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Blockchain@UBC has published a number of research papers, through various academic partners and collobarative efforts. Explore more in detail through the list on this page.

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• Published: 04 July 2019

A systematic review of blockchain

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

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

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

Introduction

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

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

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

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

Overview of the current research

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

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

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

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

Disciplines in blockchain

Articles in business and economics

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

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

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

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

Cited references

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

Most influential articles

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

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

Research themes

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

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

Disciplines and topics

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

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

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

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

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

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

What will be the future research directions for blockchain?

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

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

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

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

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

How can businesses benefit from blockchain?

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

Accounting settlement and crowdfunding

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

Data storage and sharing

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

Supply chain management

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

Smart trading

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

Conclusions

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

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

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

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

Availability of data and materials

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

Abbreviations

Initial coin offering

Web of Science Core Collection

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Acknowledgements

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

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Min Xu, Xingtong Chen & Gang Kou

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The first author contributed by retrieving literature and conducting data analysis. The second and third author contributed by writing the paper, especially the Discussion and Appendix . All authors read and approved the final manuscript.

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Three generations of blockchain

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

Blockchain 1.0

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

Blockchain 2.0

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

Blockchain 3.0

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

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

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

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Research Article

A look into the future of blockchain technology

Roles Conceptualization, Data curation, Investigation, Methodology

Affiliation Groupe ALTEN, France

Contributed equally to this work with: Francesco Fontana, Elisa Ughetto

Roles Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Politecnico di Torino, Corso Duca degli Abruzzi 24, Turin, Italy

Roles Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Politecnico di Torino & Bureau of Entrepreneurial Finance, Corso Duca degli Abruzzi 24, Turin, Italy

• Daniel Levis, 
• Francesco Fontana, 
• Elisa Ughetto

• Published: November 17, 2021
• https://doi.org/10.1371/journal.pone.0258995
• Reader Comments

In this paper, we use a Delphi approach to investigate whether, and to what extent, blockchain-based applications might affect firms’ organizations, innovations, and strategies by 2030, and, consequently, which societal areas may be mainly affected. We provide a deep understanding of how the adoption of this technology could lead to changes in Europe over multiple dimensions, ranging from business to culture and society, policy and regulation, economy, and technology. From the projections that reached a significant consensus and were given a high probability of occurrence by the experts, we derive four scenarios built around two main dimensions: the digitization of assets and the change in business models.

Citation: Levis D, Fontana F, Ughetto E (2021) A look into the future of blockchain technology. PLoS ONE 16(11): e0258995. https://doi.org/10.1371/journal.pone.0258995

Editor: Alessandro Margherita, University of Salento, ITALY

Received: June 1, 2021; Accepted: October 9, 2021; Published: November 17, 2021

Copyright: © 2021 Levis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

1 Introduction

Over the last few years, the hype and interest around blockchain technology have consistently increased. Practitioners from many industries and sectors have joined an open, yet mainly unstructured, discussion on the potential disruptive capabilities of this newly born technology [ 1 – 3 ]. In principle, the size of the phenomenon could be huge, with latest estimates predicting blockchain to store, by 2025, the 10 per cent of the world’s GDP (about $88tn in 2019) [ 4 ]. However, the complexity of the technology itself and the difficulties in assessing its impact across the different application fields have prevented the social, industrial and scientific communities to agree upon a shared vision of future blockchain-based scenarios. Very fundamental questions are still to be answered. Which blockchain-enabled applications will see the light in the next few years? Which industrial sectors will be mainly affected? How will companies react to potential industry-disruptors? How will the current societal paradigm shift? Which role will policy makers play in enhancing this new paradigm?

Despite the great and undoubted technological innovation linked to this technology, uncertainties and speculation on the potential scenarios still animate the industrial and scientific dialogue [ 5 ]. In particular, it is not yet clear which applications will see the light, and, eventually, what effects these changes will have at a societal level.

In this paper, we use a Delphi approach to investigate whether, and to what extent, blockchain-based applications will affect firms’ organizations, innovations and strategies by 2030, and, consequently, which societal areas will be mainly affected. With this methodology, we aim at reaching experts’ consensus to gain new insights and assess the likelihood about the future of the technology. This is a relevant issue, as blockchain technology applications cover a wide spectrum of areas. Blockchain can be applied vertically within an industry (e.g. disrupting its supply chain) or horizontally across different industries or within single companies (e.g. modifying the internal structures and the modus operandi of the different company functions). Given the number of potential applications and the complexity of the technology, stakeholders are divided into skeptics, who believe the technology is still too immature to become a paradigm in the near future, and enthusiasts, who instead believe that this radical innovation will disrupt many industries and completely change business models and people’s behaviors, like internet did during the 90s.

The literature on blockchain is also widely fragmented. Different works have investigated possible blockchain applications within specific domains, such as finance [ 6 – 8 ], logistics [ 9 ], healthcare [ 10 , 11 ] and education [ 12 ]. However, a holistic approach on possible blockchain-enabled future scenarios is still missing. To our knowledge, the only contribution in this direction is the one by White [ 13 ], who explores blockchain as a source of disruptive innovation exclusively with regard to the business field. We depart from his work to adopt a much wider perspective in this study. In fact, our aim is to obtain a deep understanding on how the adoption of this technology in Europe will lead to changes over multiple dimensions, ranging from business to culture and society, policy and regulation, economy and technology. Thus, our research aims at exploring if a convergence between the two divergent perspectives on blockchain can be found, bringing together experts currently working on blockchain projects to explore the possible changes that the technology will bring to the society by 2030.

Our study outlines an overall agreement among experts that the blockchain technology will have a deep impact on multiple dimensions. In the near future people will likely start using and exploit the blockchain technology potential, without really knowing how the technology behind works, in the same way as they send emails today, ignoring how the digital architecture that allows to exchange bytes of information works. Policy makers and governments will play a crucial role in this respect, by enabling productivity boosts and competitive gains from the companies operating under their jurisdictions. As such, a tight and cooperative relationship between industrial actors and regulatory bodies will be extremely important and auspicial. To this aim, it will be of key importance for all players to understand the real competitive advantage that blockchain can bring to their own industry and market.

This work aims at contributing to the raising blockchain literature by offering a holistic view on possible blockchain-enabled future scenarios in Europe, and to investigate which of the proposed scenarios is more likely to occur. As widely agreed by the academic literature, technological developments dictate the speed and pace at which societies change [ 14 ]. Under this assumption, technological forecasting appears to be a method of fundamental importance to understand “ex-ante” the potential development of technological changes, and their impact on different societal aspects [ 15 ]. Foreseeing future technological trends could help society in understanding possible future scenarios, thus contributing to a better knowledge of the new paradigms our society is heading towards. The work is structured as follows. Section 2 provides an overview on the main research streams upon which this work is based. Section 3 presents the methodology. Results are described in Section 4 and Section 5 concludes the work.

2 Background literature

2.1 the blockchain technology.

As defined by Crosby et al. [ 3 ] a blockchain can be conceptualized as a shared and decentralized ledger of transactions. This chain grows as new blocks (i.e. read transactions or digital events) are appended to it continuously [ 16 , 17 ]. Each transaction in the ledger must be confirmed by the majority of the participants in the system [ 3 , 18 – 21 ]. This means for the community to verify the truthfulness of the new piece of information and to keep the blockchain copies synchronized between all the nodes (i.e. between all the participants to the network) in such a way that everybody agrees which is the chain of blocks to follow [ 19 ]. Thus, when a client executes a transaction (e.g. when it sends some value to another client), it broadcasts the transaction encrypted with a specific technique to the entire network, so that all users in the system receive a notification of the transaction in a few seconds. At that moment, the transaction is “unconfirmed”, since it has not yet been validated by the community. Once the users verify the transaction with a process called mining, a new block is added to the chain. Usually, the miner (i.e. the user participating to the verification process) receives a reward under the form of virtual coins, called cryptocurrencies. Examples of cryptocurrencies are Bitcoins, Ether, Stellar Lumens and many others. Virtual coins can then be used on the blockchain platform to transfer value between users [ 17 – 19 ].

Thanks to a combination of mathematics and cryptography, the transactions between users (i.e. exchange of data and value), once verified by the network and added to the chain, are “almost” unmodifiable and can be considered true with a reasonable level of confidence [ 17 , 19 , 22 ]. These attributes of the technology make it extremely efficient in transferring value between users, solving the problem of trust and thus potentially eliminating the need of a central authority (e.g. a bank) that authorizes and certifies the transactions [ 7 , 23 , 24 ].

The technology can be easily applied to form legally binding agreements among individuals. The digitalized asset, which is the underlying asset of the contract, is called token. A token can be a digitalized share of a company, as well as a real estate property or a car. Through the setting of smart contracts (i.e. digitalized contracts between two parties), the blockchain technology allows users to freely trade digital tokens, and consequently to trade their underling physical assets without the need of a central authority to certify the transaction (OECD, 2020).

2.2 Blockchain technology applications

The academic literature has investigated a wide range of possible blockchain applications within specific domains, such as finance [ 6 – 8 ], logistics [ 9 ], healthcare [ 10 , 11 ] and education [ 12 ].

As mentioned, one of the undoubted advantages of the blockchain technology is the possibility to overcome the problem of trust while transferring value [ 25 ]. Not surprisingly, the technology seems to find more applications in markets where intermediation is currently high, like the financial sector, and in particular the FinTech sector, that has recently experienced a consistent make-over thanks to the diffusion of digital technologies [ 7 , 26 , 27 ]. The implementation of the blockchain technology in the financial markets could provide investors and entrepreneurs with new tools to successfully exchange value and capitals without relying on central authorities, ideally solving the problem of trust. This is among the reasons why many observers believe that the blockchain would become a potential mainstream financial technology in the future [ 28 ]. Blockchain represents an innovation able to completely remodel our current financial system, breaking the old paradigm requiring trusted centralized parties [ 6 – 8 ]. With new blockchain-based automated forms of peer-to-peer lending, individuals having limited or no access to formal financial services could gain access to basic financial services previously reserved to individuals with certified financial records [ 29 ]. Indeed, blockchain technology can provide value across multiple dimensions, by decreasing information asymmetries and reducing related transactional costs [ 30 ]. Initial coin offerings (ICOs) represent one of the most successful blockchain-based applications for financing which has been currently developed. Virtual currencies like Bitcoins can disruptively change the way in which players active in the business of financing new ventures operate [ 7 , 30 – 33 ]. Through an ICO, a company in need of new capital offers digital stocks (named token) to the public. These digital tokens will then be used by investors to pay the future products developed by the financed company [ 30 , 34 , 35 ]. ICOs represents a disruptive tool: entrepreneurs can now finance their ventures without intermediaries and consequently lower the cost of the capital raised [ 31 , 36 ]. However, some threats coming from the technology adoption can also be identified, as blockchain can also lead to higher risks related to the lower level of control intrinsically connected to the technology, especially in the case of asymmetric information between the parties involved.

