The heavy burden associated with healthcare costs as well as concerns regarding increased medical errors instigated a catalyst for general improvement in the overall delivery of healthcare services. Scholars identify the value-based approach to the delivery of healthcare services achievable from the availability and analytics of big amounts of patient data that are collected using health information technology such as blockchain [41]. The recognition of the value of blockchain technology in the improvement of healthcare delivery has prompted players in the sector to contribute many financial incentives to promote the adoption and consequently the implementation of the technology in healthcare facilities [42].

According to Donawa et al. (2019), the use of blockchain in electronic health records provides a health record storage service that therefore facilitates web-based accessibility. The system is frequently designed to give people complete authority over creating, managing, and sharing their electronic health records with friends, family, healthcare professionals, and other relevant data users [43]. As illustrated by Abunadi (2021), the main advantage of such a system is the security and confidentiality associated with it. Scholars acknowledge that the blockchain system is more reliable and secure compared to the paper storage of medical records. It is important to note, however, that there are still a number of issues of concern that are linked to the usage of blockchain in electronic health records. The aim of the current article is to provide a comprehensive investigation of the challenges and aspects of the application of blockchain in EHRs [41].

Patel, Parthit, et al. (2018) report that blockchain has always been proposed to address the issues attributed to data access and privacy [44]. Fatokun, et al. (2021) explain that it is a blockchain for electronic health records, that is to say, a growing list of blocks that comprise records that are linked through the application of cryptographic hash. There are numerous advantages linked to blockchain in electronic health records. Blockchains can be used to help secure the Internet of Things (IoT) in the healthcare sector. A governance paradigm is used by the blockchain to enforce business logic, which is understood by all participants. A smart contract can therefore be used to govern the necessary access control rules and achieve HIPAA compliance [45]. Additionally, as Keshta, et al. (2021) pointed out, the relevant stakeholder groups have the right to store data in blocks that cannot be edited retrospectively, which means blockchain can be managed by all of these organizations together [46].

The adoption of blockchain in healthcare supports retaining and sharing symmetrical patient records with the appropriate alliance of hospitals and healthcare providers in a secure decentralized system, using asymmetric cryptography like hashing, digitally signed transactions, and public key infrastructure. There are numerous specific applications which include: traceability of drugs and patient monitoring or rather HER.

Traceability of drugs is always undertaken using a centralized approach within which aspects such as authentication and privacy of data, as well as the system flexibility, are never realized. Several decentralized models have always been proposed to solve issues related to drug traceability [47]. For the privacy and authenticity of traceability data, a blockchain system known as Drugledger has widely been proposed. Drugledger usually integrates the Blockchain with the whole drug supply chain to easily trace such drugs [48]. Drugledger specifically has two different flows of drugs: the information that flows regarding the drug ledge and the physical flow of the real drug, all of which goes to the drug ledge network in the formula of a chain network of drugs. This new system alters the traditionally understood protocols by grouping the healthcare professionals into various parts: QSP, query service provider; CSP, certificate service provider; and ASP. However, it is important to note that the drug traceability scenario, as illustrated in the present paper, looks so simple theoretically but is overly complex within the real-life case scenario [49].

However, Hamza et al. (2020) [50] highlight that the entire drug traceability system becomes more dependable and secure when the internet of things is integrated with Blockchain. Numerous frameworks have been suggested in the healthcare field regarding drug traceability or patient monitoring systems. The researchers in [7] suggested a structure to help curb drug fraud by tracking every drug within the supply chain system. The greatest aim in this scenario is to help reduce incidences of counterfeit drugs within the Blockchain. The specific and commonest technologies that can be applied to help improve the traceability and visibility of commonest technologies that can be applied to help improve the traceability and visibility of commodities such as drugs are RFID and Blockchain [51].

For a more transparent movement of the drugs, the Gcoin Blockchain model, in which G stands for global control, is suggested; the model equally changes the drug supply chain system from regulating to inspection and surveillance of the drugs [52]. This means a government model that is combined with a decentralized autonomous organization.

Blockchain is applied to develop a kind of atmosphere where two different parties can trust one another. There are numerous ways through which Blockchain can be implemented, though the common approach, as claimed by Siyal et al. (2019) [53], is Gcoin Blockchain. As further argued by the scholar, Gcoin Blockchain can easily track every drug in the same ways Blockchain tracks the movement in bitcoin. It assists in building a superior level of trust and transparency between sellers and buyers [53]. It is important to note further that Gcoin aims to improve overall data efficiency.

In India, for instance, several lives are considered at risk due to the use of fake drugs. A proposed framework of Blockchain can therefore be applied to help detect the possibility of fake drugs within the supply chain. Such suggested frameworks are based on Hyperledger fabric kind of architecture, within which one PC works as the main beneficiary and five different computers are applied when making the orders. The system is fully dependent on blockchain technology [54]. Moreover, the supply chain of drugs from the drug-producing stores to the local intermediaries and clinics or retail drug shops and hospitals is managed by the application of Blockchain, which assists in tracking all the fake drugs.

The system, in this case, was tried in several case scenarios such as audits of drugs in distribution, stolen drugs, or fake distribution of drugs. The blockchain system was compared with other systems in numerous parameters such as resistance against any given point of failure, detection of counterfeit drugs, identification of diverted drugs, spying for drug shortage, security, privacy, transparency, and immutability [4]. However, Makridakis et al. (2019) [55] outline that the blockchain system never poses the capability of discovering and eliminating the usage of drugs that have not been authorized.

