Journal of Network and Computer Applications 215 (2023) 103633

Contents lists available at ScienceDirect

Journal of Network and Computer Applications

journal homepage: www.elsevier.com/locate/jnca

Blockchain for healthcare systems: Architecture, security challenges, trends

and future directions
Andrew J a, Deva Priya Isravel b, K. Martin Sagayam c, Bharat Bhushan d, Yuichi Sei e, *,
Jennifer Eunice c
a
Department of Computer Science and Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India
b
Department of Computer Science and Engineering, Karunya Institute of Technology and Sciences, Coimbatore, Tamil Nadu 641114, India
c
Department of Electronics and Communication Engineering, Karunya Institute of Technology and Sciences, Coimbatore, Tamil Nadu 641114, India
d
Department of Computer Science and Engineering, School of Engineering and Technology, Sharda University, Uttar Pradesh, Greater Noida, 201310, India
e
Department of Informatics, The University of Electro-Communications, 1828585, Japan

A R T I C L E I N F O A B S T R A C T

Handling Editor: M. Atiquzzaman Blockchain has become popular in recent times through its data integrity and wide scope of applications. It has
laid the foundation for cryptocurrencies such as Ripple, Bitcoin, Ethereum, and so on. Blockchain provides a
Keywords: platform for decentralization and trust in various applications such as finance, commerce, IoT, reputation sys­
Blockchain tems, and healthcare. However, prevailing challenges like scalability, resilience, security and privacy are yet to
Consensus algorithms
be overcome. Due to rigorous regulatory constraints such as HIPAA, blockchain applications in the healthcare
Cryptocurrency
industry usually require more stringent authentication, interoperability, and record sharing requirements. This
Distributed ledger
Healthcare data article presents an extensive study to showcase the significance of blockchain technology from both application
Security & privacy and technical perspectives for healthcare domain. The article discusses the features and use-cases of blockchain
in different applications along with the healthcare domain interoperability. The detailed working operation of
the blockchain and the consensus algorithms are presented in the context of healthcare. An outline of the
blockchain architecture, platforms, and classifications are discussed to choose the right platform for healthcare
applications. The current state-of-the-art research in healthcare blockchain and available blockchain based
healthcare applications are summarized. Furthermore, the challenges and future research opportunities along
with the performance evaluation metrics in realizing the blockchain technology for healthcare are presented to
provide insight for future research. We also layout the various security attacks on the blockchain protocol with
the classifications of threat models and presented a comparative analysis of the detection and protection tech­
niques. Techniques to enhance the security and privacy of the blockchain network is also discussed.

1. Introduction payments (Carson et al., 2018). Blockchain technology guarantees

In recent, there is an increase in the fascination with blockchain
technology. Blockchain has become popular through the success of
cryptocurrency (Narayanan et al., 2016). There is a potential increase in
blockchain-based applications extended in fields such as healthcare (Yue
et al., 2016), (Zhang et al., 2018a), finance (Treleaven et al., 2017),
commerce (Liu et al., 2019a), IoT (Miller, 2018), automobile (Sharma
et al., 2019), social services (Zheng et al., 2018a), risk management
systems (Fu and Zhu, 2019), government’s transactions (Ølnes et al.,
2017), financial department (Ojo and Adebayo, 2017), and royalty
expedient and reliable services (Prashanth Joshi et al., 2018). This has
been made possible through the transparent and distributed nature of
the blockchain. Concretely, blockchain systems are considered as a
secure platform (Ramachandran and Kantarcioglu, 2017) where the
participant’s actions on the blockchain are recorded and the incessant
accretion of the chain makes any changes in the block computationally
challenging without detection (Zhu et al., 2019).
Blockchain technology has gained momentum in recent years and is
also attracted by businesses (Weber et al., 2016), industry (Friedlmaier
et al., 2017), and the research community (Shrestha and Vassileva,

* Corresponding author. Department of Informatics, The University of Electro-Communications, 1828585, Japan.

E-mail addresses: andrewj.research@gmail.com (A. J), i.devapriya@gmail.com (D.P. Isravel), martinsagayam.k@gmail.com (K.M. Sagayam), bharat_
bhushan1989@yahoo.com (B. Bhushan), seiuny@uec.ac.jp (Y. Sei), jennifer23.phd@gmail.com (J. Eunice).

https://doi.org/10.1016/j.jnca.2023.103633
Received 20 September 2022; Received in revised form 19 March 2023; Accepted 29 March 2023
Available online 3 April 2023
1084-8045/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

2018), (Bhushan et al., 2021). Blockchain mechanism allows people to contributed to improved healthcare support for medical personnel and
transact with each other over the internet in a “peer-to-peer” fashion. other stakeholders in healthcare facilities in terms of verified and
Cryptocurrencies encourage end-users to deliver services in an auto­ authenticated records (Koteska et al., 2017)– (Gökalp et al., 2018),
mated, peer-to-peer, and trustless way. Blockchains are decentralized interoperability (Agbo et al., 2019)– (Prakash, 2016), efficient storage of
peer-to-peer systems that implement a public, trustless, append-only health records (Puthal et al., 2018), (Gökalp et al., 2018), (Kuo et al.,
ledger. Blockchain technology is a trustless system because the sys­ 2019), (McGhin et al., 2019)– (Liang et al., 2018a) and security systems
tem’s activities are completely decentralized, transparent, and are (Kuo et al., 2017), (Linn and Koo, 2016)– (Liang et al., 2018b).
conducted independently and perfectly in a trustless manner. The Several literature reviews of blockchain technology for various do­
trustless system is formed by having all the peers the ledger members. mains are previously published (Shi et al., 2020)– (Sookhak et al.,
Hence it becomes a distributed ledger, that records all the transactions 2021). However, there’s still a lack in the literatures that focus on
performed in the blockchain and maintains the history of the trans­ blockchain based healthcare and various security and privacy issues.
actions. This decentralized ledger provides many sources of legitimacy Although few literatures that covers the some of the aspects, a complete
for each transaction; also, the rules are pre-defined and are not unique to overview of all the aspects involved in of blockchain based healthcare
each wallet user. It uses a distributed network of nodes to check trans­ still scarce. Table 1 shows how this survey is different some of the recent
actions through a mining process. Blockchains do not eliminate trust but literature review papers. Hence, in this article a complete overview of
it distributes them across the many actors of the system and expects blockchain for healthcare sector. At first, we explore the features of
them to participate with well-defined protocols (Treiblmaier and Sil­ blockchain technology. Although there are many features of blockchain,
laber, 2021). A specific protocol is established by a set of rules that we explored some of the key features such as immutability, trans­
automatically promote patrons based on their compliance with the parency, traceability, secure data exchange, decentralization, and time
guidelines. It is a trustless system with a constantly updating database of and cost-effectiveness in the context of healthcare. Then we methodo­
records that are shared and distributed among the participating peers logically present use cases of blockchain technology in various domains
without the need for trust authority. To digitally move money from one such as e-commerce, digital identities, online voting, healthcare, IoT,
account to another, the underlying blockchain infrastructure is used to digital gaming, insurance claim processing, and cross border payment.
facilitate the transfer while also ensuring sender identity and currency Next, we explore the operations of blockchain with its working model
validity. In a centralized system, a single third party is used to establish and types of consensus algorithms in the healthcare context. Then, the
trust. In a decentralized system, trust is created based on public-key healthcare architecture of blockchain technology is explored. The
cryptography and a consensus system. Blockchain technology also en­ layered architecture and classifications of the blockchain are presented
ables asset transactions between untrustworthy parties (Ismail and in detail. Then, we discussed some of the major research challenges and
Materwala, 2019). The legitimacy of transactions in an untrusted envi­
ronment is ensured by spreading the ledger among many nodes in the
network and updating it via consensus. As a result, a trust mechanism is Table 1
crucial for reducing the danger of engaging with fraudulent competitors Feature wise comparison of some recent blockchain survey literature with this
in a blockchain network. survey.
Blockchain has laid the foundation for cryptocurrencies such as Characteristics (Shi (Mukta (De (Sookhak This
Ripple (Armknecht et al., 2015), Bitcoin (Radziwill, 2018), Ethereum Covered et al., et al., Aguiar et al., Survey
(Dannen, 2017), and so on. Bitcoin (Nakamoto, 2008) is top-rated as the 2020) 2022) et al., 2021)
2020)
first cryptocurrency. As the current economy is depending on digital
verification for all business transactions, blockchain offers opportunities Blockchain ✓ ✓ ✓ ✓ ✓
Architecture
for open-based decentralized platforms and services (Lindman et al.,
overview
2017). This novel technology provides transaction and payment plat­ Discussion on ✓ ✓ ✓ ✓ ✓
forms for a wide range of ingenious financial implements like Consensus Protocol
micro-payments (Lundqvist et al., 2017), peer-to-peer lending, and Features of blockchain ✓ ✓ ✓ ✓ ✓
in healthcare
simultaneously simplifies and lowers the cost of transactions. Every
Healthcare blockchain ✕ ✕ ✕ ✓ ✓
transaction is considered as a digital block that requires to be validated applications
by the consensus of many participants in the network before their Use cases of ✕ ✕ ✕ ✓ ✓
approval into the network. Since the traditional databases were not blockchain in
immune to vulnerability, the blockchain has emerged to ensure the se­ healthcare
Highlights the security
curity of data as they are cryptographically verified (Tosh et al., 2017).
✕ ✓ ✓ ✕ ✓
and privacy
Healthcare systems are designed to satisfy our health requirements, challenges of
and as our population ages, so do our productivity demands (Hollander blockchain in
et al., 2007). In addition, like in the instance of COVID 19, we can healthcare
observe the importance of real-time information. In terms of COVID 19, Presents up-to-date ✕ ✕ ✕ ✕ ✓
consensus protocol
the information on a patient’s health is highly valuable (e.g., tempera­ available in
ture or symptoms) (Halim et al., 2021), (Mahmood, 2021). As the healthcare
population ages and more people develop chronic illnesses, there is a Comparative analysis ✕ ✕ ✕ ✕ ✓
greater awareness of health issues and a need for better patient care on various security
and privacy attacks
(Khatri et al., 2021). Internet of Things (IoT) and Internet of Medical
and its defense
Things (IoMT) are the recent technological advancements in the field of mechanism
healthcare services. However, the challenges are such technologies are Security and Privacy ✕ ✕ ✕ ✕ ✓
centralized computation, processing, and storage as there is a possibility enhancing
of data manipulation, mistrust, privacy delusion, and failure at a single techniques for
blockchain
point. The other important challenge in electronic and all-pervasive Discussion on various ✕ ✕ ✕ ✕ ✓
healthcare is protecting the security of all internet-enabled equipment performance
(Islam and Young Shin, 2020). Integrating blockchain with healthcare metrics available for
yields decentralization in computation, storage, and improved security. blockchain in
healthcare
The broad and promising potential of blockchain technology has

2
A. J et al.
future research directions of blockchain in healthcare. Finally, the
various security attacks on the blockchain are paraphrased. We formu­
lated a threat model to categorize the various types of attacks on the
blockchain. We compared all the state-of-the-art techniques to identify
and combat such attacks using a table.
In summary, the contributions of this article is as follows.
1) Presented an overview of blockchain in healthcare with its features
and use cases.
2) Provided insight on the working model of blockchain, operations,
architecture, and classification of blockchain.
3) Presented various types of consensus algorithms in the context of
healthcare.
4) Presented a comparative analysis on present healthcare blockchain
applications, and a detailed study on various security attacks on the
blockchain.
5) Discussed the techniques to enhance the security and privacy of the
blockchain network.
6) Finally, the performance evaluation metrics of blockchain are pre­
sented with the current challenges and road map for future research.
The rest of the article is organized as follows: Section 2, introduces
blockchain and its features in line with healthcare technology. Section 3,
explores the healthcare use cases of blockchain technology along with
other domains. Then section 4, describes the operations of blockchain
technology and present the layers of the blockchain architecture. Section
5 discusses the detailed review of the classification of blockchain. In
Section 6, we presented the various consensus algorithms for healthcare
blockchain. Section 7 presents the threat model and various security
attacks on blockchain technology. In section 8, we discussed the per­
formance metrics of blockchain, and identified the challenges and
research opportunities. Finally, section 9 concludes the article.
2. Overview of blockchain
Blockchain is a peer-to-peer distributed ledger technology and ar­
chitecture platform that was originally introduced for the financial in­
dustry by Satoshi Nakamoto (Wright, 2019) in 2008 but it has now
progressed to the point of being considered a basic technology for a
variety of decentralized applications (Iansiti and Lakhani, 2017).
Blockchain is a fusion of cryptography and peer-to-peer communication
technologies. It consists of several blocks that are linked using crypto­
graphic hash functions. The blockchain is a basic yet clever method of
sending and receiving data in an automated and secure manner. A block
is created by one of the participants in a transaction to start the process.
Thousands of computers spread throughout the internet are confirming
this block. The confirmed block is added to a chain, which is then stored
throughout the internet, establishing not only a unique record but also a
distinct record with a unique history. Hence, in blockchain, the trans­
actions are considered valid when the consensus of blocks agrees
through contracts. The decentralized nature of blockchain technology
makes the trust decentralized therefore trust among the users of the
system is essential for sharing keys.
Over the years blockchain has evolved tremendously. We list out 5
different version of blockchain as blockchain 1.0 to 5.0. The blockchain
1.0 version released by Nakamoto is the most basic type of decentralized
ledger for keeping track of transactions and storing data across
numerous machines is this one. In plain English, the information con­
tained in the initial blockchains was restricted to the values of a “thing”
that underwent ownership changes over time. The “thing” we are
referring to was typically a form of digital currency such as bitcoin,
ripple and so on. Blockchain 2.0 is also known as the rise of Ethereum
which is the enhanced version of cryptocurrency proposed by Vitalik
Buterin (2014). The first blockchain with a smart contract system built
in was Ethereum. Smart contracts are a collection of scripts that are
automatically executed when specific criteria are met, to put it simply.
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Journal of Network and Computer Applications 215 (2023) 103633
These agreements let individuals or businesses to carry out more
complicated transactions than merely standard cryptocurrency ex­
changes. It is suitable for decentralized distribution applications and
decentralized autonomous organizations. Blockchain 3.0 has a broader
scope for distributed applications like enterprise blockchain. Health­
care, cybersecurity, supply chain management, and manufacturing are
some of the blockchain 3.0 application. Blockchain 4.0 has evolved to
support industry 4.0 and healthcare 4.0. It seeks to enhance the user
experience within the industry. Metaverse and Rchain are some of the
types of blockchain 4.0. Blockchain 5.0 is the upcoming or current
generation blockchain. It is aimed to reduce the traditional drawbacks
and security issues of the blockchain. Hashgraph, Hedra, and Relictum
pro are some of the example applications of Blockchain 5.0. The over­
view of the evolution of the blockchain over the years is depicted in
Fig. 1.
2.1. Blockchain in healthcare
Blockchain technology has a lot of potential in the healthcare in­
dustry due to the failure of conventional health information exchange
(HIE) and personal health record (PHR) based exchanges to deliver on
their promise of a shared coalescent Electronic Health Records (EHR),
competing interests and a variety of other factors continue to expose the
trust failure inherent in conventional health information exchange in­
termediations (McFarlane et al., 2016)– (Andrew et al., 2019b). Hence,
healthcare has become a prime candidate for blockchain technology and
has been a focal point recently. The overview of blockchain technology
for healthcare is shown in Fig. 2. The components of healthcare block­
chain are the healthcare professionals and patients who generate the
data, medical cloud, and blockchain network which contain distributed
ledger and smart contracts. Fig. 3 shows the global google trends on the
topic “Blockchain - Healthcare” there is clear evidence of the increase in
the interest among the research community.
The Healthcare industry has unique requirements such as security,
interoperability, non-repudiation, access control, authentication, medi­
cal data sharing, and mobility. Fig. 4 shows the pictorial representation
of healthcare industry requirements. In the era of Industry 4.0, health­
care data is being collected in the form of files, wearable sensors, and
other applications. The digitized health records are in the form of
Electronic Health Records (EHR), Electronic Medical Records (EMR),
and Personal Health Records (PHR). It is essential to provide access
control to such data with appropriate authentication. Also, to avoid
tampering attacks, the query to retrieve healthcare data must be audited
with appropriate access control (Suzuki and Murai, 2017). Further, to
protect the health records, encryption is not an efficient way. If different
encryption mechanisms are equipped to encrypt different types of health
records it raises interoperability issues (Xu, 2016)– (Vithanwattana
et al., 2016). Improper security to the healthcare data also leads to
various privacy issues (Andrew et al., 2019a), (Andrew Onesimu and
Karthikeyan, 2021), (Onesimu et al., 2021). Interoperability is another
major requirement in healthcare data. Data sharing and transmission
across multiple sources is known as interoperability (Azaria et al.,
2016). The principle of interoperability is using centralized data storage.
Storing all data in centralized storage is challenging in healthcare data
as it can lead to slow access, security, and privacy issues. Healthcare
data generally scales over time so transmitting all the data through
untrusted channels to centralized storage is not feasible. Also, secure and
timely access to the data is challenging due to its centralized nature.
Medical data sharing is essential for various medical researches so it is
important to ensure consistency, accessibility, and scalability during
data sharing (Tseng et al., 2016), (Roehrs et al., 2017). In the healthcare
sector, mobility is becoming more of a need as patients become more
mobile and expect that their data be portable as well. The capacity to
transfer data is becoming increasingly crucial as smart gadgets, sensors,
and other internet-connected devices grow more common. Mobile
health, healthcare IoT, and wireless are some of the categories of
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

Fig. 1. Evolution of Blockchain over the years.

Fig. 2. Overview of blockchain technology for healthcare.

mobility. Mobile health involves sensors, smartphones, and wireless
body area networks (WBAN). The challenges in mobile health are secure
data sharing, trust, access control, and user consent management. The
wearable body sensors of WBAN also face the challenges such as
network availability, flexibility, accountability, data integrity, and so
on. Healthcare IoT is another area that provides mobility in the
healthcare sector. Healthcare IoT provides vital advantages to the pa­
tients and the doctors. The patients can be remotely monitored and
accessed on various health conditions. However, data collection and
sharing are associated with various security and privacy challenges
(Onesimu et al., 2021), (Andrew and Karthikeyan, 2019).

