BACKGROUND: In clinical genomics, sharing of rare genetic disease information between genetic databases and laboratories is essential to determine the pathogenic significance of variants to enable the diagnosis of rare genetic diseases. Significant concerns regarding data governance and security have reduced this sharing in practice. Blockchain could provide a secure method for sharing genomic data between involved parties and thus help overcome some of these issues. OBJECTIVE: This study aims to contribute to the growing knowledge of the potential role of blockchain technology in supporting the sharing of clinical genomic data by describing blockchain-based dynamic consent architecture to support clinical genomic data sharing and provide a proof-of-concept implementation, called ConsentChain, for the architecture to explore its performance. METHODS: The ConsentChain requirements were captured from a patient forum to identify security and consent concerns. The ConsentChain was developed on the Ethereum platform, in which smart contracts were used to model the actions of patients, who may provide or withdraw consent to share their data; the data creator, who collects and stores patient data; and the data requester, who needs to query and access the patient data. A detailed analysis was undertaken of the ConsentChain performance as a function of the number of transactions processed by the system. RESULTS: We describe ConsentChain, a blockchain-based system that provides a web portal interface to support clinical genomic sharing. ConsentChain allows patients to grant or withdraw data requester access and allows data requesters to query and submit access to data stored in a secure off-chain database. We also developed an ontology model to represent patient consent elements into machine-readable codes to automate the consent and data access processes. CONCLUSIONS: Blockchains and smart contracts can provide an efficient and scalable mechanism to support dynamic consent functionality and address some of the barriers that inhibit genomic data sharing. However, they are not a complete answer, and a number of issues still need to be addressed before such systems can be deployed in practice, particularly in relation to verifying user credentials.
Introduction and Structural Organization of Transplantation in Argentina Argentina is the eighth largest country in the world (surface area of 2,780,400 km2), and the third most populated country in South America (its estimated population is 44,494,502). It is divided into 24 autonomously governed provinces (1). The health care system in Argentina, which covers >22 million people, is decentralized, with multiple state-dependent funders consisting of social security, public, and private subsectors. There are 4.5 hospital beds per 1000 inhabitants and 3.49 physicians per 1000 inhabitants (overall there are 166,187 physicians in the country) (2,3). There is one nephrologist for every 40 patients, ranking third in Latin Ame rica in terms of the number of nephrologists per million inhabitants (4,5). The first kidney transplantation in Argentina was performed in Buenos Aires in 1957 by Lanari et al. (6). Over the next several decades, a series of laws were sequentially passed, aiming to streamline the national transplantation processes. These ultimately led to the creation of a single national, decentralized organization called the National Central Institute for the Coordination of Ablation and Implantation (INCUCAI), an entity under the National Ministry of Health. INCUCAI's mission is to promote, regulate, and coordinate activities related to the procurement and transplantation of organs, tissues, and cells at a national level, guaranteeing transparency, equity, and quality (7). In 2003, the INCUCAI created a database system called The National Procurement and Transplantation Information System of the Argentine Republic to track, assess, regulate, and manage all transplant activities in Argentina. It provides free online access to all essential information related to organ transplantation and the registry of patients on dialysis. This system is also used to help guide health policies and clinical research (8). The country is divided into five procurement regions, encompassing 157 transplantation centers. Of these centers, 61 perform kidney transplants, 35 liver, 16 kidney-pancreas, 28 heart, eight lung, five heart and lung, and four intestinal transplants. Historically, the vast majority of transplant surgeries were performed by a combination of vascular surgeons and urologists, but recently general surgeons specifically trained in multiorgan transplantation services have joined the services and established laparoscopic living donor nephrectomy techniques. Pre- and post-kidney transplant care is managed by transplant nephrologists as a fundamental part of a multidisciplinary team that also includes psychologists, social workers, specialized nurses, etc. The Argentine Society of Transplantation, which brings together all transplant professionals, was established in 1982 (3,4). Argentina supports the Declaration of Istanbul and participates actively through its scientific societies in the summit of the Pontifical Academy of Sciences to combat organ trafficking and transplant tourism (3,7). Kidney Transplantation in Argentina The characteristics of the kidney transplant population in Argentina are shown in Table 1. There have been 15,774 kidney transplants performed in Argentina since 1998 (1). Of these, 89% were performed in adult patients and 11% in pediatric ones. The majority of transplants originate from deceased donors with the predominant cause of death being stroke (52%) and traumatic brain injury (39%) (1,8). In 2005, a major initiative was made to increase organ donation by the passing of the Law of Presumed Consent. However, although this law established that all persons should be considered potential donors, donation still required confirmation from a family member. This law was updated in 2018 that established that all people are potential donors, unless they had previously declared themselves as nondonors to INCUCAI. Although family refusal to donate was already decreasing (from 45% in 2016 to 33% in 2018), the new law further reduced the rate of refusal to 13% in 2019. These changes have increased the donation rate from 11.8 per million population (PMP) in 2016, to 15.8 PMP in 2018, and 19.9 PMP in 2019. Indeed, barriers to donation are now more logistical in nature (e.g., limitations in the universal harvesting and transportation of organs throughout the country), rather than due to social or cultural grounds. Table 1. - Characteristics of kidney transplant recipients in Argentinaa General Characteristics of the Health Care in ESKD and Kidney Transplant in Argentine Population 44,938,712 Population on dialysis (HD+PD) 30,607 Population of ESKD on the waiting list 5221 (17%) Population with a functioning kidney transplant 11,486 Adult LDKTs (2019) 3998 (92%) Pediatric LDKTs (2019) 367 (8%) Number of KT centers 61 Cost of peritransplant module (20 days post-transplantation) US$4840 b Monthly cost of the post-transplantation module (average) US$212 b Comparison DDKT DDKT LDKT