Business Administration
Bachelor Thesis
Blockchain technology in the Dutch healthcare sector
Author: Pim Kemp
10792678
26-06-2018
Statement of originality
This document is written by Student Pim Kemp who declares to take full responsibility for the contents of this document.
I declare that the text and the work presented in this document are original and that no sources other than those mentioned in the text and its references have been used in creating it.
The Faculty of Economics and Business is responsible solely for the supervision of completion of the work, not for the contents.
Abstract
The purpose of this study is to investigate how blockchain technology can provide added value for Dutch healthcare recipients. In order to investigate this research question, a mixed-method research design has been applied. First, a quantitative study was conducted to validate the conceptual model derived from the literature. A survey was distributed among a sample of the Dutch population. The results of this survey have been quantified and analyzed. Thereafter, a literature study was conducted to investigate how blockchain technology could add value to the Dutch healthcare sector. Relevant articles have been selected from online libraries and have been analyzed. The results of the quantitative study show that the four concepts found in the literature, can be generalized to the Dutch population. Furthermore, in the literature study multiple blockchain technologies are presented that will add value in the Dutch healthcare system. So, blockchain technology can add value for healthcare recipients in the Netherlands. This added value can be achieved by implementing new technologies which have proven to be successful in other countries. The benefits of these new technologies exceed the costs, and they can therefore be considered to be of added value.
Index
1. Introduction 6
2. Literature review 8
2.1 Blockchain technology 8
2.2 Applications of blockchain technology 9
2.2.1 Financial applications 9
2.2.2 Non-financial applications 10
2.3 The Dutch Healthcare sector 10
2.4 Added value 11
2.5 The Added value of blockchain in the Healthcare sector 12 2.5.1 Putting the patient at the centre (patient control) 13
2.5.2 Privacy and access 14
2.5.3 Completeness of information 15 2.5.4 Costs 15 2.6 Literature Gap 15 3. Conceptual framework 16 4. Method 17 4.1 Online Survey 17 4.1.1 Sample 18 4.1.2 Design 18 4.1.3 Data Analysis 19 4.2 Literature study 19 5. Results 20 5.1 Study 1 20 5.1.1 Control Variables 20 5.1.2 Patient control 21
5.1.3 Privacy & Access 22
5.1.4 Completeness of information 23
5.1.5 Costs 24
5.2 Conclusion Study 1 24
5.3 Study 2 25
5.3.1 Patient control 25
5.3.2 Privacy & Access 28
5.3.3 Completeness of information 30
5.3.4 Costs 31
5.4 Conclusion Study 2 32
6. Conclusion 33
7. Discussion 34
Appendices 40
Appendix A 40
Appendix B 50
Appendix C 59
1. Introduction
From the end of the 20th century, the internet has become an essential part of many people’s daily life (Kim, 2011). Almost everything is connected online nowadays and innovations like the use of big data and the internet of things are widely accepted. These innovations offer great possibilities, but due to the technological complexity of them, it seems that the majority of the people do not fully understand the implications of these new innovations. Data from the CBS (Dutch statistical institution) shows that half the population in the Netherlands has anxiety about online safety (CBS, 2015). About 8 percent indicated that they experienced one or several online incidents past year (CBS, 2015). Especially the anonymity and security of online stored personal data is something that raises concerns (CBS, 2015). One of the industries in which sensitive personal data is stored online more and more often, is the
healthcare sector (Mold et al., 2012). This sometimes ‘old fashioned’ sector, is slowly starting to adapt new innovations (DesRoches, Worzala, Joshi, Kralovec, & Jha, 2012).
One of these innovations is the introduction of Electronic Health Records (EHR’s). In contrast to the old paper version of patient records, these records are stored on an online server (Hoerbst & Ammenwerth, 2010). While this system offers a lot of benefits, it makes these patient records an easier target for cyber criminals. In fact, the Identity Theft Resource Center found out that inthe United States, the healthcare sector experienced 375 data
breaches in 2017 (ITCR). This represents 23,7 percent of the total amount of breaches in the US. In total, over five million personal and sensitive patient data files were exposed (ITRC, 2018). Recently, a new technology was introduced which could have a positive influence on these kind of problems. This technology, which is not widely used in the healthcare sector yet, is blockchain technology.
Blockchain technology is the underlying technology to Bitcoin and has become popular since the digital currency was introduced in 2008 (Kikitamara, 2017). Nowadays, it has proven to be successful in multiple industries like banking, finance, insurance and real-estate (Crosby, Nachiappan, Pattanayak, Verma, & Kalyanaraman, 2016; Engelhardt & Espinosa, 2017; Meijer, 2017). This decentralized, peer-to-peer electronic system is known for its security and offers many possibilities. Also, it would outsource the ‘trusted third party’ which could save costs (Nakamoto, 2008).
conducted in the Netherlands yet. The healthcare systems in the United states and the
Netherlands are not equal. Therefore, research on the Dutch population needs to be conducted to find out if conclusions can be generalized. The aim of this thesis is to fill up this gap in the literature, and to provide more knowledge about the possible added value of blockchain technology for Dutch care recipients. First, a study will investigate if the problems in the United States healthcare sector also occur in the Netherlands. The results of this study will then be used to answer the following main research question: How can blockchain technology
provide added value for care recipients in the Netherlands?
To answer the research question, a mixed-method research design will be applied. A quantitative study and a literature study will be conducted. The results of these two studies are going to be compared in order to find out where blockchain technology could provide added value in the Dutch healthcare system.
After the introduction, a literature review will explain the concepts in the research question and will show the current state of research on the added value of blockchain
technology in the healthcare sector. Next, the conceptual model will be introduced and will be shown schematically. In the fourth chapter, the research methods of the two studies
conducted, will be explained. Then, the results of both studies will be shown, analyzed and compared in chapter five. Finally, a conclusion will be drawn and the results and limitations will be discussed.
2. Literature review
This literature review will provide an overview of the existing literature on this studies subject. All the concepts of the research question are being discussed in the following paragraphs.
