Review Not peer-reviewed version

A Sustainable Digital

Transformation in Healthcare and

Well-Being: An Overview,

Integration, Design and Security

Challenges, Blockchain

Technology, Applications, and

Future Research Directions

*
Faisal Hameed and Khizar Hameed

Posted Date: 19 September 2023

doi: 10.20944/preprints202308.0867.v2

Keywords: sustainability; sustainable development goal; healthcare; information and communication

technology; blockchain; security and privacy; design goal; society; environmental; financial)

Preprints.org is a free multidiscipline platform providing preprint service that

is dedicated to making early versions of research outputs permanently

available and citable. Preprints posted at Preprints.org appear in Web of

Science, Crossref, Google Scholar, Scilit, Europe PMC.

Copyright: This is an open access article distributed under the Creative Commons

Attribution License which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

Disclaimer/Publisher’s Note: The statements, opinions, and data contained in all publications are solely those of the individual author(s) and
contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting
from any ideas, methods, instructions, or products referred to in the content.

Review
A Sustainable Digital Transformation in Healthcare
and Well-Being: An Overview, Integration, Design
and Security Challenges, Blockchain Technology,
Applications, and Future Research Directions
Faisal Hameed 1,2,3, * and Khizar Hameed 4
1 Tasmanian School of Business and Economics, University of Tasmania, 7005, Australia;
faisal.faisal@utas.edu.au
2 International Pathway College, University of Tasmania, 7005, Australia
3 UP Education Australia Pty Ltd, Sandy Bay Campus, Hobart, 7005, Australia
4 School of Information and Communication Technology, University of Tasmania, 7005, Australia;
hameed.khizar@utas.edu.au
* Correspondence: faisal.faisal@utas.edu.au

Abstract: Good health and well-being is one of the essential SDGs that ensure healthy lives and
promote well-being for all ages and further entails providing substantial medical services to the public
at low cost and with minimal adverse effects on the environment. Information and communication
technologies (ICTs) have taken on an increasingly important function as significant facilitators of
healthcare reform, with the goals of enhancing access to health services, the quality of treatment
provided, and the overall productivity of the healthcare system. However, the integration of
ever-increasing ICT technologies into the healthcare systems, also referred to as digital transformation,
is not a straightforward process, but it comes with different types of challenges from integration
level to application design level and security level. Although several studies have been proposed
to address the integration of ICT technologies into healthcare systems, there is still a need for
a comprehensive research study on the integration and design challenges, security and privacy
challenges, application areas, and possible positive and negative impacts. Therefore, this paper
contributes as the research literature study covering an important SDG, "Good health and well-being,"
and its digital transformation, along with summarising our research findings in a detailed and
taxonomical way. To start with, firstly, we present a detailed comparison of existing studies
on healthcare and well-being, mainly focusing on integrating ICT technologies in healthcare in
terms of sustainable aspects, security and privacy challenges, design and integration challenges,
E-health-related applications, and future directions. We also present an overview and the need
for digital transformation in healthcare, discuss its significant components, highlight E-health’s
importance and benefits, explore its integration and design challenges, and categorise the security
and privacy challenges. Next, we present an in-depth discussion on the role of Blockchain technology
as today’s leading technology in E-health, discussing Blockchain technology and its characteristics,
highlighting its benefits, and describing the possible types of Blockchain-based E-health use cases.
Furthermore, we discuss the positive and negative impact of ICT integration along with identifying
open issues and challenges of integrating ICT technologies into the healthcare systems and discuss
future research directions, which provide the strength for researchers to address the issues in future
solutions.

Keywords: sustainability; sustainable development goal; healthcare; information and communication

technology; blockchain; security and privacy; design goal; society; environmental; financial

1. Introduction
Among the 21st century’s global challenges, Sustainability is one of the utmost, if not the greatest,
concerns [1]. This is one of the reasons that the 17 Sustainable Development Goals (SDGs) by the United

© 2023 by the author(s). Distributed under a Creative Commons CC BY license.

Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

2 of 39

Nations, as introduced in 2015, become the common agenda of countries around the world. These
SDGs are integrated and indivisible [2]. Among these goals, the third SDG’s goal, ‘Good Health and
well-being,’ become the top priority because of the COVID-19 pandemic across the world [3]. This true
global epidemic of the digital era appeared as a great problematic concern among general populations
and healthcare professionals [4]. Hence, this situation, in addition to anxiety, also provided chances
for countries worldwide to assess and advance their healthcare systems [5]. Digital transformation is
gaining traction across all SDG sectors, but the healthcare SDG target still appears splintered and early
in its implementation process despite significant research and practical application. In this context,
developing a sustainability-focused ICT infrastructure that can better contribute to the progress of the
‘Good Health and Wellbeing’ goal of SDGs is vital. Several tangible examples of digital transformation
in healthcare include telemedicine, IoT and AI-based devices, and blockchain-based health records, all
of which are drastically altering the ways in which patients and doctors communicate and collaborate
to improve patient care and health outcomes. Therefore, reliable responses to this sustainability
concern facing the world today can be explored in the form of more reliable ICT developments such as
Blockchain (BC) and the Internet of Things (IoT) [6].
The fundamental role of digitalization in achieving all the SDGs is broadly recognized [7].
However, concerning SDG 3, digital advancements and its related technologies and challenges still
need to be endured in healthcare, though they certainly attained a level of maturity [5]. It is worth
mentioning that the healthcare industry in the United States is of significant magnitude, as seen by the
expected national health spending, which is estimated to reach a staggering $5.7 trillion by the year
2026. There is an opportunity for individuals to acquire a comprehensive understanding of digital
technology and leverage its capabilities to enhance corporate growth. In order to effectively transition
conventional practices into a successful digital framework in the year 2023, it is important to get a full
understanding of the contemporary healthcare environment. However, while 15% of businesses overall
have gone digital, just 7% of those in the healthcare and pharmaceutical industries have done so [8].
The World Health Organization (WHO), for its global strategy on digital healthcare, has recommended
appreciating principles of accessibility, privacy, interoperability, confidentiality, transparency, security,
scalability, and replicability [9]. Therefore, placing principle-based assessment criteria on several
available digital options (e.g., IoT, BC, AI, etc.) and their different underlying integrating challenges,
including design and security to advance the healthcare system across the countries, must be studied.
Therefore, to recognize the importance of incorporating digital technologies into healthcare, in this
paper, we discuss the digital transformation in healthcare concerning its components, importance, and
benefits, further, explore its integration and design challenges, and classify the security and privacy
challenges. Furthermore, we also addressed the role and application and highlighted several open
issues with key challenges concerning different ICT technologies and Blockchain in healthcare systems.
Based on our research into one of the most crucial SDGs—healthcare—and its ongoing digital
transformation with the help of cutting-edge ICT technologies, we were able to identify several
weaknesses in the survey literature on the topic of ICT integration with healthcare systems, especially
concerning the three sustainability perspectives (environmental, social, and economic): (i) research
surveys (like [10,11]) which provide an overarching view of sustainability but don’t go into the specifics
of ICT integration and the associated challenges (ii) Only environmental sustainability considerations
are presented in the survey study [12], which also describes IoT as an integration technology and
focuses on its limited applicability, (iii) The research study [13] only covered telemedicine and ICT
(5G) concerning health care, and (iv) the research papers [14–16] discuss the limited sustainability
viewpoints, highlight the limited ICT integration issues, and make use of artificial intelligence (AI)
and big data as integration technologies.
However, we motivate to present a state-of-the-art and comprehensive survey study by
conducting a detailed comparison of existing studies and highlighting their shortcomings in order
to discuss the digital transformation in healthcare with respect to its components, importance, and
benefits, explore its integration and design challenges; and classify the security and privacy challenges.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

3 of 39

As a second source of inspiration for this research, we describe the characteristics of Blockchain
technology, highlight its benefits, and list the different types of applications/use cases that can be
implemented using Blockchain in the field of electronic health records (E-health).
To address the shortcomings in the existing research studies on healthcare, an important SDG, a
growing trend towards the adoption of digital transformation in healthcare, along with discussing their
integration, design, security and privacy challenges, explore the utilisation of Blockchain technology
and its characteristics and applications, we present a comprehensive and state-of-the-art survey that
focuses primarily on the integration of ICT technologies to the healthcare (SDG), discussing the
integration, design, security and privacy challenges, discuss the positive and negatives impact of ICT
and then Blockchain integration and then highlights open research questions and future directions.
The contributions of this research work can be summarized as follows:

• Present a detailed comparison of existing studies, mainly focusing on integrating ICT technologies
in healthcare, an important SDG, in terms of sustainable aspects, security and privacy challenges,
design and integration challenges, E-health related applications, and future directions.
• Present an overview of the need for digital transformation in healthcare, discuss its significant
components, highlight E-health’s importance and benefits, explore its integration and design
challenges and categorise the security and privacy challenges.
• Present in-depth discussion on the role of Blockchain technology in E-health, discussing
Blockchain technology and its characteristics, highlighting its benefits, and describing the possible
types of Blockchain-based E-health use cases.
• Discuss the positive and negative impact of ICT integration, including Blockchain technology,
into the health systems.
• Identify open issues and challenges of integrating ICT technologies into the healthcare systems
and discuss future research directions, which provide the strength for researchers to address the
issues in future solutions.

The organisation of the research work is as follows: Section 2 presents the methodology of our
research study. Section 3 provides a related work consisting of a detailed comparison of existing
studies on integrating ICT technologies to the SDG (healthcare). An overview of the need for digital
transformation in healthcare, including necessary components, E-health’s importance and benefits,
the integration and design challenges, and security and privacy challenges, are presented in section 4.
Section 5 Present an in-depth discussion on the role of Blockchain technology in E-health. In section 6,
the positive and negative impact of ICT integration, including Blockchain technology in E-health, is
discussed. Section 7 identifies the open issues and challenges of integrating ICT technologies into the
healthcare systems. The implications of our study are presented in section 8. Finally, we concluded the
research work in section 9.

2. Methodology of Our Study

Our study’s research methodology is based on an in-depth literature evaluation of peer-reviewed
papers on digital healthcare. Using carefully chosen keywords, relevant studies were found from more
accessible resources like Google Scholar. We used terms like sustainability, sustainable development
aim, healthcare, blockchain, information technology, security and privacy, design goal, Economic,
Social, and Environmental. We created the selection criterion, which solely considers studies from
journal articles and conference proceedings; book chapters and industrial correspondences are omitted.
We considered the latest investigations, focused on studies published since 2021, and took the following
six stages to produce a more thorough conclusion.

• Development of Study design based on the literature review on healthcare management studies.
• Selection of assessable sources such as Google Scholar to find digital healthcare studies with a
sustainability focus.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

4 of 39

• Creation of a search query and keyword pursuit for sustainability, SDG3, sustainable development
objective, healthcare, blockchain, information technology, security and privacy, design purpose,
and economic, social, and environmental considerations.
• Creation of appropriate data sets and data collection using MS Excel. The main headings
of the dataset comprised Problem Focused, Sustainability Aspects Focused, ICT Integration,
Technology, Security and Privacy Challenges, Design and Integration Challenges, E-Health
Related Applications, and Future Directions were created.
• Data evaluation is completed through Textual analysis of the developed records of various
studies.
• Assessment of the findings and conclusion is established.

After application of all the conditions of our article inclusion criterion among 22 studies found at
the first stage, only 13 studies fulfilled all the criteria and were therefore included in the analysis.

3. Existing Work
This section compares the related work that focuses explicitly on the role of digitalisation
in healthcare as an important SDG. We compare the existing work on the basis of the following
significant parameters: publisher and year, paper title, problem-focused, sustainability aspects focused,
ICT integration technology, security and privacy challenges, design and integration challenges,
E-health-related applications, and future directions. Table 1 shows a detailed comparison of existing
works.
Using a case study on empirical estimation, Abbas et al. [10] provided the results of a survey
that looked at digitalization in the context of SDG3-healthcare services. The research was conducted
to aid in the formulation of long-term decisions regarding policy and ethical principles in the Asian
healthcare industry by shedding light on how cybersecurity measures might improve service quality
and increase institutional excellence. However, the proposed research is limited in that it only
describes a small subset of the possible cybersecurity solutions that could have a major effect on
the digital transformation of healthcare. Furthermore, another study by Ullah et al. [11] integrated the
implications of the China-Pakistan Economic Corridor (CPEC) and looked into the use of digitalization
and e-governance to deal with the COVID-19 problems. In light of the recent COVID-19 epidemic,
this study set out to explore and analyse the United Nations’ E-Government Development Index
(EGDI) reports and rankings. Despite the importance of discussing the security and privacy concerns,
design integration challenges, and the consequences of real-time applications, the proposed work only
focused on studying the usage of digital technology in the healthcare sector.
In another study, the hybrid method provided by Espinosa et al. [12] combines a literature study
with an analysis of the effects of healthcare’s adoption of digitalization technologies like the IoT. The
study set out to answer a wide range of concerns about the influence of the IoT and similar technologies
on healthcare and their related issues on the public. The primary limitation of this research was that it
focused solely on healthcare IoT implications without addressing security, privacy, and design issues.
A recent systematic review by Carbonell et al. [13] examines how the advent of the 5G network will
affect how doctors and hospitals use data from various digital apps to enhance the care they deliver to
their patients. This research focuses on the following use cases: Telesurgery, mobile ultrasonography,
biosensor technology, robotic surgery, and the linked ambulance were recognised as the key medical
uses. However, discussion on sustainability, security, and design challenges is limited in the proposed
study.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

5 of 39

Table 1. Existing Studies on Integration of ICT to the SDG (Healthcare and Well-Being).