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A. J et al.
Fig. 3. Google trends data visualization on the topic Blockchain - Healthcare.
2.2. Blockchain user requirements
The lack of cooperation across medical institutions exists due to
privacy concerns, technical difficulties, and a lack of a system for
reaching an agreement on how data should be utilized or shared. Health
data is not always accessible to patients and other medical institutions in
real time. The common and most prominent user requirements of
blockchain-based healthcare systems that can solve potential problems
are shown in Fig. 5 and are explained.
2.2.1. Personalized healthcare records
Confidential information on surgical procedures, treatments, and
recovery is contained in medical records. These documents are still
manually archived on paper in conventional healthcare systems. Elec­
tronic health records are fragmented and dispersed across several or­
ganizations and geographical areas, even though healthcare supply
chains are becoming more digital, and there is no complete system to
update and share these records in real time. Due to concerns about pa­
tient data confidentiality and privacy, this situation may become
Fig. 4. Healthcare industry requirements.
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Journal of Network and Computer Applications 215 (2023) 103633
considerably more problematic. With the use of Internet of Things-
enabled devices, medical data can be produced instantly. Recent de­
velopments in the usage of blockchain technology, also known as
distributed ledger technology provide solutions to challenges associated
with data access and data interchange. Personalized digitalized health
records have the potential to enable patients to control their care by
providing them with granular, individualized, and secure access to their
medical data (Sun et al., 2020). Personalized health records enable the
development of a new platform that combines smart contracts, digital
interventions, and gathering and access to medical data. The system
aims for patients to use their data to support their medical care and to
offer robust consent mechanisms for data sharing between various in­
stitutions and apps. The adoption of blockchain-based solutions for the
personalized healthcare record is essential to implement a combination
of event-driven smart contracts, health record data, and patient moni­
toring and control system.
2.2.2. Security
At every stage of hospital operation, the Healthcare system is in
charge of managing enormous amounts of data generation, information
sharing, storage, and analysis. It delivers strong, multi-layered security
to all data transfers to the cloud and adopts other cutting-edge digital
technologies for safeguarding the system against information loss or
misuse. The platform often adheres to the strictest data security and
privacy regulations imposed by a nation. The hospital system is shielded
against hacks because it is hosted on cloud-based servers that are situ­
ated outside of the facilities. Overall, blockchain-based healthcare sys­
tem encourages openness, safeguards privacy, guard against data theft
and provide a safe and secure environment for hospitals to continue
operating. Creating a blockchain network between two healthcare or­
ganizations allows organizations to communicate data over a distributed
database with Hyperledger without requiring each user to have trust in
every other user. Additionally, it enables the quick, secure, and trans­
parent interchange of medical transactions.
A. J et al.
Fig. 5. User requirements of healthcare blockchain.
2.2.3. Performance
Many processes are streamlined and integrated by blockchain-based
healthcare systems greatly boosts the system’s speed, agility, and effi­
ciency. It improves a healthcare facility’s performance and patient-
treatment capacities because of its intra-operability and flexibility.
The platform features are specifically created for a variety of tasks,
including management of OPDs, IPDs and diagnostics, emergency care
response, invoicing and payments, and operations. The system can grant
role-based control to users, enabling them to access a single function or a
number of them, and assisting in the monitoring and tracking of all
activities required for the provision of healthcare.
2.2.4. Reliability
The blockchain-based healthcare system is extremely resilient to any
technological disruptions, downtime, or breakdowns experienced by
other technological systems. From the perspective of data security, it is
quite secure and has an intuitive and sophisticated user interface that
makes them simple to use. Its upkeep tasks can be divided into pre-
scheduled intervals based on when they are least demanding, and
upgrading doesn’t require much time. The medical records are remotely
updated and enhanced without impairing the daily routine activities.
The availability of the system and resources at all times is crucial for the
success of the system.
2.2.5. Interoperability
Patient consent, governance, security, privacy, and patient partici­
pation are just a few of the issues that the move towards patient-centered
interoperability raises. By providing a framework for the safe exchange
of data, blockchain technology provides an alluring approach to over­
coming these difficulties. In summary, blockchain offers a high-level
framework for how a patient may communicate securely with several
stakeholders, identify themselves across each institution, and aggregate
their health data in a durable manner.
2.2.6. Access control
A doctor should request consent from the patient before accessing
the patient’s medical records. The system will deny access if the doctor’s
actions are not taken otherwise. Similar to this, a doctor should
personally inquire with a patient about granting a regular access
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Journal of Network and Computer Applications 215 (2023) 103633
privilege if they wish to obtain one. For the patient, this means that he
must first provide permission for any access to his medical records. The
patient can also independently grant temporary access and grant or
remove any access privileges for or from other users of the system.
2.3. Features of blockchain in healthcare
Various features make blockchain technology the most appealing
and considered to be more advantageous than the conventional method
of the transaction (Watanabe et al., 2015). This section discussed some
of the blooming features of blockchain technology. Fig. 6 shows the
pictorial representation of blockchain features.
2.3.1. Transparency
It is one of the most interesting properties of blockchain technology.
All transactions executed can be viewed by all the participants (Un­
derwood, 2016). Because of this, data integrity is assured. They cannot
be compromised as they are digitally verified after the consensus from
all the participants. Any sort of modification or change has to be
approved by every participant and therefore deletion or tampering with
data is not possible without everyone’s consensus. However, there are
issues related to implementing transparency. The high cost and energy
consumption of blockchain might stymie its deployment. Furthermore,
if it is not feasible to verify that transactions verification and smart
contracts are valid, the ledger’s integrity may be jeopardized. The
change policy must also be made visible to blockchain users (Fontana
et al., 2018). Many difficulties are only solved when the infrastructure
that leverages this ledger is built. However, there is no legal requirement
to describe this infrastructure, resulting in a shortage of documentation
regarding the software or firmware code. As a result, all of these con­
cerns must be taken into account throughout the infrastructure devel­
opment so that blockchain may be used in democratic settings and
successfully support transparency.
In the modern healthcare system, patients’ data is already kept
electronically at hospitals as EHR. However, inter-organizational trust
and openness have always been a problem. The blockchain can alleviate
this problem by offering an immutable ledger with restricted data ac­
cess. Data can’t be erased after its been captured, so it is available always
to check later on-demand. Transparency is the extent to which all
Fig. 6. Features of blockchain.
A. J et al.
stakeholders in a supply chain have a shared understanding of and ac­
cess to product-related information. In (Sunny et al., 2020), a blockchain
traceability solution was proposed that impacts the visibility of various
supply chain distribution network designs, as well as how technologies
like the Internet of Things (IoT) and smart contracts help to expand
blockchain’s possibilities (Zhang et al., 2018a).
2.3.2. Traceability
Traceability is another property that allows for the immutable
tracking of transactions across the network (Benchoufi et al., 2018).
Since all events are transparent to all the peers it is easy to trace who is
responsible for each event and when it occurred and whom all agreed to
the execution of the transaction is known. This feature makes every
participant own the responsibility and be genuine with all the trans­
actions. Many firms are now offering blockchain-enabled traceability
solutions as a result of the blockchain hype over the recent few years, but
they have failed to enhance the overall quality of data gathered and
exchanged. This has, understandably, led to considerable skepticism
about the utility of blockchain in supply chain scenarios. Each new
transaction added to a block will be both immutable and timestamped.
This makes it simple to trace data and ensures that the information
contained within the block cannot be tampered with. Any businesses
that register any specific data or transaction on the blockchain must be
trustworthy to secure traceability and authenticity.
Raw material suppliers, manufacturers, distributors, pharmacies,
hospitals, and patients are all part of the healthcare supply chain, which
is a complicated network of numerous separate organizations. Due to
several variables, including a lack of information, centralized manage­
ment, and conflicting stakeholder behavior, tracking supply across this
network is difficult. Drug traceability (tracking and tracing) is becoming
increasingly important, with some nations mandating it (Musamih et al.,
2021a). Therefore, traceability of drugs has become an important
element of the pharmaceutical supply chain, as it ensures product
authenticity and attempts to track and trace the product’s chain of
custody along the supply chain.
2.3.3. Immutability
Immutability is another important feature of blockchain (Gordon
and Catalini, 2018). It is defined as the capacity of a blockchain ledger to
remain unmodified, and the blockchain remains unaltered and persis­
tent. It’s also crucial to understand that blockchains are decentralized
and distributed in nature, with a consensus reached among the nodes
that hold the data copy. This agreement assures that the data’s
uniqueness is preserved. Centralized databases are vulnerable to secu­
rity breaches and hacking, and thus require third-party assurance to
remain safe. Blockchain maintains ledgers to record all transactions
(Fanning and Centers, 2016). Ledgers are distributed among the block­
chain participants. Once a transaction is packed into the blockchain it is
impossible to tamper, all the transactions that are recorded in the blocks
using hash keys. The hash keys are linked to the previous and next
blocks. Every block validates the transactions using the same algorithm.
Thus, any changes in the transaction generate a different hash key and it
can be identified by other blocks of the network. Blockchain keeps its
ledgers in a never-ending state. The ledgers are shared with all the nodes
and it synchronizes with each other in real-time. Tampering of the
ledgers would require 51% of control over the network which is prac­
tically difficult among millions of users (Tschorsch and Scheuermann,
2016).
2.3.4. Secure data exchange
To ensure the security of data exchange, blockchain does not require
a third party or an authority on its governance. To guarantee consistency
and reliability, blockchain adopts the decentralized consensus-based
access mechanism (Pop et al., 2018). Blockchain cryptocurrencies
secure and prevent counterfeiting transactions through public-key
cryptography. The identity network security system allows authorized
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Journal of Network and Computer Applications 215 (2023) 103633
access to digital signatures and prevents fraud and theft of data (Peter­
son et al., 2017). A successful data exchange necessitates data sharing
that is trustworthy, compliant, secure, auditable, and useful. Blockchain
technology has a number of interesting methods for facilitating easy,
traceable, and trustworthy data transmission across data ecosystem
players. Blockchain can keep data immutable, auditable, and
single-version-of-truth, ensuring transparency, privacy, interoperability,
and security.
A DASS-CARE, a Blockchain-based architecture for decentralized,
transparent, scalable, and secure access to healthcare services, including
medical data was proposed by Al-Karaki et al. (2019). This framework
can considerably simplify the process of real-time access and changes
without jeopardizing patient data security, integrity, or confidentiality.
Medical data exchange and protection plan based on the hospital’s
private blockchain was proposed by Liu et al. (2019b). This system
meets a variety of security requirements, including decentralization,
openness, and tamper resistance. Doctors can retain medical data or
retrieve patient historical data via a secure system that respects their
privacy (CHELLADURAI et al., 2021). A symptom-matching technique is
also provided between patients. It enables patients who have the same
symptoms to undertake mutual authentication and generate a session
key for future ailment communication.
2.3.5. Decentralization
The decentralized nature of blockchain confirms that there is no
central authority (Patel, 2019). This makes the system more secure and
pleasant with synchronized transactions. Blockchain utilizes consensus
mechanisms across the network of peers to securely transact with other
users rather than relying on a single authority, also to vindicate trans­
actions and record data in an incorruptible fashion. Therefore, ledger
information that is stored is honest and accurate. It provides unalterable
transaction records and high QoS delivery. The computing power of the
system is distributed which makes the network simple to manage and
operate. These QoS-aware transactions are made effective with block­
chain mechanisms. The QoS parameters include data integrity with
end-end traceability, availability, responsibility, high level of reliability,
and increased customers. Choosing the data that will be stored in
distributed ledgers is very crucial for delivering reliable quality. Some
data can be stored in local databases instead of sending all system data
onto the blockchain network. Only data from applications that require
immutability will be packed inside blocks otherwise. This reduces the
costs of storage, replication, and search for the decentralized applica­
tions that have been built (Dao et al., 2020). The computing power of the
system is distributed which makes the network simple to manage and
operate.
In healthcare applications, due to a lack of defined data formats,
dependable communication medium, interoperability difficulties, and
secure platforms to ensure users’ security and privacy (Andrew Onesimu
and Karthikeyan, 2021), data exchange across multiple stakeholders is
now exceedingly difficult. Shuaib et al. (2021a), presented a decen­
tralized electronic health record system, which, when compared to
existing systems, enables greater security and efficient exchange of
electronic health record data. A permissioned Blockchain based on an
IBFT consensus algorithm, a threshold signature method, and a decen­
tralized file system is all part of the proposed system.
2.3.6. Time and cost-effective
The conventional method of transactions can take days for the
remission of demand drafts and cheques, specifically beyond working
hours. But with blockchain technology, all transactions are performed in
a short period (Lombardi et al., 2018). This is an essential feature for
healthcare as slow access to healthcare data can lead to serious loss.
Healthcare participants can engage in online transactions at their ease
from any location. Also, the blockchain diminishes exchange charges
and overhead expenses which are not present in this system. Trans­
actions on the blockchain are reasonable, as the only nominal costs are
A. J et al.
incurred by the parties involved. However, blockchains can become
costly and inconvenient because of their complexity and encrypted
distributed nature. When compared to “traditional” payment methods
like cash or debit cards, transactions might take a long time to complete.
The transactions take longer to complete as the number of users on the
network grows. The entire transaction might take many days to
complete.
Blockchain technology is particularly well-suited to information-
intensive databases and medical applications, resulting in lower
healthcare costs, particularly in terms of platform maintenance and se­
curity, accessibility, and data redundancy. Reference (Radjenovic,
2019) presented a cost-saving role of blockchain in the healthcare sys­
tem. The various attributes reduce the cost and maintenance of the
pharmaceutical industry.
3. Operations of blockchain
Healthcare could be transformed by blockchain technology, which
would put the patient at the center of the ecosystem and improve the
security, privacy, and interoperability of health data. By increasing the
efficacy, disintermediation, and security of electronic medical data, this
technology may offer a fresh approach to health information exchanges
(HIE). Although it is not a miracle cure, this brand-new subject is
developing quickly and offers plenty of opportunity for research, fund­
ing, and proof-of-concept testing. The actual value of interoperability
might be unlocked via a blockchain-based health information exchange.
Blockchain-based systems have the ability to lessen or do away with the
costs and friction associated with present middlemen. For those involved
in the health care ecosystem, the blockchain’s promise has broad ram­
ifications. Utilizing this technology provides the ability to integrate
disjointed systems, produce insights, and improve care value assess­
ment. A statewide blockchain network for electronic medical informa­
tion could eventually increase productivity and boost patient health
outcomes. This section discuss the basic working model of a blockchain.
3.1. Working model of blockchain
Blockchain has the power to enhance the services offered in trade
finance. Blockchain combines distributed, decentralized, cryptographic
peer-to-peer networking model. It provides a platform for secure digital
cryptocurrencies. Blockchain offers tremendous opportunities to the
trade industry, society, and economy. Blockchain technology is used in
multiple areas and is challenged to meet real-time application re­
quirements such as security, high performance, scalability, and efficient
consensus models. Blockchain offers an alternative method for elimi­
nating the intermediary involved in the transaction process. The
blockchain provides traceability and security of the user’s crypto­
currencies. The blockchain is designed to exchange goods and services
without the need for trust or central authority. It has the potential to
eliminate this vulnerability with transparent transactions.
The blockchain is composed of blocks each consisting of digital in­
formation. Each block is tied combined to form a chain. Each block
contains three parts. The block stores data about the transactions, par­
ticipants involved in the transactions, and the cryptographic codes that
distinguish blocks from each other. The working of blockchain can be
summarized in four steps. They are.
1. The transaction is executed
2. The transaction is verified and then validated
3. The transaction is stored in the block
4. The block is hashed and added to the blockchain
Blockchain operates in an environment where all the business parties
network with a secure and synchronous record of transactions. The
blockchain ledger records every flow of transactions from start to end.
Here, the user’s data are secure with the owner’s private key and each
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Journal of Network and Computer Applications 215 (2023) 103633
transaction is validated with the unique ID to create a block. Each block
are interlinked with its fingerprints. Consensus will help to verify and
interlink chains of blocks (Cachin and Vukolić, 2017). Thus the content
in the block is verified in the network and can store any type of real-time
data like financial transactions, contract information, or digital asset,
etc. For example transaction of equities in the stock market is depicted in
Fig. 7. At the outset, the list of abbreviations used throughout this article
is listed in Table 2 to help in reading.
An equities market includes asset custodian (bank), broker, invest­
ment manager, central securities depositories (CSD), and central coun­
terparties (CCP). The steps involved in the transaction are as follows.
1. To buy and sell blocks of securities, the asset custodian uses a client
application to initiate a transaction or a block. Transactions can be
initiated by any peer in the network.
2. The broker receives the transactions in order to verify the orders.
3. The broker transmits the proposed order to an investment manager,
who will disseminate the transactions to all peers for consensus.
4. If the sequence of transactions is accepted, each validating node
carries out the transactions and adds them to the ledger. Next, a copy
of the ledger is sent to each network peer.
5. The central counterparty will control the cash flow for the order
transaction and do the confirmation.
6. The asset ledger is maintained by the central securities depository,
who also collaborates with custodians. It manages the movement of
funds, assets, and security services.
3.2. Architecture of blockchain
To understand the working of blockchain technology, a layered
approach is followed. The architectural layers are more generalized to
suit the diversity of any application. To attract more customers, the
business that requires high scalability and reliability can utilize the
blockchain to improve its services.
3.2.1. Layered blockchain architecture
This section details the layered architecture of blockchain. The layers
in the architecture are the application layer, execution engine layer, data
model layer, consensus layer, and network layer. Fig. 8 shows the hi­
erarchy of layers in the blockchain. Table 3 lists the various blockchain
development platforms available based on these layers (Glaser, 2017)–
(Brakeville and Perepa, 2018).
3.2.1.1. Application layer. It is the topmost layer in the blockchain ar­
chitecture. It provides a graphical user interface for users to interact
with the system. The various tools are Ethereum, solidity, parity, etc.
The data in blockchain are immutable and transparent and cannot be
modified. It is resilient to illegitimate access and fraudulent activities.
The application layer is divided into two sub-layers they are application
layer and the execution layer. The end-users use the application layer to
interact with the blockchain network. The application layer consists of
APIs, user interfaces, frameworks, etc. The smart contracts, underlying
rules, and chain code are in the execution layer. The actual code is
executed and the rules are present in this sublayer. The application layer
sends the instructions to the execution layer. The security challenges of
this layer represent the security issues related to the centralized nodes
that are involved in cryptocurrency transactions. Some of the challenges
include DDOS attacks, unauthorized access to the server, obtaining
sensitive information by cracking the password, host security, etc.
Therefore, the application developers must guarantee that their software
is fully tested and does not include any known vulnerabilities (Wang
et al., 2019).
3.2.1.2. Execution engine. The contract will be executed at runtime.
Execution time should be deterministic and fast during the execution of
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

Fig. 7. Processes inequities in stock market.

multiple contracts in the single transaction block. To avoid inconsis­

Table 2
tency in transaction deterministic execution is followed. Caterpillar
Abbreviations.
engine (López-Pintado et al., 2017) is one of the blockchain execution
Abbreviation Full Name engines that provide operations such as process model deployment,
CCP Central counterparties instance creation for the deployed model, and control and record
CSD Central securities depositories execution. A smart contract running in the blockchain network facili­
EVM Ethereum Virtual Machine
tates contract negotiation, verification, implementation. Execution of
FBA Federated Byzantine agreement
IoT Internet of Things
smart cards neglects the third party costs and provides more security and
P2P Peer to Peer reliability (Chen et al., 2018). The challenges of this layer involve the
PBFT Practical Byzantine Fault Tolerance threats and risks to smart contracts. The goal of the attack is to take over
PoET Proof of Elapsed Time the contract control flow and disrupt the transaction’s atomicity. The
PoS Proof of Stake
majority of these attacks are the result of a failure to make explicit
DPoS Delegated Proof of Stake
LPoS Leased Proof of Stake function visibility or to perform appropriate permission checks, allow­
PoI Proof of Importance ing an attacker to access or alter a function or variable that should not be
PoC Proof of Capacity accessible. Therefore to prevent data manipulation and establish trust,
PoB Proof of Burn
before the construction of smart contracts, it is important to protect
dBFT Delegated Byzantine fault tolerance
PoW Proof of Work
against existing vulnerabilities. It should go through a series of security
PoA Proof of Authority checks before being released. To prevent losses, professionals must
TEE Trusted Execution Environment execute timely code optimizations, conduct frequent code audits, and
UTXO Unspent transaction outputs monitor anomalous behavior of deployed contracts.
PoLe Proof of Learning
PoDL Proof-of-Deep-Learning
S-PoDL Separate Proof-of-Deep-Learning 3.2.1.3. Data model. The data model ensures simplicity for crypto­
HDPoA Honesty-based distributed Proof of Authority currencies. The data model varies from one application to another. The
SG-PBFT Score Grouping-PBFT data include transaction data, master data, and reference data. It rep­
DR-BFT Dynamic Random Byzantine Fault Tolerance
resents the blockchain shared database, blockchain data structure, and
physical storage. The transactions in a blockchain are arranged in blocks
in a P2P network. Without a common consensus, data cannot be altered.
The blockchain data structures have two main components they are
pointer and linked list. The location of another variable is referred to by
the pointers. The chained blocks are linked lists where each block points
to the previous block. A Merkel tree consists of many hashes. The Merkel
root is situated in each block which contains the information of the
previous block, timestone, nonce, and the version number, etc. The se­
curity of the blockchain depends on the hash power of the participating
members. The blockchain generally pays members in the form of virtual
cash to promote node involvement. However, a centralization problem
arises if the members fail to work with this.

