Distributed Ledger Technology in Healthcare: Advancing Governance Architectures and Performance Engineering in Decentralized Ecosystems

Abstract

Healthcare data infrastructures remain fragmented, insecure, and characterized by low trust, hindering interoperable, patient-centric care. Centralized architectures struggle with multi-stakeholder governance, fine-grained accountability, and performance at scale under real-world workloads. Distributed ledger technology (DLT) promises immutability, distributed trust, auditability, and strong provenance, yet most healthcare implementations focus on narrow use cases, ad-hoc governance choices, or limited performance benchmarking. This paper designs and empirically evaluates an integrated governance architecture and performance engineering framework for healthcare DLT ecosystems. The approach combines (i) a theoretical synthesis of DLT governance and health data governance, (ii) architecture and protocol design for permissioned and hybrid platforms (e.g., Corda, Hyperledger Fabric, Ethereum-based frameworks, edge–blockchain hybrids), and (iii) testbed implementations with multi-scenario benchmarking across local, cloud, and edge-integrated deployments. Results from representative use cases—EHR interoperability, m-health/IoT streaming, and self-sovereign identity and consent—show that DLT-enabled governance can strengthen integrity, accountability, and patient control while achieving acceptable throughput–latency envelopes compared with centralized baselines, subject to explicit trade-offs between decentralization, audit granularity, and scalability. The paper distils design guidelines and reusable governance–performance patterns for large-scale, interoperable DLT health ecosystems, clarifying when to Favor platform choices, consensus mechanisms, and data-management strategies given domain-specific requirements.