Total KT from 1998 to the present 15,740 5069 KT per year (2019) 1232 359 Source: DDKT versus LDKT, % 69 31 Age of the recipient, yr, mean±SD 45.5 (45.2–45.8) 36.3 (35.9–36.7) Male, % 57% 57% Cold ischemia time, mean±SD 19.37 (19.2–19.5) 1.5 (1.35–1.62) Time on dialysis until kidney transplantation, mean±SD 6.1 (5.97–6.22) 1.96 (1.89–2.05) Years on the waiting list, mean±SD 2.32 (2.35–2.40) 0 Causes of death post-transplant, % DDKT LDKT Infection 43 36 Cardio-cerebrovascular 24 19 Other 15 13 Neoplasm 7 19 Causes of graft loss, % DDKT LDKT Chronic allograft dysfunction 38 48 Others 30 32 Acute rejection 17 15 Primary nonfunction 7 1 Vascular complications 3 2 Urological complications 1 1 Infection 2 0 Noncompliance 1 0 Recurrent disease 1 1 HD, hemodialysis; PD, peritoneal dialysis; KT, kidney transplant; LDKT, living donor kidney transplant; DDKT, deceased donor kid ney transplant.aOfficial data from National Central Institute for the Coordination of Ablation and Implantation between January 1, 1998 and December 31, 2019.bUsing the unofficial exchange rate as of August 2021 (approximately 186 Argentine pesos per dollar). Despite these advances in donation, overall transplantation rates are insufficient to meet demand. The overall ESKD dialysis population in Argentina is 30,607 patients, of whom 5221 (17%) are on the waiting list (2). The average waiting time on the transplant list is >6 years. In 2019, there were 1674 kidney transplants, 69 simultaneous kidney-pancreas, 19 kidney-liver, and five kidney-heart transplants. Of the 1674 kidney transplants, 1325 (79%) were deceased donor kidney transplants (DDKT) and 349 (21%) were living donor kidney transplants (LKTD). This percentage of LKDT has hovered between 20% and 30% over the last 10 years. In total, 97% of LKDTs came from related donors, and 14% were performed preemptively. Although paired donation is allowed in the national exchange program, they are quite rare. The cost of renal transplantation is predominantly covered by governmental agencies including the National Institute of Social Security for Retirement and Pensions (47%), public insurance (35%), and provincial social security (12%); commercial insurance accounts for the remaining <10%. These insurances cover almost all transplant-related costs. In general, patients do not incur any out-of-pocket costs for any post-transplant care, other than for a few prophylactic medications. In 2021, the estimated cost for the kidney transplantation module (including kidney transplant surgery and all immunosuppression and general medication during first 20 days) was close to US$4840 (considering the unofficial exchange rate of approximately 186 Argentine pesos per dollar; however, there is an alternative market with values that differ greatly from the official ones because the Argentine government imposes very high taxes and strict restrictions for the purchase of foreign currency). It was US$212 per consult for the monthly post-transplantation module (monthly outpatient clinic visit) (4). Outcomes and most Common Complications of Kidney Transplantation in Argentina As expected, adults that receive an LDKT have better patient and graft survival rates than adults receiving DDKT (5,8). Patient survival rates for LDKT versus DDKT were 98% versus 90%, 95% versus 80%, and 90% versus 68%, at 1, 5, and 10 years, respectively. However, graft survival rates were 97% versus 83%, 87% versus 66%, and 71% versus 46%, for these same time points (Figure 1, A and B) (5,8). The main causes of graft loss in DDKT were chronic allograft dysfunction (38%) followed by acute rejection (17%), primary nonfunction (7%), infections (2%), vascular complication (3%), urological complication (1%), noncompliance (1%), recurrent disease (1%), and others (30%) (5,8). Of note, in Argentina, infection constitutes a main cause of death in patients with functioning grafts close to 43% for DDKT, similar to that reported by the Latin America Dialysis and Transplant Registry (9).Figure 1.: Patient and graft survival in deceased donor kidney transplant versus living donor kidney transplant in Argentina from 1998 to 2019. LDKT, living donor kidney transplant; DDKT, deceased donor kidney transplant.Effect of Delayed Graft Function A major challenge for optimizing transplant outcomes in Argentina, as in most of Latin America, is the high incidence of delayed graft function (DGF) after DDKT (approximately 60%). The causes of DGF in Argentina are multifactorial, but predominantly related to suboptimal organ maintenance due to prolonged cold ischemia time and limited access to extracorporeal perfusion machines (9,10). Because DGF results increased length of stay, need for dialysis, infection rates, acute rejection (with the associated decrease in graft and patient survival), and costs, it has had an increasingly detrimental effect on the advancement of kidney transplantation in Argentina. Other barriers negatively affecting organ donation in the country include: (1) sociocultural problems related to fear and myths about donation, (2) lack of educational campaigns in schools, (3) lack of early identification of potential donors in the health care facilities, and (4) suboptimal education regarding transplantation to health care personnel (3,9). Future Perspectives and New Challenges The kidney transplant program in Argentina has made much progress since its inception. Some of the major advances include (1) a legal framework and structured governmental organizations that oversee organ donation and transplantation, these have improved access to transplants; (2) the development of a network of highly skilled personnel, which has improved outcomes due to better transplant and post-transplant care; and (3) an online registry system for traceability of donation-transplantation process (5). However, there are still several challenges to overcome. First, we must further educate our health care administrators and funders so they recognize that kidney transplantation is the most cost-effective treatment for advanced CKD, because it not only restores the patient's quality of life, but also significantly improves survival (compared with patients that remain on dialysis), and lowers public health costs. That is, it needs to be recognized as the treatment of choice. Second, we must increase the donor pool by increasing the use of expanded criteria deceased donors and strongly encourage the growth of LDKT programs. Finally, we must improve organ preservation by incorporating the routine use extracorporeal perfusion machines, reduce cold-ischemia times, and develop donor procurement protocols for organ harvesting post-circulatory death. We believe these measures would further improve the national transplant program. Disclosures R.A. Maldonado reports receiving speaker honoraria from AstraZeneca, Novartis, and Sandoz; reports being a scientific advisor or member as the Coordinator of Transplant Work Group of the Argentine Society of Nephrology, and Member of Kidney Transplant Committee of Argentine Society of Transplantation; and reports other interests/relationships as President of the Córdoba Society of Nephrology. The remaining author has nothing to disclose. Funding None.