Ref Publisher Paper Title Problem Focused Sustainability ICT Security Design E-Health Related Future
and Year Aspects Integration and Privacy and Applications Directions
Focused Technology Challenges Integration
Challenges
[10] PLOS Impact of To assess the relationship Social and N/A N/A N/A N/A Proposed model
ONE 2022 cybersecurity between digitalization Economic can be applied to
measures on and security for other SDGs
improving healthcare
institutional
governance
and
digitalization
for sustainable
healthcare
[11] Springer The role of To investigate the role Social and N/A N/A N/A N/A Financial
2021 E-Governance of e-governance in Economic technology
in combating combating COVID-19 can provide
COVID-19 solutions to
and health crises such
promoting as the COVID-19
sustainable pandemic
development:
A
comparative
study of
China and
Pakistan
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

6 of 39

Table 1. Cont.

Ref Publisher Paper Title Problem Focused Sustainability ICT Security Design E-Health Related Future
and Year Aspects Integration and Privacy and Applications Directions
Focused Technology Challenges Integration
Challenges
[12] MDPI Application (a) Are IoT applications Environment IoT N/A N/A Intelligent Security for
2021 of IoT in key to the improvement Solutions management
Healthcare: of people’s health and (Vaccine and drug of intelligent
Keys to the environment? (b) Are manufacturing, systems IoT-based
Implementation there research and case logistics, framework for
of the SDGs studies implemented population SDGs
in cities or territories vaccination
that demonstrate the planning and
effectiveness of IoT management,
applications and their data management,
benefits to public health? and patient
(c) What sustainable monitoring at
development indicators home)
and objectives can
be assessed in the
applications and projects
analyzed
[13] MDPI 5G Analyse the impact of N/A 5G N /A N/A Telemedicine 5G-based
2023 Technology the 5G network on the technologies
in the Digital use of apps to improve to facilitate
Transformation healthcare monitoring and
of Healthcare, tracking for better
a Systematic healthcare
Review
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

7 of 39

Table 1. Cont.

Ref Publisher Paper Title Problem Focused Sustainability ICT Security Design E-Health Related Future
and Year Aspects Integration and Privacy and Applications Directions
Focused Technology Challenges Integration
Challenges
[14] MDPI Modeling To understand the Social and AI Privacy Governance, N/A various
2022 Conceptual significance of AI and its Economic Scalability perspectives
Framework implementation barriers on the design and
for in the healthcare systems development of
Implementing in developing countries the conceptual
Barriers of framework can be
AI in Public further expanded
Healthcare and empirically
for Improving developed from
Operational the viewpoint
Excellence: of sustainable
Experiences public healthcare
from systems
Developing
Countries
[15] MDPI State-of-the-Art To explore the AI and N/A AI and Big N/A N/A N/A Specialization in
2023 of AI and Big data technologies for data AI sub-domains
Big Data different emerging fields and BDA tools,
Analytics (Business, Engineering, AI and BDA
Reviews in Healthcare, Sustainable in selected
Five Different Operations, and management
Domains: A Hospitality Tourism) domains,
Bibliometric contributing to
Summary Smaller thematic
areas, Empirical
research base,
Legal and ethical
concerns
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

8 of 39

Table 1. Cont.

Ref Publisher Paper Title Problem Focused Sustainability ICT Security Design E-Health Related Future
and Year Aspects Integration and Privacy and Applications Directions
Focused Technology Challenges Integration
Challenges
[16] IBIMA The To describe the N/A AI N/A N/A Electronic Cards Barriers of ICT
2022 Sustainable theoretical issues of (Insurance, implementation
e-Health sustainable development Verification, in the healthcare
System in e-health, and to show Prescription, system.
Development practical issues of ICT Medical Events,
in COVID-19 Drug monitoring,
Pandemic network patient
- The information)
Theoretical
Studies of
Knowledge
Management
Systems and
Practical
Polish
Healthcare
Experience
[17] MDPI Digital To examine the effects of N/A IoT Security N/A Telemedicine N/A
2023 Transformation digital transformation on
in Healthcare: the healthcare industry
Technology
Acceptance
and Its
Applications
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

9 of 39

Table 1. Cont.

Ref Publisher Paper Title Problem Focused Sustainability ICT Security Design E-Health Related Future
and Year Aspects Integration and Privacy and Applications Directions
Focused Technology Challenges Integration
Challenges
[18] De Digital Study examines the Environmental N/A N/A N/A Telemedicine and N/A
Gruyter Transformation existing data about Teleworking
2023 and the influence of digital
Sustainability technology on healthcare
in Healthcare and clinical labs
and Clinical
Laboratories
[19] Plos Healthcare The present state of N/A N/A N/A N/A N/A N/A
Digital inequity disparity and inequity to
Health and digital assess the ramifications
2023 health–A of digital health
bridge for
the divide,
or further
erosion of the
chasm?
[20] MDPI Legacy of How are technologies N/A N/A Security Minimalistic N/A N/A
2023 COVID-19 that were originally Design,
Innovations: created for the purpose Cross
Strengthening of addressing the Functional
African COVID-19 pandemic Innovations,
Primary being employed to Modular
Health Care enhance the capacity and Designs,
through effectiveness of Primary Offgrid
Pandemic Health Care? Capabilities,
Innovations Interoperability
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

10 of 39

Table 1. Cont.

Ref Publisher Paper Title Problem Focused Sustainability ICT Security Design E-Health Related Future
and Year Aspects Integration and Privacy and Applications Directions
Focused Technology Challenges Integration
Challenges
[21] MDPI Toward a Evaluate the long-term Social, N/A N/A N/A N/A N/A
2023 Comprehensive viability and ecological Economics
Understanding impact of recently
and suggested or currently
Evaluation implemented electronic
of the health (e-health)
Sustainability solutions
of E-Health
Solutions
[22] Frontiers ICT The use of ICT N/A Big Data Privacy N/A N/A The present
2023 applications technologies and Users and Data discourse
and the personal data Accessibility concerns matters
COVID-19 pertaining to
pandemic: digital privacy,
Impacts on the data-driven
individual’s methodologies,
digital data, and legislation
digital privacy, governing the
and data protection of data.
protection
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

11 of 39

To establish SDG (healthcare) for developing countries, Joshi et al. [14] presented a survey study
intending to integrate digitalization technology like AI to comprehend its relevance and its uses for
healthcare and medicine. This research sheds insight into the social, economic, and institutional
obstacles to implementing AI in public healthcare. The study’s limitations include its narrow focus
on privacy concerns as a security criterion and a few other important design considerations like
governance and scalability. In addition to the above research, Thayyib et al. [15] investigate how
various developing fields—including business, engineering, healthcare, sustainable operations, and
hospitality tourism—can benefit from digitalization technologies like AI and big data. The study’s
primary objective was to use bibliometric reviews to investigate the effects of AI and big data on these
five areas and to inform managers of the most recent practical applications of these digitalization
trends. However, this study merely covered the basics of how these digital technologies integrate
with the aforementioned five growing industries; it did not delve into privacy and security issues, nor
did it address the difficulties of integrating these technologies into existing designs or focusing on
sustainability.
Piorunkiewicz and Morawiec [16] have published a study detailing the significance of AI in
long-term e-health systems from a theoretical perspective in light of the practical Polish healthcare
experience. However, this research was limited in that it did not specifically address security and
privacy concerns, as well as design and integration challenges; instead, it merely described the
conceptual problems of sustainable growth in e-health and made some suggestions about the role of
ICT as a knowledge management factor in the healthcare system.
In their research study, [17] conducted an investigation to assess the impact of digital
transformation on the healthcare sector. In order to do this study, a comprehensive bibliographic
review is conducted by collating a multitude of papers. Nevertheless, this study has several limitations
with regard to the examination of sustainability viewpoints, integration technologies of information
and communication technology (ICT), and future implications. In another research, Marques and
Ozben [18] conducted a comprehensive analysis that explores the available data on the impact of digital
technology on healthcare and clinical laboratories. Their study emphasises the necessity of digital
transformation in these domains, highlighting its potential to minimize inefficiencies and costs by
improving effectiveness without compromising quality. Moreover, this study examines the significance
of environmental sustainability as a crucial component. However, it fails to take into account the
aspects of security, design, challenges, and future directions.
Hadjiat [19] conducted a research to evaluate the implications of digital health on disparities
and inequities in healthcare. Nevertheless, the scope of this study was restricted as it just focused
on the fundamental aspects of the issue, neglecting to go into the intricacies of design, integration,
security concerns, as well as the applications and potential future developments. In a subsequent study,
Ngongoni et al. [20] conducted a study with the objective of elucidating the intricacies surrounding the
enhancement of scaling and the augmentation of sustainability of innovations within the African area.
The primary purpose of this research is to fortify health systems and foster innovation. This research
encompassed several design problems, including minimalistic design, cross-functional innovations,
modular designs, off-grid capabilities, and interoperability.
Alajlan and Baslyman [21] conducted a study with the objective of assessing the long-term
sustainability and ecological implications of electronic health (e-health) solutions that have been
proposed or are now being implemented. The aforementioned study highlights a lack of empirically
grounded and comprehensive sustainability models and evaluation tools that can effectively inform
and guide practices in real-world scenarios. Nevertheless, this research solely concentrates on
sustainability’s social and environmental aspects, neglecting other crucial elements such as design,
integration, security issues, and future views. In an additional study, [22] conducted a scholarly inquiry
that initially presents the utilisation of Information and Communication Technology (ICT) applications
in response to the COVID-19 pandemic. Subsequently, the study offers a comprehensive review and
subsequent analysis of the current state of ICT applications. This research primarily examined the uses
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

12 of 39

of Big Data, with a specific focus on privacy and data accessibility considerations and potential future
ramifications.
As a result, in order to address the shortcomings of existing survey studies in terms of various
aspects such as detailed ICT integration technology along with its components, security and privacy
challenges, design and integration challenges, and sustainability aspects focused, we present a
comprehensive and state-of-the-art research survey that primarily focused on sustainability aspects,
security and privacy challenges, design and integration challenges, and various potential applications.

4. Digital Transformation in Healthcare

The term "digital transformation" is commonly used to describe the process by which an
organisation adopts and integrates new information and developing technologies in order to improve
its operations and the quality of its products and services to customers [23]. Indeed, the use of
cutting-edge digital technologies in healthcare systems represents a dramatic shift in how the health
industry and its many sectors (including medicine, insurance, the supply chain, etc.) think about and
approach the many pressing problems related to medical care and health [24]. In addition, there is a
rising focus on global health problems that might be at the core of the work done by the United Nations
system on each of the three aspects of sustainable development: economic, social, and environmental
across many countries’ borders [25].
According to the World Health Organization (WHO), E-health is defined as the use of information
and communication technology (ICT) in the medical domain for the advancement of medicine and
diagnosis of patients’ diseases [26]. The extensive use of ICT for healthcare and health-related reasons
in various situations, both within and outside healthcare settings, is an example of the digital health
model. New market possibilities and healthcare business models are being created as a result
of the technological advancements in healthcare, which are improving the delivery of healthcare
obstacles by addressing concerns like medical treatment practice, economic development, and a
spectrum of challenges associated with the elderly community [27]. As a complete system/model,
healthcare consists of (a) primary service providers, including healthcare professionals, nurses, hospital
management, and support staff, and (b) supporting services like diagnostic labs and health insurance.
Examples of digital healthcare models include e-Health, m-Health, and telemedicine [28].
Due to the ever-increasing number of available devices, information and communications
technology (ICT) can be essential in treating and preventing health problems. The proliferation
of these digital gadgets among healthcare workers and professionals in hospitals and clinics is mainly
attributable to recent technological advances such as robotics and the (IoT) [29]. For instance, fitness
trackers and wearables now have the potential to play an essential part in monitoring patient health
remotely [30]. Furthermore, the remote care of many different types of patients has been revolutionised
and made much easier thanks to the introduction of electronic health records (EHR). As a result, an
ever-expanding digital data bank is linked to healthcare treatment and patient records [31].
To conclude, the healthcare system as a whole could stand to gain from the use of ICTs. No matter
how close or far a patient may be from a hospital or clinic, they can still contact medical professionals
[32]. In the medical field, this means diagnosing patients remotely, accessing expert advice during a
crisis, learning about and preparing for disease epidemics, and so on. Big Data analytics can all aid
snapshots, trend analyses, and forecasts regarding disease outbreaks, health service utilisation, and
patient knowledge, attitudes, and practises [33].

4.1. ICT-Based Healthcare System Components

To better grasp the significance of ICT requirements in healthcare, we present a comprehensive
overview of the various components of healthcare systems in this section. For example, a healthcare
system often consists of one or more medical devices, each outfitted with multiple sensors to collect
patients’ essential information and make independent judgments regarding how best to treat patients.
In general, six core elements are required for a healthcare system to carry out its essential functions,
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

13 of 39

including the patient, healthcare provider, medical device, sensor, network and data processing facility
[34]. The various healthcare components described above are depicted in Figure 1, which serves as an
example of healthcare architecture.

Figure 1. Healthcare Architecture, as an Example.

4.1.1. Patient
Patients in e-health systems access healthcare services (or consult with healthcare professionals)
via digital methods (such as telehealth, electronic consultations, or e-health platforms). Anybody
needing medical care is considered a patient, whether they have an ongoing condition, an acute illness,
or are just looking to stay healthy [35].