3.2.1.4. Consensus layer. The consensus layer is one of the most

important layers in the blockchain. The consensus algorithm is called a
conclusion algorithm. Without a consensus algorithm, there is no
blockchain. The validation of blocks is done by a consensus algorithm.
This layer is called to be the crucial layer among all the layers in the
Fig. 8. Layers of blockchain. blockchain. The consensus layer’s responsibility is to make all users

9
A. J et al.
Table 3
Comparison of Blockchain platforms.
Layers Ethereum Ripple
Application Cryptocurrency Cryptocurrency
Execution Engine EVM – Dockers
Data model Account-based UTXO based
Consensus PoW Ripple consensus ledger
Network P2P P2P
agree upon a common transaction rule. Globally accepted sets of
transactions are designated for information verification. The consensus
algorithm in blockchain has two types one is permissionless and the
other is permissioned. A permissionless blockchain is also known as a
probabilistic model that includes networks such as Ethereum, Bitcoin,
etc. The other type is Permissioned which follows a deterministic algo­
rithm such as Hyperledger Fabric. These blockchains have some nodes
which validate the ordering nodes and decide whether they are truly
false. The consensus layer receives threats from various types of attacks
such as bribe attacks, long-range attacks and Sybil attacks. Therefore,
it’s important to look into a more secure and quicker consensus mech­
anism while also making existing assaults more difficult.
3.2.1.5. Network layer. The other name for the network layer is Peer to
Peer (P2P) layer. The computer nodes are distributed and shared to
reach the end of the goal in a P2P computer network. The transaction is
performed on the blockchain through the nodes. The nodes are of two
types they are Full node and Half node. A full node is used to ensure the
verification, validation, transaction of the mining rules. The P2P layer
maintains the valid current state of the blockchain network by
communicating, propagating, and discovering through each node. Its
responsibility is to propagate or broadcast transactions among peers.
One of the key issues is to fully utilize the underlying network band­
width for transmission.
4. Use cases of healthcare blockchain
Blockchain is on the verge of changing the healthcare system; due to
its decentralized principles, blockchain can increase patient information
accessibility and security, overturning the healthcare hierarchy and
establishing a new system in which people govern their treatment (Singh
et al., 2021). In a traditional healthcare system, sensitive medical re­
cords lack a safe framework, resulting in serious data breaches. Another
concern is that patients do not yet have complete control over their
Fig. 9. Evolution of healthcare systems.
10
Journal of Network and Computer Applications 215 (2023) 103633
Hyper Ledger Parity Sawtooth Lake
Smart Contract Smart Contract Smart Contract
EVM TEE
Account-based Account-based Account-based
PBFT PoA PoET
P2P P2P P2P
medical data, a concept that is becoming more prevalent with the advent
of customized treatment and wearables. Both of these situations have
important moral implications that must be addressed.
Healthcare domain has seen a tremendous growth since the
advancement of technologies like industry 4.0. The paper based system
has moved to electronic healthcare records and electronic medical re­
cords for better patient data management and healthcare research. In
the current era, telemedicine and internet of medical things (IoMT) are
some of the recent advancement which is transforming the healthcare
domain. Blockchain can play a major role in transforming the healthcare
domain. The evolution of healthcare systems over recent years is shown
in Fig. 9 and the major healthcare challenges are shown in Fig. 10. Each
level of the healthcare supply chain may well benefit from blockchain
technology. Raw material supply, logistics, manufacturing, wholesale
distribution, and service providers are among them, as are electronic
health records (EHR), verifying patient data, and even analyzing patient
information. Blockchain has many applications in healthcare and is used
in a variety of applications such as enhancing mobile health applica­
tions, monitoring devices, sharing and storing electronic medical re­
cords, clinical trial data, and insurance information storage, among
other things (Omar et al., 2021). Fig. 11 shows the various application of
the blockchain in the healthcare system.
Healthcare practitioners and researchers tussle with broken data,
hold-up communications, and unequal workflow tools. Another issue is
the absence of secure connections that can associate all autonomous
healthcare frameworks to set up an end-to-end reachable system (Xiang
and Zhao, 2022). The healthcare sector is struggling to manage and
maintain an e-health record (Zhang et al., 2018a). The applications of
blockchain technology will provide trustless transactions via decen­
tralization with virtual anonymity. It provides an immutable feature, to
prevent the manipulation of data from a single entity and for duplication
of entries. Blockchain can be enforced to ensure the secure transaction of
confidential information such as patient records, compiling episodes,
disease records, lab results, treatment taken, ambulance services, etc.
A. J et al.
Fig. 10. Major challenges of healthcare domain.
are verified by digital signature for each user and recorded in the ledger
in minimum duration of time (Zhang et al., 2022a). However, an in­
tricacy within the healthcare industry adds several challenges to
employing blockchain technology.
To share the information across organizations by using blockchain as
a distributed ledger among networks, Hyperledger Fabric (Wutthikarn
and Hui, 2018) is the solution in this electronic health record. Com­
panies like Ripple, Ethereum, Quorum, Corda, NEO, NEM, and certain
other companies have launched many Blockchain platforms. Tele­
surgery (Vora et al., 2017) which allows a doctor to perform real sur­
geries with the help of robots and wireless communication systems is the
application of telemedicine. It saves time, expenses, and also the
shortage of doctors can be overcome with this. Medblocks (Enescu et al.,
2018) is one of the blockchain based applications that is trying to
enhance the medical and other fields for decentralization.
4.1. Patient data management
Blockchain has been used widely for patient data management
mainly to improve security and cost-effectiveness. Medical data are
Fig. 11. Applications of blockchain in healthcare system.
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Journal of Network and Computer Applications 215 (2023) 103633
stored electronically, patients’ appointments are managed, billing and
accounts are handled, and lab tests are performed (Shahnaz et al., 2019).
They’re included in a lot of the EHR systems utilized in the healthcare
industry. The main goal is to deliver medical records that are safe,
tamper-proof, and shareable across several platforms. With numerous
granularities of management by the patient, physicians, regulators,
hospitals, insurers, and others, blockchain maintains each patient’s full
medical history, offering a safe way to record and preserve compre­
hensive health information for each patient.
4.2. Drug traceability
Every year, a huge number of people are harmed or killed as a result
of taking counterfeit medications. Pharmaceutical companies suffer
significant financial and reputational losses as a result of medicine
counterfeiting. Instead of utilizing a standard supply chain management
system, blockchain-based drug traceability enables to improve the effi­
ciency of the supply chain by preventing fraud and counterfeit products.
In (Musamih et al., 2021a) a drug traceability system was designed by
Musamih et al., that enables stakeholder and their interactions with the
smart contract, as well as the medication tracking system. The smart
contract, decentralized storage system, and on-chain resources are ex­
pected to be accessed by stakeholders via software devices with a
front-end layer signified by a dApp that is connected to the smart con­
tract, on-chain services, and decentralized storage system via an API. A
G-coin blockchain was developed by Tseng et al. (2018), to create
transparent drug transactions and protect public health data.
4.3. Cryptocurrency payments
There are several benefits to cryptocurrency payments in healthcare.
With blockchain technology, a ledger keeps track of all transactions. The
stored data contains all of the information about the coin’s owners. This
guarantees that the transactions that are taking place are genuine.
Digital money is not controlled by the bank or the government because it
is a decentralized currency. The individual who created the digital
money retains ownership of the currency. Blockchain enables patients to
make exchanges. The shortfall of mediators like merchants, represen­
tatives, and banks doesn’t need the endorsement of a focal office for
executing the exchanges. It makes the entire charging measure simpler.
The patients that take a crack at clinical exercises are effectively
recognizable through the framework (Kombe et al., 2018). It checks the
legitimacy of the subtleties presented by them and the qualification of
the exchanges.
4.4. Clinical trials and data security
In clinical studies, it is critical to collect authentic and correct data.
A. J et al.
This is important to correlate, measure, and make analyses. Also, from
the standpoint of a patient, it adds a layer of safety and security to the
personally identifiable and sensitive information that a patient would be
concerned about if it were breached into locations where identity theft
may occur. Several studies have explored the importance of blockchain
for clinical trials (Jahankhani et al., 2019)– (Omar et al., 2020). From
the beginning of the procedure, with registration and informed
permission, to the release of results and drug administration, clinical
trials are being made more transparently available with blockchain
technology.
4.5. Device tracking
Another important way to revolutionize healthcare is by tracking
medical devices from their manufacture through their decommissioning.
All hospitals struggle with managing a pool of medical equipment that is
utilized by numerous departments and patients. Time is important in a
medical emergency to locate the appropriate supplies. Therefore, med­
ical device monitoring and tracking are critical to enable rapid device
retrieval and avoid unnecessary repurchasing and fraud analytics from
the supply chain to decommissioning (Jafri and Singh, 2022). A
blockchain-based approach has several advantages over conventional
location monitoring methods. The most noticeable features of block­
chain are its immutability and tamper-proof nature. To help with reg­
ulatory compliance blockchain technology can be used to create an
immutable log that reveals the device’s location, where it has been
during its history, as well as its maker reseller and its serial number. This
blockchain-based approach prevents a malicious person from changing
or removing a device’s location history from the database. Blockchain
enables us to gain crucial insight into how the loaned-out medical
equipment is used, confirm that they are in authorized areas, and finally
guarantee that clients utilize them. Some of the benefits include locating
equipment easily during an emergency, maintaining an inventory pro­
cess log and automating the utilization process.
4.6. Secure healthcare setups
Smart Healthcare has advanced to a high level of sophistication in
terms of efficiently supplying and dictating medical health care to pa­
tients while maintaining the privacy of their data, as well as the process
of presenting real-time accurate and trusted data to medical practi­
tioners (Chakraborty et al., 2019). IoT has also performed admirably in
the healthcare sector, facilitating simpler diagnosis and monitoring of
patients.
4.7. Healthcare internet of things (IoT)
The internet of things (IoT) envisions a wholly connected world,
where things can communicate and interact with each other through
data (Reyna et al., 2018). There are numerous smart applications in
several industries like smart homes, wearables, smart cities, smart grid,
automotive, etc. The expansion of IoT generates huge volumes of data.
To ensure the creditability of its data is a major issue to be maintained.
One way to provide creditability in IoT data is via blockchain technology
by providing a distributed service authorized by every participant which
guarantees that the data remains immutable.
Blockchain technology for the healthcare industry has the potential
to improve IoT data security and transparency while also enabling IoT
efficiency, scalability, and standardisation in the future. In order to
protect the devices from hackers and keep track of who has accessed the
data, patients will be able to decide who has access to the data acquired
by blockchain-enabled IoT devices used in healthcare. Supply chain
payments may be automated using blockchain-based systems powered
by smart contracts, depending on the specific conditions monitored by
IoT sensors.
Due to sensors that may be integrated with small devices for
12
Journal of Network and Computer Applications 215 (2023) 103633
monitoring patient health conditions and providing data for analysis,
the healthcare sector is creating a lot of interest in the use of IoT to help
patients and physicians. Hospitals could become “smart hospitals” with
the IoT, easing various procedures for medical professionals. Kumar
et al. (2023) have proposed an secure data transmission for an IoT
enabled healthcare system which is orchestrated by blockchain. The
proposed approach ensure secure data transmission and data integrity
through zero knowledge proof. The data security issues with inter­
planetary file system addressed through Ethereum smart contracts.
Brooks Iyengar Quantum Byzantine Agreement-centered Blockchain
Networking is another approach proposed for secure healthcare IoT by
Zhao et al. (2023). The main objective of this approach is to maintain
confidentiality and to protect the privacy of the healthcare data that are
shared over the blockchain. This approach also addresses the healthcare
blockchain issues such as authentication, consensus latency,
throughput, delay, and security levels. With the aid of various smart
particles and the usage of multimedia in the healthcare architecture,
patient data can also be stored, processed, and transmitted online in a
variety of formats, including text, voice, and photos. However, to
address the pertaining challenges like data management and data pro­
tection Taloba et al. (2023) suggested an multimedia data processing
system for healthcare IoT. Further this system aims to solve the problems
with the healthcare domain such enrollment of the diagnosis, and secure
and faster transactions. Baucas et al. (2023) in his study proposed pri­
vate blockchain with federated learning to address fog-IoT privacy and
security challenges. The fog-IoT network is focused on addressing the
problems with wearable IoT devices such as adaptive issues, privacy,
integrity and security.
4.8. Health insurance: claims processing
With the rise in health issues, health insurance has become a ne­
cessity in people’s life. Medical emergencies might be difficult for those
who cannot afford high costs. In the event of a medical emergency,
health insurance helps people pay for healthcare services and offers
financial security from the fear of debt. Security, privacy, and fraud
concerns might arise with regard to health insurance and its many ad­
vantages. Due to the significant losses it causes for individuals, busi­
nesses, and governments, fraud has been a sensitive topic in the health
insurance industry during the past few years. Therefore, the develop­
ment of technologies to identify fraudulent instances and payments is
crucial for both national authorities and commercial companies.
Claiming insurance is one of the frustrating processes where the in­
surance processors have to check for fraudulent claims, segmented data
sources, and abandoned policies that the customers state and also the
process is very huge. This technology provides risk-free management
and transparency and allows the insurers to take ownership of assets to
be insured (Raikwar et al., 2018). Nowadays the insurance system is
heavily dependent on transactions. To address productivity and security
requirements, many Fintech systems use an immutable ledger for
finding double-spending of cryptocurrencies which was created by
Blockchain technology (Raikwar et al., 2018). Blockchain-based insur­
ance system provides two insurance service models, one for personal
web identity security of end-users and another one for data security of
commercial websites, which is proposed for web identity security. For
authentication, evidence of the claim is automatically uploaded. To
make the trust between the insurer and policyholder stronger, contracts
are applied automatically (Guo et al., 2018).
4.9. Blockchain technology for Covid-19
The Covid-19 global pandemic has changed all aspects of humanity.
Information technology was hugely used to manage and control the
transmission, testing and vaccination. To handle this moment of
extraordinary medical crisis, the focus shifted to the digital health
community to offer potential health solutions to lessen the impact of this
A. J et al.
epidemic (Kapoor et al., 2020). The COVID-19 pandemic presented
significant difficulties for the world’s medical community. Digital
healthcare proved to be well-suited to offer creative solutions to combat
the epidemic. Some of the solutions include creating reliable surveil­
lance systems, telehealth, innovative diagnostic and clinical
decision-making tools, expanding the use of wearables to track physio­
logical indicators, and creating interactive chat services to disseminate
information about COVID-19 to the general public. To lessen the effect
of COVID-19 waste on the environment and public health, great effort
has been made to improve the Healthcare Waste Management (HCWM)
system. Several blockchain-based solutions were employed to address
many pressing issues (Shah et al., 2021). The following section details
the healthcare sectors that benefitted from using blockchain
technologies.
4.10. Vaccination registration and monitoring
Lockdown was implemented by governments all around the world to
slow down the transmission rate. Overseeing the population’s testing
and immunization process was a monumental task for healthcare pro­
viders. To increase effectiveness and save more lives, procedures must
be streamlined. To ensure data provenance, smart contracts were
created to automate the process of logging and documenting events
relevant to the distribution and delivery of COVID-19 vaccines. To aid in
controlling the severity of the pandemic situation a Digital Vaccine
Passport (DVP) system was proposed to prioritize safe vaccines for the
needed patients and automate testing certificates using blockchain
technologies (Nabil et al., 2022). As blockchain offers distributed system
with increased privacy, transparency, and authenticity, the DVP system
incorporated private blockchain Hyper-ledger Fabric to provide seam­
less testing and immunization. The system was able to improve cost
efficiency.
4.11. Vaccine distribution
One of the best ways to stop the spread of infectious diseases is
through vaccination. Due to the perishability of the products and the
necessity for stringent transit and storage regulations to ensure people’s
health and safety, the vaccine supply chain is different from regular
supply chains (Musamih et al., 2021b). Inefficiencies, such as poor de­
livery plans or a lack of interoperability, cause the supply of vaccinations
to halt or delay. Additionally, in the event of pandemics, the large
number of doses required for the deployment of a mass vaccination
campaign compels governments to create an appropriate logistical
network and organize a quick and effective vaccination distribution.
Physical restrictions include a shortage of medical staff, poor infra­
structure, and inadequate storage systems. Specialized storage equip­
ment is needed to ensure the preservation of the vaccines. Due to the
restricted capacity and availability of ultra-freezers, an effective man­
agement system is needed to avoid vaccine validity time. Communica­
tion issues among supply chain participants can make vaccination
supply and demand unpredictable, resulting in inefficiencies and
regional imbalances. Security concerns, such as those involving poten­
tial cyberattacks or tampering with health data; maintaining the integ­
rity of this data is important.
A model was created to simulate the potential improvement of the
supply chain performance using the blockchain, consisting of better
communication among players but also in the automation of the pro­
curement process through smart contracts, starting from the real and
current vaccine allocation criteria (Rinaldi et al., 2022). In this way, the
national vaccination programme was implemented on demand. The
simulation model developed enabled the procurement process of the
vaccine to be automated through smart contracts. Each region’s in­
ventory was monitored via smart contracts and appropriate inventory
policies were defined and applied. The analysis showed improved per­
formance in vaccine distribution by reducing stock levels with
13
Journal of Network and Computer Applications 215 (2023) 103633
transparent and integrated data sharing along the entire supply chain
(Sookhak et al., 2021).
4.12. Healthcare Waste Management
Healthcare waste management has become a challenging task due to
the spread of COVID-19. The increase in waste is due to hospital waste
and vaccine waste. The general public’s use of face masks is one strategy
to combat COVID-19. In the case of health workers, it is crucial to
maintain patient and employee safety in addition to using other personal
protective equipment. As a result of the majority of masks are made of
non-renewable petroleum-based materials, hospital trash has increased
dramatically, adding to environmental contamination. In addition to
sharps, tainted blood, body, and tissue parts, chemicals, medications,
and radioactive materials, these leftovers might be categorised as
healthcare waste. Reverse logistics (RL), which includes managing and
disposing of hazardous or non-hazardous waste from packaging and
product, has emerged as a significant alternative for the effective man­
agement of Healthcare waste. Healthcare Waste Management indicators
have proven to be very significant to assess hospital waste and aid in
environmental management. So an Analytic Hierarchy Process (AHP)
multi-criteria analysis method was used to weigh the different indicators
and prioritize the criteria (de Aguiar Hugo and Lima, 2021). The eval­
uation tool designed was enabled to identify the good indicators of
waste.
Another type of waste is the overproduction and underutilization of
vaccines due to large-scale vaccine production. Transparency, trace­
ability, accountability, trust, and security elements are typically absent
from the systems and technology used today to handle waste data about
COVID-19 vaccinations. Therefore, a five-phase blockchain-based solu­
tion was proposed. The blockchain-based solution includes trash
assessment, production and delivery, consumption, production, and
commitment. To assure accountability for all activities made by the
participating parties and minimize any extra waste brought on by
overproduction, overordering, or underconsumption, the entire life
cycle of a COVID-19 vaccination is managed by several smart contracts.
Ethereum-based smart contract was written using REMIX IDE and
implemented on Kovan Testnet (Musamih et al., 2022). The proposed
solution was able to overcome large-scale data storage and obtain higher
throughput by using the PoA consensus algorithm. Better data privacy
was achieved by using a private permissioned Ethereum blockchain.
Regulators were able to leverage smart contracts and alter the block­
chain’s setup to suit their demands by using a private permissioned
blockchain without centralized authorities. Incorporating the commit­
ment smart contract ensured that every entity is responsible for any
waste generated and thereby waste was reduced.
4.13. Supply chain management
Healthcare providers must manage the Healthcare Supply Chain
(HCSC) process effectively both during pandemics like COVID-19 and in
their everyday operations. As every day, volumes of cargo are trans­
ported both domestically and abroad, healthcare providers continue to
struggle with purchasing, ordering, forecasting, and distribution pro­
cedures despite considerable advancements in new technologies and
treatment choices. In manufacturing supply chains, the healthcare in­
dustry likewise faces significant challenges in streamlining and con­
trolling healthcare operations. Group Purchasing Organizations (GPOs)
are significant players in the HCSC and provide providers discounts for
volume purchases as well as vendor selection. To increase the effec­
tiveness of the contracting process in HCSC and to streamline the
administration of GPO contracts, a blockchain-based solution that
makes use of Ethereum smart contracts and a decentralized storage
system was proposed (Omar et al., 2021). Manufacturing, distribution,
GPOs, and healthcare providers can all be connected within the same
decentralized Ethereum network using a blockchain-based GPO contract
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

solution. The solution incorporates the key processes involved in drug
and device procurement. The proposed architecture allowed access only
to registered stakeholders to smart contracts and guaranteed trust and
transparency. The system improved cost efficiency by avoiding pricing
discrepancies with stakeholders.
The success of a global immunization campaign and the speedy roll-
out of a vaccine depends on the existence of a functioning, transparent
distribution network that can be audited by all key stakeholders. In the
vaccine supply chain things such as food, commodities, and pharma­
ceutical drugs are can get damaged while in transit. Numerous factors,
including poor storage practices, exposure to air or sunshine, and
incorrect storage conditions, might contribute to this. Basic shipment
tracking has been improved with the help of the Internet of Things (IoT)
by increasing the visibility and transparency of such transportation
systems. CryptoCargo, a smart container system that uses blockchain
technology to monitor shipping conditions and identify any infractions
that could jeopardize the shipment’s contents was proposed (Alkhoori
et al., 2021). Smart contracts are used to record these violations on the
blockchain, which offers secure and immutable storage, enhancing its
trustworthiness in a context where there are many parties and little
room for trust.
To enable the awareness of all network peers, smart contracts are
established to monitor and track the right vaccine distribution condi­
tions against the safe handling norms defined by vaccine producers. In
order to administer vaccines, a tamper-proof, transparent side effect
solution, an Ethereum test network Ropsten, a prototype was developed

Table 4
Comparative analysis on present blockchain healthcare applications.
Companies Adopted Private Public Federated Token Smart Platform Application
Blockchain Technology Usage Contract