Pedro Elkind Velmovitsky, Frederico M. Bublitz, Laura Fadrique, Plinio Pelegrini Morita
BACKGROUND: Although big data and smart technologies allow for the development of precision medicine and predictive models in health care, there are still several challenges that need to be addressed before the full potential of these data can be realized (eg, data sharing and interoperability issues, lack of massive genomic data sets, data ownership, and security and privacy of health data). Health companies are exploring the use of blockchain, a tamperproof and distributed digital ledger, to address some of these challenges. OBJECTIVE: In this viewpoint, we aim to obtain an overview of blockchain solutions that aim to solve challenges in health care from an industry perspective, focusing on solutions developed by health and technology companies. METHODS: We conducted a literature review following the protocol defined by Levac et al to analyze the findings in a systematic manner. In addition to traditional databases such as IEEE and PubMed, we included search and news outlets such as CoinDesk, CoinTelegraph, and Medium. RESULTS: Health care companies are using blockchain to improve challenges in five key areas. For electronic health records, blockchain can help to mitigate interoperability and data sharing in the industry by creating an overarching mechanism to link disparate personal records and can stimulate data sharing by connecting owners and buyers directly. For the drug (and food) supply chain, blockchain can provide an auditable log of a product's provenance and transportation (including information on the conditions in which the product was transported), increasing transparency and eliminating counterfeit products in the supply chain. For health insurance, blockchain can facilitate the claims management process and help users to calculate medical and pharmaceutical benefits. For genomics, by connecting data buyers and owners directly, blockchain can offer a secure and auditable way of sharing genomic data, increasing their availability. For consent management, as all participants in a blockchain network view an immutable version of the truth, blockchain can provide an immutable and timestamped log of consent, increasing transparency in the consent management process. CONCLUSIONS: Blockchain technology can improve several challenges faced by the health care industry. However, companies must evaluate how the features of blockchain can affect their systems (eg, the append-only nature of blockchain limits the deletion of data stored in the network, and distributed systems, although more secure, are less efficient). Although these trade-offs need to be considered when viewing blockchain solutions, the technology has the potential to optimize processes, minimize inefficiencies, and increase trust in all contexts covered in this viewpoint.
Vicent Cholvi, Antonio Fernández Anta, Chryssis Georgiou, Nicolas Nicolaou · 6 authors
In order to formalize Distributed Ledger Technologies and their interconnections, recent research has introduced the concept of a Distributed Ledger Object (denoted $$\mathcal {O}^L$$ ), a concurrent abstraction that maintains a totally ordered sequence of records, capturing the essence of blockchains and distributed ledgers. In this work, we introduce the Distributed Grow-only Set object (denoted $$\mathcal {O}^{GS}$$ ), a novel abstraction that, unlike the $$\mathcal {O}^L$$ , maintains an immutable set of records by supporting only Add and Get operations. This object is inspired by the Grow-only Set (G-Set) a well-known Conflict-free Replicated Data Type (CRDT). We formally define the $$\mathcal {O}^{GS}$$ and present a Byzantine-tolerant, consensus-free implementation (denoted as $$\mathcal {O}^{GS}_B$$ ) that ensures eventual consistency. Building on this implementation, we propose consensus-free algorithmic solutions to two fundamental problems: the Atomic Appends problem, which concerns atomically appending multiple records to distinct ledgers, and the Atomic Adds problem, its counterpart in the context of G-Sets. Additionally, we show how the $$\mathcal {O}^{GS}_B$$ can be leveraged to construct a consensus-free, Single-Writer Byzantine-tolerant $$\mathcal {O}^L$$ . We argue that the applicability of the $$\mathcal {O}^{GS}_B$$ extends well beyond these specific use cases, offering a lightweight and efficient foundation for a variety of distributed applications.