Regarding medicine, the commonest threat is that the manufactured medicine is never received by the pharmacy and can easily get replaced with a counterfeit supply chain. As emphasized by [56], the supply chain approach can never trace drugs that have landed in the wrong hands. For instance, India produced the majority of counterfeit medicines in 2017 and presently it is approximated that close to 35% of counterfeit medicine was sold across distinct parts of the globe. To come out of these problems, Abunadi (2021) [41] proposed the usage of Blockchain and claimed that it is more transparent since one change in the transaction process will automatically get reflected to all the relevant users. With its decentralization concept, Blockchain can analyze the results on two platforms: Hyperledger and Ethereum. Within the Ethereum Blockchain, every operation needs some fees. Miner is provided money to perform transactions and maintain the Ethereum network [57]. There has never been a major need to know your Customer (KYC) within such a process, resulting in some sort of blind spot, which shows us the individual who might be using the account. Blockchain applying Hyperledger, on the other hand, never needs fees, making it easy for the individual producer to undertake the transaction.

An electronic record includes the necessary vital administrative and clinical data of the patient like demographics, diagnosed clinical problems, medication, and laboratory data, among other reports. Using paper as a means of recording patient data has proved to be very extensive and non-reliable as the world has since gone digital [56]. As a result, most healthcare organizations have resorted to using electronic records to keep their data. Blockchain, a decentralized type of database whose data block is specifically linked chronologically, has widely been applied to enhance HER performance. Arunkumar (2020) points out that numerous parties within the healthcare industry need to manage the personal HER blockchain collaboratively, like the medical specialists, insurance departments, and the hospital. Since the traditionally known EHR system is trademarked with decentralized design, only one unit of supplier controls the code base, database, and system outputs [58]. It has become difficult for the centralized systems to have full confidence from the hospital management, doctors, and patients [41]. Therefore, Blockchain has been considered the solution to the trust issue associated with a centralized electronic health record system. With blockchain technology, all the patient information is stored in the Blockchain through the use of meta mas, and the details of each patient are stored in the Blockchain as independent data blocks. Each block comprises encrypted data. The system record health-related information of an individual patient so that respective health care providers and the patients can easily consult it themselves. In most cases, the data are usually encrypted by a specified algorithm to encrypt all the patient data into a single line bit that is subsequently stored in the block [59].

As Donawa et al. (2019) [43] noted, using Blockchain in electronic health records offers a convenient and symmetric health record storage service that promotes easy accessibility of such records through the web. The system is often designed to allow the patients full control of generating, managing, and consequently sharing their electronic health records with friends, family, healthcare providers, and other relevant data consumers. Abunadi (2021) [41] illustrates that such a system’s main advantage is security and confidentiality. Scholars acknowledge that a blockchain system is more reliable and secure than paper storage of medical records. However, it is important to note that several issues of concern are still linked to using Blockchain in electronic health records. The present paper presents a thorough examination of the aspects and issues concerning the use of blockchains in EHRs. For example, Alla et al. (2018) [60] indicated that the patient could lose control across the prevailing EHRs in the course of live actions, despite the fact that the service provider constantly retains the principal stewardship.

Cunningham et al. (2018) [32] report that Blockchain has always been proposed to address the issues attributed to data access and privacy. Fatokun et al. (2021) [35] explain that it is a blockchain for electronic health records, which is to say, a growing list of blocks comprising records linked through the application of cryptographic hash as an asymmetric crypto-algorithm. There are numerous advantages linked to Blockchain in electronic health records. For instance, a Blockchain is a linked peer-to-peer database in which data integrity, availability, and response time are fully guaranteed. Blockchains can adequately facilitate internet of things security in electronic health.

Moreover, the Blockchain works within the governance model, which helps enforce business logic that all the participants accept. It is, therefore, very possible to exploit a smart contract or chain code to control the relevant control policy on access and achieve HIPAA compliance. Keshta et al. (2021) [36] also highlighted that Blockchain is additionally managed collectively by the relevant stakeholders, some of whom. Some have the right to record data in the block that cannot alter retroactively.

Mehta et al. (2020) [31] noted that Blockchain in the electronic health record is symmetrically distributed and append access rights to only its ledger shared among the specified users. Fine-grained access to the ledger is equally implemented to realize an appropriate balance between availability and privacy. Figure 6 below illustrates the possible access rights of users as applied in the BlockHealthChain. The rights, in this case, include read permission, write permission, read permission with anonymized EHRs, and authorization permission.

It is clear from the figure that within blockchain protocol, different users tend to have different access qualifications for EHRs. With this arrangement, patients have the right to control access to electronic health records, including individual patient-reported information. The former comprises numerous contents like allergies, demographic information, and numerous contents allergies, demographic information, and monitoring data collected from the applied instruments [47]. The latter, in this case, refers to the updated medical record by the staff of doctors. The patient can authorize family members or health care providers to read and write their personal health information, minimizing the potential risks of tracking and replicating healthcare data.

Nurses, doctors, emergency staff, and laboratory technicians control and manage access to the electronic health record that is updated by themselves. Additionally, they effectively use or disclose protected health information for the diagnosis, treatment, and payment without seeking authorization from the patient [22]. This means having the authorization to grant read or write permission to other relevant entities, in which case the electronic health records are shared within the healthcare organizations.

Attaran (2020) [30] additionally indicated that several classes of users submit various EHRs containing test results, encounter comments, and demographic. For instance, the test result includes several fields: Patient ID, patient name, technician ID, type, indicator, and final result. Each electronic health record in the Blockchain corresponds to a transaction, which must be executed accurately and included within the ledge. All the electronic health records pose lifecycle as shown in Figure 7 below.