2.1 Blockchain technology
Blockchain technology has become popular since the digital currency Bitcoin was introduced in 2008 (Kikitamara, 2017). Satoshi Nakamoto (2008) wrote a paper in which he describes the Bitcoin as a decentralized peer-to-peer electronic cash system. This new technology makes it possible to send online payments from one party to another without going through a financial institution (figure 1).
Transactions in the blockchain are both transparent and encrypted (Kikitamara, 2017). This ensures maximum security. All the transactions on the blockchain are being saved in blocks. Data is permanently recorded in these blocks on individual computers (instead of a central location) and is accessible to the public at any time. The blocks on these computers are then linked together in a linear order, forming a chronological database of transactions,
recorded by a network of computers (Nakamoto, 2008; Wright & Filippi, 2015). To verify a transaction, a digital signature is needed. The party sending Bitcoin will encrypt a digital signature and send it to the receiving party, who decrypts it (Nakamoto, 2008). When the computers in the blockchain reach consensus about the validity of the transaction, a new block will be formed at the end of the chain. The data in this block will be unchangeable from then on (Kikitamara, 2017).
Figure 1: How blockchain technology works
2.2 Applications of blockchain technology
Implementing blockchain technology can be useful in various ways and in different kind of industries. In his paper, Kikitamara describes four types of financial applications and three types of non-financial applications for blockchain technology (2017):
2.2.1 Financial applications
Digital payment systems: Creating digital decentralized currencies like Bitcoin to ensure maximum security and privacy. No bank or financial institution is needed to verify the transaction, this is done by the blockchain (Kikitamara, 2017; Nakamoto, 2008)
Smart contracts: An online agreement between two or more parties which can be made without the intervention of a ‘third party’. Instead, the agreement is being verified by the blockchain. This will reduce costs and improve security (Kikitamara, 2017).
Insurance: With blockchain technology, insurance companies are able to register important information (like ownership and transaction history of valuable assets) in the blockchain. The information cannot be changed or destroyed (Kikitamara, 2017).
Crowdfunding: Crowdfunding using blockchain technology will outsource third parties like ‘Kickstarter’. These third parties often take a share of the raised funds, which now also goes to the receiver. Blockchain technology also enable fundraisers to give out cryptographic shares when crowdfunding (Kikitamara, 2017).
2.2.2 Non-financial applications
Decentralized Governance Services: Applying blockchain technology to notarizations ensures maximum security of documents. This will enable governments to provide more online
security to their citizens. Also, new possibilities for governments arise like secure online-voting (Kikitamara, 2017).
Decentralized storage: Blockchain provides a secure structure for the storage of sensitive personal data like electronic medical records (EMR’s). This data can be analyzed and shared, but not be changed or deleted (Kikitamara, 2017).
Decentralized IoT: The internet of things (IoT) is gaining popularity. Blockchain technology can provide more safety to and reduce costs of IoT networks. An example is ADEPT, a platform that uses elements of bitcoins underlying design for IoT networks developed by IBM (Crosby et al., 2016; Kikitamara, 2017).
2.3 The Dutch Healthcare sector
In 2006, a new healthcare system was introduced in the Netherlands (Buijsen, Centrum, & Zvw, 2006). In this new system, supervision and management have been largely delegated from the government to independent bodies (Schäfer, et.al., 2010). The goal of the new system is to create more competition in the industry, with higher quality and lower prices as a result. At the base of this new healthcare system is the Zorgsverzekeringswet (Z.v.w.,
buy healthcare from healthcare providers. This should lead to lower insurance prices. The healthcare providers, for example hospitals, also compete among themselves, which should lead to more innovation and a higher quality of the provided healthcare (Trappenburg, 2009).
Thus, providing high quality at a competitive price is important for stakeholders in the Dutch healthcare industry, in order to create a competitive advantage (Schäfer, et. al., 2010). As seen in the previous paragraph, price and quality are highly related to the creation of added value (Chernatony, Harris, Dall, & Riley, 2014).
2.4 Added value
Added value is important for companies to achieve a competitive advantage (Chernatony et al., 2014). To understand what added value is, it is important to define ‘value’ first. In their article Setting value, not price, Leszinski & Marn (1997) define ‘value’ as follows’: “Value is the trade-off between customers’ perceptions of benefits received and sacrifices incurred”. In another study, Zeithaml (1988) describes four types of consumer definitions of value:
(1) Low price (focus on sacrifice)
(2) Whatever the consumer wants in a product or service (focus on benefits) (3) The quality obtained for the price paid (trade-off between sacrifice and benefit) (4) Total benefits obtained for total sacrifice incurred (all relevant components
considered)
As described in the literature, value depends on sacrifices and benefits (Chernatony et al., 2014, 2014; Kjeldskov, Skov, Als, & Høegh, 2004; Leszinski & Marn, 1997). This suggests that an increase in value (added value) can be realized by either a reduction of the sacrifices or an increase of the benefits. This is confirmed by Chernatony et. al. in their research on added value (2014). Thus, to investigate the added value of something, it is important to understand the benefits and the costs first.
In 2012, Fernandes did a study on assessing the technology contribution to value added. He proposed a conceptual model with three dependent variables: Technology, knowledge and capital (appendix C). This model tries to asses and quantify the contribution of technology to the value-adding process (Fernandes, 2012). Together, the three variables evaluate the final product value (FPV). At first sight, it seems a logical fit for a study on the added value of blockchain technology in the healthcare sector. However, the aim in this paper is to evaluate
the technological aspect only, and not to focus on knowledge and capital. Also, it does not specifically focus on blockchain technology. Therefore, it was decided not to use this conceptual model for this research.
Another study on the added value of a technology is conducted by Pelzer, Geertman, Heijden, & Rouwette in 2014. The aim of their study is to asses added value of planning support systems (PSS) for planning practice. Their conceptual framework on assigning added value focusses on three levels: The individual level, the group level and the outcome level (appendix D) (Pelzer et al., 2014). In each of these levels, the added value is calculated using variables (figure 2). These variables can be found in the table below:
Figure 2: Added value calculation
Although this research also investigates the added value of a new technology, this conceptual model does not seem to be a fit for this paper. The reason for this is the difference in the system on which the study is based. Blockchain technology differs too much from planning support systems to generalize the conceptual model.