MedRec ✕ ✓ ✕ ✕ ✓ Ethereum Healthcare data management

BurstIQ ✓ ✕ ✕ ✕ ✓ Bitcoin & Ethereum Healthcare data management
MediLedger ✓ ✕ ✓ ✕ ✓ Ethereum Pharmaceutical supply chain
MedicalChain ✕ ✕ ✓ ✓ ✓ Hyperledger Fabric, Securely storing EHR
Ethereum
SimplyVital Health ✕ ✕ ✓ ✓ ✓ Health Nexus Securely storing EHR
Factom ✓ ✓ ✕ ✓ ✓ Bitcoin Securely storing EHR
Robomed Network ✕ ✓ ✕ ✓ ✓ Ethereum Medical data aggregation
Guardtime ✕ ✓ ✕ ✓ ✓ Ethereum Supply chain management
Healthureum ✕ ✓ ✕ ✓ ✓ Ethereum Healthcare data management
Iryo ✓ ✓ ✓ ✓ Ethereum Clinical data management
Gem ✓ ✓ ✓ ✕ ✕ All type of cryptocurrencies Patient centric approach to healthcare
Chronicled ✓ ✕ ✕ ✕ ✓ Ethereum Pharmaceutical supply chain
DokChain ✕ ✕ ✓ ✓ ✓ Hyperledger Sawtooth Financial and clinical data
Coral Health ✕ ✓ ✕ ✓ ✓ Ethereum Medical data aggregation
Patientory ✕ ✓ ✕ ✓ ✓ Bitcoin, Ethereum Securely storing EHR, Supply chain
management
EncrypGen ✕ ✓ ✕ ✓ ✓ My-Gene, Chain market Sell and share DNA information and genomic
data securely.
Blockpharma ✓ ✕ ✕ ✓ ✓ Blockpharma developed an app which Drug counterfeiting and traceability. Verify the
will control the origins of purchased authenticity of drug box.
medication.
Nebula Genomics ✓ ✕ ✕ ✕ ✓ Ethereum Enhance genomic data protection through
encryption. Acquire and manage large genomic
data.
Embleema ✓ ✕ ✕ ✕ ✓ Ethereum Provide personalized medicine unifying
clinical, real-world, molecular data, analytics
and regulatory submissions
Avaneer ✓ ✕ ✕ ✕ ✓ Fast Healthcare Interoperability Transparent, Secure and easy navigation
Resources (FHIR) and distributed through healthcare decisions and eliminate the
ledger administrative burdens
ProCredEx ✓ ✕ ✓ ✓ ✓ r3 Corda Securely transfer Credentials Data
Dentacoin ✕ ✓ ✕ ✓ ✓ Ethereum, Subscription-based platform Connect patients and dentists.
that connects patients to dentist via
Dental coins’
Clinicoin ✓ ✕ ✕ ✕ ✓ Ethereum Wellness and fitness community
Akiri ✓ ✕ ✓ ✓ ✓ All type of cryptocurrencies Create a 360-degree network of trust, only
subscribers by providing ultra-secure private
network
Curisium ✕ ✓ ✕ ✕ ✓ Patient state-centered platform effective approach to contract and rebate
management
DOC.AI ✓ ✕ ✕ ✓ ✕ All type of cryptocurrencies Intersection of artificial intelligence,
cryptocurrency, and medical software to
provide secure and confidential data.
SOLVE.CARE ✕ ✓ ✕ ✓ ✕ Bitcoin, Ethereum Reduce administrative costs of Healthcare
FarmaTrust ✕ ✓ ✕ ✓ ✓ Hyperledger Pharmaceutical supply chain and healthcare
services
iSolve ✓ ✕ ✕ ✕ ✓ All type of cryptocurrencies Clinical supply chain and patient records
security
Professional ✓ ✕ ✓ ✕ ✓ Hyperledger Identity and Credentials verification
Credentials
Exchange Inc.
Simply Vital Health ✓ ✕ ✓ ✓ ✓ Hyperledger Sensitive medical records maintenance
Inc.
Guardtime Limited ✓ ✕ ✕ ✓ ✓ Keyless Signature Infrastructure Secure data exchanges and data privacy
Blockchain
Hashed Health LLC ✓ ✕ ✓ ✓ ✓ All type of cryptocurrencies Healthcare supply chain

14
A. J et al.
(Antal et al., 2021). On the Etherscan, the outcomes of each on-chain
action were verified and checked. The outcomes for an
Ethereum-based implementation demonstrate the viability in terms of
transaction throughput and cost in terms of gas consumption. The pro­
posed system was able to successfully address monitoring campaign,
including increased efficiency and transparency of COVID-19 vaccine
distribution while ensuring traceability and a strict audit of storage and
delivery conditions. Transparency and accuracy of registration and
management of the waiting list for immunization were guaranteed.
Table 4 presents the comparative analysis of the recent companies that
adopted blockchain technology for healthcare services. The details
present in the table are some of the recent top companies that provide
solutions for healthcare systems through blockchain technology.
Table 5 summarizes the recent state-of-the-art literature with a focus
on healthcare blockchain. The table identifies the major objective of the
literature and it is observed that patient centric healthcare system and
efficient healthcare data management are the major objectives. It is
noticed that the major techniques are Hyperledger fabric, federated
learning and other cryptographic techniques. Federated learning is a
technique that preserves the individual’s privacy through collaborative
learning. The healthcare data that are used for predictive and decision
making systems’ utilizes federated learning technique. Further, we
identified the various performance evaluation methodologies that used
to evaluate the different blockchain systems.
It is realized that the healthcare blockchain system should meet the
following user and system requirements; access control, access revoca­
tion, privacy preserving, access to patients, interoperability, predictive
model, and decision making. These requirements could vary based on
the major focus of the blockchain system. Table 6 compares the user and
system requirements that are met in the recent healthcare blockchain
literature presented in Table 5.
5. Classification of blockchain for healthcare systems
A blockchain is a cryptographic-based P2P network in which a
distributed ledger is resistant to tampering and alteration. In the
blockchain, performing a transaction without relying on a middleman,
furnishes an essential trust layer for business transactions. Since every
peer of the network holds the same authenticated, non-repudiable
duplicate of the ledger, the blockchain information can be easily veri­
fied by each peer in the network (Vukolić, 2017), (Ellervee et al., 2017).
Fig. 12 shows the detailed classification of blockchain. The blockchains
can be classified into broadly two types: Permissionless blockchain and
Permissioned blockchain. Table 7 presents a suitability level of block­
chain types for the challenges in healthcare domain. The following
section discusses the types of blockchain.
5.1. Permissionless blockchain
A permissionless blockchain is a public blockchain that is available to
everyone over the network. The permissionless blockchain allows
anyone to join and participate in the network. Each transaction is vali­
dated and processed by the participants through a consensus algorithm.
It does not depend on any identity within the ledger. No trust is required
between the participating modes. In the blockchain, every party can
participate in the transactions and run a node. Every party can create
smart contracts and perform transaction verification on the network.
The decentralization of permissionless systems must be distributed to
ensure seamless network operations when a single entity failed in the
network or edits parts of it. Generally, the mining model used by per­
missionless blockchain is PoW mining where the hashing technique
helped to build trust (Gervais et al., 2016). The consensus method used
by bitcoin is the PoW model and Ethereum PoS model (Fairley, 2019). In
the private permissionless blockchain, anyone can participate in the
validation of transactions. The model used here is a federated byzantine
agreement (FBA) (Mazieres, 2015). In a digital asset exchange situation,
15
Journal of Network and Computer Applications 215 (2023) 103633
a blockchain is primarily meant to safely eliminate centralized author­
ity. In P2P transactions, a block of chains is created to ensure decen­
tralization. Before being put into the system’s immutable database, each
transaction is connected to the preceding transaction through the
cryptographic hash Merkle tree as a block of the chains. As a result,
every node in the network is compatible with the blockchain transaction
ledger. Anyone with a computer and an Internet connection will be able
to sign up as a node and receive a full blockchain record. The technology
is safe because of the repetition of synchronized public blockchains with
each network node. However, the challenges of this type of blockchain
are huge power usage during the transaction and adding a new node
(Anoaica and Levard, 2018).
5.2. Permissioned blockchain
The permissioned blockchain is a system with a well-defined user
and restricts the access to perform diverse actions in the blockchain. The
transactions are validated and processed only if the participants already
are a member of the ledger. The trust has to be proven to validate the
transaction. A smart contract can be executed and validated only by
approved entities on the blockchain. This enables trusted information to
be shared easily and in a secure context, and with the privacy that
businesses need to operate effectively. It doesn’t have computing-based
mining to reach consensus instead PBT algorithm is used to agree on
consensus without mining. In Permissioned public blockchain, anyone
who meets certain predefined criteria can download the protocol and
validate the transaction. It uses a PoS model to prove the user’s
ownership for assuring the amount of currency. The permissioned pri­
vate blockchain operates in a closed and restricted manner. Only the
member of the consortium can validate the transactions through voting
or multiparty consensus algorithm. The private platform is hyperledger
which is a modular blockchain platform consensus model to create and
allow multiple approaches to advance cross-industry blockchain
technologies.
5.3. Federated blockchain
A federated blockchain is also called a consortium blockchain which
is an integration of public and private blockchains. It’s a semi-
decentralized blockchain, in which various organizations work
together to make decisions on how to provide blockchain services to
users. Federated blockchain is different from private blockchain it is
accessible only to a closed group whereas private blockchain has
centralized management with a strict cryptographic model to validate
the transactions (Li et al., 2018).
5.4. Hybrid blockchain
The hybrid Blockchain is unique type blockchain that has all of the
benefits of a public blockchain, including security, transparency,
immutability, and decentralization, but it also controls access to trans­
actions, views, and changes in any way. Hybrid blockchains are those
that are managed by a single entity but have some supervision from the
public blockchain, which is necessary to conduct certain transaction
validations. Some examples of hybrid blockchains are open to the pub­
lic, while others are private. Hybrid is renowned for being to some
extent decentralized, whereas Federated is known for being fully
decentralized. The advantages of hybrid blockchain are as follows.
1. Allows one to work in a closed loop
2. Changes can be made easily as per the requirement
3. Transaction cost is less when compared with other blockchain
4. Immune to attacks by hackers and their by provide advanced security
5. Offers privacy of data while still communicating with outsiders.
6. Enables verification of transactions by public.
A. J et al.
Table 5
Comparison of recent state-of-the-art healthcare blockchain literature’s objectives, main technique, contributions and performance evaluation methodologies.
Reference Major Objective
Gohar et al. (2022) A patient centric healthcare
framework for healthcare
systems interoperability
Rehman et al. Secure health monitoring
(2022) system
Al-Sumaidaee et al. Healthcare governance data
(2023) management
Liu et al. (2022a) Healthcare cyber physical
systems
Azbeg et al. (2022) Secure healthcare IoT system
for patient monitoring and data
storage
Zhang et al. Hierarchical data sharing for
(2022b) healthcare IoT
Younis et al. (2022) Blockchain based architecture
for telehealth applications
Ren et al. (2022a) Blockchain-powered tensor
meta-learning-driven
intelligent healthcare system
Liu et al. (2022b) Anonymous remote healthcare
data Sharing over blockchain
Egala et al. (2023) Blockchain based decentralized
distributed smart healthcare
system
Stephanie et al. Ensemble integrated federated
(2022) learning scheme for medical
image classification
Abdellatif et al. Secure decentralized health
(2021) system for efficient medical
data exchange
Dewangan and Patient-centric IoMT-based
Chandrakar blockchain to collect and store
(2022) patient data
Journal of Network and Computer Applications 215 (2023) 103633
Main Technique Contribution Focus Performance evaluation Methodology
Hyperledger fabric • A blockchain based data sharing Data integrity, access control,
framework for cloud and IoT for better interoperability, and security analysis.
interoperability.
Federated Learning (FL) •Blockchain framework for collaborative Accuracy, Sensitivity, Specificity, Negative
model training from IoMT devices predictive value, False positive rate, False
• To enhance the patient’s privacy through discovery rate, and False negative rate.
FL by adding noise.
• To design an intrusion detection system to
further security enhancements
Hyperledger fabric •To enhance information flow and Transaction per second, Latency,
fragmentation problem between healthcare Throughput, and Send rate.
organizations
•To deal with mistrust between two parties
through fixed and linear network rate
controllers.
Federated Learning (FL) •To ensure honest data sharing by hospitals FL aggregation performance, Incentive
for FL data training evaluation
•To create new blocks, a FL training-based
consensus procedure is used.
•Reward points to hospital that honestly
share their data
Ethereum blockchain and • Secure and private data collection and Security and privacy analysis, Scalability
InterPlanetary File sharing and processing time
System (IPFS). • Reliable data storage through IPFS.
• Mobile DApp to track and monitor patient
health
Ciphertext-policy • Improved trustworthiness of shared Computational costs (key generation,
attribute-based keyword personal health records. offline encryption), Storage costs.
search (CP-ABKS) • Efficient key distribution with key leakage
resistance
• Faster computation without information
leakage.
Symmetric key • Decentralized access control to healthcare Data driven keys similarity, Model
cryptography and Smart data complexity, computational overhead,
contracts • Secure data transmission between patient smart contract performance
and cloud through data driven mechanism
• Smart contract based personalized access
control
Tensors, graph networks, • Efficient modelling of distributed Classification accuracy
and Ethereum healthcare data through tensor-prototype
graph network.
• Feature representation of healthcare data
through tensor convolution and pooling
layers.
Shamir Secret Sharing • Efficient authentication protocol not only Security analysis, computation overhead
Scheme, Proxy Re- for anonymization but also to reveal (encryption, re-encryption, & decryption)
encryption: malicious nodes identity
• On-chain off-chain based remote health­
care data sharing
Hyperledger fabric, • To establish trust between healthcare Security analysis, throughput, response
Machine learning models stakeholders for data sharing time, classification accuracy
• Selective sharing mechanism for patient
centric access control
• Machine learning based model for health
data monitoring
Federated Learning • To develop a secure multiparty Classification accuracy, model training
computation based federated learning time
model
• To develop deep learning model that
collaboratively trained by heterogeneous
models from healthcare institutions.
Ethereum and • To design a blockchain and edge Latency, computational cost.
Hyperledger fabric computing based healthcare system for
medical data exchange.
• An automated patient monitoring system
that securely exchange critical data
through edge devices
Symmetric key • To store patient health records in a Security analysis, IoT simulations time (ms)
cryptography securely adhering to GDPR regulations. versus the number of devices, number of
• Miner selection algorithm between cloud messages, number of transactions.
server and doctor node to avoid bias in
blockchain.
(continued on next page)
16
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

Table 5 (continued )
Reference Major Objective Main Technique Contribution Focus Performance evaluation Methodology

Abou El Houda Blockchain based collaborative
et al. (2022) distributed learning framework
Ren et al. (2022b) Task offloading strategy for
resource constrained fog-edge
healthcare devices.
Federated learning
Public key cryptography
• To build a robust distributed machine Classification accuracy, F1 Score, confusion
learning model where clinicians can matrix
securely collaborate
• Secure aggregation of local learning
models through secure multiparty
computation.
• Hierarchy network framework with Throughput, time efficiency, and task
centralized control and distributed success ratio
computing for smart healthcare IoT
applications.
• task offloading strategy with a low latency,
secure and reliable decision-making algo­
rithm with emergency handling capacity

Table 6
Healthcare blockchain user and system requirements that are met in Table 5.
Reference Access Control Access Revocation Privacy Preserving Access to Patients Interoperability Predictive Model Decision Making

Gohar et al. (2022) ✓ ✓ ✓ ✓ ✓ ✕ ✕

Rehman et al. (2022)
Al-Sumaidaee et al. (2023)
Liu et al. (2022a)
Azbeg et al. (2022)
Zhang et al. (2022b)
Younis et al. (2022)
Ren et al. (2022a)
Liu et al. (2022b)
Egala et al. (2023)
Stephanie et al. (2022)
Abdellatif et al. (2021)
Dewangan and Chandrakar (2022)
Abou El Houda et al. (2022)
Ren et al. (2022b)
✕ ✕ ✓ ✕ ✕ ✓ ✓
✓ ✕ ✓ ✓ ✕ ✕ ✕
✓ ✕ ✓ ✕ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓ ✕ ✕
✓ ✓ ✓ ✓ ✓ ✕ ✕
✓ ✓ ✓ ✓ ✓ ✕ ✕
✓ ✕ ✕ ✕ ✕ ✓ ✓
✓ ✓ ✕ ✓ ✓ ✓ ✕
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✕ ✓ ✓ ✕ ✓ ✓
✓ ✕ ✓ ✓ ✓ ✕ ✕
✓ ✓ ✓ ✓ ✓ ✕ ✕
✓ ✕ ✓ ✓ ✕ ✓ ✓
✓ ✓ ✕ ✓ ✕ ✕ ✓

Table 7
Suitability level of blockchain types for the challenges in healthcare domain.
Type Permissionless Permissioned Federated Hybrid
Blockchain Blockchain Blockchain Blockchain

Patient Data • Medium •Medium • High • Medium

Management
Drug • Medium •High • High • Medium
Traceability
Cryptocurreny • High • High • High • High
Payment
Clinical Trials • Low •High • High • Medium
and Data
Security
Healthcare IoT • Medium •High • High • Medium
Health • High •Medium • Medium • Medium
insurance
claim
processing
Healthcare • Medium •Medium • Medium • High
waste
management
Supply chain • High •High • High • High
management
Fig. 12. Classification of blockchain.

Chatterjee, 2018). There is always a trade-off among consistency,

6. Consensus algorithms in healthcare
availability, and partition fault tolerance (CAP) while applying
consensus algorithms. Consensus protocols have three key properties:
Consensus mechanism of blockchain is one of the key elements of the
Safety, Liveness, and Fault Tolerance. This section details and provides
distributed healthcare blockchain. Consensus mechanism (Baliga, 2017)
insights into the most widely used consensus algorithms of the distrib­
have been the focus of active research for the recent years and allow.
uted healthcare blockchain. The summary of various consensus algo­
Through this technique, distributed peers consent to validate the
rithms and its characteristics are presented in Table 8.
transaction. There are multiple consensus algorithms created under
different presumptions to address distinct issues. Still there isn’t a
consensus mechanism that is perfect for all issues. Different consensus
algorithms can be used for different healthcare use cases (Salimitari and

17
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

6.1. Proof-of-work (PoW)
Proof-of-Work (PoW) was first proposed by D.Work in the year 1993
(Vukolić, 2015). It is the way of accepting a block that is most frequently
employed by numerous peers. Choosing a participant to authenticate a
transaction becomes essential to creating the blockchain because a
network of distributed peers for a blockchain lacks a central authority to
approve or confirm the transactions (Zhang and Lee, 2020). Any unique
peer must confirm the addition of a block before it can be added to the
chain. A miner is a unique peer or node that has the ability to compile all
transactions into blocks and offer confirmation. Mining is the process of
doing this. The miners are given a challenging puzzle to solve that takes
a lot of time and effort but is simple to verify in this approach. Prior to
producing the proof of work, the puzzle is randomly solved using a
number of trial and error techniques. A new block can be created and the
transactions are verified by the miner who has solved the problem.
Hashing the input values is one of the techniques. If the number of users
and the network are high, the hash of the previous block will be con­
tained in the current block, which makes the process computationally
costly. The likelihood of new block generation is limited because all
previous blocks must be recreated before a new block can be generated.
Therefore, data manipulation is not feasible. The PoW consensus model
is used by Ethereum and Bitcoin. Though it is widely used, the high
bandwidth requirement makes it incompatible with healthcare IoT
services.
6.2. Variants based on proof-of-work
A large amount of computational effort has been extended to check
with negligible effort whether it allows verifying a Proof-Of-Work.
Tromp et al. (Tromp, 2014), The author have proposed a plan indi­
cating the cuckoo hash function. This provides an opportunity for the
miners to append the block easier and pay only little effort. The result of
the hash table will depend on two different hash functions. There will be
two positions on the hash table as some of the values are inserted into
the hash function. The hash result is put into one of the values if any one
position of the two is blank. When there is a new has value the old one
will be removed and replaced if none of the available two values are
blank. Proof of Work (POW) consensus is proposed by Liu et al. (2019c)
in the year 2012. By a committee of miners with success factors, the
block is appended. The original Proof of Work is much easier to set. With
the computing power available miners will be able to find all the
possible nonces. Each miner will have to find the possible number of
nonces for their created block. Once the nonce is received the finder will
send the block to validate and put the block in a temporary array.
6.3. Proof-of-stake (PoS)
Proof-of-Stake (PoS) was first introduced in the year 2012 as an
alternate method to the PoW consensus model. To tackle the problem of
intensive computational involved in solving the cryptographic puzzle in
PoW, the Proof-of-Stake (PoS) was developed (King and Nadal, 2012). It
is a protocol that saves computational resources and is called a proba­
bilistic protocol. This model states that in the distributed network of
peers, any peer who owns a large number of coins can become a miner to
validate and confirm the transactions. The power that the miner has is
proportional to the number of coins that they own. For example, if a
miner has 20% of the blockchain coins then they can mine only 20% of
the blocks in the chain. The miner with a greater number of coins has the
power to validate and verify the legitimacy of the transactions. As a
single miner takes a centralized approach and has control over the entire
blockchain, it is not ideal for situations where users have fewer coins. To
avoid fake stake attacks, an approach with more miners would be
secure. The varied PoS by cryptocurrencies such as Bitcoin, Peercoin
(King and Nadal, 2012), Litecoin (Haferkorn and Diaz, 2015), and Nxt
(Popov, 2016). The minimal requirement of energy and hardware re­
quirements make PoS suitable for healthcare systems.

