A general investigation into the feasibility of blockchain
applications in the Dutch health-care sector
SUBMITTED IN PARTIAL FULLFILLMENT FOR THE DEGREE OF MASTER
OF SCIENCE
Linda Zieverink
10213376
M
ASTER
I
NFORMATION
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TUDIES
H
UMAN-
C
ENTERED
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ULTIMEDIA
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ACULTY OF
S
CIENCE
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NIVERSITY OF
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MSTERDAM
July 9, 2018
1st Supervisor 2nd Supervisor
dhr. dr. F.M. (Frank) Nack prof. dr. T.M. (Tom) van Engers
A general investigation into the feasibility of blockchain
applications in the Dutch health-care sector
Linda Zieverink
10213376 University of Amsterdam
linda.zieverink@gmail.com
ABSTRACT
In theory, blockchain technology has the potential to offer a solution for the decentralized, fragmented health-care sys-tem in the Netherlands. The structure of a blockchain could, among other things, ensure for health-care institutions being able to manage authentication, confidentiality, accountabil-ity and sharing of patient data. Yet, these advantages have not been deployed on a large scale in practice. Are there concrete reasons that hinder a blockchain implementation in Dutch health-care despite the promising possibilities? And is it possible to overcome these obstacles?
To investigate this further, this research focuses on finding out whether a blockchain application in the Dutch health-care sector could be possible and feasible. This is done by constructing a potential blockchain infrastructure based on a real case example. By this, it will be examined whether it currently would be possible to implement blockchain in a health-care infrastructure. Subsequently, the built model was evaluated in practice by performing a qualitative study with different stakeholders from a hospital environment. This last part is intended to evaluate the feasibility of the model from a user perspective and to map out concrete obstacles and possibilities for a blockchain implementation.
General Terms
Theory
Keywords
Blockchain, Health-care, Dutch Hospitals, Smart Data Man-agement, Data Integrity
1.
INTRODUCTION
The exchange of health-care data between different enti-ties remains a challenge [17]. Often there is a lack of homo-geneous data structures, which causes compatibility prob-lems and semantic differences in terminology that results in a limitation of data comprehension. In addition, these inequalities evoke both security and data consistency con-cerns. This often results in patient data being fragmented across different, centralized health-care systems. As a conse-quence, the data becomes vulnerable to cyber-attacks, data sharing is hindered, and the privacy of patients is at greater risk [28].
One of the possibilities that is being investigated to solve this problem is blockchain technology [22]. Nictiz, the Dutch expertise center for e-health, however describes how there
are virtually no (influential) blockchain applications intro-duced in the Dutch health-care sector as of yet. There is only experimentation by means of pilots [3]. On the other hand, Nictiz states in their 2017 research, that they expect blockchain to offer opportunities “to deal with applications in the field of identification, permission for exchange of data and coordination of data exchange in a fundamentally dif-ferent way” (p.4).
Blockchain technology, when implemented in the health-care sector, has the potential to make medical records more tamper-proof, secure and scalable [6], to generate an up-to-date decentralized database with patient data [14], and to build a secure bridge between the massive, fragmented databases in order to increase efficiency and improve care co-ordination [13]. It therefore offers the possibility for health-care institutions to manage authentication, confidentiality, accountability and sharing of patient data [4]. This could also result in blockchain ensuring that the exchange of health-care data is securely facilitated.
Despite its potential, the health-care sector, among other sectors, continues to struggle with the implementation of
the technology. This is mainly due to its nascent phase
and since it continues to be subject to change [15]. Nictiz also indicated last year [3] that it is not yet the right time to implement blockchain in health-care as the technology is not yet fully mature. But if not now, when?
This research focuses on the possibilities that blockchain can offer to facilitate the exchange of patient data, as it is important for intelligence acquisition and the health-care sector as a whole. The aim of this study is therefor to iden-tify the opportunities for blockchain specifically in the Dutch health-care sector.
The research is structured in two parts. The first part contains an elaboration of a concrete theoretical blockchain model in order to map realistic possibilities for the Dutch health-care sector. A research review clarifies the practi-cal implementation of blockchain in health-care and investi-gates blockchain-based infrastructure. For the second part of this research, a qualitative study was carried out with var-ious stakeholder groups from different Dutch hospitals. This has been done to gather insight on the current infrastruc-tures, problems and opportunities for blockchain. Finally, blockchain experts are involved in the analysis for validat-ing the blockchain scenario in this specific environment.
2.
RELATED WORKS
The rise of blockchain technology has the potential to dis-rupt the business and financial sector as the internet has done with off-line commerce [2]. Some experts attempt to demonstrate that blockchain is in position to become the fifth disruptive computing paradigm after mainframes, PCs, the Internet, and mobile/social networking [21].
The technology ensures that verification-driven transac-tions are made possible between parties that do not com-pletely trust each other or might not even know each other [22]. Blockchain is a distributed ledger technology, making it a platform designed to establish significant cost and risk reductions in a business network with multiple parties. It is also referred to as “distributed, shared, encrypted database that serves as an irreversible and incorruptible repository of information” (p. 2) [26]. The database is designed so that no singular entity in the network can add, modify or delete anything on the ledger without permission, or rather the consensus, of the other entities in the network.
The database consists of several chronological linked blocks that contain transactions. These transactions are checked in an unalterable manner for the integrity of such a block. In this way, the system can ensure that data and legal docu-ments are unchangeable. Other researchers and proponents even argue that blockchain technology will eventually make it possible to replace transactions based on trust with rules that are mathematically defined and enforced [10]. It is im-portant to note that the blockchain as a concept does not have a unambiguous definition since it can be viewed and defined in different dimensions, such as technological, oper-ational, legal and regulatory [27].
The alternative name for blockchain, distributed ledger technology, emphasizes the characteristic that makes it pos-sible for users to access a shared database (i.e., the ledger) with information or records related to assets and holdings capable of operating with its own standards and processes
without a central point of validation [9, 23]. The ledger
technology in this form is characterized by the distributed network of participants (nodes), instead of being regulated by one central authority. Furthermore, cryptography is used to validate transactions and store assets. In this way trans-fers can be validated and confirmed in a secure way without the intervention of a third party [18].
The structure of the distributed ledger can be designed in various ways. One of the differences is related to the way nodes in the network are authorized to act as verifiers. As a verifier one is given the power to decide who is allowed to en-ter network and thus view the data in the blockchain. This refers to the difference between ’permissionless’ and permis-sioned blockchains [17]. Permissionless blockchain is public and it allows anonymous users to participate in the trans-fer of assets and contribute their computational power [1]. This variant is most common in cryptocurrencies on the mar-ket. By joining the network someone is authorized to verify transactions without obtaining any prior form of permis-sion. Hence the name permissionless. Verifiers are impor-tant for the functioning of the network and therefore their participation is encouraged and incentivised [17]. However, sometimes there may be a need to set up a more privatized environment. For example, when it concerns a database that is accessible to a limited number of entities of one commu-nity. Permissioned blockchain is used for this purpose, as it is a form that is more private and restricted. Users can be identified and can only participate after they have been
verified by a centralized third party.