4.1.2. Healthcare Provider

The component includes health service providers (i.e., hospitals and organisations), medical
doctors, and nurses. They can communicate using a wired and wireless transmission module with the
data processing element. In the cloud-based scenario, the health server specifically stores sensitive
medical and patient information. Doctors and nurses can use this information when they treat a patient
in a person [36].

4.1.3. Medical Device

A medical device is any tool, instrument, appliance, or gadget used for medical reasons like
diagnosis, monitoring, treatment, or relief. Medical devices can range from throat syringe needles
to complex programmable ICDs, as stated by the U.S. Food and Drug Administration (FDA). The
European Union also has different classification requirements for medical devices depending on
whether they are non-invasive, invasive, or have active therapeutic qualities [37].

4.1.4. Sensor
In medicine, sensors are used to track and measure a patient’s physiological parameters. Several
physiological sensors, such as a sensor for blood sugar and a sensor for heart rate, are utilised as a
trigger to automate many tasks of healthcare systems, such as diagnosis and monitoring, amongst
others. Typically, sensors are divided into physiological, biological, and environmental categories [38].
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

14 of 39

4.1.5. Network/E-Health Architecture

In E-health architecture, different networking components are concerned with how different
medical devices and sensors communicate with each other and other members of a healthcare system.
In an E-health network scenario, the primary purpose of data transmission is to transport signals from
sensors or devices to the central node and then send aggregated measures from the central node to a
health server or healthcare practitioner [39].

4.1.6. Data Processing

E-health systems rely heavily on data processing, which includes gathering, organising, and
analysing patient information to provide better care. Data processing in electronic health care entails
using different tools and technologies, such as IoT and AI, to record and later access information about
a patient’s health and treatment [40].

4.2. E-Health Importance and Benefits

ICT integration with health systems presents significant benefits to health providers and patients
in the following areas:

4.2.1. Enhancing Public Health and Medical Facilities

Improvements in hospital operations, electronic health records (EHR), and health information are
just a few examples of how this integration might help the public and private sectors of healthcare. In
addition, quick information and data sharing among healthcare providers and experts can increase
patients’ access to high-quality care [41].

4.2.2. Aiding Medical Professionals

One of the most promising applications of this integration is the enhancement of surgical
procedures/operations or guidance, including remote telesurgery. Digital health technology allows
various outlying medical facilities to offer telemedicine and remote diagnosis to their patients.
Hospitals in China, for instance, have used 5G to conduct remote surgery, such as liver procedures and
deep brain stimulation implants for Parkinson’s illness [42].

4.2.3. Real-time Monitoring and Management

Personal health and dedicated devices, such as sensors, monitors, wristwatches, and mobiles, are
widely deployed and utilised for monitoring and feedback purposes, providing an additional benefit
to integrating ICT with the existing healthcare systems. For example, remote ultrasound imaging for
kidney stones and fertilisation, as well as swab testing, have all been accomplished with the help of
mobile phones. It has been predicted that by 2025, there will be half a million different mobile health
monitoring and feedback applications available [43].

4.2.4. Improved and Accurate Analysis

Health data may now be analysed and predicted with more precision because of cutting-edge ICT
technologies and ideas, such as AI, big data, and virtual reality (VR) simulations. In addition, imaging,
diagnostics, and data analytics are all made possible by computing at the edge, which collects data
from devices and sensors [44].

4.3. E-Health Challenges

Incorporating information and communication technologies (ICT) into health systems can bring
about various beneficial effects, including improved access to health services, significant enhancement
in communication and coordination among those who provide medical care, and enhancement of
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

15 of 39

patient outcomes and treatment methods. However, several obstacles need to be overcome to integrate
ICT into health systems, including the following:
We divide the challenges into two broader categories: integration and design, and security and
privacy.

4.3.1. Integration and Design Challenges

Multiple design challenges have been explored to explain the sluggish ICT adoption and
integration rate in the healthcare industry, including ordinary users (such as patients and doctors)
and stakeholders (government and private firms). Furthermore, health-related information (EHR) is
emerged as a result of the complexities of system design, data formats, controlling accessing authorities,
policies and regulation of healthcare artifacts, and the interoperability challenges of various systems
and their used health information technologies, which can raise further issues related to system speed,
performance, efficiency, technology adoption, and increases costs.
We divided all these issues into integration and design issues. The integration issues cover the
integration challenges of ICT to existing healthcare systems [45]. Finally, the design issues enforce
the implementation and design of the health scenarios by combining different tools and technologies.
Figure 2 illustrates ICT technologies’ integration and design challenges to the existing healthcare
systems.

• Centralised Architectures: A number of issues, some of which are directly related to the
quality of treatment offered to patients, are seen as fundamental design issues in the current
healthcare systems, which are based on centralised architectures [46]. For instance, because
healthcare systems span many organisations all over the world and are expanding at a larger
scale, centralised architecture may be less scalable and less efficient. It may also lead to more
error-prone and longer wait times, which can be the reasons for deaths in severe cases [47]. In
addition, the single point of failure problem is magnified in a centralised architecture, which
means the entire healthcare system might go down and severely impede patient care [48].
• Unsecured networks: When healthcare practitioners transmit or maintain patient information
using unprotected Wi-Fi or public networks, they run the risk of making the information accessible
to third parties who are not authorised to access it [49].
• Non-trusted Storage Options: There are serious threats to patient privacy and data security
posed by using non-trusted storage solutions in healthcare systems [50]. For example, physicians
and other healthcare practitioners can keep patients’ data on their local servers without
enforcing any security system or on their own devices like smartphones, tablets, and computers.
Nevertheless, in either event, it is possible that the gadgets cannot be as secure as the rest of the
healthcare system’s infrastructure. On the other hand, there is a larger-scale risk of data breaches,
unauthorised access, and data loss when using untrusted public clouds for storage purposes [51].
• Data Collection: Data collection is a prerequisite for every healthcare setup to maintain quality,
achieve efficiency, or have a positive outcome improvement process. Various healthcare entities
acquire data from various sources, which typically flows in a disjointed or non-standardized
fashion across these entities. Therefore, healthcare organizations may encounter numerous
challenges when gathering information about patients’ race, ethnicity, and language, requiring
careful collection, preparation, and management [52].
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

16 of 39

Figure 2. Integration and Design Challenges of ICT Technologies to the Healthcare Systems.

• Non-Availability of Infrastructure and Resources: A lack of suitable ICT infrastructure, such

as internet access, hardware, and software, might hamper adopting and using ICT solutions
in health systems. For instance, many governments might not have the means to invest in ICT
technology and infrastructure, making integrating ICT into health systems challenging [53].
• Interoperability: Sharing, storing, and exchanging data across different health systems can
be difficult due to the widespread use of multiple ICT solutions and platforms supported
by heterogeneous and dispersed network architectures. Thus, interoperability protocols and
specifications are required to guarantee appropriate collaboration and interaction across various
ICT technologies [54].
• Data Management and Integration: The capacity to combine and manage diverse types of data
collected from many sources is a recurring IT challenge to the healthcare industry, primarily
as clinics and hospitals digital their work operations. Notes or transcripts from patient visits,
information about insurance, treatment plans, laboratory results, referrals, medical history, and
vital data from remote monitoring gadgets, such as wearables, are some of the various types of
data collected in e-health. Other types of data collected in e-health include health history and
referrals [55]. Since patients frequently see a variety of experts at facilities that are partnered with
one another, each category of data in a patient’s file may originate from a different source. To
compile all pertinent medical information about a patient in one location, healthcare providers
require electronic health records (EHR) software designed to collect, integrate, and manage
patients’ data efficiently. This results in improved diagnostic procedures, treatment approaches,
and patient outcomes [56].
• Data Access: Data accessibility promotes access to the patient healthcare record and prompt
reaction in an emergency, both crucial in sustaining the high standards of healthcare services. In
addition, it benefits patients since doctors may quickly access their complete medical histories, lab
findings, and related notes from other practitioners [57]. The capacity to quickly retrieve relevant
information from a patient’s record can significantly enhance clinical efficiency by minimising the
number of times a doctor has to switch between programs to finish a consultation and diagnose
a patient. However, the exponential growth of data in the field of E-healthcare highlights the
pressing necessity for enhanced data accessibility practices and information and communication
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

17 of 39

technology (ICT) models. Despite the numerous advantages of this expansion, ensuring the
availability of high-quality care data remains a significant challenge [58].
• Cost: Building health systems based on ICT infrastructure and technologies may be impossible
in low-income or other areas with few funds. For example, there can be a sizable financial
burden associated with the purchase, implementation, and support of ICT infrastructure to form
a complete healthcare system and the expenditure of training healthcare staff to use the new
technologies used to train before the manual methods [59].
• Compliance: The regulatory landscape is continuously shifting, as evidenced by the standards
for billing, the maintenance of equipment, and software updates, to name just a few instances.
Even though compliance controls are in place to protect patients and the data they provide, it still
creates a legal minefield that chief information officers in the healthcare industry need to avoid
[60]. Solution providers like Ta and Cervey help healthcare organisations and medical practices
remotely. For instance, Arena provides a specialised quality management system to the medical
device manufacturing industry. This system assists medical device manufacturers in ensuring
that their equipment complies with specific regulations such as ISO 3485 [61].
• Reluctant to Adoption New Technology: Many healthcare workers may be reluctant to accept
new technology because of the potential disruption to their practices that ICT integration into
health systems may cause. For example, the adoption and use of ICT in health systems may
be hampered because health workers may lack the technical experience and skills necessary to
utilise and maintain ICT solutions efficiently [62].

Converting these challenges requires a concerted effort from government officials, stakeholders,
health professionals, technology vendors, and legislators. This will allow for successfully incorporating
ICT into health systems and realising these technologies’ potential benefits.

4.3.2. Security and Privacy Challenges

A massive amount of sensitive health information related to patients is accessed and
communicated over the Internet daily, making security and privacy the top priority for the healthcare
industry. Furthermore, as most e-health data is transferred and shared utilising open communication
channels, there is a chance that the data could be subject to network attacks. Therefore, we divided the
section into two sub-sections: security and privacy issues. Figure 3 illustrates the categorisation of
security and privacy challenges of integration of ICT technologies to the existing healthcare systems.

• Security Challenges
Security in E-health is defined as the access to sensitive patient information strictly regulated using
security rules and processes to prevent misuse of sensitive patient information. In many countries,
patients’ individual health records (PHI) are recorded, communicated, and kept electronically for
later use.

⋆ Physical Access to Resources: One of the most critical security challenges in healthcare
systems is ensuring the safety of the resources used to implement the healthcare
infrastructure. This is especially true in situations where patient data is stored or accessible.
To prevent theft or unauthorised access to patient information, healthcare organisations
must ensure that physical access controls are in place and functioning properly [63].
⋆ Third-Party Untrusted Manufacturers/Devices: While the increasing use of IoT devices
within healthcare systems promises to bring about much-needed beneficial change, this
development also raises new security concerns. As a result of its potential to facilitate data
operations and enhance the treatment process, IoT has been adopted by many organisations
working in the health sector [64]. Nevertheless, due to the fact that most IoT devices are
designed and manufactured by unreliable vendors, they frequently lack security patches
and suitable built-in security protections, which in turn creates security concerns for entire
healthcare systems [65].
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

18 of 39

⋆ Cyber Attacks: Cyber-attacks, such as ransomware, phishing, spoofing, and malware

attacks, are increasingly targeting the healthcare industry [66]. In addition to disrupting
healthcare operations, these cyberattacks might result in the theft or disclosure of private
patient data. For example, the healthcare industry is becoming vulnerable to ransomware
attacks, in which hackers encrypt sensitive patient information and demand a ransom in
exchange for decrypting it [67].
⋆ Insider Threats: When it comes to data security threats, many businesses neglect the
possibility of insider threats because they focus instead on external attacks, despite the fact
that insider threats are typically related to overlooked basic design or security vulnerabilities
[68]. The healthcare industry has recently seen an upsurge in insider threats, which are just
as dangerous as those from the outside. In most cases involving E-health, insider threats
might come from within the organisation itself, whether they be former or current staff,
suppliers, company associates, healthcare officers, doctors, or incompetent staff [69].

Figure 3. Security and Privacy Challenges of Integrating ICT Technologies to the Healthcare Systems.

• Privacy Challenges
When discussing health information, "privacy" refers to preventing unwanted access to an
individual’s medical records and keeping those records private [70]. It is possible to achieve this
goal by strictly enforcing the relevant policies and laws. Patients have the right to know who has
access to their medical records, how those records are being used, whether or not they will be
shared with a third party and the circumstances under which such information may be shared.
For instance, the Health Insurance Portability and Accountability Act (HIPAA) protects patients’
health information confidentiality [71].
In E-health scenarios, the following are the privacy issues /challenges that patients and healthcare
service providers (such as doctors) might face.

⋆ Device Privacy: In the E-health patient scenario, device privacy is a major concern due to
the enforcement of the device anonymity principle, which states that the patient has the
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

19 of 39

right to know who is authorised to configure and install the device, what kind of medical
device the patient is equipping, and who is interacting with and responsible for managing
the devices [72].
⋆ Data Privacy: Personal and medical information are two highly sensitive data that must be
safeguarded to ensure data privacy. Data privacy in healthcare systems refers to protecting
individual patients’ health information against misuse [73].