Vicent Cholvi, Antonio Fernández Anta, Chryssis Georgiou, Nicolas Nicolaou · 6 authors
In order to formalize Distributed Ledger Technologies and their\ninterconnections, a recent line of research work has formulated the notion of\nDistributed Ledger Object (DLO), which is a concurrent object that maintains a\ntotally ordered sequence of records, abstracting blockchains and distributed\nledgers. Through DLO, the Atomic Appends problem, intended as the need of a\nprimitive able to append multiple records to distinct ledgers in an atomic way,\nis studied as a basic interconnection problem among ledgers.\n In this work, we propose the Distributed Grow-only Set object (DSO), which\ninstead of maintaining a sequence of records, as in a DLO, maintains a set of\nrecords in an immutable way: only Add and Get operations are provided. This\nobject is inspired by the Grow-only Set (G-Set) data type which is part of the\nConflict-free Replicated Data Types. We formally specify the object and we\nprovide a consensus-free Byzantine-tolerant implementation that guarantees\neventual consistency. We then use our Byzantine-tolerant DSO (BDSO)\nimplementation to provide consensus-free algorithmic solutions to the Atomic\nAppends and Atomic Adds (the analogous problem of atomic appends applied on\nG-Sets) problems, as well as to construct consensus-free Single-Writer BDLOs.\nWe believe that the BDSO has applications beyond the above-mentioned problems.\n
In this paper, we develop a foundation for a constellation of Low Earth Orbit (LEO) satellite IoT by constructing a Blockchain-based framework for continual knowledge sharing and learning collaboratively. This approach is directly applicable for a swarm of Unmanned Aerial Vehicles (UAVs). We ablate Federated Learning (FL) successful features as a basis to ensure high precision of learning inferences at timescales relevant to the underlying time-varying space network and channel dynamics. In such a dynamic setting, there is always a likelihood that miners may be compromised or fail to propagate information in time because of some intrinsic factors such as channel impairments, satellite handovers and attacks. Such transmission failures often lead to undesirable forking events in the Blockchain. Consequently, maintaining a low energy consumption and smallish delay in such an erratic network is highly nontrivial and challenging. To quantify the impacts of the forking and minimize the occurrence of such unwanted events and their adverse effects, we develop a procedure to estimate the expected energy consumption for a given set of miners, block transmissions, and LEOs’ or UAVs’ mobility. Besides, we shed light on deep learning-based resource allocation for mobile mining and demonstrate the synergic gain of FL with Blockchain.
Abstract This paper proposes a novel way to understand trust in blockchain technology by analogy with trust placed in institutions. In support of the analysis, a detailed investigation of institutional trust is provided, which is then used as the basis for understanding the nature and ethical limits of blockchain trust. Two interrelated arguments are presented. First, given blockchains’ capacity for being institution-like entities by inviting expectations similar to those invited by traditional institutions, blockchain trust is argued to be best conceptualized as a specialized form of trust in institutions. Keeping only the core functionality and certain normative ideas of institutions, this technology broadens our understanding of trust by removing the need for third parties while retaining the value of trust for the trustor. Second, the paper argues that blockchains’ decentralized nature and the implications and effects of this decentralization on trust issues are double-edged. With the erasure of central points, the systems simultaneously crowd out the pivotal role played by traditional institutions and a cadre of representatives in meeting their assigned obligations and securing the functional systems’ trustworthy performances. As such, blockchain is positioned as a technology containing both disruptive features that can be embedded with meaningful normative values and inherent ethical limits that pose a direct challenge to the actual trustworthiness of blockchain implementations. Such limits are proposed to be ameliorated by facilitating a shift of responsibility to the groups of people directly associated with the engendering of trust in the blockchain context.
5G and beyond (B5G) networks significantly promote the popularity and ubiquity of drones by providing high-throughput and low-latency communication. In B5G drone networks, data sharing among drones has great potential to improve and enrich civilian and commercial applications, such as surveillance monitoring. Nevertheless, a series of security challenges arise such as data privacy leakage due to the lack of reliable centralized supervision. In this article, we employ the permissioned blockchain technology to propose a decentralized data management system. The permissioned blockchain deployed at pre-selected ground base stations is particularly suitable and practical for ensuring efficient peer-to-peer data sharing in B5G drone networks. However, the ground base stations working as miners are widely deployed without strong security protection, which may be compromised to produce maliciously manipulated results during the block verification in the permissioned blockchain. Hence, the miner selection is crucial for the permissioned blockchain-based B5G drone networks. We therefore introduce credit as a metric and propose a secure credit-based miner selection scheme using a four-weight subjective logic model. Numerical results demonstrate that the proposed schemes are effective for secure data sharing in permissioned blockchain-based B5G drone networks.
Diana Hawashin, Dunia J. Mahboobeh, Khaled Salah, Raja Jayaraman · 7 authors
Today’s a large number of blood donation management systems fall short in providing traceability, immutability, transparency, audit, privacy, and security features. Also, they are vulnerable to the single point of failure problem due to centralization. In this paper, we propose a private Ethereum blockchain-based solution to automate blood donation management in a manner that is decentralized, transparent, traceable, auditable, private, secure, and trustworthy. The proposed solution stores non-critical and large data off-chain using the decentralized storage of the InterPlanetary File System (IPFS). We present the system architecture, sequence diagrams, entity-relationship diagram, and algorithms to briefly explain the working principles of our blood donation management solution. We evaluate the performance of our solution in terms of efficiency and effectiveness through performing security analysis. We make our smart contract code publicly available on Github1.