Table 8
Consensus algorithm and its characteristics.
Algorithm Proposed Hash Healthcare Accessibility Example Limitations
Year Power Applicability

Proof-of-Work (PoW) 1993 ✓ ✕ Open Bitcoin High network bandwidth requirement

Proof-Of-Stake (PoS) 2012 ✓ ✓ Open Ethereum Pseudo-random way to solve the blocks.
Delegated Proof-of-Stake (DPoS) 2014 ✓ ✓ Open Bitshare Costs more towards centralization
Leased Proof-Of-Stake (LPoS) 2018 ✓ ✓ Open Waves Malicious activities can be orchestrated
Proof-Of-Importance (PoI) 2018 ✓ ✓ Open NEM Increased cost
Practical Byzantine Fault Tolerance (PBFT) 1999 ✕ ✓ Prop Hyperledger Works well only with less number of
nodes
Delegated Byzantine Fault Tolerance (dBFT) 2019 ✕ ✕ Prop NEO Lack of anonymity
Proof-of-Capacity (PoC) 2019 ✓ ✕ Open Burstcoin Large storage requirement
Proof-of-Activity (PoA) 2014 ✓ ✕ Prop Bitcoin Longer delay
Proof-of-Burn (PoB) 2018 ✓ ✕ Prop Slimcoin Higher power consumption
Proof of Elapsed Time (PoET) 2016 ✕ ✓ Prop Sawtooth Reliance on a specialized hardware’s
security
Stellar Consensus Protocol (SCP) 2018 ✕ ✓ Prop Stellar Inefficient in terms of number of
messages sent
Paxos Consensus algorithm 1998 ✓ ✓ Open Ethereum Can determine one value at a time
Multi-paxos consensus algorithm 2015 ✓ ✓ Open Chubby Inu Implementation is difficult
Raft Consensus Algorithm 2014 ✓ ✓ Open Bitcoin Too many requests from servers can
choke the system
Zab Consensus Algorithm 2007 ✓ ✓ Open Ethereum Additional data exchange is needed for
leader election
Proof of Learning (PoLe) 2020 ✕ ✓ Prop Bitcoin High energy consumption
Proof-of-deep-learning (PoDL) 2019 ✕ ✓ Prop Bitcoin, Computation overhead
Litecoin
Separate proof-of-deep-learning (S-PoDL) 2021 ✕ ✓ Prop Bitcoin Improvement required to support delay
sensitive applications
Honesty-based distributed proof of authority 2022 ✓ ✕ Prop Ethereum Does not support larger number of nodes
(HDPoA)
Score Grouping-PBFT (SG-PBFT) 2022 ✓ ✓ Prop Bitcoin Consensus time is more
Dynamic Random Byzantine Fault Tolerance 2021 ✕ ✓ Prop Bitcoin Computation overhead
(DR-BFT) consensus algorithm

18
A. J et al.
6.4. Delegated proof-of-stake (DPoS)
As PoS lacks security because fakes stakes are miner, a better
consensus model is required wherein multiple verifiers of the trans­
actions are present. The Delegated Proof-of-Stake (DPoS) works by the
principle of voting and electing miners (Chaumont et al., 2019). The
election process allows the stake holds to identify witnesses and dele­
gates for managing blocks. Delegates can make core changes to the
blocks and witnesses can create and validate the transactions. As there
are delegates and witnesses for every blockchain, misuse of the power
can avoid by active voting. Since every peer has an opportunity to
participate in the voting system, the model follows a democratic
approach to the consensus algorithm. Some DPoS performs the voting
continuously to elect new delegates and witnesses. So this keeps the
miners under pressure in losing during the election. Some DPoS take the
stake size to select the voters. This is done to reduce the mining pool and
to avoid peers with small stakes from managing the blockchain. This
model supports scalability with reduced computational power and
prevents the system from attacks. This method suffers from centraliza­
tion if there are limited delegates. DPoS is employed by cryptocurrencies
such as Bitshares, Steem, etc. The efficiency of voting out malicious
nodes makes this protocol safety and thus it is highly applicable for
healthcare data sharing.
6.5. Leased Proof-of-stake (LPoS)
Leased Proof-of-Stake (LPoS) was proposed in the year 2018 that
operates similarly to PoS, but with a few enhancements. The centrality
problem in PoS is addressed by LPoS. By providing a leasing option, it
allows nodes with low balances to participate in block verification.
Wealth holders with larger balances can lend their cash to nodes with
lower balances for a certain period through leasing. During the lease
contract, the least amount will remain in the ownership of the wealth
holders, but it will enhance the chances of nodes with low balances
solving a block. When these nodes solve a block, the prize will be
distributed proportionately among the wealth holders. This makes the
system more decentralized and secure. Since LPoS is based on monetary
benefits it is less applicable to healthcare IoT however, it is suitable for
other e-healthcare services.
6.6. Proof-of-importance (PoI)
Proof-of-Importance (PoI) is an improvement for PoS that finds a
most trustworthy node for validating the transactions. There is no
guarantee that the person more stake can dominate the blocks in the
chain as in PoS. Instead of focusing just on node balances for deter­
mining the next winning node, it considers a variety of criteria,
including a node’s reputation, which is determined by a system-defined
mechanism, and the number of transactions that have happened to or
from that node. PoI has consistently good yields and has a minimal la­
tency. It also doesn’t need a lot of computing or network resources. Such
features makes PoI suitable for healthcare systems. Also, the healthcare
organizations reputations can be utilized for decision making by the
users.
6.7. Practical Byzantine Fault Tolerance (PBFT)
Practical Byzantine Fault Tolerance (PBFT) is a complex and efficient
consensus algorithm that has partially trusted and faulty nodes in the
blockchain network proposed by Castro et al. (Castro and Liskov, 2002).
This system works asynchronously with request and response messages
between the nodes. Arriving at a consensus in a distributed network is
carried by even if there are faulty nodes with correct or incorrect in­
formation. There are 5 phases in message sending in PBFT. The messages
are request, pre-prepare, prepare, commit, and reply (M. C. and Liskov,
2010). The client sends a request message to the primary node. The
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Journal of Network and Computer Applications 215 (2023) 103633
primary node sends the request message to the other entire node, who
then sends the reply to the client. This model works well in a small
network with fewer nodes and does not support scalability. As the
network scales, the number of messages exponentially rises and this
creates a message overhead. This is mostly in enterprise networks and
used platforms such as tender mint, hyperledger fabric, etc. Castro et al.
(M. C. and Liskov, 2010) have proposed a method that replicates the
algorithm that can withstand byzantine faults. Byzantine fault tolerance
algorithm is very important for software errors and malicious attacks.
Dhillon et al. (2017), proposed a method where Hyperledger Fabric used
Practical Byzantine Fault Tolerance (PBFT) as it can handle 1/3 mali­
cious byzantine. The processes are divided into phases like prepared,
committed, and pre-prepared. If the received node is 2/3 of all the nodes
which shows that a node would enter the next phase. Hence every node
must be known to the network. This technique is well-suited for
third-party-controlled private blockchains, such as the Hyperledger
initiatives. However, because of their restricted scalability and a low
tolerance for malicious activity, it is not the ideal solution for permis­
sionless, public blockchains. PBFT offers high throughput, low latency,
and minimal computational overhead such properties make it applicable
to healthcare systems.
6.8. Delegated Byzantine Fault Tolerance (dBFT)
It operates in the same way as PBFT, but this does not need all nodes
to participate in order to add new block, making it more flexible. When
there are less than (n − 1)/3 aberrant nodes, PBFT ensures the system’s
liveness and security. In comparison to other protocols, the PBFT’s
consensus is more consistent and accurate. PBFT is ineffective, though,
because of its high level of complexity, when there are a lot of partici­
pating nodes. In dBFT (ontology/consensus/dbft at master ⋅ ontio/on­
tology ⋅ GitHub, 2023), some nodes are designated as representatives for
other nodes, and they follow a consensus procedure similar to PBFT.
Hence, this model is suitable for healthcare blockchain systems. Dele­
gated randomization Byzantine fault tolerance (DRBFT) is proposed by
Zhan et al. (2021) to suit blockchain for large scale asynchronous
network applications. Random selection algorithm is used to fairly select
participating nodes to execute PBFT. The proposed algorithm satisfies
the properties such as unpredictability, uniform distribution, and
impartiality.
6.9. Stellar Consensus Protocol (SCP)
Stellar Consensus Protocol (SCP) is one of the variants of Byzantine
Fault Tolerance that is proposed in the year 2018 (Barry et al., 2018). It
provides microfinance services with minimal latency. SCP consists of
nomination and ballot protocol steps. The nomination protocol executed
first then these values are distributed to all of the quorum’s nodes, who
will vote for one of the candidate values. At the conclusion of the pro­
cedure, values for that slot are universally picked. After then, the ballot
procedure is started, which entails federated voting to approve or reject
the nomination protocol’s acquired values. Each participating Stellar
Core node (also known as a validator or validator node) in SCP chooses
which group of additional nodes they want to trust. Open network
membership (anyone can join as a Core node thanks to the flexibility of
user-defined trust) and decentralized control are made possible by
user-defined trust. On the Stellar network, validators receive no finan­
cial compensation. Instead, people are encouraged to sign up as vali­
dators since they are enhancing the network’s security and resilience,
which is advantageous for the Stellar-based businesses and services. SCP
is one of the good choices for healthcare blockchain systems due to its
security and privacy options.
6.10. Proof-of-capacity (PoC)
Proof-of-Capacity (PoC) is an improvement of PoW. PoC requires
A. J et al.
dedicated processing power and hard disk capacity for mining the next
blocks. PoC is relatively faster than PoW because of its dedicated ca­
pacities. Memory space is made available to service providers by PoC.
Through a decentralized network, this concept enables you, the miner,
to exchange your free disc space for money. The more room you have,
the more likely you are to use the service offered in exchange for the
mining return. PoC consumes less energy than other models since it just
uses your available memory space to validate blocks. The technique is
supported as a more environmentally friendly alternative to prior
consensus mechanism algorithms, such as proof of work, therefore it
should come as no surprise (PoW). Burstcoin is presently adopting this
mining method. The advantages of PoC are low energy consumption,
low maintenance and affordability, decentralized network, shorter
mining time, reusable space. There are few limitations that includes it
favors space hoarders, it is less secure, and has limited research. How­
ever, it is not suitable for healthcare systems as the node is selected
based on the capacity.
6.11. Proof-of-activity (PoA)
Proof of Activity (PoA) is a hybrid consensus technique that com­
bines PoW with PoS. In PoW, miners compete to solve a hash function in
order to locate the next block. The solved block, on the other hand, will
simply include a header and the miner’s address, with no transaction.
Then transactions are added to the block, and a set of validators is picked
to sign the new block based on the solved block’s header in order to
establish consensus. This is accomplished through the use of evidence of
stake. This method is more secure against attacks, but it may result in
longer delays, which may be unacceptable for time-sensitive healthcare
applications.
6.12. Proof-of-elapsed-time (PoET)
This is another consensus algorithm that allows a network of par­
ticipants to decide the mining rights and become a validator. Here, every
participant is equally likely to become a validator. To enable this timer is
employed and time is different for every participant. Every participant is
assigned a random time to wait and the first participant whose timer
expires and who had a short duration is allowed to create and add a new
block to the blockchain (Chen et al., 2017). This method applies a simple
approach that does require high computational power. However, this
method requires special hardware to set the time. This model is used by
enterprise distributed hyperledger.
6.13. Directed-acyclic-graph (DAG)
This Direct Acyclic Graph (DAG) ledger transaction works on a peer-
peer validation. Any node that wants to perform a transaction must
verify at least one previous transaction with the new transactions (Cao
et al., 2020). DAG is a distributed peer grading system. Instead of having
a group of miners to validate the transaction, DAG uses the very trans­
action that the user performs to confirm each other’s transaction. The
advantage of using the DAG is it increases the operation speed and does
not require miner selection. It is reliable and increases the security of the
blockchain.
Though most of the Blockchain design is distributed and decentral­
ized, centralization of the power and control can occur because it re­
quires a witness node to mitigate the attacks to the blocks. To overcome
these central points of control and failure some advanced consensus
algorithms are required.
6.14. Proof-of-burn (PoB)
Proof of Burn (PoB) is based on the concept of burning coins, which
entails transferring coins to an address that cannot be recovered. Ac­
cording to the number of bitcoin burned, miners are given precedence in
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Journal of Network and Computer Applications 215 (2023) 103633
solving the following block. Whereas this method is useful for creating
cryptocurrencies, it is ineffective for healthcare applications since it
requires the existence of a financial system and the burning of coins,
neither of which are present in healthcare networks. PoB is used by
Slimcoin, a cryptocurrency.
6.15. Paxos consensus algorithm
Paxos consensus algorithm was developed to address the issue of
consensus in distributed networks. Paxos is a metaphor for reaching a
consensus under uncertain circumstances. In the event of network par­
titioning or server outages, distributed systems can continue to function
predictably with the Paxos algorithm. Distributed storage can perform
as predictably as a thread-safe data structure as long as a client appli­
cation can connect with important roles in a distributed system (De
Prisco et al., 2000). Many of Paxos’ characteristics are accomplished by
the idea of a ballot. A ballot is essentially a one-of-a-kind identifier that
is connected to every transaction. For each partition key, Paxos ballots
are tracked independently. The total throughput and availability are
increased and there is more availability when transactions are not co­
ordinated, but there is no mutual order provided. Transactions cannot,
therefore, cross partitions. The coordinator, or the node carrying out the
transaction, starts by generating a new ballot and requesting storage
from the nodes that control the relevant token range’s data. If the ballot
is older than the one they already know, replicas won’t store it, and if it
doesn’t respond to the replica, the coordinator won’t move forward. The
coordinator should keep up to date information and allows a single
transaction to be modified at a time. Paxos is frequently employed when
huge datasets, such as files or databases, need to be replicated and
durability is required. The protocol makes an effort to advance even
when a limited number of replicates remain unresponsive. Computation
overhead of Paxos algorithm is high. To overcome the drawback, Raft
was developed.
6.16. Multi-paxos consensus algorithm
The extension to Paxos is the multi-paxos algorithm that can suitable
for distributed environment. Paxos ensure that one of the suggested
values is selected. However, in a distributed system to choose a sequence
of values, or to obtain consistent ordering over a set of values, multi-
paxos consensus algorithm is useful. The proposal is started by the
leader, who is chosen by Multi-Paxos. The preparation stage can be
bypassed to convert the two-phase process into a one-phase process,
which increases efficiency, if the leader initiates all suggestions. No
specific leader is assumed by Multi-Paxos. Instead, it enables concurrent
requests from various leaders without jeopardizing security. To allow
continuous proposal, the Multi-Paxos can be enhanced to avoid the
preparation phase and proceed to the acceptance phase. Applying multi-
paxos enables to improve the efficiency the blockchain with multiple
transactions.
6.17. Raft consensus algorithm
Raft is a successor to the Paxos algorithm and it is a leader-based
consensus algorithm designed to manage larger-sized networks
(Huang et al., Member). In a closed distributed environment of the Raft,
the main server is considered a leader and the other remaining nodes are
called followers. The leader is responsible for data updates and transi­
tion log replication. The leader accepts client requests and transmits
heartbeat messages to all followers periodically when it is alive and
configurable. Some followers will notify their peers and call for an
election if the leader cannot be reached (due to death or a network
outage). Raft separates the essential components of consensus, such as
leader election, log replication, and safety, to make them easier to grasp.
It also enforces a higher level of coherency to minimize the number of
states that need to be taken into account. The new entries are added to
A. J et al.
the log by the leader and data flows from the leader to other servers.
Node failover must be established to assure availability because the
leader is the system’s single point of failure. This failover is known as a
leader election in Raft and all the nodes are assumed to be trustworthy
and have no malicious intent.
6.18. Zab consensus algorithm
Zab is a ZooKeeper Atomic Broadcast consensus algorithm designed
for ZooKeeper coordination service as a crash-recovery mechanism
(Flavio et al., 2011). The three stages of Zab are synchronization,
broadcast, and discovery. One iteration of this protocol is executed at a
time by each process, and at any point, a process may stop the current
iteration and begin a new one by moving to the discovery phase. Ac­
cording to the protocol, the Zab process might play the leading or fol­
lower roles. A leader simultaneously performs the primary job and
suggests transactions following the primary’s broadcast call sequence.
Followers accept transactions following the protocol’s steps. A leader
also carries out a follower’s instructions. A leader oracle is implemented
by each process, and it offers the identification of the potential leader. A
process seeks advice from its leader oracle in the discovery phase to
identify which other process it should follow. The primary process ex­
ecutes client activities while using Zab to propagate the relevant in­
cremental state changes to backup processes. This is how ZooKeeper
implements a primary-backup strategy. Zab must ensure that if it de­
livers a given state change, then any other changes it depends upon must
be supplied first because an incremental state change depends on the
order in which changes were previously generated.
6.19. Proof of Learning (PoLe)
Scaling up the network and training data as well as autonomous
neural network (NN) architecture design have led to significant per­
formance advances in deep learning. Proof of Learning (PoLe) directs the
processing power used for block consensus toward neural network
optimization (Liu et al., 2021). The entire blockchain network receives
access to the training and test data, and the consensus nodes then train
NN models on it to demonstrate learning. As a fundamental part of PoLe,
a secure mapping layer (SML) was implemented as a layer of linear NN
to prevent cheating by consensus nodes. A new block is added to the
blockchain after the network’s consensus has been reached. The PoLe
protocol was evaluated and achieved improved transaction processing
and stable block generation.
6.20. Proof-of-deep-learning (PoDL)
To support multi-access edge computing (MEC) applications and
ensure security and privacy, a proof-of-deep-learning (PoDL) consensus
algorithm was developed (Chenli et al., 2019). PoDL can be applied to
any PoW-based application. The algorithm uses deep learning to main­
tain blockchains rather than pointless hash calculations. As components
are added to block headers incrementally, the PoDL can be applied to
any cryptocurrency-based PoW. In the proposed work, PoDL applied
energy recycling blockchain. The DL models are trained with the
training dataset and the accuracy is verified with the test dataset.
6.21. Separate proof-of-deep-learning (S-PoDL)
A computational efficient consensus algorithm called Separate proof-
of-deep-learning (S-PoDL) was proposed (Luo et al., 2021). The S-PoDL
performed two-stage computation using an accounting technique to
generate blocks quicker and apply them in blockchain enable MEC ap­
plications. S-PoDL divides all nodes into several parts for training
different deep-learning models. In the consensus process, the accounting
authority of N nodes is obtained. As the number of modes increased, the
accounting authority also increased. The S-PoDL improved the
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Journal of Network and Computer Applications 215 (2023) 103633
throughput with a smaller block generation interval. The extra overhead
was reduced and increased consensus output.
6.22. Proofs of Space (PoS)/proof of capacity
Proofs of Space (PoS) is a method that works similar to PoW that
considers disk resources rather than computation (Dziembowski et al.,
2013). A system called Proof of Space (PoS) is used to confirm and
validate statements. The PoS approach allows the user to commit
necessary disk space on their computer for transaction computation.
Instead of computational power, PoC storage capacity shows financial
investment in the network. Because of this, proof-of-capacity may have a
smaller environmental impact than proof-of-work. By assigning some
kind of memory, proof-of-capability requires network users to prove
they have a vested financial interest in the network’s success. The proof
achieved decentralized consensus in the blockchain. It is used to defend
against Sybil’s attack. Proof-of-Spacetime (PoST) allows the participant
of the network to have allocated storage capacity for an allotted period.
6.23. Honesty-based distributed proof of authority (HDPoA)
The Internet of Things (IoT) is capable of being dynamic and
adaptable to any changes, including changes in device statuses, loca­
tions, and network connectivity. IoT systems can grow by integrating a
significant number of devices that produce enormous volumes of data.
One of the issues with a consensus algorithm deployed in IoT space is
that some devices lack resources and computation power. Applying
blockchain to IoT provides several benefits over traditional systems,
including increased security through the guarantee of data integrity and
accountability and reliable control over numerous devices. An Honesty-
based distributed proof of authority (HDPoA) was proposed to enhance
data integrity and security (Alrubei et al., 2022). The proposed HDPoA
algorithm when deployed on multiple devices showed improved per­
formance in terms of energy consumption and hash power. The security
analyses exhibited that HDPoA is secure and appropriate for
blockchain-enabled IoT applications.
6.24. SG-PBFT (score Grouping-PBFT)
To support secure authentication in IoT of connected vehicles, SG-
PBFT (Score Grouping-PBFT) Consensus algorithm was developed (Xu
et al., 2022). The distributed architecture of the blockchain-enabled to
reduce the burden on the centralized server and decreased the single
point of attack. By adopting the score grouping mechanism, the
consensus process was optimized and the performance of the SG-PBFT
consensus algorithm was improved when compared with traditional
PBFT. Consensus efficiency was increased by increasing the throughput
and less communication overhead.
6.25. Dynamic random byzantine FaultTolerance (DR-BFT)
In edge computing, data integrity is a difficult problem to solve. The
majority of current consensus algorithms are unable to handle edge
computing in a dynamic network where nodes can join or leave the
blockchain network at any time. Dynamic RandomByzantine Fault
Tolerance (DR-BFT) consensus algorithm was proposed to protect the
data in edge computing (Fan et al., 2021). By offloading data processing
and storage to edge servers that are physically adjacent to the end de­
vices, edge computing makes data processing real-time and lessens the
pressure on data centers. String Consensus, Data Correctness Validation,
and Binary Consensus are the three sub-algorithms that makeup
DR-BFT. The proposed DR-BFT algorithm when applied to a dynamic
network was able to get guaranteed agreement, validity and termination
with low system overhead.
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