5. The Role of Blockchain in E-Health

This section begins with an overview of the basics and principles of Blockchain technology,
followed by a discussion of its salient characteristics. Then, we examine the role of Blockchain
technology in E-health and highlight its benefits. Finally, we will discuss the potential types of
Blockchain applications and use cases.

5.1. Blockchain Technology

Blockchain is made up of two different but related paradigms: the decentralised network and
Distributed Ledger Technology (DLT), which links the network nodes in a peer-to-peer (P2P) fashion
so that users can communicate with one another directly without the need for a trusted third party.
In blockchain technology, the decentralised network eliminates the need for a centralised network
(also known as a trusted third party) as part of the design process for a decentralised setting without a
central authority [74]. The distributed ledger stores records of transactions in a block-based format
that is shareable, immutable, and append-only. Each block is connected to the block that came before it
by a cryptographic hash that is contained in the block header, creating the complete chain structure
known as a Blockchain. Each block structure stores numerous pieces of information connected to a
particular occurrence, including the timestamp, nonce, and transaction-related data. The specifics of
this information are as follows: (i) a timestamp provides information about the time each block was
created; (ii) a nonce is a one-time generated, unique random number for each individual; and (iii) a
transaction contains the data or information to be sent to other nodes, which is then stored in the ledger
following an approval procedure. In addition to the nonce, Blockchain technology also makes use of
other cryptographic primitives, including hashes, encryption mechanisms, digital signatures, etc., to
establish a baseline of confidence before transmitting transactions between network nodes [75,76].
Two types of Blockchain network nodes create and validate blocks. A basic node creates account
wallets and network transactions. The others are full nodes (miner nodes) that verify and add
transactions to the Blockchain. Blockchain technology relies on a consensus protocol, which eliminates
the need for a trusted third party’s services to manage the interactions between nodes and regulates
their behaviour to maintain a trustworthy relationship and guarantee the integrity of transactions [77].
Miner nodes essentially manage the consensus protocol, and this process is known as mining on the
Blockchain network. It involves verifying transactions and adding those transactions in the form of
Blocks utilising some computational puzzles or challenges. Furthermore, each consensus method is
linked to miners’ incentives for their time and effort [78].
Several different consensus mechanisms have been proposed, each of which is dependent on
the uses of the blockchain [79]. Nonetheless, PoW (Proof of Work) [80], PoS (Proof of Stake) [81],
PBFT (Practical Byzantine Fault Tolerance) [82], and DPoS (Delegated Proof of Stake) [83] are the most
often employed consensus methods in existing Blockchain applications. The Bitcoin cryptocurrency,
the most well-known application of Blockchain technology, is a good example of an application that
typically implements the PoW consensus. Second, the Ethereum platform utilised the PoS to mine
Ether blocks and reward network nodes with Ether for their participation [84].

5.2. Characteristics
The entire Blockchain technology, from the design perspective to the security capabilities
and working scenarios, is divided into the following set of characteristics [45]: decentralisation,
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

20 of 39

immutability (or tamper proof), security and privacy, consensus mechanism, anonymity, open source,
smart contracts, and transparency. These characteristics further help the users achieve the set of design
requirements and security goals for designing efficient and secure applications. Figure 4 illustrates the
characteristics of Blockchain technology, which are shown in detail as below.

• Decentralisation: In a decentralised network, rather than having a central authority controlling

everything, a group of nodes organises themselves in a P2P fashion and takes on responsibility
for maintaining the network’s general structure [79].
• Immutability: Immutability (or tamper-proof) in the context of Blockchain technology refers
to the fact that once a significant number of miner nodes have confirmed a block of data, the
block and its associated data are irrevocably secured. Therefore, the immutability characteristic
of Blockchain data provides assurances of data integrity and authenticity and can be used to trace
its history [85].

Figure 4. Blockchain Characteristics.

• Security and Privacy: Utilising cutting-edge cryptographic techniques, blockchain technology

ensures the security and immutability of all transactions created and stored in its distributed
ledger. Using consensus protocols, for instance, Blockchain transactions are recorded in the
distributed ledger after being generated by the encryption and digital signature mechanism.
Encrypting and hashing each block in the chain with the hashing methods creates a verifiable
chain [86].
• Consensus Mechanism: The consensus mechanism is a fundamental characteristic of Blockchain
technology that ensures that only valid transactions and blocks are added to the distributed ledger,
which requires the agreement of all network nodes. The consensus method is an agreement or
set of rules that are given as a challenging problem or puzzle that all network participants must
solve and agree upon [84].
• Anonymity: Blockchain’s anonymity feature could be transformative in terms of user and data
privacy and security. Implementing anonymity in Blockchain is a promising new step towards
preserving users’ privacy and fostering trust in the veracity of data and transactions, especially in
high-stakes situations involving the exchange of financial or personally identifying information
[87].
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

21 of 39

• Open Source: Using some of the available coding attributes incorporated into Blockchain
technology, this open-source feature enables developers to create decentralised and secure
applications to establish trust between network nodes and their data. This characteristic also
gives you the freedom to create efficient and automated applications for a wide range of social
and business use cases [88].
• Smart Contracts: Smart contracts are an intriguing use case for Blockchain technology since
they are self-managing and self-executing pieces of code that execute on the Blockchain. Smart
contracts automate the process of obtaining an agreement between a sender and a recipient
on a set of established conditions by using predefined rules. Smart contracts are a facilitator,
confirming and implementing contract rules to facilitate contract negotiations and achieve
autonomy. Furthermore, smart contracts are used to ensure that all parties in the Blockchain are
held accountable for their activities, as their conditions are public and can be viewed by any node
in the network [89].
• Transparency: Transparency is yet another essential characteristic of Blockchain technology, as it
enables anyone with network access to keep track of and validate transactions in the distributed
ledger. In a public blockchain, for instance, users can record and manage transactions in a public
ledger that is accessible to everyone on the network [90].
• Traceability: For audit purposes, the blockchain’s traceability feature and the usage of security
guidelines ensure that transactions can’t be altered after they’ve been added to the ledger. As a
result, it is possible to trace the history of any transaction in detail [91].

5.3. Blockchain Benefits in E-Health

Figure 5 illustrates the Blockchain Benefits in E-Health.

• Decentralise Architecture: These days, a decentralised management system is necessary for

processing, managing, and storing health data due to the nature of E-healthcare systems
worldwide. In such scenarios, participants worldwide, including doctors, patients, hospitals,
healthcare stakeholders, drug distributors, and so on, seek remote access to the system to carry
out the abovementioned tasks [92]. To make this a reality, Blockchain has the potential to serve
as the decentralised health data management infrastructure from which all stakeholders can
enjoy secure access to identical medical records without anyone acting as the global health data
authority [93].
• Tamper-proof Record: Since the data in a distributed ledger are encrypted, hashed, time-stamped,
and appended in chronological order in the form of a chain, the immutability attribute of the
distributed ledger used in blockchain considerably improves the security of the health data
recorded on it [94]. Once data has been recorded to blockchain technology, it cannot be tampered
with, edited, or recovered by any other means. In addition, patient health records are encrypted
before being saved on blockchain technology using cryptographic keys, which helps protect
patients’ identities as well as their privacy [95].
• Data Availability: Patient information in traditional healthcare systems is regularly shared
between several providers without any security measure, increasing the risk of data leakage and
unauthorised access. Due to the distributed nature and immutable feature of the blockchain,
records are duplicated across numerous nodes, making the system highly resistant to data loss,
illicit activities, and an array of security attacks that target data availability [96].
• Data Control and Ownership: Considering patient data in E-health systems contain sensitive
and essential information, patients must retain ownership of their data and have insight into how
the healthcare system utilises it [97]. In addition, it makes it clear that patients have a right to the
certainty that the information about their health that other parties hold will not be mishandled.
Blockchain technology fulfils these needs through its secure cryptographic techniques and the
practical application of its smart contracts functionality [98]. By using such available features
of Blockchain, Patients can decide who has access to their medical records and can grant or
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

22 of 39

revoke access as needed. Furthermore, blockchain’s built-in privacy mechanisms allow patients
to control who is entitled to their health information and cease access at any time [99].
• Verifiable Record: One of the advantages of using blockchain technology in electronic health care
is that it makes it possible to verify the accuracy of medical records about patients and healthcare
providers without actually accessing the records stored on the blockchain. For instance, the
supply chain management process of medications and the processing of insurance claims both
use this capability to provide the verifiability of records recorded on a temper-proof ledger in the
event that a discrepancy occurs. Therefore, This is a crucial requirement to ensure data integrity
[100].
• Transparency: In terms of E-health transparency, Blockchain technology makes use of a
decentralised ledger to record all of the transactions and patient data using a consensus process
[101]. This feature introduces and assures an additional level of difficulty for anyone working
in the healthcare system to change or manipulate the data in any way. In addition to this,
transparency means that all parties involved, such as patients, medical professionals, healthcare
facilities, and insurance companies, have access to identical information and can validate the
credibility of the data [102].

Figure 5. Blockchain Benefits in E-Health.

5.4. Blockchain-based E-health Use Cases/Applications

Although blockchain technology has traditionally been applied to the financial and cryptocurrency
sectors, its usefulness is rapidly expanding into other areas, such as the healthcare industry. Through
its mechanism of providing decentrlised access control, secure and tamper proof data, autonomous and
tracking, blockchain technology demonstrates its potential in the medical fields, including E-health,
tele-health, medicine, genomics, neuroscience, and personalised healthcare applications. In this
section, we discussed the potential types of Blockchain-based E-health use cases whose operations and
procedures notably benefited from the Blockchain’s characteristics.

5.4.1. Management of Electronic Health Record (EHR)

One of the most important applications that can be accomplished by integrating Blockchain
technology into healthcare systems is the management of electronic health records (EHR). This involves
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

23 of 39

creating, storing, and managing patients’ personal, medical, or health-related data by utilising the
distributed and immutable storage feature of Blockchain [92]. In addition, features such as data
provenance, consensus mechanisms, smart contracts, and improved security and privacy protocols
are being argued as the foundation of reliable and robust patient EHR storage and management. For
example, one such Blockchain-based healthcare application is HealthChain [103], which was built
as a permissioned, private blockchain network using IBM Blockchain’s Hyperledger Fabric [104]
and then deployed on Bluemix. In this application, Blockchain is implemented to safely store and
manage patient health records, giving people greater control over their personal information. Another
blockchain-based medical record management application is Ancile [105]. It is designed to achieve
access control, data security, privacy, and interoperability of electronic medical records by utilising
the smart contracts feature, which is run on the Ethereum blockchain platform. Data access control,
monitoring and verifiability of data, and establishing transparency are only a few of the obstacles that
medical data sharing encounters throughout the deployment of EHR. MeDShare, developed by Xia et
al. [65], is a blockchain-based platform for the secure sharing of medical records across organisations
with which one cannot establish a reliable level of confidence. In addition, it is now very important for
healthcare systems to have accurate patient records to provide timely and effective care. To overcome
the aforementioned obstacles, Dubovitskaya et al. [106] proposed a blockchain-based framework that
makes use of permissioned blockchain technology to keep track of cancer patients’ electronic medical
records, share them safely, and guarantee access to, management of, and storage of encoded patient
data.

5.4.2. Medical Bill/Insurance Claims

As the insurance sector moves from manual to digital methods, fraud increases owing to a lack
of integrity processes and legal comprehension among significant individuals. In a recent report,
according to statistics from the International Association of Insurance Supervisors (IAIS), about a
quarter of all insurance claims have been investigated for possible fraud every year since 2010 [107]. In
the realm of medicine or health insurance, the essential key stakeholders, such as insurance companies,
medical institutions, and patients, face a variety of concerns associated with the design mechanism,
the provision of services, and security issues when engaging and communicating with one another.
With the use of Blockchain technology in ICT, particularly in the digitalisation of medical bills and the
insurance claims process, tremendous benefits have been observed due to blockchain characteristics
such as decentralisation, immutability, transparency, and traceability. For instance, immutability is
used to construct data storage systems to prevent data modification. Moreover, Blockchain’s advanced
security and privacy mechanisms are utilised to design blockchain-based transaction systems that
protect multiple parties’ privacy. In addition, the smart contract functionality of Blockchain technology
paves the way for the implementation of an efficient and automatic medical insurance claim system for
signing contracts, administration of databases, and handling payments. Since the information needed
to settle claims, such as policy details and premiums, can be pre-programmed into the Blockchain.

5.4.3. Remotely Analysing/Monitoring Patients

The rise of digitalisation in the E-health sector has made it possible to analyse data remotely and
monitor a patient’s health. The term "remote patient monitoring" refers to the practice of acquiring
patient data through various IoT devices (body sensors) or wearables connected to the patient. With
the integration of Blockchain technology into E-health, both patients and healthcare service providers
stand to benefit from RPM in several important ways. For example, from the patient’s point of
view, it may provide more freedom, such as enabling them to get treatment remotely while sitting
anywhere in the globe using the decentralised environment. Furthermore, Blockchain’s transparent
and auditability feature can promote better disease management and easily track medicine and history
by offering real-time assistance and input. To implement this idea, Griggs et al. [108] built a remote
patient monitoring system on the Ethereum Blockchain, prioritising secure data communication over
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

24 of 39

distributed platforms and facilitating automatic, real-time patient-doctor interaction. To secure the
data and preserve the privacy of patients, Ashraf et al. [109] implemented a Blockchain-based system
that enabled a patient-centric agent (PCA) to preserve end-to-end privacy and security of data in an
irreversible remote patient monitoring setup. In contrast, Ji et al. [110] put forwards an approach
known as BMPLS (Blockchain-based Multi-level Privacy-preserving Location Sharing) to facilitate
privacy-preserving geographic location sharing.