The scarcity and exigency for blood and organs has created many discrepancies in current approaches. These have created the criteria for malpractices such as organ trafficking and black market selling. This research presents a solution with a secured-smart blood and organ donation web developed system, allowing both patients and healthcare providers to access information about the blood and organ processing records. The database would be managed using the Blockchain technology which could be only accessed by authorized users. Finally, tracking all registered donors, the proposed system generates a smart identity developed by Ethereum Smart Contract (ESC). System predicts blood demand for the future ten years using Linear Regression Model with 0.998 of high R-squared accuracy value. This reduces shortages and wastage of blood. Also, using global positioning system and K-Nearest Neighbors Machine Learning algorithm, the system finds the best matches among donors and seekers according to the nearest location. Further, the system will automatically send questionnaires for registered users to identify and evaluate their awareness and issues about organ donation. Overall, this study aims for a secured and transparent web application. Thus, it facilitates an innovative and a productive blood donation and organ transplantation process in Sri Lankan healthcare sector.
Li Jiang, Bin Chen, Shengli Xie, Sabita Maharjan · 5 authors
In unmanned aerial vehicle (UAV) networks, UAVs-assisted wireless power transfer is a promising approach to charge low-power smart devices for energy replenishment. However, security and privacy concerns associated with the energy micro-transactions in untrusted wireless trading environment present serious challenges. In this paper, we exploit Directed Acyclic Graph (DAG) and consortium blockchain to propose a new distributed and secure UAVs-assisted wireless power transfer framework named aerial-ground chain, where heterogeneous consensus is developed to verify the energy micro-transactions. Specifically, the UAVs verify energy micro-transactions simultaneously but asynchronously to form an aerial tangle. The smart devices also participate in maintaining the aerial tangle. We define timeout for the energy micro-transactions, and leverage a set of Access Points (APs) to cooperatively confirm the timeout energy micro-transaction by utilizing consortium blockchain, to form a ground main chain. Furthermore, a contract theory based resource cooperation scheme is designed to motivate the UAVs to participate in wireless power transfer, and to incentivize the APs to contribute their resources in cooperatively verifying the timeout energy micro-transactions. Security analysis and numerical results illustrate that the developed aerial-ground chain and the designed contract theory based resource cooperation scheme are secure and efficient for UAVs-assisted wireless power transfer.
Since the first successful kidney transplant in 1954, organ donation and transplantation has been an important medical treatment that improves the lives of thousands of patients who experienced organ failure(s). However, the allocation of scarce kidneys is a complex process, partially due to a significant imbalance between kidney supply and demand. To solve this issue, a number of allocation algorithms have been used and a few blockchain-based solutions have been proposed. To improve organ donation and cover more patients in need, organizations responsible for organ donation around the world are looking to combine their efforts. Nevertheless, there are still many unanswered questions. For instance, organ allocation policies and guidelines considerably differ depending on the country, and hence international regulations are needed. One of the important aspects of such regulations is the fact that the data from stakeholders and the matching patients - donors algorithm is stored in the central point of these organizations. In this short survey, we investigate existing organ allocation algorithms. The focus of this paper is on blockchain-based decentralized systems. Out of many organ donation systems, the aim of this review is on kidney allocation algorithms, this choice is justified by the fact that the kidney is one of the most in-demand organ transplants. We also discuss some limitations in exiting organ donation systems and allocation algorithms and elaborate on how blockchain technologies could be the cornerstone technology to solve some of the existing issues in the area of organ donation.
COVID-19 made the world stop, with people trapped inside their homes and governments trying to restrict the public movement. However, to accomplish this, one big problem that emerged and outscored everything else was catering to the day to day necessary items of the people without human involvement. In this regard, we propose a blockchain-enabled secure communication framework for delivering the goods in COVID-19 like scenarios by leveraging the drones that are available with commercial retail providers. The blockchain scheme is used to create smart contracts to build the trust of buyers and sellers on the framework as the payments are made through the smart contract executions. The blockchain based order processing ensures the integrity and authenticity of the information. Moreover, a communication model is presented along with the order, delivery and payment phases. The results prove the effectiveness of the proposed scheme by evaluating it based on gas price, transaction time, and mining time.
Mark Gaynor, Janet E. Tuttle‐Newhall, Jessica Parker, Arti Patel · 5 authors
This study aims to review current issues regarding the application of blockchain technology in health care. We illustrated the various ways in which blockchain can solve current health care issues in three main arenas: data exchange, contracts, and supply chain management. This paper presents several current and projected uses of blockchain technology in the health care industry. We predicted which of these applications are likely to be adopted quickly and provided a supply chain example of tracking the transportation of organs for transplantation.
