creating or enhancing value. Strategic problems like resource constraints [ 50 ] and technical problems like performance uncertainty [ 56 ] and system requirements are these examples [ 99 ]. Considering these problems might help scholars to develop blockchain architectures that can offer better functional utility and productivity in terms of resource and output management. This can also guide health system administrators and personnel to adopt a holistic and strategic approach to the potential inclusion of blockchain as an essential component of a company’s value chain.

Beneficiaries

Databases built on the blockchain can provide trustworthy information to particular beneficiaries in the sector of healthcare, such as patients who keep ownership of their information. Authorities including doctors, pharmacists, medical researchers, and insurance firms are also beneficiaries. Patients may authorize them to use medical information for a range of purposes, plus collaborative medical decision-making [ 63 ], medical informatics and diagnosis (S.J. [ 61 ]), and fraud prevention [ 47 ]. Because of the blurring of the borders between the health system, wellness sectors, and mobile phones, researchers must recognize such beneficiaries ensuring data is accessed by the relevant authority. Moreover, the important thing is maintaining the integrity of data following ethical and legal bindings. As a result, scholars must concentrate to understand the perspective of the user about the perceived advantages and costs of engaging in a blockchain system. It can assist to identify and remove obstacles in the widespread application and use of blockchain.

Ethical & legal consideration

Blockchain applications are addressing critical issues for example authentication, interoperability, and safe sharing of medical data [ 49 , 118 – 120 ]. Regardless of the increased emphasis on the blockchain, the acceptance of such concerns may be regarded as a remarkable barrier to its extensive adoption. More emphasis should be placed on regulatory compliance [ 100 ] and ethical recommendation for issues like control of ownership and access of patient data [ 99 ]. We propose that future scholars take a multidisciplinary approach to determine avenues for resolving ethical and legal compliance issues in multi-national or cross-institutional contexts for blockchain adoption. We also argue that there is a need to positively impact the public and appease regulatory agencies by deliberating and highlighting the critical benefits derived by using technology based on blockchain.

Directions for future research

According to the SLR, we provide a brief summarization of the thematic problems that would require attention from future researchers:

Deployment of holistic view

In case it is critical to find solutions to security and performance-related problems, like interoperability [ 67 ] and access-control [ 68 ], we argue that scholars must take a broader view of blockchain adoption. This is critical to creating holistic, legally, and ethically compliant [ 21 , 30 ], robust data management, and authentication procedures in e-health ecosystems [ 33 ]. Furthermore [ 36 ], argues that context variables like people and culture may play an important role in the development of new technologies. Eventually, we suggest testing blockchain-based electronic health ecosystems in cross-institutional and cross-national contexts to build tailored context-based healthcare solutions in collaborating with different organizations inside the healthcare space, such as research medical centers [ 60 ].

Optimization of the architecture

Scholars might focus on improving the efficiency and performance of proposed designs to account for the higher transaction rates which may be expected if blockchain is integrated into healthcare operations in the future [ 113 ]. That can be accomplished by dealing with network congestion [ 69 ], scalability [ 99 ], throughput [ 76 ], and bandwidth issues [ 22 ].

Data protection & legal compliance

Addressing data, plus user privacy and legal problems will be an important area of future research [ 21 , 30 , 53 ]. These can be directly tackled by designing blockchain protocols in handling healthcare records that can be enforceable by smart-contract [ 36 ] and compliant with data and privacy protection regulations, for example, Health Insurance Portability and Accountability Act [ 31 , 36 , 53 ].