5.4.4. Health Data Analysis

The term "health data analytics" refers to gathering, analysing, and interpreting data from various
sources, such as electronic health records (EHRs), smartwatches, and health applications, within the
healthcare industry. Health data analytics aims to extract and analyse health trends from massive
amounts of healthcare data, which uses data analysis tools and techniques, including machine learning
and deep learning [111]. This data can be utilised to improve patient health and outcomes, reduce
expenses, and optimise resource utilisation [112]. Additionally, it can be used to realise further
predictive analytics of healthcare data and progress research in medicine and associated sectors. As a
result, the healthcare sector can be advanced and its operations optimised through the combination
of health data analytics and Blockchain technology. By merging Blockchain technology with health
data analytics, sensitive patient information may be maintained on a distributed, immutable ledger
impervious to manipulation [113]. In addition, it may be transferred safely and efficiently across
various healthcare providers and systems, enhancing interoperability.

5.4.5. Clinical Trials/Data

The past two years’ global pandemic has profoundly affected the clinical trial industry, prompting
trial donors and clinical research organisations to adopt remote studies and other innovative solutions.
The pharmaceutical business, academic institutions, government agencies, and others involved in
clinical trial research have all tried to develop remedies to these problems, but thus far, none have been
entirely successful [114]. Yet technological tools can also speed up trials and maintain data security
while ensuring that companies comply with all applicable rules and regulations. Clinical trials are
increasingly utilising blockchain technology to ensure the security of sensitive data and the reliability
of collected data [115]. Blockchain, a unique technology that can dramatically redefine businesses and
change how data is transacted, saved, and shared, is an example of an intriguing yet novel technology
that may turn out to be the breakthrough needed to solve the aforementioned issues. Blockchain’s
primary function during a clinical trial is to keep records and produce a transparent audit trail of all
the changes made to a given data collection [116].

6. Impact of ICT Integration into Health Systems

The integration of ICT and their underlying technologies have had a significant impact on
society, particularly in the digitalisation of patient records, the improvement of the quality of access
to healthcare services, the modernisation of patient treatment, the improvement of patient overall
satisfaction, the pharmaceutical supply chain, and the promotion of health and well-being. In this
section, we focus on some of the most promising potential benefits of integrating ICT technology into
healthcare, which will ultimately benefit society as a whole. We also covered the Blockchain technology
impacts from sustainability perspectives (i.e., environmental, social, and economical) and highlighted
the negative impacts on society.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

25 of 39

6.1. Positive Impacts

6.1.1. Digitalisation of Patient Records

The digitalisation of patient health records has been identified as a key positive effect of the
introduction of ICT to healthcare systems. This term describes the process of transferring previously
paper-based medical records into an electronic format to more easily store, retrieve, and share such
records among healthcare professionals [117]. When it comes to the economy, digitising patient
information can help minimise the administrative expenses resulting from paper-based maintenance
of records, such as the costs involved with storage spaces, printing, and postage. This is an important
aspect of the sustainability issue. In addition, the digitalisation of patient information in e-health
may benefit the natural world. There are many ways to lessen the healthcare industry’s impact
on the environment, such as cutting back on paper and energy use for paper-based prescriptions,
lowering transportation costs, decreasing the use of hazardous chemicals, and encouraging sustainable
procurement practices [118].

6.1.2. Improved and Quality Access to Healthcare Services

The development of ICT has allowed for the introduction of telehealth, telemedicine, remote
surgery, remote consultations, etc., all of which have significantly impacted the accessibility and quality
of healthcare services. In addition, ICT can facilitate secure, cost-effective, and safe access to healthcare
services, which is particularly important in regions with limited healthcare resources and, at times,
difficult access to them during emergencies. The integration will help patients in both urban and rural
locations by reducing the time and money spent going too far with healthcare providers and levelling
equality in terms of access to medical treatment [119].

6.1.3. Patient Independence and Autonomy

ICT-enabled healthcare systems provide patients with independence and complete access by
allowing them to manage and control their data in their own manner. It is also a requirement of data
security that no authorised individual has access to patient data via unauthorised means. In addition,
from a social perspective, it can result in improved health outcomes and increased patient trust and
participation in their own advanced healthcare systems [120].

6.1.4. Real-Time Diseases Monitoring

An important positive effect of this integration on society is the development and consistency
of real-time plans for diseases or outbreaks that have occurred in a particular region, as a result of
the collection and analysis of real-time data and the implementation of prompt responses [121]. For
instance, these ICT-enabled healthcare systems reduce the cost of individuals (healthcare providers
such as physicians or analysts) travelling to a specific region and collecting data for the analysis
perspective. E-health systems also promote environmentally cognisant cultures during outbreaks of
diseases such as covid-19 by assisting healthcare providers and policymakers in making informed
decisions and responding more effectively to public health emergencies [122].

6.1.5. Equity Healthcare Services Culture

By eliminating social, economic, and environmental inequalities, health equity ensures that
all people (individuals, groups of people, and communities) can realise their full health capacity.
This means having fair access to medical care, nutritious food, and a secure place to call home. By
implementing healthcare services more readily accessible and affordable, ICT can aid in reducing
health inequalities. Telehealth and distant consultations make it possible for healthcare services to
reach underserved and rural areas while minimising the need for patients to travel and their associated
costs [123].
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

26 of 39

6.2. Blockchain Technology Impacts on Sustainability

In addition to debating on the positive social impacts of incorporating ICT into healthcare
systems, this work will also argue that Blockchain technology has the potential to greatly contribute to
accomplishing sustainability goals, especially in healthcare, and stimulating society as a whole. Some
of the impacts of Blockchain technological advances’ potential application in healthcare’s pursuit of
sustainability are listed below.

6.2.1. Environmental Impact

Environmentally friendly ICT business practices have received a lot of attention in recent years,
and many corporations, including healthcare, have announced plans to implement ICT technologies
into their programs and processes to reduce their harmful effects on the environment. However, some
of the ICT integrations also have negative impacts on business and society. For example, when it comes
to consensus techniques like proof-of-work (PoW) used in the Bitcoin cryptocurrency, the integration
of blockchain technology into ICT-based corporate operations has often been criticised for its impact
on the environment. To reduce this impact, the Ethereum network has migrated to the proof-of-stake
(PoS) consensus mechanism, which is widely regarded as being far more energy-efficient than the
previous proof-of-work (PoW) consensus mechanism. This change will help to mitigate the network’s
negative social and environmental impacts [124].

6.2.2. Social Impact

Since its inception, blockchain technology has had far-reaching effects on social progress and
development thanks to its ability to broaden people’s access to data and information and its capacity
to change the traditional single network into a collaborative value network [125]. With the advent
of Blockchain technology and various socially beneficial applications like cryptocurrencies, the goal
is to implement sustainable behaviour-based applications to utilise smart contracts and reinforce a
long-term approach to sustainability. Cryptocurrencies like Bitcoin, for instance, benefit society because
they eliminate the need for trusted third parties in monetary transactions while providing a safe means
of transferring funds and storing value. In addition, the funds generated by these cryptocurrencies are
tailored to investments that will positively impact society and the environment. Regarding healthcare,
insurance companies have begun implementing their systems, including auditing procedures and
monitoring of funds, by utilising Blockchain technology and smart contracts without a middleman in
order to ensure the modifications made by trusted parties [126].

6.2.3. Economical Impact

The environment and social problems that aim to tackle global challenges, such as financial
inclusion, are starting to empower the benefits of leveraging blockchain technology for both businesses
and people. Many of the SDGs see blockchain technology as a key facilitator since it represents a
forward-thinking approach to the G20 agenda’s central goal of increasing economic participation in
businesses and for the benefit of society [127]. For example, in order to help more people and companies
take advantage of economic opportunities by using Blockchain technology, it is mandatory to define the
financial inclusion criteria, which establish standards for things like using financial services, investing
in businesses, putting money towards one’s education, protecting oneself from financial loss, and
putting money away for one’s retirement. By utilising the same concept for healthcare, the funds
which are spent on healthcare can lead to greater healthcare opportunities, which in turn can boost
human capital and efficiency and economic growth [128].

6.3. Negative Impacts

In addition to discussing the positive effects of this integration on society, we also emphasise
its negative aspects. The negative aspects of digital transformation, including ICT technologies and
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

27 of 39

Blockchain in healthcare systems, are illustrated as follows: Figure 6 shows the positive and negative
impacts of ICT Integration to the healthcare systems.

Figure 6. Positive and Negative Impact of ICT Integration into Health Systems.

6.3.1. Cost
Although the digitalisation of healthcare systems has many benefits for the development of
healthcare services, no one can deny the high costs associated with its design, implementation, and
successful deployment [129]. However, with the introduction of new ICT technologies and systems to
existing healthcare systems, the medical treatment process is becoming quite expensive and costly,
and patients are required to pay hefty fees for even minor procedures, with the cost potentially being
shifted onto patients in the form of greater expenses for healthcare. Ultimately, this digitalisation
process creates additional monetary strain for patients, especially those without insurance or other
subsidies [130].

6.3.2. Technical Knowledge

The requirement for technical skills from stakeholders and end-users is one of the most significant
obstacles to integrating ICT technologies with the healthcare system in society. For instance, the
installation, configuration, and implementation of the most recent ICT systems and their underlying
technologies with existing health systems can be burdensome for system developers and administrators,
as well as necessitating specialised knowledge and appropriate training for the users of such systems.
Consequently, this can result in delays in patient requests for treatment, data and information loss
during system upgrades, and other technical problems that can have an effect on the delivery of
medical treatments [131].

6.3.3. Doctor-Patient Interaction

One major social consequence of digitising healthcare systems is that doctors and patients have
less face-to-face time together, which can be important for having truthful discussions and building
trust [132]. Most patients now get their appointments and medicine suggestions over the phone
because of digital health technologies like telehealth, which raises concerns about a potential decline
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

28 of 39

in the quality of the personal connection and feelings of compassion that characterise direct contact
between patients and medical professionals [133].

6.3.4. Patient’s Information Privacy

EHRs and other patient data are particularly vulnerable to hacking and other types of
unauthorised access due to the increasing prevalence of ICT and other digital technologies inside
healthcare systems. When patient data falls into the wrong hands, it can lead to identity pillaging,
prejudice, and other adverse effects [70].

6.3.5. Over-Relience of ICT Technology

As healthcare systems become more sophisticated and digitalized, patients and clinicians are
starting to rely increasingly on them for everything from treatment to diagnosis. However, the total
reliance on such digital systems can create vulnerabilities and risks for doctors and patients if the
underlying technology fails or is compromised for some reason, potentially leading to risks such as
the death of patients, despite the fact that these transformations demonstrated the many ways to move
towards the next ledger successfully [134].

6.3.6. Increased Social Imbalance

Unfortunately, in this increasingly digital world, not everyone has easy access to the technologies
they need to participate fully. Inequalities in healthcare benefits and access to and provision of
healthcare services may result from the fact that not all patients in an E-health system have access to
digital health technologies. As a result, this difficulty can amplify pre-existing social and economic
disparities and may reduce health outcomes for vulnerable groups [135].

7. Challenges and Future Research Directions

Figure 7 shows the challenges and future research directions, which provide the strength for
researchers to address the issues in future solutions.

Figure 7. Challenges and Future Research Directions.

Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

29 of 39

7.1. Interoperability
Interoperability between blockchain-based networks, which is essential for them to interact with
and share information with one another and take quick decisions, is another major obstacle preventing
many industries from adopting the blockchain as a solution. When it comes to interoperability in
E-health care systems, a uniform set of technical standards for building and designing such systems in
order to exchange information and work together across systems is needed, but this is often lacking
due to a lack of standardised healthcare procedures. Due to the lack of a universally accepted protocol
for blockchain interoperability, it might be difficult for different blockchain networks to exchange data
with one another [136]. Furthermore, in blockchain-based healthcare models, interoperability is more
concerned with the requirement of integrating various technological elements. These components
include smart contracts, record keeping, and consensus processes, all of which can be difficult to
integrate and keep up to date [137].

7.2. Security and Privacy

In the security of EHRs, confidentiality refers to hiding sensitive information from unauthorised
users, while integrity refers to preserving accurate data. In unsecured EHR scenarios, any adversary
can modify the information that has been stored, which results in incorrect information. As a result,
securing such saved information and data from various threats to its security and attempts to modify
it is a very challenging issue to address [138]. Furthermore, authorisation is also a primary concern
in E-health security scenarios since it ensures that only approved individuals may view sensitive
patient data stored in EHR systems. But a malicious actor might utilise stolen credentials to access
sensitive patient data [139]. In addition, data ownership is an essential issue in the healthcare industry.
This challenge refers to "who owns the data" and "who has access to the data." Attackers can change
the ownership data to invalidate their ownership. So, blocking illegal access to the data related to
ownership is of the utmost importance in ensuring the system is secure and safe [140].

7.3. Use of Trusted Storage Options

Using trusted storage solutions and implementing strong security measures are essential for
healthcare providers and organisations to prioritise patient data security and privacy in the face of the
non-trusted storage dilemma. This can be accomplished by establishing distributed secure networks,
utilising an advanced encryption mechanism while transporting data between parties, implementing
proper authorisation and access control techniques, and monitoring and tracking suspicious actions on
a regular basis [141,142].