2.5 The Added value of blockchain in the Healthcare sector
Some research is already conducted to the implementation of blockchain technology in the healthcare sector, especially in the U.S. industry. In these articles, some possibilities of the implementation of blockchain technology in the healthcare sector are being discussed.
Matthias Mettler (2016) writes in his paper that blockchain technology has shown adaptability over various markets in the past few years. Also, the healthcare sector is slowly
four main areas of blockchain implementation in healthcare on which innovators are currently focusing. The main areas are as follows: Putting the patient at the centre, privacy and access, completeness of information and cost. The innovations in these areas could possibly provide added value in the sector.
2.5.1 Putting the patient at the centre (patient control)
In their article, Engelhardt & Espinosa (2017) state that patients increasingly want to be in control of what information health providers receive, and under what conditions. This statement confirmed by Kitson, Marshall, Bassett, & Zeitz (2013). In their research on patient-centric healthcare, they say that: “There is increasing agreement that information should be available to patients such that they can be active agents in their own care, and patient participation and involvement has become a cornerstone of modern medical practice” (Kitson et al., 2012).
This demand for more patient control is one of the fields where blockchain technology could provide added value. In their article, Engelhardt & Espinosa (2017) call the first
concept: “putting the patient at centre”. In this study, from now on the term ‘patient control’ will be used instead because it explains the concept more clearly. Altogether, this will lead to the first hypothesis:
H1: Implementing blockchain technology in the ‘patient control’ area will provide added value for care recipients in the Netherlands.
An example of how this could lead to added value is shown by Mettler (2016). He states in his paper that the implementation of blockchain technology empowers patients to own and control their medical records. Health bank is a platform in which patients can store and manage their medical information. Data can be retrieved from health apps (heart-rate, sleep patterns, etc.) or physical visits and save these in the blockchain. Users are not only able to save and manage their data, but can also sell them for research purposes in exchange for financial compensation (Mettler, 2016).
Furthermore, the demand for more patient control in the healthcare sector is also something that Yue, Wang, Jin, Li, & Jiang (2016) describe. In their article, an application called Healthcare Data Gateway (HGD) is proposed which enables the patient to own, control and share their personal medical data in a secure way, using blockchain technology (Yue, Wang, Jin, Li, & Jiang, 2016).
Angraal, Krumholz, & Schulz (2017) present another healthcare application build on the blockchain, named Guardtime. In this project, all of Estonia’s citizens were issued a smartcard, which is linked to their electronical patient record to their blockchain-based identity. Every change in the data is signed into a block and stored secure. In this way, patients are in control of their own data which cannot be modified or stolen (Angraal et al., 2017).
2.5.2 Privacy and access
Another important field in which blockchain technology could provide added value is privacy and access (Engelhardt & Espinosa, 2017). Health information is highly personal and must be private and accessible only by appropriate parties, with the patient’s permission.
Moreover, centralized stored medical data is an easy target for cyber criminals (Peterson, Deeduvanu, Kanjamala, & Boles, 2016). According to research, introducing a decentralized, blockchain-based system which provides maximum security can add value to the healthcare sector (Johansen, 2017; Peterson et al., 2016).
In their research, Linn and Koo (2016) also mention the potential risk of cyber
criminals. They propose a blockchain based electronic patient record system. They state that: “Utilization of the proposed health blockchain described in this paper has the potential to engage millions of individuals, health care providers, health care entities and medical researchers to share vast amounts of genetic, diet, lifestyle, environmental and health data with guaranteed security and privacy protection (Linn & Koo, 2016, pp. 9).” The foundlings in these researches lead to the second hypothesis:
H2: Implementing blockchain technology in the ‘privacy & access’ area will provide added value for care recipients in the Netherlands
Enabling patients to provide access to their medical data can also add value. Gem, a US startup, developed a shared network on the Ethereum Blockchain where healthcare specialists can access information. This provides more efficiency and saves time and money for the patient (Mettler, 2016).
2.5.3 Completeness of information
In today’s healthcare system, it is common that data is stored by individual providers or private data collectors without full patient access (Engelhardt & Espinosa, 2017). Engelhardt & Espinosa (2017) state that: “This limits the ability of patients to explore options, contribute and correct errors in their own data, and share their information with new practitioners to fully define a medical history.” These findings lead to the third hypothesis:
H3: Implementing blockchain technology in the ‘completeness of information’ area will provide added value for care recipients in the Netherlands.
An example of a blockchain based application that enables patients to have full access to their medical data is MedRec; a decentralized platform which enables the patient to control their own medial data (Angraal et al., 2017; Ekblaw, Azaria, Halamka, & Lippman, 2016).
2.5.4 Costs
Healthcare is expensive. The CBS calculated that in 2016, the healthcare costs in the Netherlands were €5.628 per capita (CBS, 2016). Also, healthcare costs are the biggest expenditure of the Dutch government. In 2018, this will be 80,4 billion euros (Rijksoverheid, 2018).
Blockchain technology could help reduce costs in the Healthcare sector (Engelhardt & Espinosa, 2017). Mathias Mettler (2016) also states in his research that: “With Blockchain, direct transactions suddenly become possible, whereby a central actor, who controlled the data, earned commission or even intervened in a censoring fashion, can be eliminated.” Another example of expected added value of blockchain technology in the healthcare sector that leads to the fourth hypothesis:
H4: Implementing blockchain technology in the ‘costs’ area will provide added value for care recipients in the Netherlands.
2.6 Literature Gap
The available literature primarily focusses on the adoption of blockchain technology in the U.S. healthcare system. No research on the possible added value of blockchain technology for hospitals in the Netherlands has been conducted yet. Due to differences in the healthcare
systems of the U.S. and the Netherlands, the results of the U.S. studies cannot be generalized. This identifies a research-gap in the current literature.
