2017 19th International Conference on E-health Networking, Application & Services (HealthCom): The 2nd IEEE International
Workshop on Emerging Technologies for Pervasive Healthcare and Applications (ETPHA 2017)
Advanced Block-Chain Architecture for e-Health Systems
W. Liu S.S. Zhu
School of Science and Technology Department of Computer Science
G.G.C. Shantou University
T. Mundie U. Krieger
School of Science and Technology Computer Science in Communication and Networks
G.G.C. University of Bamberg
Abstract—This paper describes our blockchain architecture as This paper is organized as follows. In section II, we
a new system solution to supply a reliable mechanism for describe our overall e-Health architecture evolutions. In
secure and efficient medical record exchanges. The Advanced section III we explained the Block-Chain approach in the
Block-Chain (ABC) approach was designed to meet the context of e-Health requirements and mandates. In section
demands in healthcare growth as well as in the new form of IV, we layout our ABC (Advanced Block Chain) design of
social interactive norms. It is going to revolutionize the e- the overall architecture that supplements the context
Health industry with greater efficiency by eliminating many of management capabilities, regulatory compliance, and
the intermediates as we know them today. collecting e-Health meaningful usages. The final section
concludes with a summary of our contributions.
Keywords- e-Health system; reliability; security; blockchain;
architecture; smart and connected; conformance; audit and II. E-HEALTH ARCHITECTURE DEVELOPMENTS
tracking
We have experienced the rapid changes in e-Health
technological solution for interconnection services. While
I. INTRODUCTION
the fundamental DHC (Digital Health Care) architecture [3]
The purpose of our e-Health research program is to was originated from the Service Layer solution over
develop next generation healthcare digital service solutions networked e-Health systems, the detail design have evolved
to improve patient outcomes, decrease costs, and address the from network interoperability solutions and e-Health security
complexity of challenging e-Health problems in security, framework, to cloud-computing as well as fast development
reliability, efficiency and flexibility. As demands of platforms [4,5,6].
healthcare spending outgrow many countries’ GDPs, there
are urgent needs to adapt the e-Health technological services
to meet the demands not only in numbers but also in
improvement of social interactive norms.
Recent advancements in e-Health research [1] have
enabled interoperable and scalable networking, applications,
and services for effective sharing of electronic health
records, flexible data representation including semantic
metadata, and more efficient services that access such health
data.
However, the integrated view of overall global care
outcomes, over-prescriptions and billing integrity cannot be
easily addressed by the traditional e-Health architecture
solutions as they are more focused on the needs of Figure 1. e-Health interconnections
clinical/hospital/lab usages. To optimize the accountability
of the e-Health usage data, a new solution direction is Among the many functions of a continuously scalable
necessary to enhance audit access of e-Health data while universal exchange for current and future e-Health with data
balancing it with government mandates in privacy and originating from diverse sources in multiple formats, key
security. advance processing methods are required for 1) controlling
The new approach in this paper is to explore the and maintaining data integrity, provenance, security, privacy
Advanced Block-Chain paradigm [2] for e-Health record and reliability; 2) providing trustworthy patient identification
keeping and while addressing the special needs of patient and authentication and access control protocols; and 3)
privacy. As society is moving towards peer networking and maintaining sensitivity to cultural, legal and ethical issues
on-line practices, we are going to combine the best parts of associated with universally accessible e-Health data.
two worlds in both the healthcare regulation and the One example of advanced architecture development is in
technology revolution while formulating advanced solutions. Smart and Connected e-Health Service [7]. It was designed
978-1-5090-6704-6/17/$31.00 ©2017 IEEE 37
2017 19th International Conference on E-health Networking, Application & Services (HealthCom): The 2nd IEEE International
Workshop on Emerging Technologies for Pervasive Healthcare and Applications (ETPHA 2017)
with context-aware networking capability allowing that any into blockchains. We called our new solution Advanced
application-oriented services will push the security policies Block-Chain (or A.B.C.) e-Health architecture solution.
down to the network layer. The access devices and their
adaptor gateways are regulated with the e-Health security
scheme to facilitate dynamic fork/join of the e-Health III. E-HEALTH BLOCK-CHAIN FUNDAMENTALS
network flows. Cross-layer management further provisions In the context of e-Health, a blockchain maintains a
with centralized security service management to guarantee sequence of care records, lab activities, prescription
the cross-layer performance as well as security assurance. dispense, insurance billings and other supporting activities
involving patients, healthcare service providers and
supporting organizations. Inside a continuously growing
linked list of medical records, each block contains a
timestamp and a link to a previous block.