7.4. Increased Volume of Health Data

While there are many positives to implementing blockchain technology in healthcare, particularly
in terms of data security, the proliferation of patient-related smart sensing IoT devices and blockchain’s
use in E-health has led to an explosion of data that presents a significant challenge for collection and
management of patient data [143]. When it comes to collecting and processing massive amounts
of data, the healthcare industry has quickly risen to the top as one of the most prominent users of
blockchain technology. Generally, Blockchain is developed to counteract centralisation issues by
recording and processing transaction data on a distributed tamper-proof ledger with a restricted data
set and hence low storage requirements [144]. In this context, it is necessary to collect a vast amount of
patient data from decentralised parties, including their medical history, test samples, diagnosis images,
CT scans, etc, all of which must be accessible to all the nodes in the blockchain. However, the growing
volume of patient transactions slows down record searching and access, making it unfit for many
types of transactions. Therefore, a solution that utilises blockchain technology must be both robust
and scalable. Since blockchain’s uses are largely transactional, the databases powering the technology
tend to expand rapidly [145].
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

30 of 39

7.5. Social and Cultural Adoption Barrier

Since blockchain technology is still in its infancy and faces challenges from society, such as social
and cultural shifts in addition to the aforementioned technical challenges, its applicability is limited
when it comes to designing efficient and reliable healthcare solutions, which necessitated an entirely
new way of thinking about how to get things done. In spite of the fact that the healthcare sector is
gradually adopting Blockchain technology, more work is needed from both academics and the industry
to overcome the obstacles and fully transition to this new system [146]. For instance, it’s important
to get people together to discuss how to persuade the healthcare industry and individual patients to
abandon their reliance on antiquated, insecure methods in favour of cutting-edge technologies that
promote autonomy, transparency, and security. In addition, Blockchain technology and its benefits are
viewed as being somewhat questionable because it is not widely used and has a poor success rate in
the health industry. As a result of all of these difficulties and dangers, we cannot call it a practical and
all-encompassing answer to all of the problems in the healthcare industry at this time [147].

7.6. Medical Industry Settings/Standards

The medical sector is not a unified body with its own set of rules and regulations; instead, it
comprises a wide variety of distinct entities and parties, each of which has its own set of standards
by which it operates. However, with the development of ICT technologies like Blockchain and the
health organisation’s present requirements, many authenticated and recognised standards would
be necessary from worldwide standardisation agencies. For instance, Blockchain technology is in
its early stages; thus, it will undoubtedly face many standardisation problems on the path to actual
deployment in healthcare and medicine [148]. Therefore, medical researchers must try to ascertain the
need for predefined standards that help determine the volume, type, and format of data exchanged
in blockchain-based applications. Further, these standards will act as both a check on the shared
information and a layer of security.

8. Implications of Our Study

There is an implied requirement to address sustainability concerns in the Healthcare sector by
valuing various ICT technologies, including the recently emergent Blockchain technology. The primary
decision-makers in the healthcare and well-being sector should consider and promote the development
of E-Health by introducing and supporting Blockchain-based applications due to their promising
characteristics in other similar industries, including finance, supply chain management, etc. The
findings of a few adverse effects of digital technologies suggest that the government and relevant
organisations develop policies to address undesirable challenges and outcomes in E-Health. More
specific implications of our study are as follows:

8.1. Security and Privacy Implications

Our study has implications for the security and privacy of third parties involved in storing,
analysing, and selling sensitive patient information. Health-related information is provided to related
enterprises. Such business models must evaluate the viability of incorporating Blockchain applications
to increase control, privacy, and authenticity. Instead of being dispersed among various healthcare
service providers, patient information should be possessed and maintained by the patients themselves,
and decision-makers must support this trend. These actions can aid healthcare providers in overcoming
several legal and ethical issues.

8.2. Stakeholder Implications

Considering the findings associated with ICT and Blockchain technology challenges, our study’s
outcome also serves as a wake-up call for the healthcare industry, which requires strategic partnerships
to ensure the availability of necessary resources. For example, Healthcare companies must develop
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

31 of 39

more long-lasting alliances with government and non-government organisations, such as fund
providers, training institutions, and Medical Research and development organisations.

8.3. Research and Development

For future sustainability research in E-healthcare, our findings suggest that instead of focusing
solely on an overview of sustainability issues, the time has come to investigate the sustainability-related
challenges of ICT integration in the healthcare sector through the concerted efforts of academia and
researchers.

9. Conclusion
Promoting good health and well-being is a fundamental Sustainable Development Goal (SDG)
aimed at ensuring the overall well-being of individuals across all age groups. This objective includes
the provision of affordable and environmentally sustainable medical services to the general population
while minimising any potential negative impacts. ICT technologies have become more crucial in
facilitating healthcare reform that aims to improve access to health services, enhance the quality of
treatment, and increase the overall productivity of the healthcare system. The integration of ICT
technologies into healthcare systems is a complex endeavor, characterized by several obstacles at
multiple levels, including integration, application design, and security. Despite numerous studies
examining the incorporation of ICT into healthcare systems, there remains a requirement for a
comprehensive research investigation into the challenges associated with integration and design,
security and privacy, application domains, and the potential positive and negative consequences.
Upon completing this study, we have identified and delineated the fundamental contributions
of this research, which can serve as findings and potentially benefit the broader society. First, we
present a detailed comparison of existing studies, mainly focusing on integrating ICT technologies
in healthcare, an important SDG, in terms of sustainable aspects, security and privacy challenges,
design and integration challenges, E-health-related applications, and future directions, which serves as
the literature review of existing survey studies. Second, we give an overview of the need for digital
transformation in healthcare, discuss its significant components, highlight E-health’s importance
and benefits, explore its integration and design challenges and categorise the security and privacy
challenges. Third, we extend an in-depth discussion on the role of Blockchain technology in E-health,
discussing Blockchain technology and its characteristics, highlighting its benefits, and describing
the possible types of Blockchain-based E-health use cases. Furthermore, we discuss the positive
and negative impact of ICT integration, including Blockchain technology, on health systems from
the sustainability point of view. Finally, we identify open issues and challenges of integrating ICT
technologies into the healthcare systems and discuss future research directions, which provide the
strength for researchers to address the issues in future solutions.

Author Contributions: All authors contributed equally to the concept, design and methodology, and draft writing.
“Conceptualisation, F.H. and K.H.; Methodology, F.H. and K.H.; Writing- original draft preparation, F.H. and K.H.;
Writing- review and editing, F.H. and K.H.; Proof-reading, F.H. and K.H.” All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding
Institutional Review Board Statement: Not applicable
Informed Consent Statement: Not applicable
Conflicts of Interest: The authors declare no conflict of interest.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

32 of 39

Abbreviations
The following abbreviations are used in this manuscript:

SDG Sustainable Development Goal

IoT Internet of Things
AI Artificial Intelligence
BC Blockchain
WHO World Health Organisation

References
1. Berniak-Woźny, J.; Rataj, M. Towards Green and Sustainable Healthcare: A Literature Review and Research
Agenda for Green Leadership in the Healthcare Sector. International Journal of Environmental Research and
Public Health 2023, 20, 908.
2. Mhlanga, D. The role of artificial intelligence and machine learning amid the COVID-19 pandemic: What
lessons are we learning on 4IR and the sustainable development goals. International Journal of Environmental
Research and Public Health 2022, 19, 1879.
3. Ekwebelem, O.C.; Ofielu, E.S.; Nnorom-Dike, O.V.; Iweha, C.; Ekwebelem, N.C.; Obi, B.C.; Ugbede-Ojo,
S.E. Threats of COVID-19 to achieving United Nations sustainable development goals in Africa. The
American Journal of Tropical Medicine and Hygiene 2021, 104, 457.
4. Kontoangelos, K.; Economou, M.; Papageorgiou, C. Mental health effects of COVID-19 pandemia: a review
of clinical and psychological traits. Psychiatry investigation 2020, 17, 491.
5. Monaghesh, E.; Hajizadeh, A. The role of telehealth during COVID-19 outbreak: a systematic review based
on current evidence. BMC public health 2020, 20, 1–9.
6. Chandan, A.; John, M.; Potdar, V. Achieving UN SDGs in Food Supply Chain Using Blockchain Technology.
Sustainability 2023, 15, 2109.
7. Medaglia, R.; Damsgaard, J. Blockchain and the United Nations Sustainable Development Goals: Towards
an Agenda for IS Research. PACIS, 2020, p. 36.
8. Nowak, A. The Cost of Living: The Impact of the Increasing Cost of Pharmaceutical Drugs on Public
Health 2019.
9. Organization, W.H.; others. Is the Eastern Mediterranean Region ready for digitalizing health? implications
from the global strategy on digital health (2020–2025) 2021.
10. Abbas, H.S.M.; Qaisar, Z.H.; Ali, G.; Alturise, F.; Alkhalifah, T. Impact of cybersecurity measures
on improving institutional governance and digitalization for sustainable healthcare. Plos one 2022,
17, e0274550.
11. Ullah, A.; Pinglu, C.; Ullah, S.; Abbas, H.S.M.; Khan, S. The role of e-governance in combating COVID-19
and promoting sustainable development: a comparative study of China and Pakistan. Chinese Political
Science Review 2021, 6, 86–118.
12. Verdejo Espinosa, Á.; López, J.L.; Mata Mata, F.; Estevez, M.E. Application of IoT in healthcare: keys to
implementation of the sustainable development goals. Sensors 2021, 21, 2330.
13. Cabanillas-Carbonell, M.; Pérez-Martínez, J.; A. Yáñez, J. 5G Technology in the Digital Transformation of
Healthcare, a Systematic Review. Sustainability 2023, 15, 3178.
14. Joshi, S.; Sharma, M.; Das, R.P.; Rosak-Szyrocka, J.; Żywiołek, J.; Muduli, K.; Prasad, M. Modeling
Conceptual Framework for Implementing Barriers of AI in Public Healthcare for Improving Operational
Excellence: Experiences from Developing Countries. Sustainability 2022, 14, 11698.
15. Thayyib, P.; Mamilla, R.; Khan, M.; Fatima, H.; Asim, M.; Anwar, I.; Shamsudheen, M.; Khan, M.A.
State-of-the-Art of Artificial Intelligence and Big Data Analytics Reviews in Five Different Domains: A
Bibliometric Summary. Sustainability 2023, 15, 4026.
16. Soltysik-Piorunkiewicz, A.; Morawiec, P. The Sustainable e-Health System Development in COVID 19
Pandemic–The Theoretical Studies of Knowledge Management Systems and Practical Polish Healthcare
Experience. J. e-Health Manag 2022, 2022, 1–12.
17. Stoumpos, A.I.; Kitsios, F.; Talias, M.A. Digital Transformation in Healthcare: Technology Acceptance and
Its Applications. International journal of environmental research and public health 2023, 20, 3407.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

33 of 39

18. Fragão-Marques, M.; Ozben, T. Digital transformation and sustainability in healthcare and clinical
laboratories. Clinical Chemistry and Laboratory Medicine (CCLM) 2023, 61, 627–633.
19. Hadjiat, Y. Healthcare inequity and digital health–A bridge for the divide, or further erosion of the chasm?
PLOS Digital Health 2023, 2, e0000268.
20. Ngongoni, C.N.; Wasswa, W.; Chibi, M. Legacy of COVID-19 Innovations: Strengthening African Primary
Health Care through Pandemic Innovations. Sustainability 2023, 15, 12073.
21. Alajlan, A.; Baslyman, M. Toward a Comprehensive Understanding and Evaluation of the Sustainability of
E-Health Solutions. Applied Sciences 2023, 13, 5811.
22. Cheshmehzangi, A.; Su, Z.; Zou, T. ICT applications and the COVID-19 pandemic: Impacts on the
individual’s digital data, digital privacy, and data protection. Frontiers in Human Dynamics 2023, 5, 971504.
23. Butt, J. A conceptual framework to support digital transformation in manufacturing using an integrated
business process management approach. Designs 2020, 4, 17.
24. Badidi, E. Edge AI and blockchain for smart sustainable cities: Promise and potential. Sustainability 2022,
14, 7609.
25. Clark, S.; MacLachlan, M.; Marshall, K.; Morahan, N.; Carroll, C.; Hand, K.; Boyle, N.; O’Sullivan, K.
Including digital connection in the united nations sustainable development goals: A systems thinking
approach for achieving the SDGs. Sustainability 2022, 14, 1883.
26. Stark, H.E.; Graudins, L.V.; McGuire, T.M.; Lee, C.Y.Y.; Duguid, M.J. Implementing a sustainable medication
reconciliation process in Australian hospitals: The World Health Organization High 5s project. Research in
Social and Administrative Pharmacy 2020, 16, 290–298.
27. Tajpour, M.; Hosseini, E.; Mohammadi, M.; Bahman-Zangi, B. The effect of knowledge management on the
sustainability of technology-driven businesses in emerging markets: The mediating role of social media.
Sustainability 2022, 14, 8602.
28. Westbrook, J.I.; Braithwaite, J. Will information and communication technology disrupt the health system
and deliver on its promise? Medical Journal of Australia 2010, 193, 399–400.
29. Celik, A.; Romdhane, I.; Kaddoum, G.; Eltawil, A.M. A top-down survey on optical wireless
communications for the internet of things. IEEE Communications Surveys & Tutorials 2022.
30. Yuehong, Y.; Zeng, Y.; Chen, X.; Fan, Y. The internet of things in healthcare: An overview. Journal of
Industrial Information Integration 2016, 1, 3–13.
31. Lupiáñez-Villanueva, F.; Hardey, M.; Torrent, J.; Ficapal, P. The integration of Information and
Communication Technology into medical practice. International journal of medical informatics 2010,
79, 478–491.
32. Ksibi, S.; Jaidi, F.; Bouhoula, A. A Comprehensive Study of Security and Cyber-Security Risk Management
within e-Health Systems: Synthesis, Analysis and a Novel Quantified Approach. Mobile Networks and
Applications 2022, pp. 1–21.
33. Islam, M.R.; Kabir, M.M.; Mridha, M.F.; Alfarhood, S.; Safran, M.; Che, D. Deep Learning-Based IoT System
for Remote Monitoring and Early Detection of Health Issues in Real-Time. Sensors 2023, 23, 5204.
34. Grimson, J. Delivering the electronic healthcare record for the 21st century. International journal of medical
informatics 2001, 64, 111–127.
35. Butpheng, C.; Yeh, K.H.; Xiong, H. Security and privacy in IoT-cloud-based e-health systems—A
comprehensive review. Symmetry 2020, 12, 1191.
36. Tahir, A.; Chen, F.; Khan, H.U.; Ming, Z.; Ahmad, A.; Nazir, S.; Shafiq, M. A systematic review on cloud
storage mechanisms concerning e-healthcare systems. Sensors 2020, 20, 5392.
37. Mathews, S.C.; McShea, M.J.; Hanley, C.L.; Ravitz, A.; Labrique, A.B.; Cohen, A.B. Digital health: a path to
validation. NPJ digital medicine 2019, 2, 38.
38. Jin, W.; Kim, D.H. Design and implementation of e-health system based on semantic sensor network using
IETF YANG. Sensors 2018, 18, 629.
39. Benhlima, L.; others. Big data management for healthcare systems: architecture, requirements, and
implementation. Advances in bioinformatics 2018, 2018.
40. Ross, M.; Wei, W.; Ohno-Machado, L. “Big data” and the electronic health record. Yearbook of medical
informatics 2014, 23, 97–104.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