3. Conceptual framework
Studies have proven that blockchain technology could add value for care recipients. This can be done by focusing on the new possibilities that the blockchain technology enables. In their article, Engelhardt & Espinosa (2017) describe putting the patient at centre, privacy & access, completeness of information and costs as the four main areas of blockchain implementation in healthcare, on which innovators are currently focusing. These four areas are the dependent variables in this study’s conceptual framework (figure 3).
As described in paragraph 2.5, four hypotheses can be derived from the literature:
H1: Implementing blockchain technology in the ‘patient at centre’ area will provide added value for care recipients in the Netherlands.
H2: Implementing blockchain technology in the ‘privacy & access’ area will provide added value for care recipients in the Netherlands
H3: Implementing blockchain technology in the ‘completeness of information’ area will provide added value for care recipients in the Netherlands
H4: Implementing blockchain technology in the ‘costs’ area will provide added value for care recipients in the Netherlands
The research question and its hypotheses translate themselves in the following conceptual model which shows the relationships between the variables (figure 3):
Figure 3: conceptual model
4. Method
In order to answer the main research question: ‘What is the added value of blockchain technology for Dutch care recipients?’ and to test the hypotheses, it was decided to apply a mixed-method design and to conduct two studies. First, an online survey will investigate to what extent the conceptual model can be validated. This is necessary because there are differences between the United States its healthcare system and the Dutch healthcare system. Also, the population in the United States and the Netherlands differs. Therefore, it is
important to investigate if all the variables in the conceptual model can be used in the Netherlands. A possibility is that one or more of the variables have to be eliminated because they are not significant in the Netherlands. Afterwards, the relevant variables will be further investigated in a literature study. The goal of this study is to show the potential added value of blockchain technology in the Dutch healthcare sector for care recipients. Finally, the results of these studies will be compared to give an answer to the research question.
4.1 Online Survey
A quantitative study in the form of an online survey will be done to investigate care
recipient’s current trust in and attitude towards the Dutch healthcare sector. The goal is to find out if the problems among care recipients in the United States, found in the literature, also occur in the Netherlands. In this way, the conceptual model will be validated.
4.1.1 Sample
Data will be gathered in the form of an online survey which was distributed among 55 Dutch care recipients in three different age categories: 18-30, 30-55 and >55. An anonymous link to the online survey was posted on Facebook and shared among friends and family. They were also asked to share the link in their network to generate more responses. The survey was open from 1 till 4 June, 2018.
4.1.2 Design
A survey was designed in the online program Qualtrics. The language of the survey is Dutch because this is the native language of the people in the population. Participants are asked to answer 26 questions, divided into five different categories. First, 6 control questions about themselves, thereafter 20 questions about the four categories on which the conceptual model is based: Patient control, Privacy & Access, Completeness of information and Costs. 16 out of the 20 questions are 5-point likert scale (1. Very likely – 5. Very unlikely). 4 out of the 20 questions are closed, yes/no questions.
The purpose of the survey is to test if the four concepts found in the literature, can be generalized to the Netherlands. For this reason, it is irrelevant to investigate if there are more concepts that could possibly add value for care recipients in the Dutch healthcare sector. However, this would be interesting for future research, it was decided not to include open questions in this survey.
Before the survey starts, participants read an informed consent and agree to this by clicking on the agree button. In the informed consent participants are made aware that participation is voluntary and that results will be anonymous. This is in line with the ethical procedures. After they have agreed to this, their gender, age, educational level, occupation and contact rate with healthcare are registered. Next, participants are asked if they are aware with the term ‘Medical Record’. If they are not aware with this term, the following text will appear:
A medical record contains all data relating to your treatment, such as research results, radiographs, or (referral) letters to a specialist or general practitioner. Your care provider is
Then, the participant is asked a series of questions about ‘patient control’. These questions measure the degree in which the participant finds themselves in control with their medical record (appendix A). The next page contains questions about the participants opinion towards privacy and security in the Dutch healthcare sector (appendix A). In the third section, the participant answers questions about their ability to make changes in their medical record (appendix A). Finally, the price which the participant pays for the care he or she receives is measured.
4.1.3 Data Analysis
After a sufficient number of participants is reached, the results of the survey will be analyzed. The answers on the 5-point likert scale questions will be compared in order to draw a
conclusion about the validity of the conceptual model. If necessary, some of the questions will be recoded in order to show the right intention of the question. Some questions are asked in a way that a low answer (Very much disagree) instead of a high answer (Very much agree) implies a demand for, for example, more patient control. This will be done on the following questions: Q11, Q15, Q16, Q17, Q38. When the recoding is done, the median of every
question will be calculated. The median will show which answer has the highest frequency. A high median implies a high demand for a concept. For example, if the median of the question: “I feel like I am in control who has access to my medical record” is 4 (on a 5-point scale), it suggests that participants feel a high degree of control. However, if the median would be 2 (on a 5-point scale), it suggests that participants feel a low degree of control.
All the data will be exported from Qualtrics in a .sav file so it can be imported into SPSS. In this statistical computer program, a frequency analysis will be conducted to clearly show the results of the survey. Afterwards, these frequencies will be shown in a table in the results. Also, the median of every question will be calculated in order to make statements about the results.
4.2 Literature study
Secondly, a literature study will be conducted. This is different from the literature review (chapter 2) because this literature study will show how blockchain technology could add value for care recipients in the Dutch healthcare sector. The literature review gives an overview of available literature and explains this thesis’ concepts.
After the conceptual model is validated in study 1, study 2 will investigate the
possibilities for blockchain technology to add value for care recipients in the Dutch healthcare sector. The goal is to show the added value that blockchain technology could provide in the problem areas found in the first study.
First, literature will be searched in online databases like Google Scholar and the UvA Library. When selecting literature, the aim will be to select articles from highly rated journals. Moreover, the reference lists of the consulted articles will be studied closely in order to search for more relevant literature. This is called the snowball effect.