2.2
Blockchain in Health-Care
In summary, blockchain technology offers the possibil-ity for consensus, provenance, immutabilpossibil-ity and the final-ity of transaction data [22, 15]. Now that blockchain has proven itself useful in the e-payment sector, more and more other sectors are starting to experiment with the
technol-ogy, including the health-care sector. Studies show how
blockchain technology can have big advantages for health-care because it can facilitate reliable, distributed and cen-tralized databases managed by a community [14]. As it is in this sector often essential for different parties to access the same information, these benefits can become interesting.
It remains a challenge for health-care systems to become smarter by collecting, storing and analysing personal health-care data [28]. This is an obstacle that should be overcome as health-care data is a valuable source for health-care in-telligence and sharing it is essential for making progress. Blockchain creates opportunities for (public) health man-agement in medical research, the pharmaceutical sector and in consumer-oriented health-care [21]. It creates possibili-ties for how medical treatment for a chronic disease or el-derly care could benefit from blockchain technology to save time-consuming and resource-intensive authentication and information processing.
An example of smart health-care management comes from 2016 when the American start-up Gem used the Ethereum blockchain technology for the launch of the Gem Health Net-work. Their goal is to set up a worldwide blockchain net-work for a community of companies and individuals that take part in the continuum of care [19]. They facilitate ap-plications and support infrastructures with identity schemes, data storages, and smart contracts. With this shared infras-tructure, different care specialists have access to the same information. Different relevant types of stakeholders, such as hospitals and pharmaceutics, can thus easily share patient data in a transparent way. This has ensured a decrease of medical negligence by limiting the aging of information so that health problems can be detected at an earlier stage. It has also simplified the process of tracing a patients’ med-ical record because all records of interactions between the patients and doctors can be maintained with absolute in-tegrity.
Estonia is a pioneer in the field of eHealth and uses block-chain to secure government documents and health-care data since 2011 [25]. This is done in collaboration with Estonian eHealth Guardtime. Their approach can provide an example for how it could be arranged in the Netherlands.
There are two systems involved in their blockchain infras-tructure. The traditional database where the data is stored
and a database with secure audit logs of all actions. In
this way the scalability problem is solved because the actual health records are not stored in the blockchain. Accord-ing to Guardtime, one trillion signatures per second can be processed so that the system does not collapse.
The objectives behind the model are focused on data in-tegrity, to prove that files have not been altered, and insider threat migration. Because the infrastructure is completely transparent, licensed health-care professionals such as doc-tors, pharmacists and citizens can view the data. This is regulated through the national eID card. The data cannot be protected against malicious intent, but the patient can
see exactly who has been viewing their records. Parties can also be restricted, to prevent crime, and this is a way to prevent medical employees from viewing the data with ma-licious or curious intent. According to Guardtime’s program manager, one of the most important goals in the design of the blockchain infrastructure is that users completely forget that it is blockchain-based: “All you need to know is that it’s immutable and date a specific transaction took place”.
The emergence of health wearables has created a pow-erful flood of data that can be used for medical research. The current changes in regulations in Europe mean that this health data is sensitive and needs to be very well pro-tected. Blockchain technology therefore offers various ap-plication possibilities for this field as it can preserve and manage health information in a safe environment [21].
The Swiss HealthBank is an example of a company that focuses on this and offers a platform for handling data trans-actions and the sharing of personal health data [16]. By using blockchain technology, they ensure that the user has complete data sovereignty as it can determine at all times what happens to the personal data. In addition, the users on this platform also have the opportunity to share their data for medical research. In order to stimulate sharing, the users receive suitable financial compensation.
Other research shows that such models can be further developed and supported by blockchain through the use of time stamps [21, 7]. In this way, personal patient-generated health data can be recorded at individual level and moni-tored in the research process. Something that is very valu-able for the growing amounts of data in health-care.
2.3
Blockchain in Dutch Health-Care
There seem to be different facets in the current health-care system that are experienced as improveable for which blockchain can be a potential solution. For example, the current system is characterized by complex administrative requirements, as a fragmented system causing uncertainty, and there is a feeling of uncontrollability and disproportion-ate accountability [8]. In addition, the Dutch health-care system is built up by parties with different interests that collect and document their own information, such as care providers, health insurers, CBS, municipalities. This cre-ates information asymmetry that is inherent in the natural roles of the stakeholders [8].
Different studies have been being carried out in the Nether-lands focusing on how blockchain technology could be used to simplify specific processes in the health-care sector [8]. These studies look at issues related to the accessibility of data (privacy), the transaction volume (scalability), how the management of infrastructure can be improved and how business models and industries can be redesigned. Neverthe-less, it is indicated that most blockchain proposals in Dutch health-care are still in their infancy and often involve pilots [3, 8].
One of the main critical comments made with blockchain proposals for the health-care sector, is that it quickly raises questions about privacy and data protection because of the fact that data on a blockchain cannot be erased. This char-acteristic is for instance in conflict with new European reg-ulations, the General Data Protection Regulation (GDPR). An answer to this is a common model where there is only a link to the data stored on the blockchain. And together with the development of private blockchain technologies, this
en-sures that questions about privacy and data protection are hardly different with blockchain than without their use [8]. This does not alter the fact that a blockchain implementa-tion will have to go hand in hand with various legal, technical and organizational measures to guarantee privacy and data protection. However, this will still have to be worked out.
Another challenge for blockchain in the Dutch health-care sector seems to lie in the implementation in all levels of the five-layer model [3]. This model consists of the layers of organizational policy, health-care process, information, applications and IT infrastructure. Often, only the last two layers are taken into account. If blockchain is to succeed, research must be done on all five layers in order to achieve complete integration.
Furthermore, earlier research indicates that it is important to look at two key points that can otherwise be stumbling blocks for blockchain. A blockchain implementation must be in line with the (business) interests, making it strategi-cally of added value to work with it in health-care. In addi-tion, it is important to investigate what makes a blockchain unique, compared to other technologies used. This refers to the different blockchain initiatives in the health-care sector that are not yet ready for large-scale use. The technology cannot be used because it does not exceed current proven technology in health-care. However, it is stated that impor-tant questions for blockchain in health-care can be tackled by experimenting.
Until now, several attempts have been made in the Nether-lands to explore the possibilities with blockchain. Mijn Zorg Log is one of the innovations in digital information exchange initiated by the governmental Zorginstituut Nederland in collaboration with the Dutch blockchain developer Ledger
Leopard on an Ethereum platform [20]. The aim of this
initiative is to give citizens control over their own data, to record transactions irrefutably, to create a shared truth and to optimize administrative processes. The implementation has been tested with different cases and is in theory now ready for implementation. The introduction on a large scale in practice is what is still being worked on in collaboration with organizations in government and health-care. It is not clear when the initiative will really come into effect.