34 of 39

41. Curran, G.M.; Bauer, M.; Mittman, B.; Pyne, J.M.; Stetler, C. Effectiveness-implementation hybrid designs:
combining elements of clinical effectiveness and implementation research to enhance public health impact.
Medical care 2012, 50, 217.
42. Guo, Y.; Chen, W.; Zhao, J.; Yang, G.Z. Medical robotics: opportunities in China. Annual Review of Control,
Robotics, and Autonomous Systems 2022, 5, 361–383.
43. Chan, M.; Estève, D.; Fourniols, J.Y.; Escriba, C.; Campo, E. Smart wearable systems: Current status and
future challenges. Artificial intelligence in medicine 2012, 56, 137–156.
44. Chen, M.; Decary, M. Artificial intelligence in healthcare: An essential guide for health leaders. Healthcare
management forum. SAGE Publications Sage CA: Los Angeles, CA, 2020, Vol. 33, pp. 10–18.
45. Hameed, K.; Barika, M.; Garg, S.; Amin, M.B.; Kang, B. A taxonomy study on securing Blockchain-based
Industrial applications: An overview, application perspectives, requirements, attacks, countermeasures,
and open issues. Journal of Industrial Information Integration 2022, 26, 100312.
46. Wen, H.; Wu, Y.; Yang, C.; Duan, H.; Yu, S. A unified federated learning framework for wireless
communications: Towards privacy, efficiency, and security. IEEE INFOCOM 2020-IEEE Conference
on Computer Communications Workshops (INFOCOM WKSHPS). IEEE, 2020, pp. 653–658.
47. Daglish, D.; Archer, N. Electronic personal health record systems: a brief review of privacy, security, and
architectural issues. 2009 world congress on privacy, security, Trust and the Management of e-Business.
IEEE, 2009, pp. 110–120.
48. Thota, C.; Sundarasekar, R.; Manogaran, G.; Varatharajan, R.; Priyan, M. Centralized fog computing
security platform for IoT and cloud in healthcare system. In Fog computing: Breakthroughs in research and
practice; IGI global, 2018; pp. 365–378.
49. Papaioannou, M.; Karageorgou, M.; Mantas, G.; Sucasas, V.; Essop, I.; Rodriguez, J.; Lymberopoulos, D.
A survey on security threats and countermeasures in internet of medical things (IoMT). Transactions on
Emerging Telecommunications Technologies 2022, 33, e4049.
50. Ekonomou, E.; Fan, L.; Buchanan, W.; Thuemmler, C. An integrated cloud-based healthcare infrastructure.
2011 IEEE third international conference on cloud computing technology and science. IEEE, 2011, pp.
532–536.
51. Newaz, A.I.; Sikder, A.K.; Rahman, M.A.; Uluagac, A.S. A Survey on Security and Privacy Issues in Modern
Healthcare Systems: Attacks and Defenses. ACM Trans. Comput. Healthcare 2021, 2. doi:10.1145/3453176.
52. Rolim, C.O.; Koch, F.L.; Westphall, C.B.; Werner, J.; Fracalossi, A.; Salvador, G.S. A cloud computing
solution for patient’s data collection in health care institutions. 2010 Second International Conference on
eHealth, Telemedicine, and Social Medicine. IEEE, 2010, pp. 95–99.
53. Garavand, A.; Behmanesh, A.; Aslani, N.; Sadeghsalehi, H.; Ghaderzadeh, M.; others. Towards Diagnostic
Aided Systems in Coronary Artery Disease Detection: A Comprehensive Multiview Survey of the State of
the Art. International Journal of Intelligent Systems 2023, 2023.
54. Sadhu, P.K.; Yanambaka, V.P.; Abdelgawad, A.; Yelamarthi, K. Prospect of internet of medical things: A
review on security requirements and solutions. Sensors 2022, 22, 5517.
55. Ghaderzadeh, M.; Aria, M.; Hosseini, A.; Asadi, F.; Bashash, D.; Abolghasemi, H. A fast and efficient
CNN model for B-ALL diagnosis and its subtypes classification using peripheral blood smear images.
International Journal of Intelligent Systems 2022, 37, 5113–5133.
56. Ghaderzadeh, M.; Aria, M. Management of covid-19 detection using artificial intelligence in 2020 pandemic.
Proceedings of the 5th International Conference on Medical and Health Informatics, 2021, pp. 32–38.
57. Roy, S.; Das, A.K.; Chatterjee, S.; Kumar, N.; Chattopadhyay, S.; Rodrigues, J.J. Provably secure fine-grained
data access control over multiple cloud servers in mobile cloud computing based healthcare applications.
IEEE Transactions on Industrial Informatics 2018, 15, 457–468.
58. Rosenbaum, S. Data governance and stewardship: designing data stewardship entities and advancing
data access. Health services research 2010, 45, 1442–1455.
59. Garavand, A.; Salehnasab, C.; Behmanesh, A.; Aslani, N.; Zadeh, A.H.; Ghaderzadeh, M.; others. Efficient
model for coronary artery disease diagnosis: a comparative study of several machine learning algorithms.
Journal of Healthcare Engineering 2022, 2022.
60. Elsharkawy, N.B.; Abdelaziz, E.M.; Ouda, M.M.; Oraby, F.A. Effectiveness of health information package
program on knowledge and compliance among pregnant women with anemia: a randomized controlled
trial. International Journal of Environmental Research and Public Health 2022, 19, 2724.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

35 of 39

61. Ghaderzadeh, M.; Asadi, F.; Hosseini, A.; Bashash, D.; Abolghasemi, H.; Roshanpour, A. Machine learning
in detection and classification of leukemia using smear blood images: a systematic review. Scientific
Programming 2021, 2021, 1–14.
62. Gheisari, M.; Ebrahimzadeh, F.; Rahimi, M.; Moazzamigodarzi, M.; Liu, Y.; Dutta Pramanik, P.K.; Heravi,
M.A.; Mehbodniya, A.; Ghaderzadeh, M.; Feylizadeh, M.R.; others. Deep learning: Applications,
architectures, models, tools, and frameworks: A comprehensive survey. CAAI Transactions on Intelligence
Technology 2023.
63. Haleem, A.; Javaid, M.; Singh, R.P.; Suman, R. Medical 4.0 technologies for healthcare: Features, capabilities,
and applications. Internet of Things and Cyber-Physical Systems 2022.
64. Al Alkeem, E.; Yeun, C.Y.; Zemerly, M.J. Security and privacy framework for ubiquitous healthcare IoT
devices. 2015 10th International Conference for Internet Technology and Secured Transactions (ICITST).
IEEE, 2015, pp. 70–75.
65. Xu, T.; Wendt, J.B.; Potkonjak, M. Security of IoT systems: Design challenges and opportunities. 2014
IEEE/ACM International Conference on Computer-Aided Design (ICCAD). IEEE, 2014, pp. 417–423.
66. Dogaru, D.I.; Dumitrache, I. Cyber security in healthcare networks. 2017 E-Health and Bioengineering
Conference (EHB). IEEE, 2017, pp. 414–417.
67. AlZubi, A.A.; Al-Maitah, M.; Alarifi, A. Cyber-attack detection in healthcare using cyber-physical system
and machine learning techniques. Soft Computing 2021, 25, 12319–12332.
68. Zafar, F.; Khan, A.; Suhail, S.; Ahmed, I.; Hameed, K.; Khan, H.M.; Jabeen, F.; Anjum, A. Trustworthy
data: A survey, taxonomy and future trends of secure provenance schemes. Journal of network and computer
applications 2017, 94, 50–68.
69. Walker-Roberts, S.; Hammoudeh, M.; Dehghantanha, A. A systematic review of the availability and
efficacy of countermeasures to internal threats in healthcare critical infrastructure. IEEE Access 2018,
6, 25167–25177.
70. Price, W.N.; Cohen, I.G. Privacy in the age of medical big data. Nature medicine 2019, 25, 37–43.
71. Ahmed, S.M.; Rajput, A. Threats to patients’ privacy in smart healthcare environment. In Innovation in
Health Informatics; Elsevier, 2020; pp. 375–393.
72. Ali, M.; Naeem, F.; Tariq, M.; Kaddoum, G. Federated learning for privacy preservation in smart healthcare
systems: A comprehensive survey. IEEE journal of biomedical and health informatics 2022, 27, 778–789.
73. Shahid, J.; Ahmad, R.; Kiani, A.K.; Ahmad, T.; Saeed, S.; Almuhaideb, A.M. Data protection and privacy of
the internet of healthcare things (IoHTs). Applied Sciences 2022, 12, 1927.
74. Battula, S.K.; Garg, S.; Naha, R.; Amin, M.B.; Kang, B.; Aghasian, E. A blockchain-based framework
for automatic SLA management in fog computing environments. The Journal of Supercomputing 2022,
78, 16647–16677.
75. Swan, M. Blockchain: Blueprint for a new economy; " O’Reilly Media, Inc.", 2015.
76. Nofer, M.; Gomber, P.; Hinz, O.; Schiereck, D. Blockchain. Business & Information Systems Engineering 2017,
59, 183–187.
77. Maleh, Y.; Shojafar, M.; Alazab, M.; Romdhani, I. Blockchain for cybersecurity and privacy: architectures,
challenges, and applications 2020.
78. Crosby, M.; Pattanayak, P.; Verma, S.; Kalyanaraman, V.; others. Blockchain technology: Beyond bitcoin.
Applied Innovation 2016, 2, 71.
79. Zheng, Z.; Xie, S.; Dai, H.; Chen, X.; Wang, H. An overview of blockchain technology: Architecture,
consensus, and future trends. 2017 IEEE international congress on big data (BigData congress). Ieee, 2017,
pp. 557–564.
80. Gervais, A.; Karame, G.O.; Wüst, K.; Glykantzis, V.; Ritzdorf, H.; Capkun, S. On the security and
performance of proof of work blockchains. Proceedings of the 2016 ACM SIGSAC conference on computer
and communications security, 2016, pp. 3–16.
81. Gaži, P.; Kiayias, A.; Zindros, D. Proof-of-stake sidechains. 2019 IEEE Symposium on Security and Privacy
(SP). IEEE, 2019, pp. 139–156.
82. Castro, M.; Liskov, B.; others. Practical byzantine fault tolerance. OsDI, 1999, Vol. 99, pp. 173–186.
83. Larimer, D. Delegated proof-of-stake (dpos). Bitshare whitepaper 2014, 81, 85.
84. Mingxiao, D.; Xiaofeng, M.; Zhe, Z.; Xiangwei, W.; Qijun, C. A review on consensus algorithm of blockchain.
2017 IEEE international conference on systems, man, and cybernetics (SMC). IEEE, 2017, pp. 2567–2572.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