The first blockchain was invented by Satoshi Nakamoto
in 2008 [2]. Functionally, a blockchain can serve as an open,
distributed ledger that can record transactions between two
parties efficiently and in a verifiable and permanent way.
The ledger itself can also be programmed to trigger
transactions automatically.
After a successful implementation in the Bitcoin
transactions, the design of a public ledger for all transactions
has been the inspiration for other applications such as
automatic legal services, insurance processing and even
supply chain tracking of merchandize. All require to solve
the security integrity problem, while without the use of a
Figure 2. Smart and Connected Secured e-Health Clouds trusted authority or central server.
Before we describe our architecture design, let us review
some technical features [17, 18] in the contexts of blockchain
Another major architecture advancement is the BDeHS
e-Health flows.
[8,9] approach for big data e-Health model that provided
trustworthy patient identification and authentication and A. e-Health Block Chain
access control protocols, maintaining the sensitivity to the The key concept is an e-Health transaction which is re-
legal, cultural and ethical issues associated with universally defined as any occurrence of healthcare record generation,
accessible e-Health data of variety of types (structured, semi- submission and exchange. This broad concept can cover
structured and unstructured) from variable data sources, EMR, EHR, e-Prescribe, a Lab request and report including
including simple blood test and complex DICOM files, as well as
• HL7 (Health Level 7) well-structured messaging [10,11]; insurance billing and payment.
• NCPDP (National Council for Prescription Drug The e-Health Block Chain constitutes all published care
Program) prescription insurance claims and NCPDP related transactions in the block format, each linking to the
SCRIPT for electronic prescription messaging [12]; previous block and linked to by the next e-Health block.
• DICOM (Digital Imaging and Communications in B. Distributed Database
Medicine) semi-structured data for radiology image Each party on a blockchain has access to the entire
exchanges over IP networks [13]; database and its complete history. After the e-Health data is
• ISO/IEEE suite of protocols and messaging standards for posted and validated, no single party controls the data.
digital health monitoring and diagnostics devices [14]; Because the open access to the e-Health blockchains,
correlations between records will pave new ways for medical
• HIPAA transactions for insurance claims and other research and pandemic or epidemic reporting. The whole
privacy and security regulation standards [15,16]; society can benefit from this architecture arrangement.
• Internal e-Health system logging and security audit C. Peer-to-Peer Transmission
records with semi-structured data as far as end-to-end Communication occurs directly between peers instead of
system flows are concerned; and through a central node. Each node stores and forwards
• Operational data including security events and usage information to all other nodes. In healthcare activities, the
accounting/charging functions. patients and service providers’ records no longer have to be
shuffled around via a huge admin center or insurance.
While most of these system architectures could be Instead each party posts the activities involved to the e-
preserved for a blockchain environment, the external data Health blockchain. Once they are validated and agreed upon
links and communication format will be totally revamped via the blockchain protocol, the admin center and insurance
companies become a pure consumer of the original e-Health
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2017 19th International Conference on E-health Networking, Application & Services (HealthCom): The 2nd IEEE International
Workshop on Emerging Technologies for Pervasive Healthcare and Applications (ETPHA 2017)
activity blocks. Of course, the insurance payments could further woven into multiple dimensional blockchains as
form their own blocks outside the healthcare one which are illustrated in Figure 4.
the center of the next generation e-Health solution. Healthcare service providers (SP) applies digitization of
fast e-Health resources and publish available records during
D. Transparency and auto tracking transfer of ownership in handling patient cares, so cares can
Every transaction and its associated value are visible to be conducted at a speed more in line with the pace of doing
anyone with access to the system. Each node, or user, on a e-business.