BACKGROUND: The widespread death and disruption caused by the COVID-19 pandemic has revealed deficiencies of existing institutions regarding the protection of human health and well-being. Both a lack of accurate and timely data and pervasive misinformation are causing increasing harm and growing tension between data privacy and public health concerns. OBJECTIVE: This aim of this paper is to describe how blockchain, with its distributed trust networks and cryptography-based security, can provide solutions to data-related trust problems. METHODS: Blockchain is being applied in innovative ways that are relevant to the current COVID-19 crisis. We describe examples of the challenges faced by existing technologies to track medical supplies and infected patients and how blockchain technology applications may help in these situations. RESULTS: This exploration of existing and potential applications of blockchain technology for medical care shows how the distributed governance structure and privacy-preserving features of blockchain can be used to create "trustless" systems that can help resolve the tension between maintaining privacy and addressing public health needs in the fight against COVID-19. CONCLUSIONS: Blockchain relies on a distributed, robust, secure, privacy-preserving, and immutable record framework that can positively transform the nature of trust, value sharing, and transactions. A nationally coordinated effort to explore blockchain to address the deficiencies of existing systems and a partnership of academia, researchers, business, and industry are suggested to expedite the adoption of blockchain in health care.
In mass disasters with multinational victims, it is critical to identify the deceased for judicial, ethical, religious and human rights reasons, as well as to allow the next of kin to complete the grieving process. Disaster Victim Identification (DVI) process is a complex procedure where Post-mortem (PM) identifying data, essentially fingerprints, DNA and dental, is collected in order to be compared with equivalent Antemortem (AM) data related to the missing persons list. Although there are solutions used in the field of human identification, they all fall short of equipping them with the tools needed for achieving human identification in a timely manner. Initially, it is significantly challenging to manage missing person lists containing years, and sometimes decades, of family AM data resources’ updates. Furthermore, there is currently no record of any holistic technical solutions for managing both AM and PM for human identification to support collaborative multinational and interjurisdictional processes. Blockchain technology provides the tools to facilitate building trustworthy, secure and holistic ecosystems, and it can disseminate siloed AM and PM data across systems, protecting data breaches, redundancies, inconsistencies, and errors. As such, blockchain technology can revolutionize the human identification process worldwide in terms of managing missing person lists, AM data repositories for living people, PM data repositories of recovered unidentified victims, and contribute to the comparison of compatible biological profiles for definitive identification. Using real-world scenarios, the authors propose a number of promising use cases to attain a holistic understanding of the challenges, and present how blockchain technology meets such challenges and facilitates multi-jurisdictional data information-sharing in conjunction with the forthcoming circulation of patients’ electronic medical and dental records.
Unmanned aerial vehicle (UAV) is used in various smart applications, such as defense, civilian, and healthcare services. As data in these applications flow through an open channel, i.e., the Internet, so security and privacy always a challenging issue. Though many solutions exist for this problem in literature, but these solutions are not adequate to handle security, privacy, latency, and efficient real-time delivery of healthcare services remotely over the wireless communication channel. Moreover, the existing UAV systems have security, reliability, latency, and storage cost issues, which restricts their applicability shortly. Motivated from these facts, this paper proposes VAHAK, an Ethereum Blockchain (BC) based secure outdoor healthcare medical supplies using UAVs. VAHAK provides reliable communication between the UAVs and the entities in a decentralized manner, which ensures the early delivery of required medical supplies to the critical patients. In VAHAK, security, privacy, and reliability issues have been resolved using Ethereum smart contract (ESC), while storage cost issues are handled with IPFS protocol. The security vulnerabilities of the VAHAK are tested on MyThril open-source tool. VAHAK is efficient in terms of data storage cost as it uses the InterPlanetary File System (IPFS) for healthcare record storage and 5G-enabled Tactile Internet (TI) for communication, respectively. Finally, VAHAK performance evaluation demonstrates its effectiveness as compared to the traditional systems where it outperforms the existing schemes with respect to various performance evaluation metrics, such as scalability, latency, and network bandwidth.
During the past few years, medical Internet-of-Things devices have experienced a massive growth and they are currently generating tremendous volumes of data every day, which are highly valuable as they can be of great importance to all stakeholders within the healthcare industry. In this context, many blockchain-based solutions have been proposed to mitigate the siloed burden in different healthcare systems which prevented achieving a patient-centric, transparent, and secure data sharing. However, when multiple independent entities try to share their data, trust is not necessarily guaranteed. The scope of this paper is to explore the impact of verification on the level of trust among the different entities of the health data-trading system by proposing an evolutionary game theoretic model. We also present the numerical analysis of the evolution of trust in terms of different game parameters adopted to evaluate their impact on eliminating malicious (i.e., untrustworthy) players from the system.