7. Security & privacy challenges because many fraudsters and hackers have come in many now. In recent,
governments, healthcare providers, telecommunications companies,
Blockchain technology is essentially secure. The data entered in banks, and businesses of all sizes depend on digital identity. No
blockchain cannot be changed or modified hence it is said to be more Centralized Authority, Secured Blinded Infrastructure, Decentralized,
secure. Additionally, it has a very good consensus mechanism that is Secured, and Private Data Architecture, Privacy and Controls, Book
used to make a decision and cryptographic proofs that make the Keeping, Audit, and Billing are the policies used here. Secure Key
blockchain impossible to hack. Even though blockchain is very secure Technologies’ blockchain-based environment (Wolfond, 2017) permits
and impossible to hack it has some security issues. Some of the security different accomplices to fortify verification and give character trait
attacks their effect, detection method, and how to protect them are approval, as a texture of trust and as a strong establishment to grasp
presented in Table 9 and their explanation is listed below. Fig. 13 shows another computerized time.
the taxonomy of the threat model for blockchain. Some attacks will duplicate their identities to act as the valid user for
Table 9 shows the layer-wise security challenges in blockchain a transaction. There are four types of identity-based attacks they are 1)
technology. The layers in blockchain can be classified as physical, Replay Attack 2) Impersonation Attack 3) Sybil Attack 4) Key Attack.
network, transport, and application layer. The different types of security Each of the attacks is explained below.
attacks on each layer are presented along with the system design
challenges. 7.1.1. Replay attack
The attack in the form of the network where the valid transmission is
7.1. Digital identities repeated or delayed maliciously or by fraud is called a replay attack
(Khan and Salah, 2018). A replay attack (cyber-attack) is also called a
There are many problems in the current identity management sys­ playback or duplication attack. In a network, the transmitted valid data
tem. Users don’t have control over their data because users register in is repeated where the malicious entity is intercepted. An exploit that
various online portals and their data is present in different databases. occurs when two forked cryptocurrencies allow transactions to be valid
Users cannot simultaneously update their credentials in all the databases across both the chains. Owing to the validity of the data from an
(Pilkington, 2016). This limitation can be overcome by utilizing block­ authorized user, the attacks were treated as normal data transmission by
chain technology. With blockchain users get more control over every the security protocols. With the actual data, the process of recording
single data element, such as user attributes and credentials that can only timestamps continuously is called time stamping which is one of the
share with trusted parties and also included in the system as distributed ways for preventing the replay attack. During the signature process if
consensus. It improves accessibility, the privacy of their data, and has blockchain generates a private key there are chances of the key being
control over their data. The data in the documents of IDs, e-residency, leaked, Huang et al. (2018) propose an idea of LNSC that generates
passports, birth certificates, wedding certificates, etc., which are recor­ temporary private keys for each session so that the key is changed every
ded in the databases of an individual cannot be modified or tampered time and hence difficult to find out the key and elliptical curve
with. It reduces identity management costs, eases the monitoring pro­ encryption to calculate the hash function.
cess, and improves customer service and efficiency. It offers a protected
method to oversee character in the advanced world that stops clients to 7.1.2. Impersonation attack
share a large amount of weak individual data. An impersonation attack or collusion attacks (Gupta et al., 2018) are
It has become a highly critical problem for the public and private an attacks in emails that attempt to gain access over the individual or a
sectors to identify the people with their identity and authentication company to share that information or data to the corporate. A business
email compromise is also known as a CEO attack which is a popular
Table 9 example of an impersonation attack. CEO fraud is a type of attack that
Layer wise security challenges in Blockchain. targets a specific organization or individual. An impersonation attack
contains an email coming from a trusted source. A valid user performs
Layers Security Modules Attack Type System design
challenges unauthorized operations and this type of attack might occur when the
private key is leaked. To get illegal payment an impersonation attack
Physical Tamper evidence, Physical damage Device connection,
Layer Tamper response, Jamming recovery, condition
may be launched. Wang et al. (2018), proposed a system called a
Detachment monitoring, Distributed incentive-based cooperation mechanism. This mechanism
detection hides the user’s private information, user privacy, and transaction
Data Layer Key management, Quantum attack Merkle tree, data verification. Ling et al. (Lin et al., 2018), proposed a method for
Cryptographic blocks and code
detecting these types of attacks called an ECDSA algorithm. ECDSA is a
components vulnerability
Network Anonymous Manipulation Node’s network signature that is attribute-based which is available only to valid users to
Layer internet based attacks topology, Privacy generate a valid signature. When the corresponding operation fails the
communication cryptanalytic protection issues, impersonation attempt will be detected.
technology attacks Centralized/
Decentralized mixer
Consensus PoS, PoW, BFT, 51% attack Scalability, security
7.1.3. Sybil Attack
Layer Sharding assumptions, When a person creates several accounts in a network and tries to take
complexity, over the network, this kind of security threat in an online system is
reconstruction called a Sybil attack. This attack is nothing but it happens when a single
Incentive Strategic behavior Selfish mining Rewards distribution,
person tries to create multiple social accounts in media. In a peer-to-peer
Layer detection, block withholding,
Optimization unsustainable problem network, a node in a network operates multiple identities at the same
mechanism time. To gain the majority of influence in the network and to carry out
Contract Formal validation, Service based Formal verification, illegal actions in the system is the aim of this attack. The capability to
Layer Sandbox attacks Privacy issues, create and operate multiple identities is there for a single computer.
environment, Test Exploited code
network
Proof of Work consensus algorithm in Bitcoin is used to prove the
Application Regulatory Identity based Authentication, authenticity of any block that is added to the blockchain. The main aim
Layer mechanism attack Identity management, of the eclipse attack is only a single node. To protect this type of attack
Reputation based trust establishment ‘Trust Chain’ is proposed by Otte et al. (2020). The Trust chain uses a
attacks
mechanism called PoW to check the validity of the transaction. An

22
A. J et al.
Fig. 13. Blockchain threat model.
immutable chain is temporarily created by to trust chain to solve this
issue. The consensus algorithm is used to detect these types of Sybil
attacks. A Trust chain along with a consensus algorithm is used to check
the trustworthiness in an online community.
7.1.4. Key Attack
It occurs when there is leakage of data from the private keys. Huang
et al. (2018), explain this attack using an electric vehicle. In an electric
vehicle if the same private key is used for a long time there are chances
of the key being leaked. To deal with this attack Huang et al. (2018),
proposed a method called a mutual authentication mechanism between
the charging piles and the electric vehicles. It uses the temporary private
key and elliptical curve-based encryption to ensure safety against the
leakage of the private key.
7.2. Manipulation based attack
The attacks which involve unauthorized access and destruction of
the data are termed manipulation-based attacks. They are broadly
classified into four types they are 1) False Data injection Attack 2)
Tampering Attack 3) Overlay Attack 4) Modification Attack. The
explanation of all the attacks is listed below.
7.2.1. False data injection attack
When any attack joins with the sensor it creates an event that does
not occur, this type of attack is called a false data injection attack. Due to
the generated false data, the system data is misled without having any
control. To prevent this attack Liang et al. (2019), proposed a method
called a distributed voting algorithm where the consensus mechanism is
used to carry out the interaction among the nodes. Each node has the
power to verify the correctness of the node. When there is a positive
agreement among the nodes the data is considered to be correct. When
negative agreement has arrived among the nodes the false data injection
is identified.
7.2.2. Tampering attack
To modify the data certain parameters are exchanged between the
client and the server to modify the application data. The data such as
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Journal of Network and Computer Applications 215 (2023) 103633
user credentials, permission, products, etc., belong to the application
data. In case of any data, there is a distributed copy of the data, this
distributed data prevents a tampering attack as there are many copies of
the same data and no official copy is needed. In case of any exploits,
there is a chance of vulnerability that tamper with the Bitcoin address.
To avoid these kinds of attacks Wang et al. (2020), used a method called
public-key cryptosystem. To hide the data such as transactions and to
encrypt the amounts Wang et al. (2020) proposed a method called a
homomorphic pallier encryption system. This encryption method cre­
ates a dumb account that can receive the transaction of the bitcoins but
it cannot be spent. If the input sum and the output sum are positive then
there is equality in the transaction. If there is any negative-sum, then
there are chances that there can be an attack. This is how the tampering
attack can be detected.
7.2.3. Overlay attack
The user enters a piece of confidential information on a website any
malware that overlays its window on the top of the other and steals the
confidential information. When the target application is running, the
overlay attack opens a new window similar to the original window and
steals the information from the user. To the original encrypted amount,
the attacker adds a forged encrypted amount by the receiver’s public
key. Wang et al. (2020), used a method called timestamp to detect these
types of attacks. Every attack is joint with the timestamp to keep all the
transactions unique. To resist these types of attacks different inputs are
given under the same trader so that the trader can distinguish the two
different linked transactions and hence the overlay attack is resisted.
7.2.4. Modification attack
When an attacker modifies, steal or capture important information in
the personal system or from an organization then this type of attack is
called a modification attack. In some cases, the attacker edits and
changes the personal data or the organization data. This type consists of
modifying the broadcast transaction or response message. Huang et al.
(2018), use the temporary private key for each session agreement and
elliptical curve encryption to calculate the hash function.
A. J et al.
7.2.5. Man-in-the-middle attack
The communication between two or more persons can happen with
some man or any server as centralized. These types of communication
made are always centralized. When user A sends some information to B,
it is passed on to B by any communication in between. There is a pos­
sibility that the man in the middle between A and B could even change
some information and pass it to the other. So there are chances that
wrong information may be exchanged between two sources. This type of
attack is called a Man-in-the-Middle attack. To resist this attack Lin et al.
(2018), used mutual authentication between two parties. Elliptical
curve encryption is used by Huang et al. (2018), for protection.
7.3. Reputation-based attacks
Any agent or an attacker that can control his reputation or the duties
is called reputation-based attacks. They are classified into two types they
are 1) Hiding Blocks Attack 2) Whitewashing Attack. The explanation of
both attacks is listed below.
7.3.1. Hiding Blocks Attack
In a transaction, there is a positive impact and a negative impact. In
this attack, the agent will reveal the transaction that has a positive
impact and hide the negative impact on reputation. Otte et al. (2020),
used a chain of temporarily ordered interactions for each agent. Each of
the records presented has an individual sequence. Any agent can request
specific records of others. The agents will stop interacting with them if
they refuse to provide the records to the agents.
7.3.2. Whitewashing attack
When an attacker resets a poor reputation with a new identity by
rejoining the system, this type of attack is called a whitewashing attack.
This attack affects the performance significantly. It can get rid of identity
and make a new one when the agent has a negative reputation. To
prevent this type of behavior there is no system yet proposed. But by
providing low priorities to the agents of new identities it can be reduced.
7.4. Service-based attacks
The attack where the attackers aim to make any service unavailable
or make it behave differently from its original behavior. In other words,
it can be said that an attacker can change or modify the data to duplicate
values rather than getting the original values. Some of the attacks
available under this attack are 1) DDoS Attack 2) Refusal to Sign Attack
3) Double Spending Attack 4) Collusion Attack.
7.4.1. DDoS attack
DDoS is a short form of Distributed Denial of service. It is a type of
DoS attack. In one or more web servers, multiple systems flood the
bandwidth or the targeted system, this type of attack is called a
Distributed denial-of-service attack. In this attack, multiple systems
overwhelm the targeted system with more traffic than it can handle.
Some of the types of DDoS attacks are traffic attacks, bandwidth attacks,
and application attacks. The main objective of the DDoS attack is to
prevent valid users from accessing the website. The attackers need to
send more requests than the victim server can handle to make the DDoS
attack to be successful. DoS attack uses only one system and one internet
connection to the targeted system whereas the DDoS attack uses mul­
tiple systems to flood the targeted systems.
7.4.2. Refusal to Sign Attack
An agent who is intended to harm can decide whether to sign in a
transaction or not. He will decide not to sign in a transaction that is of no
use to him. No method has been proposed to reduce or stop this type of
attack but it is possible to take preventive measures against these types
of attacks. Otte et al. (2020), proposed a method to not interact with any
unwanted agents or split the whole transaction into smaller amounts.
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Journal of Network and Computer Applications 215 (2023) 103633
The interaction is aborted if the agent refuses to sign in a transaction.
7.4.3. Double Spending Attack
If an attacker spends the same Bitcoin on multiple users to gain extra
amounts then this type of attack is called a Double spending attack.
Aitzhan et al. (Aitzhan and Svetinovic, 2018) proposed a method called
a multi-signature transaction where some keys must sign a transaction to
spend tokens. Wang et al. (2020), use the timestamp to detect the attack
and PoW mechanism to prevent this attack. Hence by these proposed
methods, the double-spending attacks can be reduced. The user should
validate the transaction immediately to get a valid transaction. This step
should to taken to reduce all the double-spending attacks. If the user
validates the transaction the same cannot be used again.
7.4.4. Collusion attack
The hash tries to find out two inputs that produce the same hash
value. The nodes can collide with each other to maximize profit. He et al.
(2018), proposed an incentive mechanism and a pricing strategy that
can reduce the selfish behavior between the two nodes. Further research
is going on to reduce these types of attacks.
7.5. Cryptanalytic attacks
The attack which is based on the cryptographic algorithm to break
the keys is a cryptanalytic attack. A Quantum attack is one type of
cryptanalytic attack.
7.5.1. Quantum attack
To expose the keys by breaking the cryptographic algorithm is the
aim of this attack. Yin et al. (2017), investigate the quantum attack. The
design of this attack is to solve the elliptical curve digital algorithm. It is
used to get the private key from the elliptical curve public key. The
attacker can duplicate the signature of valid users. Yin et al. (2017)
proposed an idea such as a lattice-based signature scheme that allows
many sub-private keys. Hence in this way these attacks can be reduced.
7.6. MiscellaneousAttacks
Some of the other attacks that do not fall under any of the five cat­
egories are listed below. The attacks are 1) Eclipse Attack 2) Timejacking
Attack 3) Race Attack 4) Finney Attack 5) Vector 76 Attack.
7.6.1. Eclipse attack
Attacking the decentralized network through which an attacker at­
tacks a specific network rather than attacking the whole network, this
type of attack is called a Sybil attack. The node in a decentralized
network does not let all the nodes connect to another network, instead,
this node connects to only a selected group. This type of attack is a
simple attack that an actor may deploy to the interface with nodes on a
network. Eclipse attack is nearly the same attack as that of a Sybil attack.
As the similarities are the same between both the attacks the bot will
flood the network with many fake accounts or peers. Sybil attack is
targeted to wide attack in a whole network.
7.6.2. Timejacking attack
The attacker can change the node network and convert them into an
accepting blockchain only when the attacker can change or broadcast a
duplicate or fake timestamp of the transaction when Bitcoin is connected
to it. It means that the attacker can make full use to make of double-
spend on the network. The internal clock present in the Bitcoin is
responsible for the timestamps. This timestamp is the foundation of the
blockchain. Timejackers connect to multiple peers and report inaccurate
timestamps that could speed up or slow down the nodes. Alternation of
the network timer counter of the node is done in a timejacking attack.
For accepting an alternative blockchain an external force is given here.
Bitcoin timestamp handling is exploited by a timejacking attack. Node
A. J et al.
system time and restricting acceptance time ranges are prevented using
this attack.
7.6.3. Race attack
This network accepts only one transaction. This type of attack is
called a race attack. In this attack, the attacker will send the same coin to
different vendors in a similar kind following one after another by using
multiple machines. This will happen when the vendors deliver the goods
before the confirmation. During the mining process, the vendors will
realize that the transaction was canceled due to the same coin sent to
multiple vendors. The vendor who accesses the coin first will get the
coin. This is the reason this type of attack is called a race attack. While
creating conflict between two transactions this race attack is obtained.
The transaction which has no confirmation shops and services which
accept payment can be exposed to a so-called ‘race attack’. The trans­
action is done without any confirmation here. This risk can be but not
eliminated.
7.6.4. Finney Attack
The slight variation in the double-spend attack is the Finney attack.
In a Finney attack, the attacker creates two transactions. Once the block
is mined the participation of miners is required as it is a fraudulent
double-spending attack. The attacker includes several transactions in his
generated blocks that can transfer some coins between his address. After
the attacker double-spends the same coin using zero-confirmation pay­
ments after the blocks have been released in the network. To perform
this attack the user needs a lot of mining power. Hence the success
probability depends upon the computing power. These types of attacks
are exposed when the trader or merchant is exposed when accepting the
payment that can be confirmed or unconfirmed transactions. This attack
works when the merchant accepts unconfirmed transactions.
7.6.5. Vector 76 attack
Vector 76 attacks are also called one-confirmation attacks. For any
transaction, there is only one confirmation message hence it is one
confirmation attack. In other words, the attack that performs a double-
spending attack on Bitcoin exchange by using previously mined blocks
in a network is called a Vector 76 attack. The places where traders can
buy, sell, or exchange Bitcoin in a digital marketplace are called Bitcoin
exchange. This attack is a combination of a race attack and a Finney
attack.
8. Security and privacy enhancing techniques
All data must be given to every node in the blockchain network in
order to provide the traceability and verifiability of data on the network,
which unquestionably poses some privacy issues. There is always a
chance that attackers might get privacy based on specific nodes’ trans­
action data by connecting anonymous network addresses to their real
addresses. Anonymization is one of the common technique to address to
address the privacy issues. The anonymization process removes the
identification information from the transaction process without
affecting its actual process. Additionally, because data saved on the
blockchain cannot be removed or modified once it has been disclosed,
anybody may access it publicly without the need for any protective
measures. Similarly, security issues are also prevalent in blockchain
network due to the nature of the network. Therefore it is important to
enhance the security and privacy of the blockchain network. Public key
cryptography, hash functions, homomorphic encryption, secure multi-
party computation, trusted execution environment, and zero-
knowledge proof are some of the security and privacy enhancing tech­
nologies. Since smart contracts are kept on the blockchain, they logically
inherit the network’s privacy features. The blockchain privacy protec­
tion method for smart contracts is built mostly on a mixture of crypto­
graphic technologies. Table 11 presents the various security and privacy
enhancing techniques with the attacks it can combat and other
25
Journal of Network and Computer Applications 215 (2023) 103633
information.
8.1. SmartPool
SmartPool is mining pool system proposed by Loi et al. (Luu et al.,
2017). The problem addressed by SmartPool is that the vast computing
power of the users in centralised pools is controlled by the operators of
those pools. Currently, just 10 mining pools account for at least 95% of
Bitcoin’s mining power, while 6 pools account for 80% of the Ethereum
network’s mining power. This leads to cryptocurrency attacks such as
double spending, network partitioning and 51% attacks. Through the
getblocktemplate protocol, which now only allows an option between
mining with a transaction set selected by the pool or mining an empty
block, bitcoin pools currently provide miners just a limited amount of
influence over transaction selection. The scenario is even worse in
Ethereum because miners in controlled pools are still not theoretically
able to reject the transaction set chosen by the operator. Replacing the
pool protocol with a decentralized network of miners instead of
centralized miners would combat the situation. However, they are not
compatible for Ethereum based blockchain. Hence, SmartPool is devel­
oped to enhance the security of the Ethereum cryptocurrency through
decentralized pool of miners, that is scalable and efficient in terms of
number of participants. For secure and efficient verification, augmented
Merkle tree is introduced. SmartPool gives miners the freedom to choose
the transaction they want in the block. Security, fairness, efficiency and
decentralization are the core of SmartPool protocol.
8.2. Proof-of-work based framework
Blockchain performance cannot be enhanced without impacting
their security. The tradeoff between the performance and security in the
PoW consensus algorithm is studied by Gervais et al. (2016). A novel
quantitative framework is proposed to analyze the performance and
security tradeoffs with the parameters of PoW. The security of PoW is
based on the idea that no single entity should possess more than 50% of
the processing power since that individual may effectively take over the
system by maintaining the longest chain. The proposed quantitative
framework consists of PoW blockchain simulator and security model as
their major components. Consensus and network parameters are given
as input to PoW blockchain. The performance of the blockchain is
measured through stale block rate, block propagation time, and
throughput. Security model on the other hand gets the security param­
eters as the input along with the stale block rate of PoW blockchain and
ensures optimal adversarial strategy and security provisions. As stale
blocks produce chain forks, which slow down the growth of the main
chain and have severe performance and security ramifications, they are
bad for the security and performance of the blockchain. Stale blockages,
on the one hand, provide the network’s adversary a competitive edge.
On the other side, stale blocks consume more bandwidth and are often
not rewarded for mining. The proposed framework enhances the secu­
rity of the blockchain by combating the attacks such as selfish mining,
double spending, and eclipse attacks.
8.3. Oyente
Smart contracts are readily able to manage massive quantities of
virtual currencies with a value of hundreds of dollars each, creating
financial incentives that are strong enough to draw competitors. In
contrast to conventional distributed application platforms, smart con­
tract platforms like Ethereum run in open (or permissionless) networks
where anybody may participate. As a result, the execution of these
systems is susceptible to manipulation attempts by arbitrary attackers, a
vulnerability that is only present in traditional permissioned networks
like centralized cloud services. Oyente is a symbolic execution tool
proposed by Luu et al. (2016) to find potential security bugs in Ethereum
smart contracts. The Ethereum global state and the bytecode of the
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