After an introduction, every concept of the conceptual model will be discussed in a paragraph. In these paragraphs, new technologies and innovations regarding blockchain technology in the healthcare sector will be presented. These new technologies and innovations will provide added value in the Dutch healthcare sector for care recipients, if they would be implemented. Finally, a conclusion will be drawn. Based on the results of these two studies, an answer can be given to the main research question: What is the added value for care recipients in the Dutch Healthcare sector?
5. Results
5.1 Study 1
The goal of the first study was to validate the conceptual model and, if necessary, eliminate one or more concepts from this model. To do so, a survey was distributed among a sample of the Dutch population. 26 questions tested control variables and all four concepts of the conceptual model, which were separated into four different categories. The results of the study will be discussed in the following paragraphs. All the questions can be found in appendix A, the SPSS output of the frequencies can be found in appendix B.
5.1.1 Control Variables
The first part of the survey consists of control questions. The exact SPSS output can be found in appendix B.
This part of the survey consists of 6 control questions. The first question asked the participants about their gender. 35,2% of the participants turned out to be male, 64,8% was female. The age of the participants was as follows: 40,7% in the category 18-30, 37% in the category 30-55 and 22,2% in the category >55. The results show that the main occupation of the participants is ‘employed’, this is 63,0%. 33,3% is occupied as a student and 3.7% of the participants filled in ‘other’. The educational level of the participants turns out to be
reasonably high. To the question: ‘What is your highest completed (not current) educational level?’, 27,8% answered university (WO). 29,6% of the participants have a degree in higher vocational education (HBO). 25,9% have finished a higher general secondary education or a pre-university education (VWO, HBO). The remaining 1,9% has lower general secondary education as a highest degree (VMBO). No participants chose ‘no education’, ‘primary school’, ‘intermediate vocational education (MBO)’ or ‘other’. Next, participants were asked how frequently they get in touch with the healthcare system (general practitioner, doctor or specialist). The results are as follows: 0-1 times a year 35,2%, 2-6 times a year 55,6%, 6-12 times a year 5,6%, 12-24 times a year 3,7%, >24 times a year 0%. The final control question was: ‘I know what a medical record is’. Almost all the participants, 96,3% answered ‘yes’ to this question. The remaining 3,7% answered ‘no’ and got a brief explanation about the term.
5.1.2 Patient control
The first variable of the conceptual model is patient control. To verify if this variable can be generalized to the Dutch population, five 5-point likert scale questions were asked to the participants (table 1). These questions reflect the attitude towards the current state of control on medical records in the Netherlands.
The table below shows the outcome of the answers given:
Very much agree (1)
Agree (2) Neutral (3) Disagree (4) Very much disagree (5) Q10 8 20 9 13 4 Q23 15 10 7 9 13 Q18 17 15 19 2 1 Q19 22 18 13 1 0 Q21 17 21 12 2 2 Table 1 N=54
The results clearly show that the majority of the people crave for more control over their personal medical record. Medians of the five questions are: 2, 1, 3, 1 and 2. This is in line with the findings in the literature. So, it can be assumed that the variable ‘patient control’ is validated and generalizable to the Dutch population.
5.1.3 Privacy & Access
The second variable of the conceptual model is ‘privacy and access’. To verify if the second variable can be generalized to the Dutch population, four 5-point likert scale questions and one yes/no question were presented to the participants (table 2, 3). These questions reflect the attitude towards the current state of privacy and access on medical records in the Netherlands.
The table below shows the answers to the question: “I know where my medical record is being stored”:
Yes No
Q12 14 39
Table 2 N=54
This result shows that the majority of the participants does not know where their medical record is being stored. The table below shows the outcome of the answers given to the four 5-point likert scale questions:
Very much agree (1)
Agree (2) Neutral (3) Disagree (4) Very much disagree (5) Q11 (-) 3 8 10 14 19 Q13 4 13 25 7 5 Q24 36 9 4 5 0 Q14 6 16 14 11 7 Table 3 N=54
The data in the table seems to be divided. An explanation for this can be found in Q1. In contradiction to the other questions, this question suggests a high outcome (very much agree) to be negative instead of positive. This is why this question has to be recoded and has to be interpreted the other way around. If this is taken into consideration, the results of all four questions tend towards the upside. The medians after re-scaling are: 1, 3, 1, 2. Again, the results suggest that there is demand for more ‘privacy and access’ in the Dutch population. Because of that, the second variable of the conceptual model is validated and can be generalized to the Dutch population.
5.1.4 Completeness of information
The third variable of the conceptual model is ‘completeness of information’. To verify if the third variable can be generalized to the Dutch population, three 5-point likert scale questions and one yes/no question were presented to the participants (table 4, 5). These questions reflect the attitude towards the current state of the completeness of information in medical records in the Netherlands.
The table below shows the answers to the question: “I have ever requested my own medical record”:
Yes No
Q40 9 45
Table 4 N=54
The results show that only 16,67% of the participants ever requested their medical record. The table below shows the outcome of the answers given to the three 5-point likert scale questions:
Very much agree (1)
Agree (2) Neutral (3) Disagree (4) Very much disagree (5)
Q16 (-) 6 10 7 17 14
Q15 (-) 0 6 26 7 15
Q41 13 15 14 8 4
Again, Q1 and Q2 have to be recoded because a higher outcome implies that there is a higher demand for more completeness of information. After recoding, the medians are as follows: 2, 3, 2. The results are not as centered as in former two concepts. However, they still tent towards a higher demand for more completeness of information in medical records. This is why it can be assumed that the third variable of the conceptual model is validated and can be generalized to the Dutch population.
5.1.5 Costs
The final variable of the conceptual model is ‘completeness of information’. To verify if this variable can be generalized to the Dutch population, participants had to answer three 5-point likert scale questions (table 6). These questions reflect the attitude towards the current state of the costs of healthcare in the Netherlands.