Another example comes from the municipality of Amster-dam in cooperation with the Social Insurance Bank (SVB) to further explore the blockchain application [8]. The aim of the research is to create a smart personal health-care budget (PGB) supported by blockchain. After completing the pilot, it was concluded that blockchain technology can make the implementation of the PGB more efficient and cost-saving. The research was taken over by the Ministry of Social Af-fairs and Employment and is under development, but there are no concrete implementations yet.
2.3.1
Nico.lab
Nico.lab is also a Dutch company that is experimenting with blockchain in the health-care sector. They specialize in improving stroke care through artificial intelligence
sup-ported neuroimaging assessment. The company analyzes
brain scans using various algorithms to achieve rapid di-agnosis and treatment. For this they receive scans from the hospital to analyze. To protect this data exchange, encrypt it, and to ensure for data integrity, they are investigating the possibilities that blockchain offers for this.
blockchain in health-care and in addition Nico.labs investi-gation. Therefore Nico.lab will be used as a real case study. It is looked at how blockchain can support collaboration be-tween hospitals and external parties, such as Nico.lab. It will be examined whether it is actually possible to build in blockchain a specific health-care setting and whether it is also feasible to do this.
To take account of the aforementioned five-layer model [3], specific attention will be paid to how the various stake-holders view a blockchain implementation from a theoreti-cal perspective. In this way, the feasibility of blockchain in health-care can be analyzed as completely as possible.
To do this, a realistic blockchain implementation will first be developed in collaboration with blockchain experts and developers to analyze how a possible blockchain in a specific health-care scenario will look like. Subsequently, this same model will be tested with the various stakeholders involved in the information exchange to examine the feasibility of the model.
3.
DESIGN SCIENCE FOR BLOCKCHAIN
To analyze and explore the possibilities for blockchain in health-care, the technology will be viewed from a design science perspective as described by [12]. In this approach, information systems are examined twofold: by building and by evaluating. During the building phase an artifact is con-structed to show that it is actually possible to develop the artifact in question. The evaluation phase is necessary for developing criteria and performance measures in order to evaluate the artifact.
The approach is suited for blockchain technology, as a type of information system, that continues to evolve and change. The approach also aims to give greater guidance in making choices relating to which important interactions and themes to prioritize within the study [24]. In addition, it recognizes that artificial phenomena operate within an en-vironment and cannot be properly evaluated without taking the environment into account. For this reason, the analysis consists of a combination of building a theoretical blockchain model and evaluating that same model in practice.
The next part of this research will therefore first focus on the building process to investigate whether it is actually possible to implement blockchain in Dutch health-care and how such a model would be constructed. In order to build a reliable model that is applicable to a practical example, unstructured interviews were conducted with blockchain ex-perts for gaining valid insights. The evaluation phase con-sists of a qualitative analysis based on semi-structured in-terviews with stakeholders who are directly involved in the implementation of the blockchain application. During the interviews the built infrastructure is presented to the stake-holders to analyze how certain elements would fit in prac-tice. In this way, both the possibilities and feasibility of a blockchain application will be examined.
It should be emphasized here that the blockchain possi-bilities in the health-care sector as a whole will not be ex-amined, but rather a representative sample will be studied. This sample is aimed at the radiology department for when data, such as scans, needs to be exchanged with an external party for support of treatment. Often these are relatively large files, which means that they can not simply be sent via traditional channels. To use a realistic and represen-tative example, Nico.lab has collaborated on this research.
The company was used as a case study as it is an example of an external party that the radiology department can collab-orate with. In addition, the case study made it possible to collect concrete information about data exchanges between different stakeholders in a hospital.
Finally, it is important to state that the interviews in both phases have been conducted in Dutch. This choice was made because the interviewees are all of Dutch descent and it con-cerns the Dutch hospital structure. Subsequently, English codes were abstracted based on [5], in order to then encode the interviews on the basis of the evaluation model.
4.
THE BUILDING PHASE
The building phase is intended to construct an artifact (the information system) for a specific purpose. In this case, the artifact is a blockchain infrastructure in a hospital facil-itating or supporting information exchange with an external party. Specific attention will be paid to data in the form of images from the radiology department.
The building process is based on the example of Nico.lab and for this, several unstructured interviews and brainstorm-ing sessions were held with (N = 4) blockchain experts in order to examine the possibilities for building an blockchain infrastructure. The experts work at Tymlez, an indepen-dent commercial Dutch company, that focuses on develop-ing blockchain in the form of an enterprise solution. Two of the four experts are blockchain developers and the other two focus on the business side of implementing blockchain. The interviews and meetings that were conducted to iden-tify the possibilities for the specific case of Nico.lab as an example that can be used for the purpose of this research. A complete elaboration of the interviews and the outcomes can be found in Appendix A.
In the sessions it was discussed and studied how a block-chain infrastructure can be designed as realistically and con-cretely as possible in Dutch hospitals when they have to exchange information with an external party. In collabora-tion with the blockchain experts, a relevant structure was devised for this part of the research to map the blockchain possibilities.
Eventually, with the information gathered during the in-terviews, the blockchain infrastructure is built up and ob-jectives are defined according to [5]. The model of analysis consists of different layers that as essential for construct-ing a complete artifact. First, the requirements for
defin-ing the information system must be determined. This is
done by mapping the objectives and then analyzing what the possibilities are with the current information infrastruc-ture. Then the resources needed to provide the information system, the production resources and the level of investment resources are determined. In this way, it will ultimately be decided whether and how blockchain implementation will be possible in this scenario.
4.1
System objectives and measures
The building phase started with investigating the current infrastructure in a specific Dutch hospital to analyze where it can be improved by a blockchain implementation. The original reason for the start of this study arose from un-certainties that occurred in practice. Namely, the case of Nico.lab brought forward that hospitals are very reluctant to allow data to be exchanged with external parties. Despite the fact that the data is only used for analysis to support
Figure 1: An overview of the by blockchain sup-ported information infrastructure
treatment and the data is not used or saved for any other purposes. This mainly concerned patient data in the form of scans from the radiology department and therefore became a starting point for the analysis. With this information, a blockchain framework has been developed in collaboration with the blockchain experts (N = 4) on which the following results will be based.
The interviews and brainstorming sessions ultimately led to a proposal for a blockchain infrastructure by the blockchain experts as shown in Figure 1. The model was then acquired and elaborated in more detail as part of this research. The model outlines the possibility of implementing blockchain in an infrastructure where information must be exchanged between a hospital and an external party.