Table 10
Summary of security attacks.
Attack Type Type of Attack Name Attack Effect Detection Method Protection Technique
Consensus
Algorithm

Identity-based PoID Replay Spoof the communication between One-time private-public key pair Elliptical Curve based Encryption (Huang
attacks two parties (Lin et al., 2018), (Huang et al., et al., 2018)
2018)
Impersonation Gain Access ECDSA Algorithm (Lin et al., Distributed Incentive-Based Approach (
2018) Wang et al., 2020), (Wang et al., 2018)
Sybil Peer to peer in which multiple Consensus Algorithm (Otte Trust Chain (Otte et al., 2020)
fraudulent identities are created et al., 2020)
Key Leakage of data from private keys Mutual authentication Elliptical curve based approach (Huang
mechanism (Huang et al., 2018) et al., 2018)
Manipulation PoW&PoA False Data False event is created Negative Agreement (Liang Distributed Voting Algorithm (Liang
based attacks Injection et al., 2019) et al., 2019)
Tampering Leakage of data Negative sum between the input Homomorphic Paillier Encryption (Wang
sum and the output sum (Wang et al., 2020)
et al., 2020)
Overlay The forged encrypted amount is Timestamp (Wang et al., 2020) Different input among the same traders (
overlayed above the original Wang et al., 2020)
amount.
Modification Data from a person or an The temporary private key for Elliptical Curve based Approach (Huang
organization is modified each session (Huang et al., 2018) et al., 2018)
Man-in-the- Data transfer between two partieTs Mutual Authentication (Huang Elliptical curve encryption (Huang et al.,
Middle can be modified by the man in et al., 2018) 2018)
between the two parties.
Reputation-based PoS&PoA Hiding Blocks There is a negative and positive Negative reputation (Otte et al., Immutable chain (Otte et al., 2020)
attacks impact based on the transactions. 2020)
Whitewashing Negative reputation is hidden Nil Lower priorities of new agents (Otte et al.,
2020)
Insider attack Trusted insider with high privilege Smart metering infrastructure ( Calculating reputation score from
behave maliciously Singh et al., 2022) neighbors (Singh et al., 2022) (Zhang
Selfish node Sending fake information to other Indirect reciprocal incentive et al., 2022c)
attack nodes for its benefit mechanism (Zhang et al., 2022c)
Service-based PoLe&PoI DDoS Attack Denial of service to the legitimate The hijacked network is Ethereum blockchain based
attacks nodes leveraged with a great number authentication (Ibrahim et al., 2022)
of requests
Refusal to Sign Unfavorable transactions are not Nil Interaction is aborted if the agent sign is
signed missing or transactions are split to lesser
amounts
Double The attacker spends the same Bitcoin Multisignature Transactions ( Timestamp (Wang et al., 2020)
Spending on multiple users. Aitzhan and Svetinovic, 2018)
Collusion Nodes collude with each other to Nil Node reputation is calculated based on
lower the reputation of the target the average of all scores from the nodes (
node Dennis and Owen, 2015).
Miscellaneous PoS Quantum The attacker duplicates the signature Elliptical curve public key (Yin Lattice-based Signature (Yin et al., 2017)
attacks of valid users. et al., 2017) An Anti-Quantum Transaction
Authentication Approach in Blockchain
PoW Eclipse Monopolize all the incoming and Lookup Method Limit the number of nodes per IP address
outgoing connections (Heilman and increase the number of connections. (
et al., 2015) Marcus et al., 2018)
PoET Timejacking Skew’s target node timestamp by Node uses network time to Network encryption randomized port
connecting the target with multiple validate a new block negation (Apostolaki et al., 2017)
peers
PBFT Race The attacker created two Conflicting transaction message The minimum number of transactions
transactions one is genuine and the should be done
other is fraudulent.
PoB Finney Attack The pre-mined block will hold a Unbroadcasted blocks Confirm the transaction before it is
fraudulent transaction processed.
SCP Vector 76 Combines Finney and race, it Using a Single Direct Connection Connect the outgoing to a well-connected
Attack requires single confirmation node

smart contract are inputs to the Oyente tool. First, the CFG Builder will
statically construct the smart contract’s CFG (Control Flow Graph) from
the bytecode. Then, using static symbolic execution, EXPLORER simu­
lates the execution of a smart contract in accordance with Ethereum
state and CFG data. Because some jump targets are not constants and
should be determined during symbolic execution, CFG will be further
enhanced and improved through this procedure. Oyente is capable of
addressing the security issues such as transaction ordering dependence,
timestamp dependence, mishandled exceptions, and reentrancy
vulnerability.
8.4. Town Crier
In most cases, smart contracts must communicate with off-chain data
sources. However, there is no assurance that the data offered by such
sources is reliable. HTTPS seems to provide solution to this problem
however, smart contract cannot have network access and digital sign is
missing. To authenticate the data feeds of smart contracts Zhang et al.
(2016) proposed a system called Town Crier. The architecture of Town
Crier (TC) consists of a TC contract and TC server. The TC contract is the
interface between the user and the TC server. The main objective of TC is
to authenticate and digitally sign the data feeds that are retrieved from
web sources. Another key objective of TC is to achieve the security

26
A. J et al. Journal of Network and Computer Applications 215 (2023) 103633

Table 11
Techniques to enhance and security and privacy of the blockchain technology.
Technique Security Privacy Attacks Minimization Security Model Security/Privacy Guarantees
Enhancement Enhancement

SmartPool ✓ 51% attack, Block withholding Augmented Merkle tree Security, fairness, efficiency and
attack, decentralization
Proof-of-Work ✓ Eclipse attack, Double spending Stale block rate, mining power, Optimal throughput, Optimal tradeoff
based attack, Selfish mining attack, mining costs, propagation between performance and security
Framework ability
Oyente ✓ Double spending attack, Ethereum Virtual Machine, CFG transaction ordering dependence, timestamp
resource exhaustion attack, builder, Symbolic execution dependence, mishandled exceptions, and
tool reentrancy vulnerability
Town Crier ✓ ✓ DoS attack, Relay attack, Side Blockchain simulator, trusted Gas sustainability, hybrid trusted computing
channel attack computing server, enclave base minimization.
Ekiden ✓ ✓ Integrity attack, Side channel Randomization, Key Correct execution, consistency, secrecy,
attack, Rewind attack management, Distributed key graceful confidentiality degradation
generation
Hawk ✓ Deanonymization attacks, front- Pseudonymity, Decentralized On-chain privacy, Contractual security,
running attacks, identity attacks Smart Contracts Transactional privacy
Engima ✓ Incentive attack, Identity attack Secure multiparty computation, Distributed hash-table for storage, Privacy
Secret sharing scheme enforcing computation, heavy processing
Zether ✓ Replay attack, fron-running ElGamal encryption, Anonymity, Confidentiality, Zero knowledge
attacks Anonymization proofs, Interoperability

properties such as gas sustainability and trusted computing base. The
security model of TC consists of TC contract, data sources, enclave,
relay, blockchain and network communication. Relay module is
responsible for the communication between enclave, blockchain and
network environments. TC is designed to be robust even when the relay
is attacked. Hence, TC ensures security and privacy of data feeds.
8.5. Hawk
Hawk is a privacy preserving smart contract framework designed to
address the privacy issues with the smart contracts. Kosba et al. (2016)
proposed a decentralized smart contract system that avoids storing the
transactional information directly on the blockchain. The Hawk frame­
work allows programmers to split the contract into private and public
parts. The private part contains the financial and identification infor­
mation whereas the public part can have other information which can be
revealed to the outside world. Hawk program can be divided into three
pieces. They are the blockchain program that executes by all nodes,
executed by the users, and executed by managers. Hawk manager is a
trusted node and not a third party who can see the user inputs however,
he protects the privacy of the users not only from the public but also
between the smart contracts. Hawk manager has the control to abort the
protocol during mishap and users can be compensated appropriately.
8.6. Engima
Enigma is privacy preserving decentralized computation platform
proposed by Zyskind et al. (Zyskind Oz et al., 2015). It is based on secure
multiparty computation model for verifiable secret sharing. A highly
optimized variant of SMPC is used by Enigma, a decentralized compu­
tation platform, to implement a verifiable secret-sharing method to
guarantee the anonymity of its computational model. A customised
distributed hash table is used by Enigma to encrypt off-chain private
data and communicate secret information. Enigma offers independent
control and security of personal data, much like Bitcoin, while doing
away with the need to rely on reliable outside parties. Unlike the typical
blockchain redundancy systems, Enigma distributes data among the
nodes in a way that each node maintains a copy of all the transactions.
On the blockchain as well as Enigma, the code is run. Executing Enigma
can guarantee both secrecy and correctness, as opposed to the block­
chain’s ability to guarantee only the latter.
8.7. Zether
Zether is fully decentralized confidential payment model proposed
by Bünz et al. (2020). Zether is similar to Ethereum and Libra and it
addition it provides privacy preserving payments with trustless mech­
anism in smart contracts. Zether guarantees confidentiality of the
transactions through cryptographic proofs. Zero knowledge proof is one
of the important building block of Zether that enhances interoperability
through ZK-proof mechanism called Σ-Bullets. Zether also makes it
possible for arbitrary smart contracts to communicate with one another
for uses like consensus, voting, and payment channels. Zether still has a
lot of drawbacks, the most obvious of which is the exorbitant price.
Another is that privacy leaking might result via Ethereum’s gas process.
8.8. Ekiden
Smart contracts are suffer from poor performance due to the
complexity and confidentiality. Secure multi party computation and
zero knowledge proof system tried to address the smart contract issues
however, due to complexity of the cryptographic approaches makes it
complicated. Trusted execution environment (TEE) provides a reason­
able solution to the aforementioned problem as it isolates the applica­
tions that runs on the environment and protects confidentiality.
Utilizing TEE for blockchain application is challenging to address this
Ekiden a privacy and confidentiality preserving blockchain system is
proposed by Cheng et al. (2019). Ekiden’s TEE-based computations can
guarantee secrecy so that strong encryption primitives like functional
encryption and black box obfuscation, which are known to TEE, may be
utilized successfully. TEE also offers the randomization of reliable
sources. Ekiden executes smart contracts in TEE over private data on
off-chain processing nodes, and then employs a remote attestation
protocol to confirm the chain execution’s accuracy. Ekiden illustrates
that blockchains and trusted enclaves have complimentary security
qualities and may be coupled to offer a strong, general framework for
confidentiality-preserving, reliable, and effective smart contracts.
9. Performance evaluation metrics of healthcare blockchain
The performance evaluation metrics of blockchain are used to assess
the quality, performance, and scalability of blockchain applications, as
well as to set benchmarks to compare against different blockchain ver­
sions (Zaabar et al., 2021)– (Khan et al., 2021). The following are some
of the frequent metrics that are monitored while running the blockchain
application.

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9.1. Transaction throughput how much CPU is used. Loops will use up a many of the CPU resources in
the contract with encryption. Committing the block and computing the
Transaction throughput is a measure of the number of actions that hash of the global state both take a significant amount of CPU time. The
are completed within a time frame. This statistic is used to determine encryption methods, hash calculations, and consensus procedures used
how long it takes to append valid data to blocks. This helps to determine in Transaction per CPU varies from one application to the next. As a
how fast the transactions are processed by the blockchain. The entire result, we’ll need a metric to track CPU use when smart contracts are
number of committed and validated records is divided by the total operating. The following equation is used to calculate the Transactions
amount of time it takes to commit (validate, and store) those data (in Per CPU for every node n in the blockchain network (Kombe et al.,
seconds). 2018).
Transaction throughput = Total committed transactions/time taken to commit Count(Trsac in(a, b))
TCn = ∫b (Trsac / GHz . s) (5)
(1) a
F × CPU(t)
To improve the blockchain’s throughput, developers use numerous
where the frequency of a single CPU core is F, while the CPU con­
strategies which include roll-ups, sidechains, nation channels, new
sumption of a blockchain programme from a to b is CPU(t). Then TC for
consensus mechanisms, and block length increases. The consensus
the whole blockchain network of N nodes can be calculated as follows,
mechanism of a blockchain platform determines a decentralized pro­
∑
tocol’s transaction throughput. For example, a proof-of-work (PoW) TCn
blockchain like Bitcoin has a decreased throughput as compared to a TC = n (Trsac / (GHz.s)) (6)
proof-of-stake (PoS). Other elements that affect throughput include a N
blockchain’s block length, site visitors, and complexity of transactions.
9.5. Transaction per memory second (TMS)
9.2. Transactions per second (TS)
TMS (Zheng et al., 2018b) is a measurement that represents the
Transactions per Second (TS) (Kombe et al., 2018) is a metric used to consumption of physical and virtual memory for transactions of
determine the number of records or transaction records that have been blockchain-based programmes. The following formula was used to
submitted and saved per second. It is used to figure out the processing determine the TMS of a node (n) linked to a blockchain network between
capability of a blockchain network and its scalability requirement. time period a and b with the execution of a specific number of trans­
However, in most cases, the number of records sent to the blockchain actions (Trsac).
( /
network and the quantity of data saved in the ledger are measured
Count (Trsac from (a, b))
independently. To increase the transaction per second, there should be TMSn = ∫ b Trsac (MB.s) (7)
PMEM (t) + VMEM (t)
an increase in the block size and a decrease in the block time. It is a

measured as follows,
where PMEM (t) and VMEM (t) are the physical and virtual memory occu­
Count(Trsac from(a, b)) pied by blockchain application between the time a and b. The TMS of the
TSn = (Trsac / s) (2)
b− a whole blockchain network can be calculated as follows
∑ ⎛ /
where a and b are time periods, Trsac is the number of transactions, s is TMSn
the number of seconds, and TPSn specifies the particular node for which TMS = n ⎝ Trsac (MB.s) (8)
N
the TPS is calculated. Therefore, TS for all nodes (N) can be calculated by
the average TS as follows,
∑
Trsacn 9.6. Transactions per disk input/output (TDIO)
TS = n (Trsac / s) (3)
N A dedicated storage is allocated for blockchain applications to
maintain data along with the world state. TDIO (Zheng et al., 2018b) is a
9.3. Transaction latency (TL) metric that tracks the measure of the input/output while performing the
blockchain operations such as contracts execution and block commits
Transaction Latency (TL) (Zaabar et al., 2021) metric is used to during a particular time period. The TDIO for a specific node n in
calculate the time taken for a transaction to be confirmed and sent to the blockchain network is calculated as follows,
blockchain network to be written to the ledger (or rejected). This sta­
Count(Trsac from (a, b))
tistic is calculated by comparing the time transactions were submitted to TDIOn = ∫ b (Trsac / kbs) (9)
the time they were verified and stored using their timestamps. This a
DiskR (t) + DiskW (t)
measure can also reveal how quickly consensus techniques are being
implemented. Blockchain transaction latency is the time in filing a where DiskR (t) and DiskW (t) denotes the amount of data disk read and
transaction to a blockchain network and the first validation of the write performed in-between the time period a and b. The overall TDIO
transaction. It also represents the time to wait after pressing the send for the blockchain network can be calculated as follows,
button and seeing the appearance of the transaction on the screen. ∑ ⎛ /
TDIOn
TL = Netθ × Trsacct − Trsacst (4) TDIO = n ⎝Trsac (kbs) (10)
N

where Netθ represents the network threshold, Trsacct denotes the

transaction confirmation time, and Trsacst denotes the transaction sub­
mission time.
9.4. Transactions per CPU (TC)
Smart contracts need a lot of CPU resources when they’re being
executed. The business logic implemented in the contract determines
9.7. Blocks per hour/blocks per day
Blocks per hour/blocks per day (Ferretti and D’Angelo, 2020) metric
allows to track how quickly records are submitted and stored on the
blockchain network, as well as how quickly the network can execute its
consensus method. Based on a block’s capacity, the number of blocks
that can be processed may be determined accordingly. As timestamp is