Disintermediation plays a key role in the healthcare sector as well, where blockchain has recently found numerous applications. Indeed, many players currently need to exchange a huge amount of information to effectively manage the whole sector: from hospitals, to physicians, to patients. The ability to trustfully exchange data and information becomes of undoubted value in this context [ 10 , 11 ]. It should not be difficult to envision blockchain applications in other fields as well. In every sector in which information, value, or goods are supposed to flow between parties, blockchain can enable a trustful connection between the players, with the need of a central body entrusting the transaction. Within supply chain, it can increase security and traceability of goods [ 9 , 37 ]. Within education, it can help in certifying students’ acquired skills, reducing, for example, degree fraud [ 12 ]. To conclude, a recent work from Lumineau et al. [ 38 ] highlights possible implications of the technology in the way collaborations are ruled and executed, shading light on new organizational paradigms. Indeed, the authors show how the intrinsically diverse nature of the technology could strongly affect organizational outcomes, heavily influencing and modifying (possibly improving) the way in which different entities cooperate and collaborate.

3 Research methodology

3.1 forecasting technique: the delphi method.

In the past decade, an increasing number of forecasting techniques has been employed in the academic literature to predict the potential developments induced by technological changes. In particular, the Delphi method, whose term derives from the Greek oracle Delphos, is a systematic and interactive method of prediction, which is based on a panel of experts and is carried out through a series of iterations, called rounds. Many academic works have adopted this method since its development [ 14 , 39 – 44 ]. As the core of the Delphi approach, experts are required to evaluate projections (representations of possible futures) and assess their societal impact and the likelihood that they will occur within a specific time horizon.

While the majority of forecasting methods does not account for the technological implications on the social, economic and political contexts, the Delphi technique allows subjective consideration of changes in interrelated contexts [ 45 ]. Many different variants of the Delphi methodology have been developed according to the needs and goals of each research. For the purpose of this research, we decided to follow the four-steps procedure suggested by Heiko and Darkow [ 46 ] ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0258995.g001

The first step of the method requires to develop and envisage projections and possible scenarios that might arise through the adoption of the technology. These projections must be short, unequivocal, and concise [ 14 ]. This phase requires researchers to deeply understand the technology by analyzing the existing literature, attending courses and workshops and conducting a number of face-to-face interviews with experts ( Fig 2 ). Once the insights are gathered, the results are synthetized in future projections that will help develop the survey. The second step consists in presenting the study to the panel of selected experts who will take part in the first round of the survey. The main challenge during this phase is to select an appropriate panel of experts and maintain their commitment and response rate. The third step consists in a statistical and quantitative analysis of the answers received and in the selection of the second-round scenarios that experts will need to evaluate again. Through the analysis of the second round of answers, updated scenarios are developed adding to the projections the qualitative and quantitative insights provided by the research. The ultimate goal of this iterative process is to reach consensus among the experts on the scenarios that are most likely to happen in the future.

https://doi.org/10.1371/journal.pone.0258995.g002

3.2 Formulation of the Delphi projections

The formulation of the projections represents a key aspect of the methodology and requires a particular attention and effort. In this phase, the projections that are later tested by the panel of experts are generated. Vagueness and inaccuracy might generate confusion in experts, leading to less meaningful results. To avoid this situation, we developed the projections by means of triangulation: literature review, interviews with experts and participation to workshops and conferences. The analysis of the literature on blockchain technology (and its benefits) allowed us to understand which industries and businesses will be mainly impacted by the technology.

We chose 2030 as a time horizon for the generation of the scenarios. This is a recommended time span for a Delphi study, since a superior period would have become unmanageable to provide relevant advice for strategic development. As reported in Table 1 , projections span among different areas. To the scope of the work, i.e. to grasp a holistic view of the most likely scenarios, it was necessary to investigate a number of multiple dimensions. Projections are related to socio-cultural, policy and regulations, economic, technological and business aspects. As it can be noticed, projections are all structured in the same way, to facilitate their understanding by experts.

https://doi.org/10.1371/journal.pone.0258995.t001

3.2.1 Interviews with experts.

Twelve blockchain experts were interviewed among academics, startups’ founders and professionals working in consultancy firms, banks and legal institutions. The selection of the experts was made in order to get different points of view and a high level of expertise, as provided by the Delphi method guidelines. We conducted interviews that took between thirty and forty-five minutes on average, according to the interviewee’s availability. Each single interview was tailored for each participant by providing guidelines and reflection tips to encourage discussion. However, a certain degree of freedom was given to the expert to allow his/her spontaneous contribution and to gain some original insights that helped in the final design of the future scenarios. Some common aspects were discussed in all interviews generating redundancy and repetition of already emerged scenarios (e.g. ICOs, business model evolution, security and utility tokens, and legal issues). This is one of the reasons why twelve interviews were considered to be sufficient for the purposes of our research.

3.2.2 Conferences.

One of the authors attended three main events in order to strengthen the knowledge about blockchain and have a broader view of its implications in different fields and industries: one in Milan and two in Paris. Of particular notice, the Community Blockchain Week, a blockchain tech-focused initiative organized voluntarily by actors engaged into the technology and with the will and vision to spread the knowledge among citizens. Thanks to various workshops and speeches during the week, it was possible to dive deeper into many aspects of the technology, as well as to meet some knowledgeable experts of various fields, some of which agreed in participating to the research. The event was extremely useful not only to understand how the technology is evolving, but also to see how the community engages itself to spread the knowledge in order to generate more and more interest around it.

3.2.3 Desk research.

We performed desk research to formulate the initial set of projections. Through the survey of the literature, we gained a comprehensive view of all the potential scenarios of the technology. The analysis of consulting companies’ reports also offered a broader vision of future scenarios, thanks to their strategic rather than technical approach [ 1 , 2 ]. This process led to identify 76 projections that represented the basis for a reflection during the expert face-to-face interviews. After screening the relevant articles and reports, a first filtering of the identified 76 projections was made in order to dismiss redundant or incomplete projections, and to keep only the most complete and varied ones. This process reduced the number of projections to 33 and to 20 after the review of two experts.

3.3 The Delphi projections

The formulation of the projections represents the most sensitive part of the research since it influences the whole study. A detailed analysis was carried out in order to avoid mistakes and confusion. In order to facilitate the respondents filling the questionnaire and to avoid any kind of ambiguity, an introduction explaining the meaning of the terminology used in the questionnaire was presented before starting the survey. The developed scenarios were broken down into six macro categories (the same as proposed by Heiko and Darkow [ 46 ]) to guarantee a more complete and systemic view of how the blockchain ecosystem and community can change and shape the future. The choice of 20 projections to be evaluated by experts is in line with prior studies exploiting the Delphi method [ 46 , 47 ]. Parente and Anderson-Parente [ 47 ] have proposed to limit the number of Delphi questions (e.g. to 25 questions) in order to guarantee a high response rate and properly filled-in questionnaires, including only closed answers. We decided to add the possibility to comment the given answers in order to gather additional qualitative data to improve the quality of the results, in line with the methodology proposed by Heiko and Darkow [ 46 ].

3.4 Selection of the panel of experts

As blockchain experts that took part to the survey, we selected individuals working in companies and institutions on the basis of their experience and knowledge of the field. Following Adler and Ziglio [ 48 ] and Heiko and Darkow [ 46 ] four requirements for “expertise” were considered:

• knowledge and experience on blockchain technology;
• capacity and willingness to participate to the Delphi study;
• sufficient time to participate to the Delphi study;
• effective communication skills.

A minimum panel size of 15–25 participants is often required to lead to consistent results. In our case, a panel of 35 experts was reached for the first round. For the reliability of the study the panelists were selected with different backgrounds and profiles. To be aligned with the European focus of the study, we considered experts working in twelve European countries, being France and Italy the ones with the highest number of respondents. The panel characteristics are reported in Figs 3 , 4 and 5 .

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https://doi.org/10.1371/journal.pone.0258995.g004

https://doi.org/10.1371/journal.pone.0258995.g005

3.5 Execution of the Delphi surveys

In line with the methodology proposed by Heiko and Darkow [ 46 ], two rounds of surveys were executed. We decided to carry no more than two rounds because participating to a Delphi study requires a lot of effort and is a time-consuming task for panelists. By limiting the rounds to two, we reached a sufficient number of respondents that led to have valuable results and consistent conclusions. Moreover, since for each scenario the possibility to include a qualitative argumentation was included, the smaller number of iterations worked as a stimulus for the experts to explain the reasons of their quantitative answers.

The survey was carried out following the standards of the Internet-based Delphi, also called e-Delphi [ 39 , 40 ]. Giving the possibility to respondents to answer digitally allowed experts to be more flexible in responding to the survey, ensuring a greater participation. The way the questionnaire was structured was exactly as the e-Delphi website suggests, but for practical reasons we edited the survey using Google Form. Other standards, such as the real-time Delphi solution proposed by several studies [ 14 , 42 , 43 , 49 ] could have led to a better comparison among experts, but would have likely caused more withdraws to the survey.