Other technologies integration

For improved functionality, deployment of block-chain might be advantageous by the technology with business processes in healthcare [ 36 ]. For example, researchers can concentrate to advance the incorporation of edge computing, AI, and ML through blockchain health service ecosystems in developing an improved anticipatory analytic model to provide customized health treatment and diagnostics (e.g. [ 52 , 63 , 64 ]). Furthermore, research may aim to improve accessibility, remote control, and emergency services via the integration of sensors based on IoT. Furthermore, we propose two additional potential directions for future scholars to extend the existing scope of academic boundaries in this sector. First of all, it proposes the requirement to understand the implications of blockchain deployment in more niches in healthcare, but related fields i.e. managing the digital rights of users’ [ 13 ], drug prescription management [ 11 ], and prescription fraud prevention [ 47 ]. Furthermore, the research could be conducted to investigate the implications of blockchain usage across the whole health system supply and value chain. It can help scholars better understand user-related interoperability problems and additionally enables creating standard protocols to use systems working under the blockchain.

This research study is designed to understand completely the application of blockchain in the domain of healthcare. To achieve this goal, SLRs were conducted on nine highly regarded databases using particular protocols to pick out relevant articles for review. The outcomes were used, to sum up, current knowledge on applications of blockchain in the specific sector of medical care, but to also summarize past and the present academic research theme trends in this field. Future research possibilities have been showcased in the form of a synthesized framework created by combining insights from existing restrictions, suggestions, and emerging gaps in current knowledge observed throughout this review.

Supporting information

Data availability.

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Pandi vijayakumar.

25 Nov 2021

PONE-D-21-33056Blockchain Technology in Healthcare: A Systematic ReviewPLOS ONE

Dear Dr. Malik,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Additional Editor Comments:

Based on the comments of the reviewers, I recommend minor revision for this paper.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: irst of all, I congratulate all of the authors for working on the significant topic of blockchain technology in health care. I have a few suggestions listed below:

In table 3, write a complete name instead of writing single alphabets.

Correct the sequence of Figure 6. (i.e. Security and Privacy).

Reviewer #2: In this work, the authors have done a survey on Blockchain Technology in Healthcare. The study is compiled by reviewing research articles published in nine well-reputed venues such as IEEE Xplore, ACM Digital Library, Springs Link, Scopus, Taylor & Francis, Science Direct, PsycINFO, Ovid Medline, and MDPI between January 2016to August 2021. A total of 1,192 research studies were identified out of which 51 articles were selected based on inclusion criteria for this SLR that presents the modern information on the recent implications and gaps in the use of BCT for enhancing the healthcare procedures. A framework is developed to address the probable field where future researchers can add considerable value, such as data protection, system architecture, and regulatory compliance. Hence, The paper can be accepted after making the following Minor corrections.

1. There are few grammatical errors in the manuscript. So English proof reading is required. For example, “The research studies of [13] and [14] have been discussed” could be written as “The research studies of [13] and [14] have discussed”.

2. I don’t find X-Axis and Y-axis values in “Figure 3”.

3. Some important recent references are missing, the following references must be totally added in the Section "References" (otherwise, the reference is not enough, then it must be revised again until it is enough):

The Application of the Blockchain Technology in Voting Systems: A Review

Homechain: A blockchain-based secure mutual authentication system for smart homes

Human-in-the-loop-aided privacy-preserving scheme for smart healthcare

Profile Matching for IoMT: A Verifiable Private Set Intersection Scheme

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Author response to Decision Letter 0

Collection date 2022.

12 Feb 2022

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Author response: Figure 4 is deleted from the updated manuscript.

Decision Letter 1

22 Mar 2022

Blockchain Technology in Healthcare: A Systematic Review

PONE-D-21-33056R1

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Additional Editor Comments (optional):

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1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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6. Review Comments to the Author

Reviewer #1: author addressed all the review comments satisfactory. Hence, I recommend the acceptance for this paper.

Reviewer #2: The authors have done all the corrections given in the previous round. So the paper can be accepted in the present form.

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #1:  Yes:  MARIMUTHU KARUPPIAH

Acceptance letter

Dear Dr. Malik:

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PLOS ONE Editorial Office Staff

on behalf of

Dr. Pandi Vijayakumar

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

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Data availability statement.

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