The table below shows the outcome of the answers given to the three 5-point likert scale questions:
Very much agree (1)
Agree (2) Neutral (3) Disagree (4) Very much disagree (5)
Q38 (-) 19 19 5 6 5
Q17 (-) 6 30 17 0 1
Q19 19 23 4 5 3
Table 6 N=54
The results show that the population in the Netherlands thinks that healthcare in the Netherlands is expensive. To the proposition: “I find the price that I pay, for the care I
receive” 55,56% responded ‘High’. 11,11% responded with ‘Very high’. This implies that the Dutch population would like to see a decrease in healthcare costs. This is in line with the findings in the literature. Therefore, it can be assumed that the fourth variable of the conceptual model is validated and can be generalized to the Dutch population.
5.2 Conclusion Study 1
have shown that the problems found in the literature, also occur in the Netherlands. The Dutch population would like to see more patient control, more privacy and access, more completeness of information, and a reduction of healthcare costs. Therefore, it can be concluded that all the variables in the conceptual model are valid, and the model can be generalized to the Dutch population.
5.3 Study 2
In the previous study, the conceptual model has been validated. Now that it is clear that all the concepts of the conceptual model can be generalized to the Dutch population, more research has to be done in order to answer the main research question: “What is the added value of blockchain technology for care recipients in the Dutch healthcare sector?”.
To form a comprehensive answer to this question, a thorough literature study will be conducted. The aim of this study is to show the current state of value-adding technologies and innovations in the literature. In the literature review (chapter 2), some examples of new technologies were already given. In this study however, a clear overview of all the innovations currently available will be presented. In study one it was found out that blockchain technology could add value in four areas: Patient control, privacy and access, completeness of information and costs. In every paragraph, new innovations that are currently available in one of these four concepts will be discussed.
In the literature review, it has been explained that an increase in value (added value) can be realized by either a reduction of the sacrifices or an increase of the benefits
(Chernatony et al., 2014) (§2.4). The new technologies presented in this literature review all provide benefits for Dutch care recipients, while their cost remain stable. Therefore, if implemented in the Netherlands, every new technology will add value in one or more concepts of this thesis its conceptual model.
5.3.1 Patient control
The first concept that was validated in study one is ‘patient control’. Patient control about the health care recipients demand for more control over their medical data. Research has shown that healthcare recipients increasingly want to be in control of what information health providers receive, and under what conditions (Engelhardt & Espinosa, 2017). Especially in the United States, startups arise who use blockchain technology to develop innovations in the
Healthcare sector which give care recipients more control over their medical record. In this paragraph, value adding technologies and innovations of blockchain technology regarding ‘patient control’ will be discussed.
An example of such an innovation is Healthcare Data Gateways (HDG) (Yue et al., 2016). HDG is a mobile smartphone application which allows care recipients to view and control access to their medical data. All the medical data is being saved in the blockchain which ensures maximum security. Sharing this data with will only happen when the care recipient agrees to this in the mobile application (Yue et al., 2016). The process works as follows: When a doctor wants access to the care recipients’ medical data, he requests this in the mobile application. The recipient receives this request and can either choose to accept or reject this request (figure 4).
Figure 4: Interface HDG care recipient
When the care recipient accepts the request to share their medical data, the doctor receives the data in his mobile application (figure 5). Now the doctor is able to access the data in a secure environment, without violating any privacy issues (Yue et al., 2016).
Figure 5: Interface HDG doctor
A second company that uses blockchain technology to improve patient control is the global Swiss startup Healthbank (Healthbank, 2018, Mettler, 2016). Healthbank is a data exchange platform where care recipients can save health data from multiple sources like health applications, wearables or physical visits. This data will be stored using blockchain technology, providing maximum security. When the data is stored, users can manage the data and share it with doctors, care teams or anyone else who is using the network (Healthbank, 2018). Healthbank also has another functionality related to costs. This will be discussed in paragraph 5.2.4. Introducing a technology like Healthcare in the Netherlands will improve the patient control and will therefore be an added value for care recipients.
More startups are currently innovating with new, blockchain based, technologies. Startups like ConnectingCare, Patientary, Nebula Genomics, Doc.ia and Iryo are developing decentralized platforms similar to HDG and Healthbank. Since there is no literature about these startups yet, it was decided to not discuss them further.
Research has shown that healthcare recipients increasingly want to be in control of what information health providers receive, and under what conditions (Engelhardt & Espinosa, 2017). In study one, it was confirmed that Dutch healthcare recipients also desire more control over their medical data (table 1, §5.2.1). Results from study one however, show that 61,1 percent of the participants does not feel to be in control over their medial record
(table 1, Q11). Since Healthcare Data Gateways and Healthbank provide a rise in control, they provide more benefits for care recipients in the Netherlands. Because no additional costs occur, the benefits will exceed the costs. Therefore, it can be concluded that blockchain technology will add value for Dutch care recipients.
5.3.2 Privacy & Access
The second concept that was validated in study one is ‘privacy and access’. Privacy and access are about the security of, and access to the medical data. Healthcare data contains a lot of personal and sensitive information that may be attractive to, for example, cybercriminals. As Esposito, De Santis, Tortora, Chang, & Choo state in their article: “For example,
cybercriminals seeking to benefit financially from the theft of such data may sell the data to a third-party provider, who may perform data analysis to identify individuals who may be uninsurable due to their medical history or genetic disorder. Such data would be of interest to certain organizations or industries” (2008, pp. 33).
Moreover, results obtained in study one show that healthcare recipients in the
Netherlands desire more privacy and access (table 2, 3. §5.1.3). Therefore, companies start to use blockchain technology to improve privacy and access. In this paragraph, value adding technologies and innovations of blockchain technology regarding ‘privacy and access’ will be discussed.