3.5.1 First round.

In the first round of the survey, the experts assessed the expected probability and impact of the twenty outlined projections. Some Delphi studies [ 50 , 51 ] include a third factor that helps to assess the desirability of a scenario (i.e. how much an expert is in favour of the realization of a prediction). However, we decided not to include this last aspect to make the questionnaire lighter and faster to be filled in, and to reduce drop-outs ( Table 2 ).

https://doi.org/10.1371/journal.pone.0258995.t002

Impact, evaluated at the industry level, was measured on a five-point Likert scale [ 52 ]. Since there is not a general consensus among experts regarding the number of points the scale should have, and due to the general nature of the scenarios, we preferred to use a five-point Likert scale. The corresponding probabilities are: 0%, 25%, 50%, 75% and 100%. Gathering quantitative data allowed to perform a first set of analyses based on descriptive statistics (e.g. mean, median and interquartile range-IQR). We used qualitative data, instead, to build the final scenarios during the fourth step of the forecasting technique. Even though the literature regarding the Delphi method does not suggest a standardized way to analyze consensus, central tendency measures, such as median and mean values, are useful to grasp a first understanding and are frequently accepted and adopted ( Table 3 ). Scenarios with an IQR equal or lower than 1.5 were considered as having reached an acceptable degree of consensus. It should be noticed that most of the projections that achieved the highest probability, having a median value of 75% achieved also the consensus, i.e. IQR below 1.5. This was the case for projections 3, 4, 8, 9, 10, 13, 15, 19, 20.

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These results show that it was easier for experts to find a consensus over the projections that resulted as very likely to occur. Only projection number 18 achieved a high probability score but could not reach a consensus.

3.5.2 Second round.

During the Delphi’s second round only the projections with an IQR above 1.5 (i.e. which did not reach consensus in the first round) were tested. In order to allow the respondents to easily understand the answers that the panel gave as a whole in round one, for each projection a quantitative report was provided. This report was made of a bar chart with the distribution of the first round’s answers and the correspondent qualitative details, i.e. some of the argumentations provided by some of the panelists. Experts were asked to reconsider the likelihood of occurrence of the projections number 1, 5, 7, 11, 12, 14 and 18. The second round was again structured using Google Form. Following the Delphi’s approach, we did not ask again to estimate the impact for each projection, since this would have presumably been not subject to any change. Moreover, we decided to leave the opportunity to offer again some qualitative comments in support of the answers for a better analysis of the results. The number of experts who successfully completed the second round of the survey dropped to 28, i.e. the 80% of the experts that completed Round 1 and 56% of the selected initial panel. Again, we evaluated the central tendency measures for the projections tested during the second round ( Table 4 ).

https://doi.org/10.1371/journal.pone.0258995.t004

In order to provide a more effective and structured analysis of the results, we first report the final summary table of the Delphi survey and then describe the insights obtained from the analysis. It has to be noticed that Table 5 reports quantitative data only, while during the survey qualitative data were collected as well. In presenting the results of this research, both quantitative and qualitative data are used to provide the best possible picture of what the blockchain-based future will look like. Alongside with standard statistics, we build on qualitative insights obtained during the interviews carried on with experts.

https://doi.org/10.1371/journal.pone.0258995.t005

Firstly, it is interesting to analyze which projections, out of the initial 20, reached a significant consensus (IQR <1.5 after the two rounds of the surveys) and were given a high probability of occurrence by the experts. We can summarize the findings in this domain around three major axes: efficiency, security, and innovation.

By 2030, it will be easier, faster and leaner to exchange value and data among users, institutions and countries. Efficiency will boost and uncover innovation potential within companies and societies if these latter will be able to exploit such a new opportunity. Policies will be a necessary pre-requisite for companies to be able to build a competitive edge globally. From this perspective, the capability of central governments to spur innovation with lean and flexible regulations will be a key driver in explaining the ex-post productivity differential among companies belonging to different countries. From the interview with an investment banker part of the BPCE French group (one of the largest banks in France), it emerged how efficiency is often hampered by the lack of an equally efficient regulation. To provide the reader with an interesting example, in 2018, Natixis, the international corporate and investment banking, asset management, insurance and financial services arm of BPCE, entered the Marco Polo consortium, an initiative born to provide a newly conceived trade and supply chain finance platform, leveraging Application Programming Interfaces (APIs) and blockchain technology. Many other leading banks joined the consortium as well. However, as highlighted by the investment banker, the main limiting factor of the consortium, strongly hampering its efficiency and ability to provide a competitive edge, was the “old-style” bureaucracy linked to it. Although transactions were in principle to be executed smoothly, a bulk of legal paperwork was required to approve them formally. In this case, it appears evident that technology often runs faster than policy, consistently lowering its potential. Interestingly, this view is also shared by regulatory bodies. An experienced lawyer and notary, also member of a panel of experts elected by the Italian government to define the national strategy on blockchain, highlighted that, sometimes, regulators working on blockchain-related policies are trying to adapt existing regulations to the new paradigm. Due to the intrinsically different nature of the technology, this could represent a wrong approach. At the same time, building a new set of policies from scratches could represent a challenging task. From this perspective, projections 4 and 5 confirm this insight: policy and technology should come hand in hand to synergically boost productivity. The three projections reached consensus after the two rounds and were assigned a high probability of occurrence. Overall, it is evident that regulatory aspects linked to the adoption of this new technology shall not be underestimated.

As previously mentioned, security, and specifically cybersecurity, is another dimension around which blockchain could bring consistent advantages, as projections 3, 10, 11 and 15 suggest. On this specific aspect, we interviewed a project leader of the World Economic Forum who previously worked for the United Nations for more than ten years. She dealt specifically with digital regulations, justice, and cybersecurity, and in the last three years before the interview, she specifically worked on blockchain implications and how the technology could be implemented in existing ecosystems. Thanks to her experience in the domain, she clearly explained how the blockchain represents a meaningful technology to avoid cyberattacks to sensitive data and digital files. In her opinion, the avoidance of a single point of failure is the main reason behind a possible blockchain adoption over the next years, since cyberattacks are becoming more frequent and dangerous and related costs for companies are exponentially increasing (e.g. 2020 has been a record year for cyber attacks). Consequently, companies will be increasingly investing in distributed ledgers as a form of contingency budget to lower the cybersecurity risk and its related cost. Given the centrality of data in today’s businesses, serious attacks and loss of data could represent a serious threat to business long-term sustainability.

The third relevant aspect on which blockchain will have a strong impact is, not surprisingly, innovation. Although regulation could represent a non-negligible limiting factor, experts foresee many sectors to be impacted by the technology adoption. For example, the financial sector could be heavily affected by this new paradigm. Particularly, companies’ capital structures and their strategic interlink with business models will drive a differential competitive power. Most likely, enterprises will have to rethink their business models to account for the possibility to digitize/tokenize their assets (Projections 8 and 18). The capability in flexibly adapting their service offerings to the new opportunity and the ability to raise, and re-invest, new capitals will shape the global competition landscape across different industrial sectors and geographies. From one side, blockchain will enable new strategic decisions, from the other side, it will be of fundamental importance to build technological capabilities to enable these decisions. The underlying technology behind transactions, equity offering and equity share transfers will most likely be the blockchain (Projections 13 and 16). Disintermediation and the ability to exchange value, information, and data trustfully without a central authority will enable a new way of funding and cooperation on open-source projects (Projection 19). Most likely, people will refer to blockchain systems as they now refer to browsers such as Chrome, Firefox or Internet Explorer. Many blockchains are already available and are constantly improved and developed, and it is foreseeable that this will remain the case in the future. Users will just need to know the characteristics that a blockchain provides to choose the most suitable one for their business and purposes. Blockchain-based systems will require new skills and knowledge that developers and engineers will need to develop. Big efforts will be needed to make the blockchain more and more user friendly and attractive for those who just want to benefit from the immutability, traceability, and security that it intrinsically brings. At the time of the writing and in line with the Abernathy and Utterback model [ 53 ] many players are currently investing and innovating on blockchain to provide services that will satisfy the new market needs.

The opportunity for people to deal freely will in fact generate opportunities that were unforeseeable before. Self-enforcing smart contracts (Projection 20) will let parties to buy and sell products or to rent them with pay-for-use schemes in an automated way, the digitization of shares and assets will allow companies to raise capital in new ways, without the need to rely on banks, venture capitals or traditional IPOs. Indeed, it is important to understand how the digitization of assets can challenge existing investments and the funding industry represented by traditional private equity firms and banks. Blockchain could allow the creation of platforms for the issuance of traditional financial products on a tokenized nature, making it easier, more transparent and cheaper to manage and access these tools for everyone, including both individual savers and SMEs. Two different types of companies can and will operate in the market: those which have blockchain at their core since their foundation, and those which have (or will have) to embark in a digital transformation process to reconvert themselves into blockchain-based enterprises. In both cases, companies are investing to get a competitive advantage over competitors, betting on the technology that is promising to reduce costs and increase efficiency. Once a dominant design in product and services will be achieved, companies that took a different path will likely exit the market, letting firms following the dominant design to gain market shares.

To conclude and to conceptualize the insights we obtained from both quantitative and qualitative data, we derived four scenarios that we organized in a matrix framework, reported in Table 6 . The framework was built around two main dimensions: on one hand the digitization of assets, and on the other hand the change in business models. The proposed framework leads to the identification of four quadrants: scenarios which envision both the digitization of assets and business model changes and scenarios which do not foresee neither of these two changes. These four main development scenarios were completed and analyzed in the light of the conducted interviews and of the quantitative and qualitative data gathered through the Delphi survey. Each quadrant was given a label: Internal Processes, Flow-less Coopetition, Suppliers Potential and Investment Opportunities. When discussing the quadrants, we try to highlight which of the three improvement areas previously identified (efficiency, security, and innovation) are exploited in the discussed scenario.

https://doi.org/10.1371/journal.pone.0258995.t006

To derive relevant insights from the framework, it is useful to start from the bottom left quadrant, Internal Processes. This name was chosen to highlight the absence of any particular evolution for the company at a strategic level through the blockchain adoption. In this case, it is conceivable to use the technology to incrementally improve firms’ operation performances. Blockchain’s main benefits are to increase traceability of transactions and guarantee their immutability. All these characteristics adopted on today’s processes will result in an automation of routine business functions, such as settlements and reconciliation, customs clearance, heavy payments, invoicing, and documentation, boosting operational efficiency and cost performance. In this scenario, security and efficiency will see a consistent improvement.