Introduction Argentina is the third most populated country in South America with an estimated population of 44,494,502. Despite having an area of 2,780,400 km2 (eighth largest in the world), 90% of the population resides in urban areas, with the majority concentrated in and around Buenos Aires. Life expectancy is 79.7 years in women and 73.6 years in men, with cardiovascular disease as the leading cause of mortality. Argentina spends approximately 10% of its gross domestic product on health care (1). There are 3.94 physicians and 4.5 hospital beds per 1000 inhabitants in Argentina (2). The physician-patient ratio is similar to that of Australia, Italy, Spain, and Switzerland, and is double than Brazil and almost four times than Chile and Peru. Argentina has a multitiered, decentralized health care system that is plagued by fragmented management and financing. There are national, provincial, and municipal government–sponsored health care insurances, which together with union-sponsored insurances, provide health care coverage to nearly 22 million people. An additional approximately 10% of the population has private health insurance, leaving nearly 36% of the population without health care coverage or the financial means to pay for private insurance. These individuals are cared for at cost-free public hospitals and community facilities (1,2). The first hemodialysis (HD) treatment in Argentina dates back to 1955. Five years later in 1960, the Argentine Society of Nephrology was founded (3). Epidemiology The incidence and prevalence of CKD and ESKD have been growing steadily, most likely because of increasing rates of diabetes and obesity as well as an aging population. Indeed, CKD is now the seventh leading cause of mortality in Argentina, and CKD-related deaths have increased by 15% between 2007 and 2017 (4). The National Transplantation Institute (INCUCAI) supports a National Dialysis and Transplant Registry (5,6). Patient reporting is obligatory; therefore, national data are valid and representative. Reporting is the responsibility of the dialysis center director, and it is provided online. Patient identity is preserved by data security systems. The annual incidence of ESKD is 160 patients per million population, with diabetes and hypertension as the most common etiologies (Table 1). At the end of 2018, there were 29,929 patients with ESKD on chronic dialysis, representing a prevalence rate of 673 patients per million population (Figure 1) (5,6). Of these, approximately 93.5% are on in-center HD, 6.5% on peritoneal dialysis (PD), and none are on home HD. Of the patients on HD, 70% receive dialysis via an arteriovenous fistula, 15% receive dialysis via an arteriovenous graft, and 15% receive dialysis via central venous catheters. First year and annual mortality rates on dialysis are 18% and 16.4%, respectively (Table 1), with cardiovascular cause being the most common (6). Annual mortality rate has been above 16% for the last 4 years (Figure 2). RRT in Argentina has incidence and prevalence rates above the mean for Latin America, most likely because dialysis and transplant are readily available in the country (Table 2). Nevertheless, PD is relatively less used compared with the rest of Latin America (7–9). Table 1. - Characteristics of patients on dialysis in Argentina Characteristic Value Country population 44,494,502 Patients on hemodialysis 29,929 Patients on peritoneal dialysis 1945 Patients with functioning kidney transplant 11,486 Prevalence of hepatitis B, % 0.2 Prevalence of hepatitis C, % 1 Prevalence of HIV, % 0.8 Prevalence of diabetes, % 28 Membrane dialyzer (reuse), synthetic/substituted cellulose/cellulose, % 83/14/4 Type of vascular access, native AVF/prosthetic AVF/catheter 70/15/15 Prevalence of patients with ESA, % 87 No. of hemodialysis centers 597 Hospital-based dialysis units, % 25 Nonprofit dialysis units, % 11 No. of peritoneal dialysis centers 79 Dialysis covered by insurance, % 100 Out-of-pocket expenses, % 0 Dialysis unit staffing, nurses/technicians, % 95/5 Payment per hemodialysis session, USD 55 Patient-nurse ratio in hemodialysis units, adult/pediatric 4–5/2–3 Average length of dialysis session, h 4 Minimum patient evaluation by physician per mo 4 No. of transplant centers 55 Adjusted annual mortality dialysis rate, % 16.48 Etiology of ESKD, % Diabetes 36.5 Nephroangiosclerosis 20 Unknown cause 17 GN 9 Myeloma and amyloidosis 1 Obstructive uropathy 6 Polycystic kidney disease, adult type 5 Epidemic uremic hemolytic syndrome 0.5 Other 5 Cause of death, % Cardiovascular 50 Infection 25 Neoplasia 6 Other 19 Source: Argentinean Registry of Dialysis and Transplantation (5,6). AVF, arteriovenous fistula; ESA, erythropoiesis-stimulating agents; USD, United States dollars. Figure 1.: Annual prevalence of dialysis patients ( 5 , 6 ).Figure 2.: Annual dialysis mortality rate . Rate is expressed in deaths per 100 patients at risk with 95% confidence interval bars. Source: Argentinean Registry of Dialysis and Transplantation (5,6). Table 2. - Comparison of RRT between Argentina and Latin America Argentina Latin America Prevalence of patients with ESKD under RRT (dialysis and transplant) a 976 805 Dialysis incidence rate a 160 154 Kidney transplant rate a 30 21 Patients on peritoneal dialysis, % 6.5 11.5 Nephrologist a 30 18 aRates are expressed per million population. Source: Latin American Registry of Dialysis and Transplantation (7). Structural Organization and Logistics of Dialysis Argentina has dialysis units in both hospital and private settings. There are a total number of 597 dialysis centers in the country. Eleven percent (68 centers) of these centers are government owned, 377 (63%) are independent dialysis centers, and the rest (152 centers; 26%) are owned by foreign dialysis companies. One hundred eighty-seven dialysis units are in the province of Buenos Aires, and the rest are located throughout the rest of the country. Dialysis is covered by patients’ union health system or health insurance; ultimately, the government pays if the patient does not have insurance. Government coverage is universal if a patient does not have union or health insurance. This includes illegal immigrants, noncitizens, and refugees. Payment for HD and PD is capitated at approximately United States $700 per month or United States $55 per HD session. Physicians across the country are paid by monthly salaries, and some also have private practice. PD solutions are not manufactured in the country and are, therefore, imported. Bundle HD and PD payment includes vascular access, erythropoietin, appropriate vaccination, and transfer to and from the dialysis unit. Monthly reimbursement is irrespective of procedure number. Average HD sessions last for 240 minutes, with 95% of