4.1.1
Current Infrastructure
The starting point of analysis began with observing the current information infrastructure of a hospital for when col-laborating with Nico.lab for data exchange. The infrastruc-ture of the model starts at the moment the data, for instance a brain (CT) scan, is created. This is when the patient enters the hospital with complaints resembling those of a stroke. The patient is placed in a CT scanner to make a brain scan. The doctor then sends the scans to the workstation as input data. The scan is produced fitting into the Digital Imaging and Communications in Medicine (DICOM) protocol so that it can be exchange and communication with other medical systems can be established [11]. The data is then simul-taneously pseudonymised in a pre-defined function of the workstation.
The scans are uploaded from a secure IP-address set up by the external party using the DICOM protocol (EN ISO 12052: 2017). In this way the scans can be transferred safely to the external server, which is a cloud environment in this scenario. On this server, the automated analyses take place and the results are processed in a report. These files are
bundled and visualized in a web-viewer, built to display DI-COM files (using the EN ISO 12052: 2017 standard). After this, the files are encrypted and sent back to the recipient via a transfer service.
The recipient can view the files via the DICOM web-viewer when in possession of the right log-in credentials. The recipient of the output data must validate or discard the results. Furthermore, the recipient of the data can also enable the DICOM web-viewer to a secondary user.
4.1.2
The Blockchain Solution
During the interviews it became clear that there are al-ready a number of obstacles to the implementation of a com-plete blockchain infrastructure. A primary obstacle being that hospitals are not yet willing to adapt their devices to the blockchain technology. Therefore, a design decision was made to not put the medical data in the blockchain. In ad-dition, from the expert sessions it became evident that it is currently not realistic to build a closed circuit with all the entities in the network, including medical devices such as CT, into the blockchain infrastructure. The alternative pro-posal is that only meta-data is recorded in the blockchain. This is also what the minimal viable product (MVP) of the blockchain application focuses on.
As is shown in figure 1, a Proof of Existence of the received CT scan is generated and put in the blockchain. This creates the possibility to always be able to prove which CT scans have been received. With the built model, the network is assured of protection against data corruption and tampering that could occur between the hospital and the cloud of the external party. Smart contracts are used to ensure for data integrity and to control that only designated parties can add data. The smart contract will also make sure that the ownership of the files is transferred to the external party only if all the available images have been transferred correctly. This is done by cross-checking the hashes of the hospitals with those of the external party. In addition, every step in the process is stored in the blockchain to create a transparent infrastructure. This concerns recorded meta-data such as:
• Which algorithms were used and which version; • Times and the chronological order of all the events; • When the notification was sent to CoE;
• When the notification was sent to the hospital; • Who accessed the data from the CoE;
• When the result was sent to the hospital;
4.1.3
Technical Quality
In this scenario, blockchain can help validate the files that come from hardware withing the hospital and are received by the external party. By installing a Proof of Existence focused on the received CT scans and result report, it can be determined that the files are received by the external party without distortion or corruption. The Proof of Existence thus functions as a verification mechanism. In addition, it can be proven with certainty that the hospital will also get the right scans back.
The blockchain application has the potential to help se-curing the connection between the hardware and network in the hospital and the external party. Before the data leaves
the hospital network, it will be encrypted by the encryp-tion mechanisms of the blockchain. The data can only be decrypted by the external party who holds a key for this. The connection between the network of the hospital and the external server takes place on the basis of a Transport Layer Security (TLS) with a secure IP-address. However, it is still possible that vulnerabilities occur inside the hospital. It is also possible that the hospital does not take effort to en-able the TLS. Blockchain could support this by verifying the connection.
The blockchain can collect tamper proof audit logs for each activity. Currently this is not possible for hospitals because the analysis of patient data, as performed by for instance Nico.lab, takes place in an external server. Because of this, hospitals cannot control what exactly happens to the files. Blockchain could help with establishing data integrity by ensuring that the data that is sent back to the hospital is completely up-to-date and all A.I. results.
Another characteristic described by the experts is that blockchain provides assistance in anonymizing the DICOM files before they are sent to the external party. The same service can also be used to de-anonymise the files when the data are returned to the hospital.
The critical aspect of this model stems from the fact that the hardware itself is not involved as a node in the blockchain network, as the hospitals are not yet willing to adjust their devices. If the blockchain network is to be fully deployed, nodes must be installed in the machines or scanners. During the meetings with the blockchain experts it became clear that this is not possible at the moment, as the hospitals have their own reasons not do make these investments in infrastructure. What is possible, is creating a relay server in the hospital’s network. This can ensure that blockchain can still be implemented. In the sessions it was mentioned that this makes it that the validity of the blockchain model can be influenced by users. For example, photographs of screens can always be made. In this way it is not possible to keep full control over the data and data integrity.
4.1.4
Controls Quality
In consultation with the blockchain experts it is deter-mined that the exchange of the DICOM files is controlled by the smart contract with a hashing function. The hashing function has a deterministic output. It is a digital fingerprint with one way compression which takes only milliseconds. A new contract should be published per CT scan. This con-tract will ensure that the ownership in the blockchain is transferred to the external party only if all the available im-ages have been transferred correctly. At the same time, it cross checks whether the hash of the CT scan recorded in the hospital matches the one that is reported by the exter-nal party. The contract ensures that all data additions and enrichment’s of that specific CT scan are recorded. The con-tract therefore serves as Proof of Existence for the relevant DICOM files. The contract also enforces a proof of Existence from image analysis results that are added after the analysis. The results are then stored in the external party’s database, but the contract itself stores only the hash. Overall, the infrastructure is supported by a blockchain database called BigchanDB based on majority voting. This database must ensure that there is a powerful, functional and high data flow with low latency. With this, this structure solves one of the criticism, such as scalability. In addition, this
compo-nent ensures that the decentralized control can be performed to facilitate the immutable data storage. Eventually, it has to be investigated how a Public Key Infrastructure (PKI) can be implemented into the blockchain. According to the blockchain expert, a PKI security method can be used to implement a strong authentication mechanism for identity proofing of users. Because this investigation focuses on an MVP, the elaboration of a PKI is beyond the scope of this research.
4.2
Outcomes building phase
In conclusion, it can be stated that a realistic elaboration of a possible blockchain infrastructure has been set up in col-laboration with the blockchain experts. The building phase has led to an MVP where meta-data of medical data can be stored into the blockchain, instead of the actual data. Thus in theory, it would be possible to implement this model in Dutch hospitals. It should be noted here, that the grounds of this blockchain application comes from blockchain experts who are optimistic about the possibilities. For this reason, the blockchain infrastructure will be further tested during the evaluation phase with various stakeholders that will be directly involved in the information exchange. In this way it can be examined whether the proposal is actually appropri-ate for the health-care environment for which it was built.
5.