28
A. J et al.
attached to each block that is formed, it helps to track how many blocks
are generated and appended during specific time intervals, such as an
hour or a day. The results of these tests are used to evaluate the block­
chain system’s performance and scalability.
9.8. Full node/Partial Node Ratio
Active nodes represent the total number of unique nodes that have
downloaded the blockchain application. This enables us to measure and
evaluate how many people have downloaded the blockchain application
and are currently utilizing it. The measure can also provide the IP
address and geographic location of each node that downloaded the
application. This measure may also provide information on whether the
blockchain application is easily accessible for download.
Full Node/Partial Node Ratio (Su et al., 2022) metric is used to
determine the number of active full nodes and partial nodes on a
blockchain network, as well as the ratio of full to partial nodes. The Full
nodes locally store the full Blockchain Ledger. Therefore, they download
each block and transaction that ever occurred at the Blockchain. This
allows for a bitcoin to operate in a trustless manner. Also, the full nodes
are secure and not affected by attacks. Partial nodes don’t store complete
ledger and so are called lightweight nodes. They download only a
portion of the blockchain that is required for the transactions. Knowing
this ratio is significant because if a blockchain network has no opera­
tional full nodes, the historical data in the whole copy of the blockchain
would be lost.
10. Discussions, challenges & research opportunities
Blockchain technology has a lot of potential in the healthcare in­
dustry due to its popular features of decentralization, immutability,
consensus mechanisms, and increased capacity. In this article, we have
presented the concept of blockchain technology with its applicability to
healthcare systems. The features of the blockchain are very well aligned
with the requirements of the healthcare industry thus it integrating
blockchain technology in the field of healthcare has become inevitable.
At first, the features of blockchain are presented in line with the
healthcare systems. Secondly, we presented the various use cases of
blockchain and its applicability with more light on the healthcare
domain. We have identified patient data management, drug traceability,
cryptocurrency payment, clinical trials and data security, and secure
healthcare setups as the applications of blockchain technology in
healthcare. Fig. 4 Compares the features of the applications. Then, we
presented the working model of blockchain with the layered architec­
ture of blockchain. The different types of blockchain such as permis­
sioned blockchain, permissionless blockchain, and consortium
blockchain are explained in terms of healthcare blockchain systems.
The consensus mechanism is one of the key features of blockchain.
The various consensus algorithms are presented along with their
applicability to the healthcare domain. A comparative analysis of
various consensus algorithms and their characteristics is presented in
Table 8. We noticed few consensus algorithms are not suitable for the
healthcare domain due to their limitations such as high bandwidth, huge
power consumption and transmission delay. Finally, we presented the
security challenges for blockchain technology. Though blockchain is
secure and immutable still there are a number of security challenges that
are yet to be addressed. In order to make the blockchain more promising
for healthcare applications, the security challenges must be carefully
evaluated during implementation. A detailed comparative analysis of
the security attacks is provided in Table 10. Further, we discuss the
challenges and research opportunities in healthcare blockchain
technology.
This section presents the challenges and research opportunities
based on the literature review presented in this article. The following are
some of the most prevalent challenges that require considerable
research and attention.
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Journal of Network and Computer Applications 215 (2023) 103633
10.1. Data privacy
The key feature of blockchain is transparency. Since the user’s
transaction is traceable and transparent, measures must be taken to
protect the transaction privacy of users (Ben Hamida et al., 2017),
(Kumar and Mallick, 2018). The users should be assigned a private key
to each transaction so that the attacker will not be able to infer any
actual coins or information from the cryptocurrency. A
blockchain-based privacy-preserving model is proposed to protect social
network data. This model protects sensitive information through a
distributed blockchain system and non-sensitive information is pro­
cessed by the primary system. In (Chen et al., 2019) a method is
designed to solve the data synchronization problem. The data security
and efficiency are ensured through a stochastic homomorphic elliptic
curve cryptography encryption model. However, data privacy is a
prevalent challenge in blockchain especially when it is dealing with
healthcare data. Healthcare data contains personal sensitive information
that needs to be protected. Any form of personal information leak would
affect the individual. Hence, health data privacy requires research focus
on blockchain technology. Providing tamper-resistance and
non-repudiation in e-health systems is a new study field that has just
developed in the healthcare industry. A Privacy Preserving Biometric
Authentication (PPBA) system was created to ensure patient privacy
when accessing healthcare services by requiring anonymous patient
authentication (Sarier, 2022). This method of blockchain-based safe
biometric identification offers processing and offline encryption in the
encrypted domain scheme. The public blockchain that ensures the data’s
integrity is used to host the infrastructure required for online authenti­
cation. The approach decreases the number of transactions required for
authentication, allowed for the revocation of biometric identities, and
has auditing capabilities for bad actors. The findings demonstrated that,
even when the templates are stored as encrypted, the proposed archi­
tecture resulted in a natural defense against these attacks. The
blockchain-based PPBA system employs transaction fees as a deterrent
against hill-climbing attacks. The General Data Protection Regulation
(GDPR) demands that the use of biometric data be kept private. Private
matching of sensitive biometric data was secured as per the GDPR using
the same cryptographic method. This was done using secure sketches
which are provably the secure biometric template protection mecha­
nisms. As data integrity and auditing are the two primary advantages,
integrating blockchain-based PPBA systems enabled the prevention of
threats.
10.2. Block size and scalability
The maximum capacity for a block to be filled with transactions is
referred to as block size. If the network’s capacity is exceeded, the block
will be denied. A blockchain is a type of decentralized database. As a
result, distributed ledger denotes that each node processes each trans­
action and contains a copy of the complete ledger state. In the healthcare
system, however, simply the relevant ledgers for certain nodes would
suffice, rather than a complete copy of the ledger (Zhang et al., 2018b).
Unprocessed patient data, such as genomics and vital organs, is another
illustration of the block size issue. Despite the fact that larger data
packets on-chain result in greater storage costs, there is more data
accessible on-chain to audit (Odhran et al., 2019). As a result, main­
taining a balance in the ever-present store and exchange transactions is
critical. Another important challenge in implementing blockchain
technology is handling the decentralized system with a huge number of
peers. The volume of the transaction involved is enormous. As a result
transaction processing rate and the latency of communication increase.
Due to the consensus protocol, the latency between the transaction
submission and confirmation is affected.
A. J et al.
10.3. Number of nodes and system responsiveness
In a blockchain-based system, a node is a component. It is the tech­
nology’s basis, and it symbolizes each thing linked to the network. When
more nodes are connected to the network, the internode latency grows
logarithmically with each new node. Furthermore, in a Communication
area, as the number of nodes grows, so does the amount of computa­
tional resources available. In the healthcare field, it is envisaged that
vast communities will be connected, which would include the usage of
blockchain. As a result of the growing use of blockchain, a large number
of transactions will be produced and recorded. After numerous entities
agree on every transaction related to the transactions in the ledger, the
blockchain-distributed ledger will add new transactions. Although this
approach appears to be complicated, it is successful since the blockchain
is restricted in size (Al-Jaroodi and Mohamed, 2019). Some parties who
employ short-term data sharing use pre-authorization fees to reduce the
amount of memory needed on the blockchain. As the number of users
who are part of the blockchain network increases, the responsiveness of
the system slows down. With a large number of participants, to perform
even a single transaction requires consensus from all participants, which
makes it complicated and leads to degradation of system responsiveness
(Koteska et al., 2017).
10.4. Data analysis and visualization
Analyzing and extracting intelligence from the blockchain network is
complex. Digital currency analysis and capturing data are very crucial in
private organizations to satisfy intelligence analysis and management
needs (Vo et al., 2018). It helps to reveal suspicious activity while per­
forming fraud, security, and compliance investigations. Entity identifi­
cation, Privacy protection, Network portrait, Network visualization,
Market Effect Analysis, Illegal behavior detection, and Transaction
pattern recognition are the seven problems in blockchain data analysis
(Yang et al., 2019).
10.5. Transactions and blockchain audit
A blockchain transaction is a method of transacting business with
numerous parties in a network. As developers continue to find the most
up-to-date techniques for conducting blockchain transactions, the
blockchain market is progressing. When the blockchain system expands
up the technology for large transaction volume, however, difficulties
arise. The Ethereum blockchain, in particular, necessitates the verifi­
cation of every transaction by every validator on the network. This is a
contributing element to the network’s poor performance as a result of
the data load. As a result, reaching a consensus or verifying digital
identification will take a long time. Auditing a blockchain brings several
complexities. Firstly, real-time analysis is difficult because of the pos­
sibility of forks, which guarantees no reliability of data. The streamline
of financial reports and audit processes are required to manage the
network. The written records could still have been tampered and the
blockchain could be rebuilt if a majority of the participants reach a
consensus. In this perspective, it becomes extremely difficult for a reg­
ulatory authority to audit blockchain and to check whether the data and
transactions have been tampered with or not. Therefore, it is a challenge
to secure the data and prevent vulnerabilities from fraudulent users.
10.6. Consensus algorithm selection
The consensus algorithm is a mechanism that makes all blockchain
peers agree with the same message and ensures that the latest block
added to the chain is correct. It should guarantee that the message stored
by the peer will not create any fork attack and the system remains
protected from malicious attacks. If the consensus of peers agrees upon
the transaction’s validity, then the transaction is considered valid.
However, arriving at an effective consensus with a large number of users
30
Journal of Network and Computer Applications 215 (2023) 103633
is difficult and time-consuming. For example, every validator on the
Ethereum blockchain must confirm each transaction. Depending on the
data load, this effect causes a relatively slower network. Furthermore,
owing to its irreversible nature, blockchain may be unsuitable for a
variety of different applications. In some emergencies, the blockchain
system was unable to handle some patient problems, such as the
unpredictability of access. Furthermore, access to their data by a sur­
geon was not previously permitted during an emergency. Because there
are now insufficient acceptable methods, patients are often hesitant to
participate or provide their permission for data sharing. As a result, in
situations like these, a reasonable duration length is required to achieve
a quick response from the system, as well as agreement from all parties
on the important transactions.
10.7. Data transmission cost
Data transmission systems based on blockchain enables small and
large file transfers by avoiding nonrepudiation difficulties with secure
data transport. Although data transmission is included in practically all
Internet-based apps, few of them consider confidentiality to be an aspect
of data security. Because a dishonest participant can deny the fact of a
particular data transmission instance if a data transmission scheme is
carried out without the approval of a third party or a central computer, it
is easy to raise conflicts while transmitting valuable data, especially
digital goods. Signing and encrypting can be used to overcome the dif­
ficulty described above. Digital signature techniques, on the other hand,
often presuppose public key infrastructure (PKI), which adds to the
complexity of certificate administration and makes them unsuitable for
distributed networks (Jin et al., 2020). So the blockchain technology has
provided a powerful tool for achieving automated data transfer. While
blockchains do not require a central authority to store data, they do not
eliminate the requirement for any kind of authority. Because of the
nature of the health-care industry and the fact that its data is frequently
personal and sensitive, blockchain applications will rely on regulation,
monitoring, and standards and protocols. Any blockchain’s consensus
method is not dependent on technology, but rather on an agreement
among the attendees. Blockchain is being utilized to produce unique and
sophisticated treatments to enhance current medical data and personal
health record management, sharing, and processing standards. In the
healthcare business, where it has provided considerable value through
enhanced efficiency, remote access, technical innovation, personal pri­
vacy, and security of data management operations, blockchain tech­
nology is experiencing a conceptual metamorphosis (Tandon et al.,
2020).
10.8. Commercial applications
The application of blockchain to commercial applications is in high
demand and yields numerous benefits. The well-known Bitcoin is the
first use of blockchain in business. Non-monetary blockchain applica­
tions include securities clearance, logistics, HR management, health­
care, strategic planning, personal database administration, and so on. In
terms of Business as a service (BaaS), the blockchain platform is
employed in a variety of fields. There would be a plethora of circum­
stances in which BaaS may be used. The number of benefits an appli­
cation receives from both blockchain technology and services
determines how well it fits into BaaS (Song et al., 2021), (Frommelt,
2020). The various domains where blockchain technology can be
applied. Manufacturing is the first domain, with a desire for traceable
goods. Food tracking, for example, is an appropriate use of BaaS to
assure the food’s origin and checkpoints before reaching end-consumers.
In this situation, BaaS might assist in providing information about the
food source as well as ensuring that the food is not infected throughout
delivery from the sender to the recipient. The second domain is e-pay­
ments that follow predetermined rules or contracts. For example, the
payment of royalties to publishers. When it comes to royalties, it’s
A. J et al.
important to know when and how they’ll be paid. Because the block­
chain is based on smart contracts, this is an ideal BaaS application
because pre-defined requirements might be incorporated into the smart
contract to aid automate these payments. The financial management of a
company is the third domain. BaaS solutions that provide money man­
agement and product provenance, for example. It provides end-to-end
traceability and counterfeiting services, which assist businesses in
addressing challenges such as data tampering and lack of information
transparency. The fourth domain is an immutable, verifiable, and
authenticated public ledger or information-sharing system.
10.9. Administration of business processes
Future research should look at how smart contracts and distributed
ledger technology enable digital integrity, demand-supply chain man­
agement, customer order secrecy, and inter-organizational business
processes using blockchain. Inadequate infrastructure and significant
hurdles to blockchain implementation remain important problems for a
variety of businesses (Dutta et al., 2020). Some of the major roadblocks
are a lack of knowledge of blockchain implementation, data storage
centers and maintenance expenses, scalability concerns, data ownership
issues, a lack of top management and organizational support, qualified
technical employees, partner trust, and legal challenges.
10.10. Laws and regulations
Although the blockchain has altered society in many ways, it has also
posed legal and legal institutions with new challenges. Due to the nov­
elty of blockchain technology and the lag in legal supervision, it sparked
a slew of legal difficulties, particularly in its early stages of development
(Lu, 2019a). A thorough grasp of the blockchain’s properties aids in the
creation and improvement of blockchain-related legislation and regu­
lations. Many governments are implementing blockchain technology
and tightening regulatory controls. Delegation of authority and legal
interpretation and jurisdiction issues, privacy protection and online real
names issues, reliability and deletion rights issues, and transparency and
personal data privacy difficulties are only a few examples. Furthermore,
technology and law are mutual substitutes in the fields of national and
social governance (Lu, 2019b). In a social setting, if the cost of a tech­
nology solution is less than the cost of a legal solution, the technical
instrument can take the place of the legal form as the primary way of
generating orders. Blockchain-enabled distributed trustworthy data­
bases and smart contracts have the chance of breaking down technical
and legal barriers and creating new governance models.
10.11. Future directions
It is essential to think about blockchain technology’s future and how
the discipline itself might be a potential career for people with experi­
ence in blockchain as its importance develops. Blockchain is a perma­
nent, uncrackable digital database that records transactions in a
verifiable manner. Several firms from numerous industries have been
drawn in by the potential of blockchain technology and its uses.
Blockchain technology has been incorporated into several studies and
has the potential to be accepted internationally due to its disruptive
qualities.
For obvious reasons, cybersecurity is where blockchain technology is
most likely to take off in the future. Despite the Blockchain ledger is
open and distributed, the data is still secure and verifiable. Data is
encrypted using cryptography to eliminate security flaws like unau­
thorized data tampering. Centralized systems run the major hazards of
data loss, hacking, and human error. Blockchain technology can be used
to increase security and resistance to hackers of cloud storage.
The promise of blockchain technology has been proven reliable in
terms of its goal of tracking financial assets. Several financial organi­
zations invested in this technology after seeing its potential and
31
Journal of Network and Computer Applications 215 (2023) 103633
advantageous results. Blockchain’s transparent ledger architecture en­
ables it to handle the flow and transactions of black money. With these
successes, governments around the world are now examining the po­
tential of applying blockchain technology to have more effective rules
over the nation’s finances and economy. Also, the concept of blockchain
can help with the management of massive volumes of data, which is
quite advantageous for governmental institutions.
Businesses are utilizing blockchain technology to build a distributed
network of IoT devices. Integrating blockchain-based solutions in IoT
access control enables the management of device-to-device communi­
cation and operations like software updates, error handling, monitoring
energy usage, etc.
Using blockchain technology can monitor hiring, spending, and re­
leases at every stage of the supply chain while reducing delays and
human error. With traceability, blockchain can help ensure that prod­
ucts are both legal and fair trade-certified. The potential for blockchain
to prevent income losses from illicit goods.
Nowadays, trade between nations is discouraged since it is an inef­
fective and disorganized process that slows down commerce. Foreign
trade is likewise rife with faults, dishonesty, and counterfeiting. Adding
cryptocurrency using blockchain technology will enable us to solve a lot
of these issues. Most of the fraud and inefficiency can be addressed by
combining payment methods, paperwork, and regulation through a
single digital international system. This will usher in a new era marked
by increased trade and improved international relations.
As blockchain technology continues to develop and grow with
greater advancements, not only in cryptocurrency but also in several
commercial applications including smart contracts, automated tracking,
and rule enforcement. The effects of blockchain will impact businesses
and society.
11. Conclusion
Blockchain technology offers the potential to address some of the
issues that the healthcare industry encounters. Due to the general ledger
and block-related architecture, the biggest potential of blockchain
technology in the healthcare sector is its highly explored applications,
namely: security, integrity, decentralized nature, availability, and
authentication principles. The healthcare industry is having trouble
adjusting to a rising technology infrastructure that includes Internet-
enabled devices, Internet of Things (IoT), smart devices, and sensing
gadgets. As a result of these technologies’ ability to help the healthcare
industry to better serve its patients in an increasingly interconnected
world, malicious actors can use vulnerabilities in such technologies to
gain access to and duplicate data, making it more difficult to share re­
cords between hospitals. This can lead to obsolete data, which can lead
to health issues or misdiagnosis, as well as difficulties authenticating a
patient’s identification. According to the research reviewed in this
study, blockchain technology has the potential to address a variety of
existing challenges in the healthcare sector. The objective is to give
patients authority and ownership over their medical data, allowing them
to share it with whomever they choose in a safe setting. Hence, this
article provides an in-depth survey of various features of blockchain,
uses cases, architecture, types of blockchain, consensus algorithms for
healthcare blockchain, various security challenges, and performance
evaluations metrices. Furthermore, we presented several comparative
analyses on blockchain and its features with healthcare applications.
Blockchain has several advantages that may be applied to the
healthcare industry to address a variety of issues related to data sharing
and security. Blockchain, on the other hand, is not a solution that can be
pushed into any circumstance. Instead, a thorough analysis of particular
blockchain concerns and their implications for the healthcare industry is
required. Mining incentives, which are a key component of blockchain,
as well as particular blockchain assaults that may bring the entire system
to a stop, have not been thoroughly explored in the healthcare industry.
The potential of blockchain technology in the health industry is
A. J et al.
overhyped, and its value may be exaggerated. The most difficult barriers
to the health sector’s digital transformation, like a lack of data inter­
operability, are not eliminated by blockchain, and it also doesn’t provide
any new benefits.
While the data included in blockchain-based ledgers is intrinsically
secure and tamper-proof, this does not guarantee that the data inputted
are accurate or of acceptable quality. Together with user error, mali­
cious actors may try to sway people’s choices about giving their consent
and granting access to their data. With an increase in the number of
persons who are physically and intellectually weak in older populations,
this danger is especially significant. Only governance, regulation, and
enforcement are capable of controlling this vulnerability.
Healthcare organizations are not allowed to keep or transmit sensi­
tive information due to the installation of Blockchain, which demands
trust in data repositories without relying on an unbiased broker to
confirm a transaction. The combination of blockchain and AI technol­
ogies can raise the standard of treatment in healthcare systems.
Healthcare will become more accessible and affordable as a result of the
reduction in medical sector expenditures. Blockchain adoption is being
impacted greatly by the expert shortage. Firstly, to meet the demand,
there aren’t enough people working on innovation. Secondly, hiring
current blockchain professionals is expensive. It would be ideal if people
were to learn more about Blockchain technology as it continues to gain
popularity.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Data availability
No data was used for the research described in the article.
Acknowledgments
This work was supported in part by the JSPS KAKENHI under Grants
JP21H03496 and JP22K12157, and in part by the JST, PRESTO under
Grant JPMJPR1934.
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Andrew J, Andrew J, is currently working as an Assistant Professor in the Department of
Computer Science and Engineering (CSE) at Manipal Institute of Technology (MIT),
Manipal, India. He received his Ph.D. in the year 2021 from Vellore Institute of Technology
(VIT), Vellore, India. He received his Bachelor of Engineering (B.E.) in CSE in 2011 and
received his Master of Engineering (M.E.) degree in in 2013 from Anna University,
Chennai, India. He is a member of International Association of Engineers (IAENG), Internet
Society, EAI Innovating Research and Computer Science Teachers Association. He is an
active researcher published scientific research articles in reputed journals and conferences.
He also served as speaker in many prestigious conferences worldwide. His research interest
include data privacy, healthcare data analysis, deep learning, machine learning, computer
vision, and blockchain technologies.
Deva Priya Isravel, Deva Priya Isravel is an Assistant Professor in the Department of
Computer Science and Engineering at Karunya Institute of Technology and Sciences. She is
36
Journal of Network and Computer Applications 215 (2023) 103633
presently pursuing her Ph.D. degree in Computer Science and Engineering at KITS. She
received her B.E degree from Anna University in 2005. She received her M.E degree from
Karunya University in 2008. Her areas of interest include computer networks, wireless
sensor networks and software defined networks.
K. Martin Sagayam, K. Martin Sagayam received his Ph.D in the research field of Signal,
Image processing and machine learning approaches in 2018. Master degree in Commu­
nication Systems from Anna University in the year 2012 and B.E degree in Electronics and
Communication Engineering from Anna University in the year 2009. Currently, he is
working as an Assistant Professor in the Department of Electronics and Communication
Engineering at Karunya Institute Technology and Sciences (Deemed University). He has
authored/ co-authored in several referred International Journals, and conferences. He is
an active member in various professional bodies. His area of interest includes pattern
recognition, artificial intelligence, big data security, privacy preserving and signal pro­
cessing in imaging.
Bharat Bhushan, Bharat Bhushan (Senior Member, IEEE) received the B.Tech. degree
(Hons.) in computer science and engineering, the M.Tech. degree (Hons.) in information
security, and the Ph.D. degree in computer science and engineering from the Birla Institute
of Technology, Mesra, India, in 2012, 2015, and 2021, respectively. In the past, he worked
as an Assistant Professor with the HMR Institute of Technology and Management, New
Delhi; and a Networks Engineer with HCL Infosystems Ltd., Noida. He is an Assistant
Professor with the Department of Computer Science and Engineering (CSE), School of
Engineering and Technology, Sharda University, Greater Noida, India. He earned
numerous international certifications such as CCNA, MCTS, MCITP, RHCE, and CCNP. He
has published more than 100 research papers in various renowned international confer­
ences and SCI-indexed journals, including Journal of Network and Computer Applications
(Elsevier), Wireless Networks (Springer), Wireless Personal Communications (Springer),
Sustainable Cities and Society (Elsevier), and Transactions on Emerging Telecommuni­
cations Technologies (Wiley). He has contributed more than 30 book chapters in various
books and has edited 14 books from the most famed publishers like Elsevier, IGI Global,
and CRC Press. He is a member of numerous renowned bodies including IAENG, CSTA,
SCIEI, IAE, and UACEE. He has served as a Keynote Speaker (resource person) in numerous
reputed international conferences held in different countries including India, Morocco,
China, Belgium, and Bangladesh. He has served as a reviewer/Editorial Board Member for
several reputed international journals.
Yuichi Sei, received his Ph.D. degree in information science and technology from the
University of Tokyo, Tokyo, Japan in 2009. From 2009 to 2012, he was with the Mitsubishi
Research Institute, Tokyo, Japan. He joined the University of Electro-communications,
Tokyo, Japan in 2013, and is currently a professor in the Graduate School of Informatics
and Engineering. He is also a visiting researcher at Mitsubishi Research Institute and an
adjunct researcher at Waseda University, Tokyo, Japan. His current research interests
include pervasive computing, privacy-preserving data mining, and software engineering.
Jennifer Eunice, received his Bachelor of Engineering and Master of Engineering from
Anna University, Chennai, India in the year 2012 and 2014. Currently she is pursuing her
Ph.D., full time in Karunya Institute of Technology, India. Her research interest includes
sign language recognition, transformer models, image and video processing, and deep
learning.