blockchain has a unique 30-plus-character ID that identifies Through the use of IDs and permissions, patients can
it. Users can choose to remain anonymous or provide proof specify which e-Health record details they want others to be
of their identity to others. permitted to view. Permissions can be expanded for
Every party can verify the records of its transaction government agencies and auditors, who may need access to
partners directly, without an intermediary. Audit of care more healthcare detail. Having a shared blockchain that
services become feasible by all interested parties. Excessive serves as a single source of truth improves the ability to
cure procedures or abusive consumption of healthcare monitor security and audit the cares.
resources can be detected by constantly mining the public e-
Health blockchains.
E. Irreversibility of Records
Blockchains are secure by design and are an example of a
distributed computing system with high security fault
tolerance. Blockchains are inherently resistant to
modification of the data, because the data in any given block
cannot be altered retroactively without the alteration of all
subsequent blocks and the collusion of the network.
Once a transaction is entered in the database and the
accounts are updated, the records cannot be altered, because
they’re linked to every transaction record that came before
them (hence the term “chain”). Various computational
algorithms and approaches are deployed to ensure that the
recording on the database is permanent, chronologically Figure 3 e-Health block solution
ordered, and available to all others on the network.
F. Computational Logic
The digital nature of the ledger means that blockchain
transactions can be tied to computational logic and in
essence programmed. So users can set up algorithms and
rules that automatically trigger transactions between nodes.
The embedded procedures cover security audits,
regulation compliance reporting, billing updates, medication
allergy alerts, over-prescription thresholds and personalized
medicine tied-in to a specific patient cure blockchain.
IV. E-HEALTH BLOCK-CHAIN ARCHITECTURE
Decentralized consensus is achieved with a blockchain,
which makes blockchains potentially suitable for the
recording of medical records, treatment events, patient Figure 4. Advanced Block-Chains
identity management and documenting provenance.
However, there are additional hurdles to overcome when an In the figure 4 above, there are two dimensional
e-Health application is riding directly on a classical processing threads for the e-Health blockchains. The patient
blockchain implementation of care record distributions. initiated chains forms the information equivalent to the
currently know EHR (Electronic Health Records) yet in a
A. e-Health Blockchain Protocol total different format (i.e., in the e-Health block format with
These blocks can contain any subset and combinations additional block ID and initiating parties’ digital signatures).
of the existing HL7 messages, Lab LOINC codes, ICD On the vertical processing threads are the e-Health blocks as
codes, e-Prescribe as well as the block ID and corresponding processed by the service providers for their rendered
signatures from the e-Health service providers and/or the treatment services. Each blocks have to be signed by all
patients acknowledging to the acceptance of care. Figure 3 involving parties before posting. And they are validated by
below is an illustration of the e-Health block that can be the e-Health blockchain protocol.
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2017 19th International Conference on E-health Networking, Application & Services (HealthCom): The 2nd IEEE International
Workshop on Emerging Technologies for Pervasive Healthcare and Applications (ETPHA 2017)
While the above figure only shows a two-dimensional decision making and collaboration. The engine provides the
blockchain structure, a multiple dimensional blockchain are essential supports to other functional blocks in:
conceivable when we adds regulatory processing flows and • adaptation rules,
other conformance requirements. Additional system level • orchestration of service logics,
components will be shown on next page, after the key e- • API abstraction virtual machine,
Health blockchain functions are described. • decision rules and processing supports,
B. Inter-Domain Adatations • regulatory compliance rules to drive other additional
services such as reporting, discovery and research.
Before each party issues an e-Health record to document
the activity, adaptations into a common block syntax is F. e-Health Value Added Systems
required for healthcare service providers and patients alike to Additional value-added service systems are derived from
post those blocks. accessing to the SP-and-patient identities with voluntarily
While traditional e-Health element platforms may be disclosure. For example, a supporting entity such as
used by the blockchain to augment processing. They now insurance may obtain identification information and extract
have to be augmented via adaptation gateways such that and process the e-Health blocks as referenced by a billing
requests and responses can become part of the blockchain. block chain without the physicians to submit billing requests
Existing data systems may provide data to influence the as in existing flows. These activities are in turn automatic
behavior of smart contracts and help to define how because of the computational logic in e-Health blocks
communications and data transfer will occur between automatically trigger billing processing and payment
traditional applications/data and the blockchain via gateway transactions between nodes in insurance and in a doctor’s
API calls through an e-Health cloud. office.