patients receiving three or more dialysis sessions per week (5,6). Online hemodiafiltration has been recorded since 2015. Approximately 20% of HD centers have this technology. Although 70% of patients on incident dialysis start with a temporary catheter as their vascular access, at 6 months into treatment most have permanent vascular access. Seventy percent of prevalent patients have an arteriovenous fistula. Nephrologists insert all temporary catheter access. Permanent HD catheters are placed by nephrologists also but mostly by vascular surgeons. Arteriovenous fistulas are 100% done by vascular surgery. Interventional nephrologists do not perform arteriovenous fistulas. Almost 87% of the patients are on erythropoietin or similar agents, and synthetic HD membranes are most commonly used. (Table 1) (5,6). The advent of technologic advancement, biosecurity implementation, and specific treatment has decreased the prevalence of hepatitis B, hepatitis C, and HIV in the dialysis population (0.2%, 1%, and 0.8%, respectively). Isolation of patients with hepatitis B is mandatory. No formal end-of-life care support programs are available in Argentina. Staffing of Dialysis Units Argentina is third among Latin American countries considering nephrology physicians per million inhabitants (Table 2) (7,8). There is one nephrologist for every 40 patients, and a nephrologist must be present in the dialysis unit at all times. There are approximately 80 renal fellows in training per year. Most patients are seen daily or at least four times a month. In continuous ambulatory peritoneal dialysis, they are seen once a month. Historically, non-nurse technicians accounted for the majority of dialysis personnel, but this has progressively decreased to approximately 5%. Nurses now provide the lion’s share of dialysis care. The main driving force for this change occurred 10 years ago when regulations were changed to increase the number of dialysis nurses taking care of these patients. The nurse to patient ratio is four to five adult patients per nurse in HD units and two to three children per nurse in pediatric units. In PD, the ratio is 20 adult and 15 pediatric patients per nurse (5,6). No formal dialysis nurse certification is in place in the country. Transplantation in Argentina The International Registry of Organ Donation and Transplantation reports that in 2019 there were approximately 1674 kidney transplants (1325 from deceased donors and 349 from living donors) in Argentina. There were 69 simultaneous kidney-pancreas transplants, 19 kidney-liver transplants, and 5 kidney-heart transplants. More men (62%) were transplanted than women. The availability of kidney transplants differs regionally around Argentina, with approximately 6546 patients with ESKD currently on the transplant list waiting for a new kidney. Average waiting time on the transplant list is over 4 years. Swap living kidney transplants have occurred, but there are very few cases (5). Transplantation is regulated by the INCUCAI (5,6). Since 2004, the INCUCAI has supported a National Dialysis and Transplant Registry. Patient reporting is obligatory, and therefore, national data are valid and representative. The INCUCAI in conjunction with the Argentine Society of Nephrology analyzes and reports the data of the National Dialysis and Transplant Registry (5,6). The INCUCAI, the Argentine Society of Nephrology, and the Argentine Transplant Society promote organ donation campaigns regularly. A recent law has declared the general population as presumed donors, and this has increased donation by 20%–25%. There are barriers to donation, but none are due to social or cultural barriers. Some of these barriers include logistics of organ harvesting and transportation in a large country, insufficient organ harvesting teams in some regions, etc. Future Directions and Challenges RRTs are accessible and available in Argentina, and utilization rates are acceptable compared with other countries in the region. It will be challenging to improve what is currently available with limited economic resources. An advanced kidney care program is not available nationwide and needs to be designed and implemented to guarantee early and programmed dialysis initiation and preemptive transplant when possible. PD is underused in Argentina for many reasons: peritoneal solutions are not manufactured in the country and are expensive, and most nephrologists have not been trained in PD because HD has been the predominant form of dialysis historically. Because many patients still begin dialysis without previous planification, the preferred dialysis modality used in urgent situations is HD through temporary catheter access. Training and economic incentives will help develop PD further. Home HD will most likely be set aside for some time. This technology is not available yet, and no reimbursement plans are underway for this dialysis modality. Disclosures G.J. Rosa Diez is employed by Fressenius. The remaining author has nothing to disclose. Funding None.
Gamze Gürsoy, Charlotte M. Brannon, Eric Ni, Sarah Wagner · 6 authors
Abstract The genomic characterization of individuals promises to be immensely useful for biomedical research and healthcare. However, a critical barrier to expanding personal genome sequencing is achieving secure, high-integrity storage of raw data. While cloud storage offers solutions to access such data from any place and device, the vulnerabilities of centralized storage in relation to security, data integrity, and robustness, such as single points of failure, have not yet been addressed. Blockchain is a potential alternative to these storage modes. However, storing large-scale data on blockchain can be challenging due to slow transaction speeds, the potential for chains to reach large sizes, and limitations on querying data stored on-chain. Currently, several genomic storage applications incorporate blockchain, but likely because of these challenges, many use blockchain only to facilitate and log data-access transactions, rather than to store raw genomic data on-chain. While this secures the process of data access, it does not secure the data itself, which is often stored off-chain (i.e. in a cloud or file-hosting services). Here, we developed a novel method of storing reference-aligned reads on-chain in a private blockchain network. We also developed tools for accessing and analyzing the on-chain data. We addressed the challenges of on-chain data storage by minimizing the data inserted to the chain using reference-based data compression techniques and by binning the on-chain data by genomic location to reduce retrieval times. Our tools provide open-source blockchain-based storage and access for advanced genomic analyses such as variant calling.