THE EVALUATION PHASE
During the building phase, a general framework for a pos-sible blockchain implementation has been established. In this section, the built model will be further investigated to find out whether the blockchain technology is actually fea-sible for the various stakeholders involved. To gather in-formation about how the stakeholders are facing a possible blockchain implementation, semi-structured interviews (N = 9) were held with employees from different Dutch hospi-tals (N = 3). The interviews have been conducted in Dutch because all interviewees are of Dutch descent. The analysis was subsequently carried out in English.
To get a complete picture of the feasibility of the blockchain model, the interviews were set-up and analyzed according to [5]. This model of analysis states that a developing infor-mation technology can best be evaluated from three per-spectives. First, the way in which the blockchain provides information and support to the stakeholders must be exam-ined. Next, improvements in user performance and processes will be evaluated. Finally, the effects on organizational per-formance will be investigated. The built blockchain model has been presented to the interviewees on the basis of these themes in order to evaluate how they view a possible imple-mentation.
5.1
Involved Users
Given that several parties are involved during a data ex-change in the health-care sector, this research will look at the direct potential users of the blockchain infrastructure. The interviews are intended to gain insight into the daily work activities, objectives and performance as well as the possi-bilities or obstacles for blockchain that are seen by them. It should be noted that the blockchain infrastructure is based on the Nico.lab case study, but that none of the hospitals of employees work together with the company.
Direct users in this study include doctors, who work with patient data on a daily basis, and information architects and
network administrators in a hospital, who maintain a safe in-formation infrastructure. Doctors will not necessarily come into direct contact with blockchain, but it potentially has consequences for their way of working. Namely, the com-plete history of the information exchange is stored in the blockchain and it is not possible to alter this once it has been entered. How does this affect the work of a doctor? Furthermore, after the Minimal Viable Product, a next step can be considered by working with a Public Key Infrastruc-ture (PKI) as mentioned in section 4.1.4. For this, doctors might have to perform additional actions for decrypting the patient data. The information architects and network ad-ministrators do come into direct contact with the blockchain application, so it will be relevant to evaluate their vision. In addition, there are employees in hospitals who are respon-sible for the purchase and innovation of medical devices, such as CT scans or monitors for analysing high resolution results. The latter influence the feasibility of a blockchain implementation as they can effect decisions made in rela-tion to medical devices. The last two stakeholder types are in this research grouped as IT employees in hospitals.
For validation and reliability purposes, different (types) of hospitals are involved in the qualitative study (N = 3). It concerns academic and general hospitals that differ from
each other in terms of structure. Furthermore, attempts
have been made to involve different types of doctors (N = 4) and IT employees (N = 5) in the research in order to map different perspectives. The different questionnaires for the stakeholders can be found in Appendix B.
Finally, the blockchain building process, for cross-valida-tion, will be evaluated by an independent blockchain expert (N = 1). This blockchain expert can thus help to objec-tively evaluate the proposed blockchain application in the environment it will function in. The questionnaire for the blockchain expert can be found in Appendix B.3.
5.2
Information and Support
In this layer of the earlier mentioned model of analysis, it is being investigated how information is provided by the blockchain technology. The main purpose of the different types of questions related to the information and support theme was to investigate into the current information infras-tructure in the hospital from different perspectives. Ques-tions were asked to examine what positive features the in-frastructure have at present and where can it be improved? And how will the presentation form and system interface be improved in terms of responsiveness, convenience and avail-ability? In addition, questions are asked to map the security and data integrity of the current system. The IT staff was asked how data integrity is established and how the privacy of the data is protected. Doctors received less technical ques-tions and they were asked about privacy and how their work processes were influenced by the new privacy regulations.
The purpose of this is to analyze more concretely how the blockchain technology would function in such an envi-ronment. The existing cooperation protocols with external parties, other hospitals and different departments are also being examined.
5.3
Use process and User Performance
The second layer of the evaluation model is used to map the potential use of the blockchain technology and the ef-fect on user processes and performance. These efef-fects are
originally intangible but are nonetheless relevant for
assess-ing system effectiveness. The questions that support the
evaluation of this layer are aimed at the different users and the related decisions that they have to make during their work. Questions were asked about which issues they have to deal with and which stumbling blocks they encounter in their daily work. It is also important for this theme to find out what goals and objectives they have set for themselves with regard to the exchange of patient data. In this way, it can be analyzed whether blockchain technology actually stimulates or hinders these decision processes.
5.4
Organizational Performance
The last layer that is evaluated revolves around the ef-fect of the information system on the organizational perfor-mance. Questions are asked about whether employees think that it is possible to implement blockchain. Not only in a technical manner, but also socially, legally or other possible ways. When asking these questions, the degree of technical background among the various stakeholders was taken into account. In addition to being able to implement blockchain, it was also be evaluated whether the stakeholders think it would really add value for the organization and why or not.
Who or what benefits of blockchain technology? Lastly,
questions are asked about the complexity of a possible im-plementation in the current infrastructure.
6.
FINDINGS
After conducting the interviews, the results were analyzed on the basis of the model of analysis [5] that helped and structured measuring instruments for evaluating the effec-tiveness and feasibility of the blockchain model. Based on the different themes, codes have been generated qualitatively for sorting, categorizing and analyzing the findings. In this way, the perspectives of the various stakeholders can ulti-mately be compared to investigate whether the implemen-tation of blockchain is actually possible in this environment and will be feasible for health-care.
6.1
Findings IT Staff
A total of N = 5 interviews were conducted with dif-ferent types of IT staff from three difdif-ferent hospitals. It concerns three information architects (IA1, IA2, IA3), one network administrator (NA1) and one clinical computer sci-entist (CCS1). Both academic and general hospitals were involved. Their responses to the interview questions are cat-egorized according to the aforementioned three-layer evalu-ation model [5].
6.1.1
Information support
From the interviews it becomes clear that in at least two of the three hospitals information is exchanged only via the central IT department, via controlled systems. Exchanges with external parties are limited, they only take place with suppliers, or do not take place at all. CCS1 explains that it is even more rare that information is sent directly from the radiology department outwards. IA3 even specifically states that the hospital she works in makes “an active attempt to keep all information ’inside’ [the hospital]”.
In the hospital of IA2 they are experimenting with hash-ing for information exchanges: “Well, encryption, that’s a thing...”. He explains: “Encryption methods, such as digi-tal signatures are used. This way you can be sure that the
recipient is actually the recipient. That works both ways”. In a contrasting statement, CCS1 describes that currently a lot is already being logged, but that there is no centrally managed system for the tracking and tracing of patient data. When it comes to collaborations with external parties, all IT experts indicate that little is happening in their hospital. CCS1 explains that: “Data exchange is self-evident when it comes to research”, but that little is being done with (semi) commercial parties. These types of collaborations are de-scribed as “very complex” by at least two experts.