The top-left scenario shows instead a different perspective, by considering a broader adoption of blockchain that generates new cooperative business models among different stakeholders, potentially even among competitors. This is why it is called Flow-Less Coopetition. In this case, the benefits of blockchain will help at generating a more democratic ecosystem in terms of information. Those actors that base their business models on information asymmetry, having access to key information before others, will need to revisit their business models if they want to stay competitive. It is of interest to notice how big financial institutions, traditionally competing, are now exploring potential collaboration models in the light of this new technology (e.g. JP Morgan Chase, Morgan Stanley). This quadrant envisages an advance in all three blockchain-enabled dimensions: efficiency, security, and innovation.

The bottom-right scenario, called Suppliers Potential, highlights how, thanks to the digitization that blockchain allows, many actors could jump in the market providing solutions to those companies that would like to benefit from the advantages of digitizing their assets, but are lacking means and competences to internally develop them. Those companies would rather outsource the development of blockchain-based solutions. For this reason, the potential for the creation of a remunerative B2B market exists. Even though there are already protocols that are leaders in the market (Hyperledger Fabric and Ethereum), new solutions with different configurations will likely be needed to support different industries and use case solutions. As for the first scenario, also in this context efficiency and security will be mainly affected.

Finally, the last scenario (Investment Opportunities) focuses on the combination between the complete digitization of the assets of a company and the new business models that this major change could generate. As already mentioned in previous paragraphs, industries are experimenting many ways to facilitate the access to capital. Since the explosion of ICOs in 2017, new and easier ways to access capital have become possible and achievable. However, due to their unregulated nature, ICOs still present numerous potential threats (Projection 14 did not reach consensus). For this reason, other solutions, such as STOs (Security Token Offerings), are on the way of being tested. Bringing a higher degree of freedom to investments will allow companies to receive funds from diverse and non-traditional investors, and it will also boost investments by private individuals into early-stage companies. Efficiency and innovation will be at the core of this last scenario.

5 Conclusions

In this paper, we studied different blockchain-based projections and we assessed their likelihood and impact thanks to the participation of a pool of experts. We built our findings around three dimensions (efficiency, security, and innovation) and we derived four scenarios based on experts’ shared vision. Being the current literature widely fragmented, we believe this research represents a useful starting for conceptualizing blockchain potential and implications. While many research papers focus on blockchain specific applications or general reviews of the state of the art, we try to propose a unifying framework building on different typologies of insights and analyses. We merged quantitative observations derived from standard statistics with qualitative insights obtained directly from experts’ opinions.

Overall, we believe our research can constitute a useful tool for many practitioners involved in the innovation ecosystem and for managers of small, medium and large enterprises to look at future possible scenarios in a more rational and systematic way. From one side, a company’s management can use these forecasts as a starting point for the implementation of new strategies. As previously highlighted, blockchain offers endless possibilities. However, the ability to focus on activities and projects with a positive return on investment will be crucial. Firstly, managers will face the choice between insourcing or outsourcing the technological development of the platform. While the former choice ensures higher flexibility, it also generates high development and maintenance costs. Companies which will identify blockchain as their core service will be entitled to adopt this first strategy, while the majority of the enterprises will probably gain better competitive advantages adopting Blockchain as a Service (BaaS) solution. This latter approach will boost companies’ performances, by enhancing new service offerings as well as a new level of operational efficiency, without carrying the burden and costs of technological complexity.

As mentioned, we believe this research provides useful insights for policy makers as well. The adoption of blockchain represents a tremendous technological change bringing along interesting and tangible opportunities. However, different threats can be foreseen. Central authorities do not only solve the problem of trust in certifying value transactions. They also provide essential supervision on the process itself, for example ensuring that information asymmetry is kept at reasonable levels between parties engaging in any sort of contracts, especially in the financial world. Letting people directly exchange value between themselves or allowing companies to easily raise capitals can boost financial efficiency, but also provides room for frauds and ambiguous behaviours. Today, companies which are interested in raising capitals both through innovative tools such as crowdfunding or through traditional entities such as public financial markets, have the duty to disclose relevant information and usually go through a deep process of due diligence. Regulators should ensure the same level of control on companies that will raise money through Initial Coin Offerings or other sort of blockchain-enabled offerings. We believe that the first step towards a fair regulation of this newly born technology is the understanding of its foreseeable impact on the society in the near future. This work aims to be a precious enabler in this direction. As highlighted in the body of this research, it appears fundamental for policy makers, regulators and government to deeply understand the potential upsides and threats of this new technology, and to correctly navigate the different possible blockchain-enabled scenarios. The successful cooperation between companies’ management and regulators could enable significant productivity shifts in the economic tissue of many countries. Failing in efficiently grasping and enhancing these new paradigms from a regulatory perspective could result into a heavy deficit for the competitive edge and productivity of the industrial sectors of the governments’ respective countries, potentially leading to macroeconomic differentials in productivity.

To conclude, this research could be a useful reference for orienting into this complex and dynamic environment, reducing the perceived uncertainty associated to such a new technology. Thanks to the experts’ advice, it is now possible to have a clearer picture of the evolution of blockchain technologies and of the opportunities and threats that the technology will generate. Certain limitations and characteristics of this study must be considered to correctly and effectively take advantage of its results. The main objective of this work was to examine the most disrupting aspects that are likely to occur in Europe by 2030, with a particular focus on how the technology will facilitate financing, reduce costs, increase transparency and, in general, influence firms’ business models. From this point of view, the objectives and assumptions presented at the beginning of this paper can be considered as fully achieved, but further works exploring other industries and geographies are required to get an organic understanding of the new enhanced paradigms.

Our research only paves the way for a better understanding of what a blockchain-based future will look like, as the differences between industries are too large to be analyzed in a single work. Organizations and businesses in the financial world are consistently changing, but it will be necessary also for companies belonging to different sectors to completely rethink their core activities. From this perspective, we believe further works are needed in these directions. We hope researchers will use and explode our framework to further characterize and meticulously describe the new possible paradigms around the multiple dimensions examined in this work.

Supporting information

https://doi.org/10.1371/journal.pone.0258995.s001

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IEEE Talks Blockchain

In our latest IEEE Talks Blockchain Q&A session, we spoke with Dr. Ramesh Ramadoss, co-chair of the IEEE Blockchain Initiative. Dr. Ramadoss discusses the evolution of the blockchain ecosystem, including emerging applications, standardization efforts, and opportunities for future growth and development.

IEEE White Papers

This Position Paper describes the basic framework and principles for using blockchain technology in power and energy domains with the emerging participatory grid. A key goal is the development of the most promising global Transactive Energy use cases which can be advanced toward broader commercialization using blockchain technology.

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Reinforcing the Links of the Blockchain IEEE Future Directions - November 2017

The purpose of this white paper is to explore the various ways by which the IEEE can lead and support an initiative on Blockchain while providing educational materials that will foster the next generation of blockchain engineers. This white paper summarizes and expands upon the IEEE Blockchain Incubator Workshop held by IEEE Future Directions at the end of October in 2017.

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Blockchain for Business Value: A Contract and Work Flow Management to Reduce Disputes Pilot Project IEEE Engineering Management Review - December 2018

By Liang Xi Downey; Frédéric Bauchot; Jos Röling

Blockchain technology has seen significant growth, hype, and potential new developments over the past few years. In this article additional insights into how blockchain can add value to a business process relationship is detailed. Specifically an engineering contract workflow use application pilot including various high level system architectural aspects are presented. This application shows the integration of blockchain technology with existing legacy systems. Some management and technology issues are also overviewed for the reader.

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Blockchain-Enabled E-Voting IEEE Software - July/August 2018

By Nir Kshetri and Jeffrey Voas

Published in the July/August 2018 issue of IEEE Software ; recognized among the top eight winners of the 2018 Most Influential Blockchain Research Papers by the Third Blockchain Connect Conference Awards.

"E-Voting is among the key public sectors that can be disrupted by blockchain technology. The idea in blockchain-enabled e-voting (BEV) is simple. To use a digital-currency analogy, BEV issues each voter a “wallet” containing a user credential. Each voter gets a single “coin” representing one opportunity to vote. Casting a vote transfers the voter’s coin to a candidate’s wallet. A voter can spend his or her coin only once. However, voters can change their vote before a preset deadline."

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By Claudio Lima, Ph.D., Blockchain Engineering Council, BEC Co-Founder; Vice Chair, IEEE Blockchain Standards

"The General Data Protection Regulation (GDPR) that was recently approved for implementation in the EEUU by May 25th, 2018 is already creating some controversies, when confronted with emerging Blockchain technologies, regarding what they have most in common: data privacy and protection. These are two are essential areas where Blockchain shines."

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Enhanced Distributed Ledger Technology NIST Computer Security Resource Center - September 2019

The blockchain data structure and proof-of-work protocol were designed to solve the problem of double spending in cryptocurrencies. Although blockchain has found many applications outside of cryptocurrency, many of its features are not well suited to common data management applications. The added trust of distributed ledgers is a valuable feature, providing greatly simplified auditability and verification of actions among multiple parties in applications such as supply chain and others, but there are tradeoffs.

Blockchain's hash-based integrity verification provides trust, at the cost of an inability to delete or update records, leading to design complications that would not arise with conventional database management systems. Similarly, the sequencing guarantees of blockchain consensus protocols are needed for cryptocurrency in the absence of a universal timestamp. Moreover, actions within the distributed ledger must be connected with other actions in the real world, through accurate timestamps. We are developing a new architecture that provides the trust features of blockchains, with characteristics that allow for simpler designs and greater practicality in conventional data management problems. We believe this alternative can lead to new approaches to incorporating trust into distributed systems applications.

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Blockchain and Economic Development: Hype vs. Reality Center for Global Development - July 2017

Increasing attention is being paid to the potential of blockchain technology to address long-standing challenges related to economic development. Blockchain proponents argue that it will expand opportunities for exchange and collaboration by reducing reliance on intermediaries and the frictions associated with them. The purpose of this paper is to provide a clear-eyed view of the technology’s potential in the context of development. In it, we focus on identifying the questions that development practitioners should be asking technologists, and challenges that innovators must address for the technology to meet its potential.

