@Article{info:doi/10.2196/12426,
author="O'Donoghue, Odhran
and Vazirani, Anuraag A
and Brindley, David
and Meinert, Edward",
title="Design Choices and Trade-Offs in Health Care Blockchain Implementations: Systematic Review",
journal="J Med Internet Res",
year="2019",
month="May",
day="10",
volume="21",
number="5",
pages="e12426",
keywords="blockchain; interoperability; distributed ledger technology; scalability; health information exchange",
abstract="Background: A blockchain is a list of records that uses cryptography to make stored data immutable; their use has recently been proposed for electronic medical record (EMR) systems. This paper details a systematic review of trade-offs in blockchain technologies that are relevant to EMRs. Trade-offs are defined as ``a compromise between two desirable but incompatible features.'' Objective: This review's primary research question was: ``What are the trade-offs involved in different blockchain designs that are relevant to the creation of blockchain-based electronic medical records systems?'' Methods: Seven databases were systematically searched for relevant articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Papers published from January 1, 2017 to June 15, 2018 were selected. Quality assessments of papers were performed using the Risk Of Bias In Non-randomized Studies---of Interventions (ROBINS-I) tool and the Critical Assessment Skills Programme (CASP) tool. Database searches identified 2885 articles, of which 15 were ultimately included for analysis. Results: A total of 17 trade-offs were identified impacting the design, development, and implementation of blockchain systems; these trade-offs are organized into themes, including business, application, data, and technology architecture. Conclusions: The key findings concluded the following: (1) multiple trade-offs can be managed adaptively to improve EMR utility; (2) multiple trade-offs involve improving the security of blockchain systems at the cost of other features, meaning EMR efficacy highly depends on data protection standards; and (3) multiple trade-offs result in improved blockchain scalability. Consideration of these trade-offs will be important to the specific environment in which electronic medical records are being developed. This review also uses its findings to suggest useful design choices for a hypothetical National Health Service blockchain. International Registered Report Identifier (IRRID): RR2-10.2196/10994 ",
issn="1438-8871",
doi="10.2196/12426",
url="https://www.jmir.org/2019/5/e12426/",
url="https://doi.org/10.2196/12426",
url="http://www.ncbi.nlm.nih.gov/pubmed/31094344"
}