TY  - JOUR
AU  - O'Donoghue, Odhran
AU  - Vazirani, Anuraag A
AU  - Brindley, David
AU  - Meinert, Edward
PY  - 2019
DA  - 2019/05/10
TI  - Design Choices and Trade-Offs in Health Care Blockchain Implementations: Systematic Review
JO  - J Med Internet Res
SP  - e12426
VL  - 21
IS  - 5
KW  - blockchain
KW  - interoperability
KW  - distributed ledger technology
KW  - scalability
KW  - health information exchange
AB  - 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 
SN  - 1438-8871
UR  - https://www.jmir.org/2019/5/e12426/
UR  - https://doi.org/10.2196/12426
UR  - http://www.ncbi.nlm.nih.gov/pubmed/31094344
DO  - 10.2196/12426
ID  - info:doi/10.2196/12426
ER  -