The Electronic Patient Dossier (EPD) is mentioned by IA2, IA3, CCS1 and NA1. The initiative is described as a “failure” and IA2 explains that it results into local alterna-tives. CCS1 thinks that the system failed because: “Within the EPD it is well organized. [...] But all systems around it do not connect properly to it. You then have your own log-in but it is not well integrated”. He therefore fears blockchain: “That will probably be the same and will not be properly
attached”.
6.1.2
User Processes Performance
Data integrity is very important for the work of the ex-perts, they state. They are constantly evaluating the data. IA1 explains that certain questions are regularly asked when data exchange takes place: “What elements does it contain? How is the information maintained? Is the connection sta-ble? Does it concern a cloud environment?”. In the hospital of CCS1 they are especially very “alert” and for him, data in-tegrity is about keeping the data “complete, valid and safe”. In addition, CCS1 says: “Within the hospital, the chance of a data leak is small, but out there, [the chance] is much big-ger”. IA1 complements this with the fact that “things must always be demonstrable” and that the data when external, must be controlled. “But how do you secure data on the other side?”, is a question that IA2 has no answer to. In the hospital of IA3, this is attempted to be solved, as far as pos-sible, by “mapping all adjustments, filtering and changes, in the message traffic”, but she states that it remains a “gray area”.
6.1.3
GDPR Work Processes
Various improvements are mentioned when it comes to working with the new privacy regulations. For example, it is states that the regulations ensure for less risk for patient data (IA1), that hospitals now have more ways to handle personal data (IA2), that people are now more alert (CCS1) and that the privacy awareness among the employees has grown (IA2, CCS1, NA1). IA2 describes the introduction as a “European party” with the result that we are now all talking about the same: “The GDPR makes life a lot eas-ier because [Europeans] have to deal with everything in the same way”. Furthermore, IA2 describes that he notices that the awareness among employees ensures that less data leak-age takes place.
There have been a number of changes in the way hospitals address privacy. IA1 explains how a Data Protection Offi-cer (DPO) has been appointed to his hospital who is now responsible for answering questions about the GDPR. In his department, the key privacy issues, concepts and other im-portant changes were investigated thoroughly. In addition, a processing register has been drawn up in which different types of permissions are registered. Furthermore, Privacy Impact Assessments (PIA) are performed as soon as a new
information exchange has to take place. IA3 states that
due to these changes it is now necessary to log everything, because otherwise you can never find out who has viewed what. Data portability is a new big challenge for IA3, she says. Once, choices were made to arrange certain systems in a certain way. This now clashes with the introduction of the GDPR because the data are fragmented in different systems and logging is now difficult.
The new regulations also affect external collaborations when it comes to information exchange. CCS1 says that contract formalities are now a lot more stringent. On the other hand, IA1 states most processing agreements are par-tially based on a “relationship of trust”. According to him, it works to an advantage if the companies with a hospital must cooperate have a type of privacy certification, because you never know what is happening on the other side. This makes it easier to check whether they comply with privacy laws. When a request is made for an external collaboration, an evaluation process is set in motion: “the whole battery of privacy-related employees is involved”, NA1 to indicate how much effort is spent.
Another important change ensured by the introduction of the GDPR is the educating of employees, says IA2. Accord-ing to him, “privacy awareness starts durAccord-ing the introduc-tion days of new employees” and “It has to be in their DNA”. IA2 and NA1 independently say that people remain to be the weak link in the process and therefore you have to be extra careful.
6.1.4
Organizational performance
Hospitals are described as part of a chain, states AI1. There is cooperation between different types of entities in-volved in health-care, such as suppliers and pharmaceuti-cals. In addition, according to AI1, a hospital is made up of various influential departments that each have different tasks and responsibilities. The structure is “fragmented”, as IA1 describes. Furthermore, IA2 also describes this cur-rent structure as something that hinders most technological developments.
Another characteristic of hospital environments, accord-ing to NA1, is that many different systems are used when it comes to information exchanges. The methods that are used in hospitals to communicate or exchange data are described by IA2 as “traditional, such as the old email”. The different types of systems used differ mainly per region. They are set up regionally, explains IA2. He refers to the XDS environ-ment used in his hospital: “a register containing references to source systems”. CCS1 works with a different system for managing patient data: Epic. In addition, CCS1 explains that his hospital CSI is accredited. This means that they work with many rules and protocols. To prevent mistakes and to control the information exchanges.
6.1.5
Blockchain Advantages
In general, the IT employees (N = 5) are positive about blockchain technology. It is argued that it has a lot of po-tential and that it is an “influential technology”. IA2 is con-vinced that: “blockchain will be the norm in five years, also in health-care”. He is triggered by the possibility of control being in the hands of a broad community: “This develop-ment will very likely benefit the data integrity”. However, it becomes clear that the technology is not completely un-derstood by the experts. IA1 states on the one hand that:
“personally I think it is a beautiful technology” while he later states “I don’t know all the details. It does have potential, I think.”
The positive arguments that were given relate to the tam-per -proof audit logs that can be produced in a blockchain environment. CCS1 stated that blockchain adds value when
it comes to “tracking and tracing purposes”. He argues:
“[Blockchain technology is] certainly [of added value] for these new special projects that are cloud-based”. IA2 agrees independently: “You need more than one person to check if data is correct. So when someone changes something in the chain, nothing is correct anymore. You therefore need mul-tiple checks to evaluate whether a chain is actually good. I really think that will be the future. It would make life a lot easier, let me put it this way ”. He explains how this struc-ture can result in more control and therefore higher data security.
NA1 expresses his doubts: “Well, for safety [a blockchain implementation] could be possible. But everything is hack-able, even your fridge”. On the other hand he states that it would be useful if you can use a blockchain application to check whether the data you send out, is the same data you receive back: “That you don’t suddenly receive back the CT [scan] off a different patient. That would be very nice, because it is stupid when that happens”. According to NA1, it would be a good verification mechanism: “This way you can verify that the laboratory technician has not made a mistake”.
IA2 comments that we all have a job to do when it comes to blockchain: “It is fairly new. At least, it is new in that sense that it is used for other things than just for mining coins. So yes, something needs to be done about that. We all have to do something about that”.
A final comment made by NA1 is that anonymization is currently done manually by his department: “We also do anonymization. We delete all personal details. Even the patient number is removed because with that you can also trace someone. It’s purely the DICOM data”.
6.1.6
Blockchain Disadvantages
In addition to positive reactions, there we also points of criticism. IA1 says that a blockchain application should not make things unnecessarily complex and make it result into taking extra measures. CCS1 argues: “Blockchain technol-ogy can offer new possibilities that may not be necessary for this purpose”. NA1 also expresses criticism: “At the mo-ment I do not really see any added value”. CCS1 explains that he wonders whether there is any added value compared to the technology that is already being used: “We are al-ready very well able to establish secure connections between two points”. NA1 adds to this independently: “We have al-ready built in a kind of own control mechanism [...]. With our own lists, we already solve a lot. The system is already waterproof. But that is mainly because we stay within our own system”.