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A Case Study for Blockchain in Healthcare: “MedRec” prototype for electronic health records and medical research data MIT Media Lab, Beth Israel Deaconess Medical Center - August 2016

A decentralized record management system to handle electronic health records, using Blockchain technology that manages authentication, confidentiality, accountability and data sharing.

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Blockchain-based privacy and security preserving in electronic health: a systematic review

• Published: 17 February 2023
• Volume 82 , pages 28493–28519, ( 2023 )

Cite this article

• Kianoush Kiania 1 ,
• Seyed Mahdi Jameii   ORCID: orcid.org/0000-0002-9407-665X 2 &
• Amir Masoud Rahmani 3  

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In today’s world, health and medicine play an undeniable role in human life. Traditional and current Electronic Health Records (EHR) systems that are used to exchange information between medical stakeholders (patients, physicians, insurance companies, pharmaceuticals, medical researchers, etc.) suffer weaknesses in terms of security and privacy due to having centralized architecture. Blockchain technology ensures the privacy and security of EHR systems thanks to the use of encryption. Moreover, due to its decentralized nature, this technology prevents central failure and central attack points. In this paper, a systematic literature review (SLR) is proposed to analyze the existing Blockchain-based approaches for improving privacy and security in electronic health systems. The research methodology, paper selection process, and the search query are explained. 51 papers returned from our search criteria published between 2018 and Dec 2022 are reviewed. The main ideas, type of Blockchain, evaluation metrics, and used tools of each selected paper are discussed in detail. Finally, future research directions, open challenges, and some issues are discussed.

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Avoid common mistakes on your manuscript.

1 Introduction

Nowadays, healthcare is considered to be one of the most important human concerns. A lot of data related to healthcare are generated, stored, and reused frequently. One of the most important subsets of healthcare systems is Electronic Health Records (EHR). Electronic patient records provide many opportunities for healthcare stakeholders. For example, it allows medical records to be accessed by patients and avoids expensive tests, radiology, and repetitive imaging. Moreover, even if the patient is treated in different medical centers or in hospitals located in different cities, provinces, or other countries, physicians based in all those medical centers can access the patient’s records across far distances from each other using EHR. Another advantage of using EHR is having access to a history of medications used by the patient, which will help physicians in prescribing a new drug for the patient. Another advantage of using EHR is the use of patients’ medical records for research purposes and finding new treatment methods.

One of the basic challenges of using EHR in healthcare is how to preserve the patient’s privacy. With the wide access to patient records, the patients’ privacy is an important challenge. Another challenge for EHR is that the patient does not own his/her data and instead, it is the medical centers who own the patient’s data. Physicians and researchers can access a patient’s EHR without his or her consent to use these data for treatment and research purposes, and this is one aspect of the patient’s privacy. From a security perspective, using EHR brings up several challenges: First, the abundant use of IoT (Internet of Things) and wearable sensors to diagnose the disease and record data in the medical record of that patient can increase the risk of attacks. This could affect the physician’s prescription for the disease and endanger the patient’s life. The second security issue is fraud detection. There have been many cases where doctors have prescribed a drug for a patient that is not necessary for him/her just because that certain drug is available at the hospital’s pharmacy or medical center where the doctor works. As a result, the patient’s health may be compromised and/or the patient may be forced to bear unnecessary costs. Another security challenge is counterfeit drugs. Many people die of the use of counterfeit drugs or suffer from serious side effects from the use of these drugs. To address this challenge, a drug supply chain must be put in place in which critical information is accessible. This information must include the name of the pharmaceutical plant that has manufactured the drug, then where and how it has been stored; by what distributor it has been transported to the pharmacy, the distribution date, etc. To overcome the above-mentioned problems, Blockchain technology can be used. The distributed ledger of Blockchain has a distributable feature so it reduces the risk of an attack on an integrated center. Moreover, this distributed ledger cannot be changed and the transactions registered in it cannot be modified. In addition, only the patient can permit a third party to read or change their data by having their private key and public key. To do this systematic review, the guidelines proposed in [ 30 , 64 ] were adopted and the existing Blockchain-based approaches that tried to preserve privacy and security in healthcare are reviewed. The remaining of the paper is organized as follows. In Section  2 , previous review papers are discussed. Section  3 describes the methodology and criteria for selecting the papers. In Section  4 , the advantages and disadvantages of using Blockchain in the field of healthcare are discussed. The existing Blockchain-based approaches that tried to improve the privacy issue in healthcare are mentioned in Section  5 . The existing Blockchain-based approaches that tried to improve security issues in healthcare are described in Section  6 . In Section  7 , the reviewed papers are discussed and analyzed. Section  8 describes the open Issues and future research directions. Section  9 is dedicated to the conclusions and limitations of this SLR study.

2 Related work and motivation

In this section, we discuss the related survey and SLR papers that examined the Blockchain-based privacy and security approaches in healthcare.

The authors of [ 23 ] reviewed 143 papers on the role of Blockchain in healthcare and discussed the existing challenges in the EHR domain (including power consumption, failure, and attack points). Blockchain was used to solve these challenges of trustless environments and secure data exchange. In this paper two platforms were introduced: permissionless Blockchain (Ethereum) and permissioned Blockchain (Hyperledger) to solve EHR challenges. The authors reviewed the issues of privacy and security, and compared traditional EHR methods with those implemented by Blockchain. Finally, the limitations of the methods were mentioned.

In another study [ 55 ], 52 papers were reviewed. These papers discussed how Blockchain technology, along with smart contract systems, can support healthcare applications for physicians, patients, insurance companies, and assets such as patient’s data, medical information, equipment, and pharmaceutical chains.

The authors of [ 7 ] reviewed 31 papers. This paper described how this technology improves healthcare and prevents diseases and suggested a new protocol to ensure patient privacy and guarantee confidential data. Secure encryption methods and digital signatures were introduced to ensure authorized access to shared information using Blockchain. Then, a strong review of the accuracy of the EHR data was presented.

The authors of [ 31 ] reviewed 69 papers. This paper discusses the role of Blockchain in healthcare. This paper addressed the challenges of system security, interoperability, data sharing, and mobility in the field of EHR and explained how Blockchain can handle these challenges. Then, the following platforms were introduced to implement Blockchain in healthcare: Gem Health Network, OmniPHR, Medrec, Inclusive Social Networking System (PSN), and Virtual Resources.

Another study [ 54 ] was a systematic literature review that reviewed 42 papers published between 2016 and 2019 related to applying Blockchain in healthcare. In this paper, some challenges such as using Blockchain in healthcare, sharing and processing medical data and patient records were analyzed. The authors examined the implementation model, limitations, and costs of using Blockchain in healthcare.

The authors of [ 52 ] conducted a systematic review of 62 papers related to Blockchain-based approaches in healthcare systems published between 2016 and 2020. In this paper, the authors reviewed the use cases, challenges, and structures of Blockchain-based approaches in healthcare. Then, the implementation methods, technical cases, and the use of Blockchain in the field of medicine were evaluated. Finally, future directions and future works in this field were discussed.

The authors of [ 4 ] studied 37 papers related to Blockchain-based approaches in healthcare published between 2017 and 2020. This paper examined how to access medical records, security, data tracking, and medical information and how to exchange information in the Blockchain healthcare network. Also in this paper, challenges such as how to register and accept transactions, how to implement interoperability, regulations, and restrictions related to medical data in the community, and issues related to scalability and management of access permissions were mentioned.

The authors of [ 18 ] reviewed 39 papers that used Blockchain in healthcare approaches published between 2018 and 2020. This paper mentioned that using Blockchain can be effective for data integration, access control, and interoperability. The authors of this paper believed that using Blockchain in healthcare systems is expanding rapidly and therefore research in this field can be absolutely vital and useful.

Another study [ 19 ] reviewed a total number of 940 papers, and books published between 2016 and 2020 that used Blockchain technology in healthcare. This paper discussed telecare and the role of security and privacy. In this paper, some issues of using Blockchain in healthcare such as interoperability, scalability, and storage were discussed.

In another study [ 24 ], 50 papers published on reputable scientific sites between 2015 and 2020 that used Blockchain in healthcare were analyzed. This paper highlighted the role of quality criteria. First, new trends of using Blockchain in healthcare were introduced, then these new trends were analyzed, and finally, the challenges of using these new trends were discussed. This paper also discussed issues such as integrating cloud computing technology and Blockchain in healthcare.

The authors of [ 46 ] reviewed a total of 626 papers published between 2016 and 2020 that used Blockchain technology in healthcare. In this paper, systematic methods for reviewing papers were presented. These systematic methods include: relying on scientific methods, the number of authors of the paper per year, the introduction of the institutions that created the paper, and the separation of papers based on the country of the author of the paper.

Akbar et al. [ 5 ] reviewed 72 articles between 2017 and 2021 on the role of Blockchain in healthcare. In this research, the fuzzy technique has been used to prioritize and sort the existing solutions in the field of Blockchain-based healthcare. Also, in this research, new methods have been used to optimize and create a road map in the field of Blockchain-based healthcare.

Sharma et al. [ 51 ] reviewed 47 articles between 2017 and 2021 on the use of Blockchain in healthcare. In this research, challenges such as optimal use of resources, data integrity, and rapid development of the healthcare Blockchain have been addressed.

Rahmani et al. [ 42 ] reviewed 34 articles between 2016 and 2021 in the field of using Blockchain in the Internet Medical of Thing (IoMT). In this research, the challenges of trust in the context of cloud computing for storing Internet of Things data have been discussed. Blockchain is mentioned as a solution for decentralization and security of data generated by sensors and wearable devices.

The authors of [ 48 ] reviewed 51 articles between 2017 and 2021 on the use of Blockchain in the field of healthcare. In this research, the major challenges such as lack of integrity, manipulation, and fraud in medical care data have been identified, and Blockchain has been mentioned as a solution to overcome these challenges. Also, in this research, the benefits of using the Blockchain in the field of healthcare are mentioned, such as more efficiency, less delay in information transmission, more data security, and improved management of resource consumption.