C. Certificate Authority and Security Operations As another example, various reporting services can be
supplied when working with the ABC e-Health service
Before any party can participate in the blockchain, it has engine after appropriate compliance rules are provisioned
to be certified and be issued with an authenticated certificate. and constantly updated. Additional value added applications
A security manager in the e-Health blockchain cloud will
can be extended to health care research and discoveries.
constantly monitoring the security with a predesignated
The following figure 5 summarizes the key components
domain.
as a system solution.
While the e-Health blockchain usually operate without
intermediary intervention, a regulated operational authority
can still be instituted. When there are any occasionally non-
convergence in blockchain reconciliation as demonstrated in
the 2014 Bitcoin (i.e., occurrences of inconsistent and non-
convergence transaction records), the e-Health services
industry cannot simply rely on the faith of the underlying
blockchain protocol to resolve. Since timing is the essence
in most of e-Health services, especially in accurate care
scenarios.
D. Regulatory Conformance
The e-Health blockchain enhances the privacy as
required since HIPAA [15, 16] and facilitates regulatory
conformance. Through the use of IDs and permissions,
patients can specify which e-Health record details they want
others to be permitted to view. Permissions can be expanded
for government agencies and auditors, who may need access
to more healthcare detail. Having a shared blockchain that Figure 5. Advanced Block-Chain Systems
serves as a single source of truth improves the ability to
monitor security and audit the cares. Besides the patients and service providers described
E. Advanced Blocck-Chain (ABC) e-Health Engines earlier, additional participants on an e-Health blockchain
network play a role in its operation. An e-Health blockchain
Unlike the passive adaptation gateways that mechanically regulator attends special permissions to oversee the records
translate with the e-Health blockchain protocols, the ABC e- happening within the network. Blockchain developers create
Health engines provide health-specific logic to trigger smart the e-Health application services and smart e-Health
transactions defined as a proven treatment procedure flows contracts that follow the healthcare flows. The e-Health
with maximize automation in mind. blockchain operators have special monitor the blockchain
This is where the AI (artificial intelligence) and machine network. Last but not least, the Certificate authority issues
learnings are integrated with the blockchain technology for and manages the different types of certificates required to
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2017 19th International Conference on E-health Networking, Application & Services (HealthCom): The 2nd IEEE International
Workshop on Emerging Technologies for Pervasive Healthcare and Applications (ETPHA 2017)
run a permissioned blockchain either for blockchain users or of interactions (among healthcare service providers) must
to individual transactions. serve as the primary sequence of events for the reason of
placing the Patient-SP interactions. Future flows have to be
V. BENEFITS AND LIMITATIONS migrated to the new Advanced Block-Chain paradigm and
The key benefits of adopting an Advanced Blocked- derive the inter-SP events using the Patients as focal points.
Chain e-Health architecture approach are in many folds. Even with these challenging limitations, we are still very
The opening of accountable treatment records and confident with this direction of e-Health advanced
insurance billing records sets new cost-effective analysis and blockchain solution as our design and analysis have shown
place them directly into the hands of the public. Our solution the feasibility and great potential in access, reliability and
provides auditable e-Health records while preserving patient growth of new services. The most significance of this efforts
privacy and security. Medical researchers are open to access is in the ultimate purpose of fulfilling the calls for digital
the vast e-Health blocks, while government and regulatory health care priorities [19, 20, 21] around the global world.
agencies are given additional identifiers for audit and
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2017 19th International Conference on E-health Networking, Application & Services (HealthCom): The 2nd IEEE International
Workshop on Emerging Technologies for Pervasive Healthcare and Applications (ETPHA 2017)
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