Only IA2 is predominantly positive about a possible
im-plementation. He only wonders if right now is the right
time: “[...] Knowing the health-care sector, I think it will take some time before it is fully integrated. Yes, I’m afraid of that. [The health-care sector] is pretty decentralized”. He explains that he expects the blockchain implementation to raise all kinds of questions, for example in the IT de-partment: “How will this be implemented in the current
infrastructure? Do you want to extend it to other depart-ments? Those kinds of questions. [...] Do you understand the technology? What can you do with it?”. Other con-cerns that are expressed come from IA1: “I am afraid of for small alternative solutions on departments that gener-ally work differently. This makes the complex to connect”. NA1 concludes that: “[implementing] blockchain technology is basically not a bad idea. But, you should examine what it solves and whether it makes any sense. Perhaps it would [make sense] for keeping patient data protected according to the new [GDPR]”.
6.1.7
Complexity of Implementation
The opinions are divided when it comes to the complex-ity of implement blockchain in their hospital. IA1 thinks it will not be complex: “It is something that takes place under the bonnet, just like virtualization”. He supplements: “As long as it functions according to the protocols, it makes no difference”. On the other hand, IA2 does wonder whether it is the right time: “It is not very mature yet. Well the tech-nology is, only whether the implementation is ... I wonder”. He gives the example of how the majority of the hospitals are still migrating to Windows 7, in order to give a picture of the current state of technological developments in hospi-tals. NA1 also says: “At the moment I do not really see the added value of [a blockchain application].” IA2 empha-sizes that “looking for a pioneer” and “taking risks to take a step forward” are necessary steps that have to be taken in order to make it succeed earlier. In conclusion, it is men-tioned that it will probably be a “challenge” to implement blockchain technology in their hospitals. Furthermore, all employees state afterwards that they are very curious about the possible “links between blockchain technology and IT systems in hospitals”.
6.2
Findings Doctors
In total N = 4 doctors were interviewed. It concerns
one neurologist (N1), one gynecologist (G1), one doctor of medicine and PhD in neuroimaging (MD1) and one doctor of medicine and PhD in pathology (MD2). The doctors work
in both academic and general hospitals. Questions have
been asked to map out their interactions with patient data and medical devices. In addition, they were asked about user processes, performance and a possible blockchain im-plementation. The findings are categorized on the basis of the three-layer evaluation model [5].
6.2.1
Information support
In order to map which actions are performed by doctors on a daily basis, questions were asked about their current work-ing environment. The doctors are divided in opinion when it comes to the current information infrastructure in their hospital. It becomes clear that the software and databases used, differ a lot between hospitals. In two of the three dif-ferent hospitals that have been investigated, Epic happens to be used as a general patient system. This system is only for written information. Images and other laboratory data are stored in other types of software, such as PaxDb , an overarching system for images and laboratory data. There
is no connection between the different systems. G1 says
that the current communication methods are “actually call-ing, letters and care mail”. MD2 agrees and adds: “That is quite cumbersome. That costs a lot of time and money”. In
addition, all doctors agree that the systems are not able to communicate properly with the systems of other hospitals, making information exchange more difficult. N1 describes the scenario: “So what happens now when patients are re-ferred to me from another hospital, they send a letter or a CD-ROM with the images on it. Then these images are transported to our department so that they can be put into the system. That is of course a bit archaic”.
A subject that is mentioned by all doctors is the Electronic Patient File (EPD). They are disappointed that the national introduction has not gone through. MD2 says: “The way we have to work now, it is very old-fashioned”. He does see why there was critique: “It is difficult to throw everything nationwide on a bulk. Because you can easily reach a patient with whom you have nothing to do”. MD2 makes another remark on this topic is: “Now that the EPD has been shot down, I think it is quite difficult for politicians to reorganize health data when it comes to the subject of privacy. There is a very big risk that things will go wrong ”.
In conclusion, it can be said that the doctors find that there is no synergy between different computer systems, that bad communication takes place, that communication out-side is not possible and that the systems are complex and have many different layers. The terms “old-fashioned”, “ar-chaic” and “cumbersome” are mentioned. The positive thing about the systems, according to the doctors, is that they work reasonably well within the hospital, that there is easy accessibility and that you can easily view images.
6.2.2
User Processes Performance
When it comes to work processes, the four doctors em-phasize that it is nearly impossible to share data with other hospitals. N1, who is very satisfied with internal commu-nication in his hospital, says about the external communi-cation flows: “Of course there is the pinch. It is incredibly ridiculous that [sharing files with entities outside their hos-pital] is not possible”. When it comes to exchanging data with external parties, all four doctors confirm that this does not happen as far as they know.
N1 thinks that patient privacy is therefore at risk because the systems are not linked to each other. Privacy is on the one hand considered to be very important by the doctors, but on the other hand it is privacy is mentioned by both MD1 and N1 as an argument that hinders the sharing of information. MD1 describes that previous initiatives have failed while it “could have generated a huge gain in fight-ing diseases. Now everyone is reinventfight-ing the wheel all the time”. N1 describes the privacy argument as an “obstacle” and a non-argument because: “Dutch people share every-thing via social media and Facebook, but then this is not allowed”.
Subsequently, the new privacy regulation is mentioned with mixed feelings. MD1 says that he is not an expert, but that it is good to pay attention to it. MD2 is also fairly positive about the introduction of the GDPR: “In general, I think it is really good, because privacy is playing an in-creasingly important role in our daily lives”. He gives the example: “Often there are Excel spreadsheets somewhere on a laptop, with names, patient numbers, what type of cancer they have, and telephone numbers. I think that is bit of a mess. I think that the [GDPR] is reasonable, and that this can be kept under control”. N1 calls the current methods used for information exchange “archaic”: “Faxing is such a
dreadful thing. They arrive at a sort of secretariat and then that fax is open or exposed there for a day. If you are talking about privacy, that is such a strange system”.
Furthermore, MD1 describes that there is always some-thing to improve in hospitals, but that above all, doctors work has to remain practical. For the same reason, he also expresses a criticism towards dealing with the GDPR: “It is always good to keep everyone in class, but the point where it is no longer workable is what we are approaching”. G1 describes how the introduction of the GDPR caught her by surprise and she does not really know what to do: “The only thing we know about it, is that it is very strict. Now every-one is scared”. In addition she explains: “Because I don’t know what to do, I’m now solving it over the phone. Nor-mally I always sent her an e-mail”. MD2 calls the GDPR a “pain in the ass” for his research: “It is so strict that I can-not request patient data from other hospitals”. Asking extra permission supposedly takes a lot of time and effort. MD2 explains: “In general hospitals say no [when asked permis-sion]. This is because hospitals do not know exactly what is allowed because the GDPR is very new. They do not know what the GDPR means and then saying no is much safer than saying yes”. Only N1 described how his work is not affected by the GDPR.