A technology startup that focusses on implementing blockchain technology in the healthcare sector to improve privacy and access is Guardtime. This startup is based in the Netherlands and started working together with the Estonian government in 2016. Guardtime uses blockchain technology to encrypt and secure over a million health records of citizens of Estonia (Heston, 2017). This innovative approach leads to multiple benefits as described by Heston in his case study on the implementation of blockchain technology by the Estonian government: “The distributed nature of the blockchain can ease the sharing of data among authorized parties, and bridge traditional data silos, dramatically increasing efficiencies and improve coordination of care” (2017, pp.2). Also, Guardtime could help reduce costs in the healthcare sector (Heston, 2017). This aspect will be discussed in paragraph 5.2.4. Although it might be too early to draw reliable conclusions about the effectiveness of this technology, it
Another network which is improving the privacy and access in the healthcare sector is MedRec (Azaria, Ekblaw, Vieira, & Lippman, 2016). In their paper about MedRec, the founders of the company describe it as a decentralized record management system to handle EMR’s (Azaria et al., 2016). In contradiction to other networks, MedRec does not store the medical record in the blockchain. As they say on their website: “MedRec does not ‘store’ the record directly; rather encodes metadata that allows records to be accessed securely by patients, unifying access to data across disparate providers” (MedRec, 2016) (figure 6).
Figure 6: Visualization of MedRec storage.
This means that the system integrates with every provider its local data storage. The data stays in hands of the provider but is now linked together. Thereafter, the system gives users a comprehensive, immutable log which provides them with easy access to their medical data across providers, while maintaining confidential. Using the blockchain technology, this personal log is encrypted and therefore only accessible by authorized users (Azaria et al., 2016).
In 2016, the in blockchain technology specialized US company Gem, launched Gem Health (Pilkington, 2018). This shared network, build on the Ethereum blockchain, provides different healthcare specialists access information (Mettler, 2016). The network provides all medical stakeholders transparent and clear access to the latest healthcare treatment
Figure 6: Visualization of Gem Health
This will prevent medical negligence due to outdated information which will prevent health issues in an early stage (Mettler, 2016). Gem Health would improve efficiency and save costs. This will furthermore be discussed in paragraph 5.2.4. Moreover, it allows medical experts to track the interactions between the patient and all medical institutions (Mettler, 2016).
The literature suggests that there is a rising demand for more privacy and access over healthcare recipients their medical records. This statement has been confirmed in study one, were also has been concluded that Dutch healthcare recipients desire more privacy and access over their medical data (table 2, 3). The new technologies discussed in this paragraph show that implementing blockchain technology can lead to substantial benefits for care recipients. Since the costs remain equal, blockchain technology will provide added value in privacy and access for care recipients in the Netherlands.
5.3.3 Completeness of information
The third concept that was validated in study one is ‘completeness of information’. Completeness of information is about the ability of care recipients to know the content of
Phillips, 2004). A reduction of this misinformation in medical records will reduce medical errors and reduce costs (Woolf et al., 2004).
The completeness of information is also something that startups are trying to improve using blockchain technology. In this paragraph, value adding technologies and innovations of blockchain technology regarding ‘completeness of information’ will be discussed.
Almost every blockchain technology application in the healthcare sector enables uses to access the content of their medical record. MedRec, a decentralized management system which was already discussed in the previous paragraph, does not only give users easy access to their medical information across institutions and treatment sites (Azaria et al., 2016). This platform also enables users to correct mistakes in the data, add missing data or delete wrong data. The results of study one show that if people will check their medical record for mistakes regularly, if it would be possible (table 5, Q41). Healthcare Data Gateways also enables users to make corrections to their medical data (Yue et al., 2016). This will also reduce the number of mistakes in medical records.
In study one, it was concluded that Dutch healthcare recipients desire more completeness of their medical data (table 4, 5). Many new technologies offer users the possibility to access and view their medical data. However, MedRec and HDG also enable users to correct mistakes in this data. Since over 21% of the medical records contain mistakes, the introduction of a new technology which reduces these mistakes will provide benefits for care recipients in the Dutch population. Since no additional costs occur, the benefits exceed the costs, which indicates that blockchain technology provides added value for Dutch care recipients.
5.3.4 Costs
Finally, the ‘costs’ concept was validated in study one. Healthcare costs in the Netherlands are rising fast (Schäfer, W.; Kroneman, M.; Boerma, W.; van den Berg, M.; Westert, G.; Deville, W.L.J.M.; van Ginneken, 2010). Results from study one show that Dutch healthcare recipients would like to see a decline in healthcare costs (table 6, §5.1.5). Since there is a desire for new technologies which could help to reduce these healthcare costs, in this paragraph value adding technologies and innovations of blockchain technology regarding costs will be discussed.
In his case study on the implementation of blockchain technology in Estonian government, Heston states that the costs of medical care can be decreased through better insurance claim coordination with treatment rendered (2017, pp.2). As discussed in paragraph 5.2.1, Guardtime improves the coordination and efficiency of processes (Heston, 2017). This will lead to lower healthcare cost and will therefore lead to added value.
In paragraph 5.2.1, the blockchain network Healthbank was explained. Besides empowering care recipients to have control over their medical data, Healthbank also has another interesting functionality. When the Healthbank network is being used to store all the medical data of a user, the network enables the user to sell this data anonymously to
researchers. As a return, the user will receive financial compensation (Healthbank, 2018, Mettler, 2016). This financial compensation can partly countervail the rising healthcare costs. Although not everyone in the Netherlands would be willing to sell their medical data for research purposes, it might be an interesting solution for a part of the Dutch population to lower their medical costs.
Gem Health, another blockchain based technology which is discussed earlier, will prevent medical negligence due to outdated information. This will prevent health issues in an early stage which will lead to more cost efficiency (Mettler, 2016).
Literature and study one both concluded that Dutch healthcare recipients would like a decline in healthcare costs (table 6). The technologies discussed show that implementing blockchain technology will often eliminate inefficiencies. Since these inefficiencies can lead to high costs, implementing blockchain technology will decrease the costs of healthcare. Therefore, blockchain technology will have an added value for Dutch care recipients.