Abbas et al. [ 1 ] reviewed 53 articles between 2016 and 2021 on the use of Blockchain technology in healthcare. In this article, advantages such as non-alteration and manipulation of healthcare data, anonymity of participating parties, protection of patients’ privacy, improvement of drug supply chain management, and safe and fast access to patient’s records in the healthcare Blockchain are mentioned.

Examining the mentioned papers, several defects are found. For example, some of these papers are not SLR or the selection process is not clear or the tools used for evaluation and the framework are not specified in these papers. In this systematic review, we attempted to address these shortcomings.

Table 1 lists survey and SLR papers on healthcare security and privacy using Blockchain in recent years. In this table, each paper is examined considering the publication year, main topic, review types, paper selection processes, tools or framework, and covered years.

3 Research methodology

In this section, a methodology for doing this systematic review is mentioned. A systematic literature review has several advantages over traditional reviews, including: greater transparency, more accurate reviews, step-by-step analyses, and more regular reviews. The article selection process and the research questions are also explained in this section.

3.1 Question formalization

The research questions that are answered in this study are as follows:

RQ1: What are the advantages and disadvantages of using Blockchain in Healthcare?

RQ2: How the patient’s privacy in EHR is guaranteed by Blockchain?

RQ3: How the patient’s security in EHR is guaranteed by Blockchain?

RQ4: What evaluation metrics are applied for evaluating the Blockchain-based approaches for improving security and privacy in healthcare?

RQ5: What are the tools or frameworks used in the Blockchain-based approaches for improving security and privacy in healthcare?

RQ6: What kind of Blockchain was used in the existing research studies?

RQ7: What are the open issues and future research directions of using Blockchain for improving the privacy and security of healthcare?

3.2 Paper selection process

Figure 1 summarizes the papers selection process in three steps:

At this step, the papers are selected based on the title, abstract and keywords. 487 papers were selected at the end of this step.

At this step, the continuation of the selection process of papers has been carried out based on the inclusion and exclusion criteria given in Table 3 . At the end of this step, 331 papers were remained.

Finally, by studying the full text of the papers and removing inappropriate ones, 51 papers were remained as final selected papers to be reviewed in this systematic review.

Paper selection process

This study reviews papers published between 2018 and August 2022 that focused on Blockchain-based approaches for improving security and privacy in healthcare. Various databases have been used to conduct this study. The URLs of the used database are listed in Table 2 .

The search keywords for the papers were as follows:

“Blockchain” AND (“Healthcare” OR “EHR” OR “Medicine” OR “Electronic Health Record”)

Table 3 lists the criteria for including and excluding the papers.

After applying the above keywords, 331 journal papers and 156 conference papers were found at the end of step 1. The number and percentage of journal and conference papers are shown in Fig.  2 .

Total selected papers at the end of step 1

Figure 3 illustrates the number and percentage of final papers selected from each database.

The number and percentage of final papers selected from each database

Figure 4 shows the number of final papers selected at the end of step 3 categorized by years.

The number of selected papers at the end of step 3 categorized by years

4 Advantages and disadvantages of using Blockchain in healthcare

In this section, we try to answer RQ1: What are the advantages and disadvantages of using Blockchain in Healthcare?

Using Blockchain technology can improve the integrity, privacy, and security and it provides better access to the necessary services. With Blockchain technology, both specialists and health organizations can act faster and more efficiently based on the available information which is safe and reliable. A safe and effective infrastructure can be created using smart contracts to increase the quality of healthcare and improve the well-being of individuals.

The authors of [ 47 ] presented the creation of the prototype and evaluation of the OmniPHR architectural model. A Personal Health Record (PHR) is a file that allows patients to access and manage their data. The OmniPHR integrates the Blockchain distributed records and OpenEHR. The performance of the OmniPHR was evaluated by dividing it into workloads and simultaneous sessions to transfer the database to a network of ten clouds. The results of the experimental evaluations in this paper showed that the Blockchain architecture of OmniPHR provides high-quality performance at the network level.

In another study [ 66 ], some applications of Blockchain in healthcare domains were presented as follows: (1) Track prescriptions to detect drug overdoses. (2) Sharing data for integrating traditional care into telemedicine. (3) Sharing data with the provider so that the patient can specify what data is being authorized. (4) Sharing the registered cases of cancer; collecting all of the observed cases of cancer. (5) Managing the patient’s digital identity to better match the patient’s history. (6) Creating a personal health record that can be fully accessed and controlled. (7) Automation of health insurance claims for error detection and fraud. This paper also discusses the challenges of using the Blockchain in healthcare, such as system evolution, privacy protection, etc.

Another study [ 29 ] mentioned some healthcare projects that benefit from Blockchain technology. One of the projects worth mentioning here is PokitDok. With PokitDok, organizations related to healthcare can implement modern business in Blockchain and a secure network of electronic health records and pharmaceutical equipment is provided.

In another study [ 60 ], a Blockchain-based security model was presented for electronic health records called EMRSB. In this model, medical data can be shared safely and effectively. By using Blockchain technology in EMRSB, Data loss and manipulation problems can be easily solved. Large files are stored in the IPFS file system Footnote 1 and the hash file is added to the Blockchain, which saves important resources in the Blockchain. This can increase the security level of the patient’s privacy information.

The authors of paper [ 27 ] believed that the decentralization of the Blockchain would safeguard healthcare data and preserve the privacy of stakeholders in the field. Another important point mentioned in this paper is the lower cost of transferring data in the Blockchain compared to traditional methods. Data transfer in the Blockchain is done without the use of a central entity, which makes it less costly. It also uses Blockchain data tracking to ensure that healthcare data comes from a reliable source.

In another study [ 34 ] the characteristics of data integration and the immutability of data in the Blockchain were mentioned, which makes the Blockchain a suitable platform for maintaining healthcare data. In the healthcare network implemented by the Blockchain, the data added to the ledger cannot be changed and manipulated. The decentralization of the Blockchain means that there is no single failure point for the healthcare network. The paper also referred to smart contracts that allow transactions and agreements to be drawn up between parties involved in the healthcare Blockchain network without third-party intervention.

Another study [ 62 ] listed several advantages of using Blockchain in healthcare, including: 1- Data accuracy in healthcare applications: Storing all healthcare data in the Blockchain makes this accompanying information up-to-date, traceable, and non-manipulative. These capabilities help medical professionals improve the treatment process of patients. 2- Interoperability of healthcare data: By using interoperability in the Blockchain network, the exchange of information between stakeholders in this field becomes better because all data in the Blockchain follow a certain standard, so the exchange of information is more efficient. 3- Data security in the field of healthcare: Capabilities such as hashing and data immutability in the Blockchain network make data healthcare more secure. 4- Lower cost of healthcare data management: The cost of data management in traditional healthcare data systems is much higher than storing these data seamlessly in a Blockchain network because the information is stored in different centers and databases. 5- Global sharing of healthcare data: A patient may be treated in one country and then travel to another to continue treatment. In this case, if traditional medical care systems are used, sharing patient’s data among several different countries will be very difficult and perhaps impossible. Using a Blockchain network, patient’s data can be easily shared globally. 6- Improving the audit of healthcare data using Blockchain: Using data audits in healthcare ensures that laws and regulations are fully complied with by institutions and stakeholders in this field. As data in the Blockchain is verifiable and information in the Blockchain is non-manipulative, it improves the audit of healthcare data.

The authors of [ 33 ] believed that wearable devices and patient-connected sensors play an important role in modern healthcare systems. In this paper, the data generated from these devices are integrated with Blockchain technology. This integration plays an important role in maintaining the security of this data.

The authors of [ 59 ] dealt with parallel healthcare systems (PHSs) and the role of Blockchain in maintaining data security of these systems. This paper proposed a method in which Blockchain is combined with PHS and using a consortium, healthcare data is shared more effectively.

Another study [ 20 ] pointed out some of the challenges in using Blockchain in healthcare, including high energy consumption, inefficient scalability, and relatively low throughput. To address these challenges, this paper introduced an architecture called lightweight Blockchain. In a lightweight Blockchain network, nodes were distributed in several clusters and a ledger was maintained in each cluster. This reduced the computational and communication costs of the healthcare network.

In [ 53 ], the attribute-based signature scheme was introduced to further protect the privacy of medical stakeholders. In this design, keys called master key to authenticate users and update key to specify attributes related to certain nodes were introduced. In this scheme, a number of parties participating in the Blockchain network (such as physicians) were identified with certain characteristics (such as < Hospital A. Department of Oncology. senior Physician>. After analyzing the patient information, these attributes are taken away from them by an algorithm called KUNodes.

Jeet et al. [ 21 ] developed a Blockchain-based framework for IoT data. In this framework, patient’s data were collected by sensors and wearable devices, and were updated every moment. Therefore, new symptoms of illness and sensitivity in response to drugs can be recorded in the Blockchain immediately. Sha-256 encryption was used in this framework and the techniques used in this research reduce the encryption time.

Rajasekaran and Azees [ 43 ] presented a scheme for authentication of participating parties in the healthcare Blockchain. This scheme is a lightweight authentication scheme that supports the anonymity of participating parties in the healthcare Blockchain. In this scheme, doctors given the opportunity to share information about patients with other doctors without compromising the privacy and security of patient’s data. Using the authentication method of this scheme, only authorized users can view the data of the healthcare field.

The authors of [ 69 ] presented a scheme for secure storage and sharing of medical data based on Blockchain. In this research, the authentication of all parties involved in the healthcare system has been carefully examined and a solution to the problem of information dispersion in the healthcare field has been provided.

5 Privacy in healthcare using the Blockchain

In this section, we try to answer RQ2: How the patient’s privacy in EHR is guaranteed by Blockchain?

Blockchain technology can create a balance between the privacy of health data and access to those data. The purpose of the privacy policy is to protect patients’ privacy while disclosing PHI Footnote 2 . Four goals must be achieved here: 1- Giving t full control of EHRs to patients. 2- Determining who can access and track the documents. 3- Making possible the secure transfer of the records. 4- Minimizing the chance of unauthorized people obtaining PHI. Blockchain technology can help achieve these four goals.