6.2.3
Organizational performance
One of the things, regarding organizational performance, that the doctors are dissatisfied about is the degree of ad-ministration. MD1 says: “It’s just a lot. Doctors have to implement a great deal of bureaucracy and administration. We have to deal with a complicated program with all kinds of different layers” and “Bureaucracy is running out of con-trol ”. In addition, MD1 describes that there is too little money for good solutions: “Often, the cheapest solutions are chosen and that simply does not work”. According to MD1, this is caused by the fact that in medicine people look at a diseases from their own perspective and do not talk to each other. G1 agrees with this last argument and says that doctors now have to do more and more administrative work. In addition, MD1 argues that there is a lot of friction in health-care that is caused by two things: “on the one hand that there is too little money and on the other hand that there are now developments taking place coming from something that used to be super rigid. Now it becomes more fluid and is it very difficult to make such a transition if you have too little money”.
A final relevant comment made about hospitals is that there is always something to improve, but that it should, above all, remain practical: “The work of the doctors should remain practical”, says MD1. He explains: “The way dealing with solutions in the hospital depends on how workable the rules are and how good the information exchange is”.
6.2.4
Blockchain Advantages
What becomes clear after interviewing the doctors is that doctors know little to nothing about blockchain. G1 says: “I’m totally lost in that area” and “when I ask my colleagues, they also stare at me with glassy eyes”. MD1 states: “The only thing I know is that it is a way to encrypt information and even that may not even be true. Someone explained
it to me once, but I forgot”. MD2 emphasizes: “I know
nothing. Zero.” The association with bitcoin is mentioned by MD1 and N1.
N1, MD1 and MD2 mention that it is no problem as long as external parties, or doctors who have nothing to do with the patient, cannot see the data. They also stress that it im-portant that you can supplement things afterwards because this is often necessary during their work. The doctors also see benefits in using blockchain. They describe that it is good that you can detect errors (MD2), if you make a mis-take, you can apply for an addendum (G1), when there is a disciplinary case, a judge can see exactly what happened (MD1) , and that in many systems it is already the case that it keeps track of which documents are opened by whom, for example if there is a celebrity (MD2) and that it is safe if things cannot be changed (N1).
6.2.5
Blockchain Disadvantages
MD1 does not know what he thinks of the tamper proof audit-log characteristic provided by blockchain. He describes: “You just have to ask yourself: do you insist that everything
is always stored? That’s a bit of a general philosophical question” and “You are not doing anything wrong, but then, do you want everything set in stone? I have no answer to that”. Regarding the generating of keys as extra action, the doctors describe that in theory it does not have to be a problem, as long as it does not take too much time. MD2 indicates that doctors, such as surgeons, sometimes have up to 20 patients who all have scans. In such a case you can lose the overview, says MD2: “If you have to use your phone for every one of those 20 patients or do something else for that key, then it is a bit cumbersome”.
In summary, the doctors responded positively to the ques-tions about a blockchain implementation. The most impor-tant thing is that it is not complex, but is very user-friendly (G1), that it should be possible to supplement entries and does not cost extra time (MD1), and as long as only peo-ple who are authorized have access (MD2). N1 is especially positive about the technology for when it would facilitate data exchange and security. He states: “It is true that every action is one, but if it could facilitate the exchange of data, then [generating a key] is much easier than to write a letter or upload data on a CD-ROM”.
6.3
Findings Blockchain Expert
Lastly, an semi-structured interview was held with one in-dependent, non-commercial blockchain expert and researcher (coded as BE1) to validate how optimistic the proposed blockchain model actually is. As the other interviews and literature have shown, blockchain is still an abstract concept. For this reason, an evaluation by an experienced blockchain researcher can contribute to sketching a more complete pic-ture of the possibilities for blockchain implementation in
health-care. The questions that have been asked can be
found in Appendix B.3.
BE1 explains that for him, blockchain is a kind of data structure: “You want each party to have the same view of
the data. You also want that in the health-care sector.
What treatments are done, how much costs, economic as-pects, what equipment is used, MRI scanner. You want to be able to compare this. You can find out where you need to be for a certain treatment”. He describes how this can be relevant for the health-care sector because there is a lot of interaction between hospitals, health insurers, and sup-pliers: “It is a big chain. It is important in health care to look at how you are going to include these parties”.
BE1 says about the complexity of implementing the built blockchain model: “It depends on how it is done, I think”. He then explains that the question lies more with: “if you want to ’blockchainify’ the process”, but it is in any case possible to implement this”. It is important to formalize agreements clearly and a blockchain can provide a kind of consensus between different parties. It should be noted that people always remain a “liability”, says BE1. He also says: “Many people are convinced that they should use blockchain. Even if you put it in your name, the value of your product goes up 500 times. That does not have to say that you have to use it”.
Finally, he adds that blockchain is a form of encryption and there are more and more developments in the area of en-cryption. He describes how homomorphic encryption could actually do the same thing blockchain does. It is a way of encrypting data: “Then you give [the data] to a third party that will perform calculations on the data, without know-ing what kind of data they are workknow-ing with. Then they send back the analysis and you can decipher what the out-come of the analysis is”. That is homomorphic encryption. The only drawback of this form of encryption is that it is computationally expensive, says BE1.
7.
DISCUSSION
During the first part of the research, interviews and brain-storming sessions were conducted with four blockchain perts and developers, so that a concrete and realistic ex-ample model could be developed for Dutch hospitals. This indicated that in theory it would actually be possible to implement blockchain technology in the current informa-tion infrastructure of hospitals. Subsequently, a qualitative study was conducted for which two different semi-structured questionnaires were drawn up to map the feasibility of a blockchain implementation in Dutch hospitals. The ques-tions are based on [5] to investigate the possibilities for infor-mation and support, changes in user performance and pro-cesses, and connection to the organizational performance. The interviews were conducted with various relevant
stake-holder groups in Dutch hospitals. It concerns a total of
four doctors, with different disciplines, and five IT employ-ees from three hospitals.
7.1
The Blockchain Model
After conducting the interviews, a number of obstacles arise for the model that was built. For example, the block-chain experts describe how a node can be built in, or just after, the medical device. The hospital IT employees, how-ever, describe that it is not the case that data is exchanged directly from the radiology department. All exchanges go via the central IT department present in the three exam-ined hospitals.
Furthermore, it becomes clear from the interviews that the systems in hospitals differ greatly from each other and that
this makes the information exchange more difficult. The
blockchain model is based on the assumption that the scans are sent back to one type of system at a given moment. Since systems apparently differ from each other, it is necessary to further investigate the impact of this on the blockchain infrastructure. Does this mean that the application must be slightly different for every system?
Both the doctors and IT staff report that a blockchain im-plementation would be feasible if it is user-friendly and not