5.4 Conclusion Study 2
The goal of study two was to show the value-adding blockchain technologies and innovations in the healthcare sector. After conducting a thorough literature research, all the companies which have developed blockchain technologies in healthcare were discussed. The companies provide added value because the benefits of the technology exceed the costs. For every concept of the conceptual model, the value adding technologies were presented.
In ‘patient control’, Healthcare Data Gateways adds value for care recipients by providing a mobile application in which users can control and share their medical data.
Almost every startup which uses blockchain technology in the healthcare sector pursues improved security. However, Guardtime, MedRec and Gem are highly developed on this topic, and offer interesting technologies in the ‘privacy and access’ concept. Using blockchain technology encryption, all the data in the medical records can be stored as secure as possible. When these technologies will be introduced in the Netherlands, they will add value for care recipients.
To improve the ‘completeness of information’, many new technologies offer the possibility to access and view users their medical data. MedRec and HDG however, also offer the possibility to correct mistakes in this data. This will prevent medical errors and wrong diagnoses (Woolf et al., 2004). Therefore, these blockchain technologies will add value for Dutch care recipients.
Finally, cost reducing technologies that could add value were discussed. Guardtime and Gem Health provide more efficiency which will reduce healthcare costs. Healthbank even allows users to sell their medical data anonymously, which will countervail the rising
healthcare costs. Therefore, the reduction of the costs provides added value for care recipients in the Dutch healthcare sector.
6. Conclusion
In this thesis, the following research question has been investigated: ‘What is the added value of blockchain technology for care recipients in the Dutch healthcare sector’. To answer this question, a mixed method research design has been applied and two studies have been conducted. First, a quantitative study in order to investigate if the conceptual model could be generalized to the Dutch population. Secondly, a literature study to show the added value of blockchain technology in the Dutch healthcare sector.
The results of the quantitative study have shown that the conceptual model can be generalized to the Dutch population. After distributing a survey among a sample of the Dutch population, all four variables of the conceptual model have been tested. The results have shown that the problems found in the literature, also occur in the Netherlands. All four hypotheses have been confirmed. The Dutch population would like to see more patient control, more privacy and access, more completeness of information, and a reduction of healthcare costs. Therefore, it can be concluded that all the variables in the conceptual model are valid, and the model can be generalized to the Dutch population.
The results of the literature study have shown that value can be added, in all four of the concepts because the blockchain technologies provide more benefits than costs. First of all, Healthcare Data Gateways and Healthbank are two startups who have developed new technologies that add value in the ‘patient control’ concept by enabling users to own and control their medical record. For the ‘privacy and access’ concept, Guardtime, MedRec and Gem offer value adding networks. Using blockchain technology encryption, all the data in the medical records can be stored as secure as possible. This higher level of security will have an added value in the Dutch healthcare sector. In the ‘completeness of information’ concept, value adding technologies have been developed by MedRec and HDG. They offer users the possibility to access their medical record, and if present, even correct mistakes. Finally, many of the blockchain technologies in the healthcare sector are offering cost reducing advantages. However, Guardtime and Gem Health are two startups who are well developed on this subject. Their technologies add value for care recipients by decreasing healthcare costs. Healthbank even allows users to sell their medical data anonymously, which will countervail the rising healthcare costs.
In conclusion, blockchain technology could add value for healthcare recipients in the Netherlands. This added value can be achieved by implementing new technologies which have proven to be successful in other countries. The benefits of these new technologies exceed the costs, and they can therefore be considered to be of added value.
7. Discussion
In the final chapter of this thesis, the results of the two studies will be discussed. Also, the limitations of this thesis will be explained. Finally, suggestions for future research will be given.
7.1 Implications and limitations
The results of study one are as expected. All four hypotheses are confirmed which validates the conceptual model. In advance, it was unknown how blockchain technology could add value in the Dutch healthcare sector. After conducting two studies, it has become clear how
results about the population) will only be significant if the sample size is above 385
respondents (5% error). Due to practical restrictions, this was not a realistic sample size for this thesis.
Due to the rapidly changing technologies, some of the studied literature might already be outdated. Because this was known in advance, is had been tried to consult the most recent literature as possible. However, the technology might already be improved when this thesis is finished.
Blockchain technology is a new technology in the healthcare sector. A considerable small amount of literature about this subject is currently available. New literature on this subject might change some outcomes in this study.
Also, Startups in the healthcare sector are now slowly adapting this technology but as a result, many technologies are still in their development or concept phase. For this reason, technologies described in this thesis might change over time. This will of course impact the results of the literature study. Therefore, this study has to be replicated frequently to remain relevant.
7.2 Suggestions for future research
Due to practical constraints, the results of the survey were only used for the validation of the conceptual model. Although it was beyond the scope of this thesis, the data can be used to perform more analysis. It would be interesting for future research to investigate possible relationships between control variables. For example, it is plausible that participants who undergo a lot of medical care, think that the price they have paid for the care they have received is reasonable. This might be in contradiction to participants who almost never get in touch with the healthcare system. They probably think that healthcare is too expensive. Like this example, more plausible relationships could be suggested by the data. These relationships could be confirmed by conducting statistical analysis in future research.
Moreover, it was decided not to include open questions in the survey. The reason for this is that the sole purpose of the survey was to test if the concepts of the conceptual model could be generalized to the Netherlands. However, it would be interesting to further
investigate if there are more concepts in which blockchain technology could add value in the Dutch healthcare sector. This could be done by conducting explorative research and, for example, interview different parties in the Dutch healthcare sector.
A third suggestion for future research is to explore the opportunities of selling personal medical data to researchers, in return for financial compensation. This financial compensation can partly countervail the rising healthcare costs. Although it might be an interesting solution for a part of the Dutch population to lower their medical costs, not
everyone in the Netherlands might be willing to sell their medical data for research purposes. More research on this topic needs to be conducted in order to draw conclusions about this subject.
Also , as discussed in the previous paragraph, the survey has to be distributed among more respondents in order to obtain valid data. Future research has to point out if the
conceptual model still can be generalized to the Dutch population if the sample size is correct. Finally, I would like to point out that the data from this thesis will be available for future research.
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