In [ 12 ], the authors recommended an efficient and secure Blockchain-based framework for accessing medical records called Ancile. Smart contracts in this framework were used for controlling and preventing data misuse. In addition, for improving security, advanced encryption techniques were applied. The purpose of this paper is to address privacy and security issues in healthcare. This framework focused on the rights of patient’s data ownership. Data ownership is held by the patient, while parental or caregiver control is provided.

Paper [ 63 ] mentioned that in modern healthcare systems, patient participation is an important matter. This paper discussed Blockchain-based location sharing for E-health systems. The first step defines the basic needs for Blockchain-based location sharing, including decentralization, privacy, and reliability. Then, using Merkel’s cryptography and root, a Blockchain-based privacy-preserving scheme called BMPLS was proposed for Location Sharing Footnote 3 . The results showed that this plan meets the necessary requirements. Finally, the outputs of this project and the results of the analysis confirm that this project is useful and feasible for the field of medical care. In short, the scheme could be used to share telecare Blockchain-based privacy for medical information systems.

In another study [ 66 ], Healthchain, a large-scale Blockchain-based health data privacy project was presented, in which health data were encrypted to control micro-access. With the introduction of the Healthchain, IoT data and physician diagnoses cannot be deleted or manipulated. Security analysis and experimental results suggest that Healthchain’s proposal applies to the smart healthcare system. The important points mentioned in this paper are as follows: 1- A Blockchain-based healthcare system is recommended to protect the privacy of large-scale health data, called a Healthchain. The Healthchain allows users to download IoT data and receive feedback from physicians. Physicians are then able to read data and upload feedbacks. 2- In the Healthchain, for reducing the computational overhead and ensuring privacy, data is encrypted and stored in the IPFS Footnote 4 . 3- In addition, by transferring updated transactions, Healthchain allows users to revoke physicians’ access at any time.

In another study [ 39 ], a Blockchain-based data storage scheme in healthcare was proposed. The proposed scheme can help improve privacy. Encryption techniques were used to protect patient’s data and alias. In this approach, data processing methods as well as the cost-effectiveness of smart contracts used in the system were analyzed. Patients and health organizations participate as data transmitters and data receivers. With the assistance of these EHR systems and storing data in cloud network, patients share their personal data with physicians and health organizations.

The authors of [ 50 ] proposed a plan for implementation of EHR, which would protect EHR data more securely and privately. In this design, a framework was introduced that used the Hyperledger Fabric Blockchain.

In the proposed platform in [ 40 ], many problems are solved by storing encrypted health information in the cloud system. This platform ensures that patient’s data in the cloud environment is controlled only by the patient himself. The goal is to maintain important healthcare data for network integrity and security. Current health systems do not have a pseudonym because they only store data in the cloud environment. But the proposed platform guarantees patients’ aliases. Acquired aliases are obtained using cryptographic functions.

The proposed approach in [ 15 ] used four technologies that could be used in Blockchain for improving privacy. These four technologies are: zero-knowledge proofs, trusted execution environments, homomorphic encryption, and federal learning. In zero-knowledge proofs, one party involved (the prover) is allowed to validate a transaction or validation for the other party (the verifier) without disclosing any critical information. In healthcare contexts, for example, how a patient is treated can be expressed without disclosing the patient’s true identity. In federal learning, an algorithm is sent to a node, then that node analyzes the algorithm and finally shares the updated algorithm among all the nodes in the Blockchain. In this way, by separating how to update the algorithm from other nodes, the risks of privacy and security breaches are minimized. Homomorphic encryption allows calculations to be performed on encrypted data. For example, a patient can encrypt their data and send it to an unreliable third party. This third party performs an analysis on the encrypted data and then sends the result of its analysis to the patient in an encrypted form. In this way, the patient can utilize another person’s review of their data without exposing his/her data. In trusted execution environment technology, privacy is met through hardware. Most cell phones today use this technology in their structure.

In [ 44 ], Blockchain-based knapsack algorithms were used for privacy. The greedy algorithm of knapsack can lead to Blockchain-based privacy and security in healthcare. In this method, first the healthcare data is encrypted by the knapsack algorithm and then this encrypted data is transferred to the Blockchain. In the Blockchain, healthcare data is validated and then decrypted by the knapsack algorithm and finally sent to the desired nodes. Knapsack algorithms are symmetric cryptographic systems. This method uses public keys to encrypt and private keys to decrypt.

Paper [ 32 ] suggested a framework that uses off-chain computing and storage technology. Off-chain Blockchain hybrid design architecture (OCBS) processes and manages information through distributed software that interacts with off-chain sources. This system tries to improve privacy and scalability. In the framework proposed in this paper, the ownership rights of patient’s data are observed. Moreover, in this framework, patients can manage their own data and digital identity.

Paper [ 67 ] proposed a Blockchain-based telephone privacy tracking plan in the field of healthcare. In this plan, healthcare stakeholders can connect to the Blockchain network with their mobile phones. In this plan, first, the location of the caller is determined and then it is determined whether a particular patient has called this system. In the design proposed in this paper, the integration of emerging 5G technology with Blockchain-based healthcare systems leads to higher reliability, less communication delay and improved privacy of medical stakeholders.

Another study [ 58 ] pointed to the role of Blockchain technology in better management of healthcare data and maintaining the security of this data. In this paper, a prototype using the Hyperledger platform was proposed. This prototype was an authorized private Blockchain that ensures better control of access to healthcare data.

The paper [ 3 ] proposed a reliable framework for wearable devices and patient-connected sensors that utilized Blockchain technology. With data management, this framework protected the privacy of information related to the field of healthcare and ensured the confidentiality and integrity of data.

The authors of [ 25 ] introduced a framework that uses Blockchain technology. Using smart contracts, this framework provided effective management to conserve human resources. In this framework, the human resource data were created and then these data were distributed on a global platform based on Blockchain.

In another study [ 65 ], fuzzy analytic on the blockchain platform was introduced. Using fuzzy analytic network, a Blockchain implementation model to improve the security of healthcare data was introduced. In this study, a permissioned private Blockchain network was used to manage access to medical data.

A decentralized architecture based on Blockchain was proposed by Nishi et al. [ 38 ]. In this architecture, the patient is the real owner of his/her data, in such a way that any permission to view the data related to the patient must be done with his/her permission. In this architecture, attribute authorities can issue or revoke the attribute only with the patient’s permission.

Alsayegh et al. [ 8 ] investigated how the privacy and security of EHR sharing can be maintained in two types of Blockchain networks. Private Blockchain was used to store encrypted EHRs and consortium Blockchain along with smart contracts to verify the identity of patients.

The authors of [ 2 ] introduced a framework for greater security and privacy of individuals who received the Covid-19 vaccine using Blockchain. In this framework, the W3C standard certificate is used to prove the certificate of receiving the vaccine. In this framework, IPFS has also been used to protect the privacy of vaccine recipients. In this framework, users have been given the opportunity to share their data with other people without compromising their security and privacy.

6 Securing healthcare data by using the Blockchain

In this section, we try to answer RQ3: How the patient’s security in EHR is guaranteed by Blockchain?

In the smart health scenario, one of the most important issues is the security of the health system. The main challenges for a smart health system are security and the reduction of accurate data with the rule. Blockchain technology suggests that a consortium shall consist of several stakeholders such as hospitals, physicians, pharmacists, pathologists, researchers, and insurance companies. The security debate here means the secure exchange of data among all the parties involved. Moreover, all the stakeholders must be authenticated and authorized to enter each level of the Blockchain.

The authors of [ 26 ] stated that Blockchain may provide a solution to address current EHR performance limitations. In Blockchain, the patient’s entire record is stored in the ledger and encrypted by the patient’s private key. Although the Blockchain system is not completely impenetrable, it is more secure than most current systems.

The authors of [ 11 ] suggested that data theft in the EHR can endanger patient privacy. In general, most data in the EHR remains unchanged after being uploaded to the system. Therefore, Blockchain can be used to share this data more effectively. Participating organizations and medical parties can more confidently access EHRs stored in Blockchain. In this paper, a cryptographic scheme for healthcare was proposed based on Blockchain technology. The index for the EHR is stored in the Blockchain. Because only this index is transferred to Blockchain for ease of publication, patients have complete control over who can view their EHR data. In this system, only search indices are added to the Blockchain and facilitate EHR distribution, while real EHRs are stored encrypted on another server. To access EHRs, users must grant their permission to the information owner with a decryption key.

Paper [ 36 ] presented a new EHR sharing scheme based on cloud computing and Blockchain. Initially, the authors identified the main challenges of current health systems, and effective solutions to these problems are proposed through the implementation of a real prototype. To test the proposed method, an Amazon-based Ethereum Blockchain is proposed. Moreover, to achieve data storage and data sharing, the IPFS storage system integrates with Blockchain. The results of this program showed that the proposed framework can share medical information more safely and quickly compared to conventional methods. By using access control, unauthorized access to health data can be detected and prevented. The advantages of the proposed model showed that the Blockchain solution is a more effective way to manage medical records compared to traditional methods.

Paper [ 28 ] addressed the problems of data collaboration and the use of healthcare programs in a heterogeneous cloud environment. A framework called ChainSDI suggests that the Blockchain technique, along with many computational resources, may be used to manage secure data. The prototype shows how this framework works.

The proposed method in [ 10 ] had the following architecture contributions: First, a healthcare framework called ChainSDI is presented which is based on a combined “home-edge-core” SDI to provide real-time performance and accountability for home-based healthcare services. Second, they are looking to build a secure Blockchain network to ensure that any transaction in ChainSDI is in accordance with the regulations, while still being able to interact with the data.

Paper [ 17 ] provided telemedicine services on demand (MoD). This technology is used to overcome challenges and improve telemedicine services. This paper proposed an approach to achieve authentication and licensing with greater flexibility and efficiency for the department of defense’s services in the medical trap system. A key program has been distributed for independent updates in the telemedicine system, which aims to update the patient’s keys separately. Using Blockchain and distributed ledger also protects the integrity of private healthcare data. This prevents malicious users from trying to change the physicians’ diagnosis. Using the Blockchain technique in EHR, patient’s data is stored in a chain to prevent a user or unauthorized users from manipulating it. Finally, it is concluded that the proposed approach resists collusion attacks in (N-1) destructive attacks.

In [ 22 ], containers in the Blockchain substrate were used for greater security of healthcare data. These containers are connected to multiple ports to improve the data transfer process. In this research, a framework called Medichain on a Blockchain platform is proposed. In each block of the proposed framework, a list of patient records is maintained, which is secured using the security features of Blockchain technology. This framework was implemented by the Python programming language and used object-oriented concepts.

The authors of [ 61 ] used Blockchain technology to further secure healthcare data. The scheme proposed in this paper places great emphasis on protecting patients’ medical records from information theft and unauthorized intrusion. This paper first identified how to manage and control access to medical care data. Then, using Blockchain technology, a platform for data storage and transmission was introduced. In this platform, data transfer and storage were done through cryptographic algorithms. The results of the implementation and simulation of the proposed platform showed better performance in data storage as well as more efficient data transfer than similar schemes.

The authors of [ 68 ] emphasized the privacy and security issues of healthcare stakeholders. In this paper, several features of Blockchain technology such as: anonymous signatures, zero-knowledge proofs, attribute-based encryption, and approval of smart contracts were used for more security of healthcare data. This paper also used various security techniques to ensure the data sharing process.

In another study [ 45 ], the characteristics of the Blockchain network were investigated. Then, consensus algorithms were analyzed, and finally, a framework for maintaining the security and privacy of data related to patients in the field of healthcare was introduced.

The authors of [ 57 ] discussed remote patient monitoring (RPM). In this paper, an architecture was presented that effectively transfers healthcare data and stores them in a Blockchain.

In another study [ 14 ], Blockchain’s smart contracts were used for the proper analysis and management of data generated in the field of medical care. Using the method presented in this paper, the generated data by sensors connected to the patient’s body are analyzed by smart contracts. If the patient-generated data were in critical condition, a warning was sent to the medical center so that the patient could receive immediate intensive care.

In [ 13 ], a Blockchain-based healthcare data management system was proposed. Using this information management system, patients can easily access their medical records located in various medical centers. Asymmetric encryption was used to further secure the system data.

The authors of [ 56 ] integrated smart health care systems (SHSs) with Blockchain technology. This paper examined the challenges of SHS systems and used Blockchain technology to maintain greater security and data integrity in the field of smart healthcare.

Another study [ 16 ] presented an attribute-based signature scheme with different authorities. In this paper, the patient disclosed part of his data without exposing the rest of his information. This part of the information disclosed by the patient is provided to physicians and researchers by healthcare providers. The physician or researcher performs the desired analysis on this data. At the end, these authorities were taken away from them.

The authors of [ 41 ] proposed solutions to prevent the production and distribution of counterfeit drugs in the healthcare network using Blockchain technology. This plan covers the drug distribution cycle from production to consumption by the patient. The distribution and production of counterfeit drugs in the healthcare system is prevented by using Blockchain.

Paper [ 35 ] dealt with the safe storing of healthcare data. It provided a Blockchain-based framework using a keyless signature protocol for the security of patient’s medical records and ensured the integrity and security of data in this area.

Another study [ 49 ] introduced a framework based on Blockchain. In this framework, the management and control of access to medical data were effectively proposed. The use of this framework improved data privacy, confidentiality, and decentralization in the medical care system.

Qadar Butt et al. [ 9 ] presented a Blockchain technology for use in medical communication and developed a location-independent global health record exchange system for transferring medical data. Using Blockchain technology and a federal identity management system, the proposed system authenticates users and the person requiring user information under the guidance.

The authors of [ 37 ] presented a scheme for sharing data in the field of healthcare using Blockchain and edge computing. This scheme guarantees the security and privacy of shared data. In this scheme, the hash and filtering functions were used to maintain the security of the shared data. Also, in this research, a process has been designed to determine the amount of reward for miners to mine healthcare blocks.

In [ 6 ], Blockchain was used to access keywords for searching in distributed healthcare databases and a new mechanisms are used to revoke the public and private keys of users. Therefore, any user will not be able to access the healthcare blockchain after a certain period of time. This makes the healthcare Blockchain more secure. In the proposed approach, public and private keys are given to the participating parties only for a certain period of time to prevent unauthorized people from entering the healthcare Blockchain.

7 Discussion

This section analyzes the reviewed papers to answer the remaining research questions:

RQ4:  What evaluation metrics are applied for evaluating the Blockchain-based approaches for improving security and privacy in healthcare?

Table 4 lists the evaluation metrics for assessing the Blockchain-based approaches for improving security and privacy in healthcare. Evaluation metrics such as integrity (in 10% of papers), access control (in 8% of papers), security (in 25% of papers), privacy (in 17% of papers), availability (in 6% of papers), latency (in 4% of papers), scalability (in 10% of papers), performance (in 17% of papers) and cost (in 4% of papers) were reviewed and analyzed. Figure 5 represents the percentage of using each evaluation metrics considered in the selected papers.

The percentage of using each evaluation metric considered in the selected papers

RQ5:  What are the tools or frameworks used in the Blockchain-based approaches for improving security and privacy in healthcare?

Table 4 lists the tools and frameworks used in the existing Blockchain-based approaches for improving security and privacy in healthcare. Various frameworks, platforms and tools have been used in the papers reviewed in this review paper. These frameworks, platforms and tools have various features, the most important of which are: Use of smart contracts to control access and protection of data, guaranteeing access to data and ensuring that the patient owns the information about himself/herself, protection of data generated by sensors and wearable devices, distribution of data globally and Internationally, artificial intelligence decision making for better disease diagnosis, searchable encryption for sharing medical records, secure management of healthcare data, telemedicine services, etc.

RQ6:  What kind of Blockchain was used in the existing research studies?

Table 4 lists the types of Blockchains used in each paper. Figure 6 represents the percentage of the Blockchain’s type, used in each reviewed paper. 35% of the reviewed papers used private Blockchain, 10% used hybrid Blockchain, 43% used public Blockchain, and 12% used consortium Blockchain.

The percentage of Blockchain’s type used in the reviewed papers

8 Open issues and future research directions

In this section, we aim to answer RQ7: What are the open issues and future research directions of using Blockchain for improving the privacy and security of healthcare?

Some issues of using Blockchain in Healthcare such as cost, profitability, and scalability require further research. Using a distributed system for eliminating intermediaries can effectively overcome many of the current challenges in the medical and healthcare systems. Moreover, despite the existence of a pandemic such as Corona (Covid-19), the creation of a Blockchain network, which is a consortium of all the parties involved in the disease, could be the subject of future research. Using this Blockchain consortium network, various medical centers, governments, patients, insurance companies, information centers, etc. can exchange all information about epidemics. Therefore, by using this safe platform, all treatment methods as well as accurate statistics of epidemic diseases, can be obtained. Some other important open issues and future works are:

Pharmacy: The use of Blockchain in the pharmaceutical industry improves the tracking of products in this area and prevents the distribution of counterfeit drugs.

Globalization of healthcare networks: Blockchain-based healthcare networks can be implemented globally. Using global healthcare networks, patients’ medical records can be accessed from anywhere in the world.

Improving the scalability of Blockchain-based healthcare: Due to the increasing use of Blockchain technology in healthcare networks, more research is needed to improve the scalability of these networks.

Use more efficient cryptographic techniques: Healthcare transactions contain critical information that is considered by many hackers and attackers. Therefore, the development of new and more effective encryption methods requires more researches.

Use of artificial intelligence in Blockchain-based healthcare networks: As Blockchain-based healthcare systems are growing exponentially; analyzing data in this area will become increasingly difficult. Using artificial intelligence and machine learning can make it easier to parse and analyze data in this area.

9 Conclusion and limitation

This review provided a systematic review of the existing Blockchain-based approaches that tried to preserve privacy and security in healthcare. At first, Blockchain and its characteristics were defined, and then the electronic health records and the role that Blockchain can play in maintaining security and privacy in this area were examined. We selected and reviewed recent papers from valid scientific databases. The advantages and disadvantages of using Blockchain in healthcare compared to traditional methods were mentioned. After applying the mentioned query, 331 journal papers and 156 conference papers were found in all of the above-mentioned databases. Finally, we selected 51 papers published between 2018 and December 2022 according to the mentioned paper selection process. We discussed the main idea, evaluation metrics, and tools or framework, and type of Blockchain used in each selected paper. Evaluation metrics such as integrity (in 10% of papers), access control (in 8% of papers), security (in 25% of papers), privacy (in 17% of papers), availability (in 6% of papers), latency (in 4% of papers), scalability (in 10% of papers), performance (in 16% of papers) and cost (in 4% of papers) were used in the reviewed papers. Regarding the type of Blockchain used in the papers, it was observed that 35% of the reviewed papers used private Blockchain, 10% used hybrid Blockchain, 43% used public Blockchain and 12% used consortium Blockchain.

Regarding the limitations of this paper, we can mention the non-use of conference papers. Conference papers can sometimes contain interesting and innovative materials. In this paper, seven research questions were mentioned and answered, while other researchers may consider additional questions. Also in this review paper, six valid scientific databases were used to search for papers, while other valid scientific databases were also available for search. In this paper, only international journals have been used and national and domestic journals have been omitted. Moreover, non-English papers and book chapters were not used. Finally, this paper reviewed papers that were published between 2018 and August 2022, and papers that were published before 2018 were not reviewed.

Data availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

The InterPlanetary File System.

Personal Health Information.

Blockchain-Based Multi-level Privacy-Preserving Location Sharing.

Inter-Planetary File System.

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Kiania, K., Jameii, S.M. & Rahmani, A.M. Blockchain-based privacy and security preserving in electronic health: a systematic review. Multimed Tools Appl 82 , 28493–28519 (2023). https://doi.org/10.1007/s11042-023-14488-w

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From exploration to execution: what’s next for blockchain technology.

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Mrinal Manohar is the cofounder and CEO of Casper Labs , a leading enterprise blockchain software company.

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