36 of 39

85. Zheng, B.K.; Zhu, L.H.; Shen, M.; Gao, F.; Zhang, C.; Li, Y.D.; Yang, J. Scalable and privacy-preserving data
sharing based on blockchain. Journal of Computer Science and Technology 2018, 33, 557–567.
86. Zhang, R.; Xue, R.; Liu, L. Security and privacy on blockchain. ACM Computing Surveys (CSUR) 2019,
52, 1–34.
87. Khalilov, M.C.K.; Levi, A. A survey on anonymity and privacy in bitcoin-like digital cash systems. IEEE
Communications Surveys & Tutorials 2018, 20, 2543–2585.
88. Muzammal, M.; Qu, Q.; Nasrulin, B. Renovating blockchain with distributed databases: An open source
system. Future generation computer systems 2019, 90, 105–117.
89. Mohanta, B.K.; Panda, S.S.; Jena, D. An overview of smart contract and use cases in blockchain technology.
2018 9th international conference on computing, communication and networking technologies (ICCCNT).
IEEE, 2018, pp. 1–4.
90. Wang, Z.; Lin, J.; Cai, Q.; Wang, Q.; Zha, D.; Jing, J. Blockchain-based certificate transparency and
revocation transparency. IEEE Transactions on Dependable and Secure Computing 2020, 19, 681–697.
91. Galvez, J.F.; Mejuto, J.C.; Simal-Gandara, J. Future challenges on the use of blockchain for food traceability
analysis. TrAC Trends in Analytical Chemistry 2018, 107, 222–232.
92. Shahnaz, A.; Qamar, U.; Khalid, A. Using blockchain for electronic health records. IEEE access 2019,
7, 147782–147795.
93. Abu-Elezz, I.; Hassan, A.; Nazeemudeen, A.; Househ, M.; Abd-Alrazaq, A. The benefits and threats of
blockchain technology in healthcare: A scoping review. International Journal of Medical Informatics 2020,
142, 104246.
94. Cerchione, R.; Centobelli, P.; Riccio, E.; Abbate, S.; Oropallo, E. Blockchain’s coming to hospital to
digitalize healthcare services: Designing a distributed electronic health record ecosystem. Technovation
2023, 120, 102480.
95. Abunadi, I.; Kumar, R.L. BSF-EHR: blockchain security framework for electronic health records of patients.
Sensors 2021, 21, 2865.
96. Tagde, P.; Tagde, S.; Bhattacharya, T.; Tagde, P.; Chopra, H.; Akter, R.; Kaushik, D.; Rahman, M.H.
Blockchain and artificial intelligence technology in e-Health. Environmental Science and Pollution Research
2021, 28, 52810–52831.
97. Jabbar, R.; Fetais, N.; Krichen, M.; Barkaoui, K. Blockchain technology for healthcare: Enhancing shared
electronic health record interoperability and integrity. 2020 IEEE International Conference on Informatics,
IoT, and Enabling Technologies (ICIoT). IEEE, 2020, pp. 310–317.
98. Ray Chawdhuri, D. Patient privacy and ownership of electronic health records on a blockchain.
Blockchain–ICBC 2019: Second International Conference, Held as Part of the Services Conference
Federation, SCF 2019, San Diego, CA, USA, June 25–30, 2019, Proceedings 2. Springer, 2019, pp. 95–111.
99. Biswas, S.; Sharif, K.; Li, F.; Mohanty, S. Blockchain for e-health-care systems: Easier said than done.
Computer 2020, 53, 57–67.
100. Hameed, K.; Garg, S.; Amin, M.B.; Kang, B.; Khan, A. A context-aware information-based clone node attack
detection scheme in Internet of Things. Journal of Network and Computer Applications 2022, 197, 103271.
101. Li, S.; Zhang, Y.; Xu, C.; Cheng, N.; Liu, Z.; Du, Y.; Shen, X. HealthFort: A Cloud-Based Ehealth System
With Conditional Forward Transparency and Secure Provenance Via Blockchain. IEEE Transactions on
Mobile Computing 2022.
102. Sharma, Y.; Balamurugan, B. Preserving the privacy of electronic health records using blockchain. Procedia
Computer Science 2020, 173, 171–180.
103. Chenthara, S.; Ahmed, K.; Wang, H.; Whittaker, F.; Chen, Z. Healthchain: A novel framework on privacy
preservation of electronic health records using blockchain technology. Plos one 2020, 15, e0243043.
104. Cachin, C.; others. Architecture of the hyperledger blockchain fabric. Workshop on distributed
cryptocurrencies and consensus ledgers. Chicago, IL, 2016, Vol. 310, pp. 1–4.
105. Dagher, G.G.; Mohler, J.; Milojkovic, M.; Marella, P.B. Ancile: Privacy-preserving framework for access
control and interoperability of electronic health records using blockchain technology. Sustainable cities and
society 2018, 39, 283–297.
106. Dubovitskaya, A.; Xu, Z.; Ryu, S.; Schumacher, M.; Wang, F. Secure and trustable electronic medical
records sharing using blockchain. AMIA annual symposium proceedings. American Medical Informatics
Association, 2017, Vol. 2017, p. 650.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

37 of 39

107. Zheng, H.; You, L.; Hu, G. A novel insurance claim blockchain scheme based on zero-knowledge proof
technology. Computer Communications 2022, 195, 207–216.
108. Griggs, K.N.; Ossipova, O.; Kohlios, C.P.; Baccarini, A.N.; Howson, E.A.; Hayajneh, T. Healthcare
blockchain system using smart contracts for secure automated remote patient monitoring. Journal of medical
systems 2018, 42, 1–7.
109. Uddin, M.A.; Stranieri, A.; Gondal, I.; Balasubramanian, V. Continuous patient monitoring with a patient
centric agent: A block architecture. IEEE Access 2018, 6, 32700–32726.
110. Ji, Y.; Zhang, J.; Ma, J.; Yang, C.; Yao, X. BMPLS: Blockchain-based multi-level privacy-preserving location
sharing scheme for telecare medical information systems. Journal of medical systems 2018, 42, 1–13.
111. Raghupathi, W.; Raghupathi, V. Big data analytics in healthcare: promise and potential. Health information
science and systems 2014, 2, 1–10.
112. Zaabar, B.; Cheikhrouhou, O.; Jamil, F.; Ammi, M.; Abid, M. HealthBlock: A secure blockchain-based
healthcare data management system. Computer Networks 2021, 200, 108500.
113. Odeh, A.; Keshta, I.; Al-Haija, Q.A. Analysis of Blockchain in the Healthcare Sector: Application and
Issues. Symmetry 2022, 14, 1760.
114. Wong, D.R.; Bhattacharya, S.; Butte, A.J. Prototype of running clinical trials in an untrustworthy
environment using blockchain. Nature communications 2019, 10, 917.
115. Nugent, T.; Upton, D.; Cimpoesu, M. Improving data transparency in clinical trials using blockchain smart
contracts. F1000Research 2016, 5.
116. Ahmad, R.W.; Salah, K.; Jayaraman, R.; Yaqoob, I.; Ellahham, S.; Omar, M. Blockchain and COVID-19
pandemic: Applications and challenges. Cluster Computing 2023, pp. 1–26.
117. Wyatt, D.; Lampon, S.; McKevitt, C. Delivering healthcare’s ‘triple aim’: Electronic health records and
the health research participant in the UK National Health Service. Sociology of health & illness 2020,
42, 1312–1327.
118. Shaharul, N.A.; Ahmad Zamzuri, M.I.; Ariffin, A.A.; Azman, A.Z.F.; Mohd Ali, N.K. Digitalisation Medical
Records: Improving Efficiency and Reducing Burnout in Healthcare. International Journal of Environmental
Research and Public Health 2023, 20, 3441.
119. Nundy, S.; Cooper, L.A.; Mate, K.S. The quintuple aim for health care improvement: a new imperative to
advance health equity. JAMA 2022, 327, 521–522.
120. Deutschbein, T.; Reimondo, G.; Di Dalmazi, G.; Bancos, I.; Patrova, J.; Vassiliadi, D.A.; Nekić, A.B.; Debono,
M.; Lardo, P.; Ceccato, F.; others. Age-dependent and sex-dependent disparity in mortality in patients with
adrenal incidentalomas and autonomous cortisol secretion: an international, retrospective, cohort study.
The Lancet Diabetes & Endocrinology 2022, 10, 499–508.
121. Chakraborty, C.; Kishor, A. Real-time cloud-based patient-centric monitoring using computational health
systems. IEEE transactions on computational social systems 2022, 9, 1613–1623.
122. Karidakis, M.; Woodward-Kron, R.; Amorati, R.; Hu, B.; Pym, A.; Hajek, J. Enhancing COVID-19 public
health communication for culturally and linguistically diverse communities: An Australian interview
study with community representatives. Qualitative Health Communication 2022, 1, 61–83.
123. Kaihlanen, A.M.; Virtanen, L.; Buchert, U.; Safarov, N.; Valkonen, P.; Hietapakka, L.; Hörhammer, I.;
Kujala, S.; Kouvonen, A.; Heponiemi, T. Towards digital health equity-a qualitative study of the challenges
experienced by vulnerable groups in using digital health services in the COVID-19 era. BMC health services
research 2022, 22, 188.
124. Martine, G.; Alves, J.E.D. Economy, society and environment in the 21st century: three pillars or trilemma
of sustainability? Revista Brasileira de Estudos de População 2015, 32, 433–460.
125. Agarwal, B.; Gautam, R.S.; Jain, P.; Rastogi, S.; Bhimavarapu, V.M.; Singh, S. Impact of Environmental,
Social, and Governance Activities on the Financial Performance of Indian Health Care Sector Firms: Using
Competition as a Moderator. Journal of Risk and Financial Management 2023, 16, 109.
126. Pentescu, A.; Cetină, I.; Orzan, G. Social media’s impact on healthcare services. Procedia Economics and
Finance 2015, 27, 646–651.
127. Raghupathi, V.; Raghupathi, W. Healthcare expenditure and economic performance: insights from the
United States data. Frontiers in public health 2020, 8, 156.
128. ŞENKARDEŞ, İ.Ç.G. A Discussion On The Effects Of Blockchain Technology Within The Context Of
Sustainable Development. Bilgi ve İletişim Teknolojileri Dergisi 2021, 3, 243–262.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

38 of 39

129. Schmitt, T.; Haarmann, A. Financing health promotion, prevention and innovation despite the rising
healthcare costs: How can the new German government square the circle? Zeitschrift für Evidenz, Fortbildung
und Qualität im Gesundheitswesen 2023, 177, 95–103.
130. Popov, V.V.; Kudryavtseva, E.V.; Kumar Katiyar, N.; Shishkin, A.; Stepanov, S.I.; Goel, S. Industry 4.0 and
digitalisation in healthcare. Materials 2022, 15, 2140.
131. Konttila, J.; Siira, H.; Kyngäs, H.; Lahtinen, M.; Elo, S.; Kääriäinen, M.; Kaakinen, P.; Oikarinen, A.;
Yamakawa, M.; Fukui, S.; others. Healthcare professionals’ competence in digitalisation: A systematic
review. Journal of clinical nursing 2019, 28, 745–761.
132. Botrugno, C. Information technologies in healthcare: Enhancing or dehumanising doctor–patient
interaction? Health 2021, 25, 475–493.
133. Bertakis, K.D. The influence of gender on the doctor–patient interaction. Patient education and counseling
2009, 76, 356–360.
134. Kabanda, G. Cybersecurity risk management plan for a blockchain application model. Trans Eng Comput
Sci 2021, 2, 221.
135. Mahgoub, I.M.; Abdelrahman, A.; Abdallah, T.A.; Mohamed Ahmed, K.A.H.; Omer, M.E.A.; Abdelrahman,
E.; Salih, Z.M.A. Psychological effects of the COVID-19 pandemic: Perceived stress, anxiety, work–family
imbalance, and coping strategies among healthcare professionals in Khartoum state hospitals, Sudan, 2021.
Brain and Behavior 2021, 11, e2318.
136. Torab-Miandoab, A.; Samad-Soltani, T.; Jodati, A.; Rezaei-Hachesu, P. Interoperability of heterogeneous
health information systems: a systematic literature review. BMC Medical Informatics and Decision Making
2023, 23, 18.
137. Reegu, F.A.; Abas, H.; Gulzar, Y.; Xin, Q.; Alwan, A.A.; Jabbari, A.; Sonkamble, R.G.; Dziyauddin, R.A.
Blockchain-Based Framework for Interoperable Electronic Health Records for an Improved Healthcare
System. Sustainability 2023, 15, 6337.
138. Shakeel, T.; Habib, S.; Boulila, W.; Koubaa, A.; Javed, A.R.; Rizwan, M.; Gadekallu, T.R.; Sufiyan,
M. A survey on COVID-19 impact in the healthcare domain: worldwide market implementation,
applications, security and privacy issues, challenges and future prospects. Complex & intelligent systems
2023, 9, 1027–1058.
139. Zubaydi, H.D.; Varga, P.; Molnár, S. Leveraging Blockchain Technology for Ensuring Security and Privacy
Aspects in Internet of Things: A Systematic Literature Review. Sensors 2023, 23, 788.
140. Qahtan, S.; Yatim, K.; Zulzalil, H.; Osman, M.H.; Zaidan, A.; Alsattar, H. Review of healthcare industry 4.0
application-based blockchain in terms of security and privacy development attributes: Comprehensive
taxonomy, open issues and challenges and recommended solution. Journal of Network and Computer
Applications 2023, 209, 103529.
141. Albahri, A.; Duhaim, A.M.; Fadhel, M.A.; Alnoor, A.; Baqer, N.S.; Alzubaidi, L.; Albahri, O.; Alamoodi,
A.; Bai, J.; Salhi, A.; others. A systematic review of trustworthy and explainable artificial intelligence in
healthcare: Assessment of quality, bias risk, and data fusion. Information Fusion 2023.
142. Mahajan, H.B.; Rashid, A.S.; Junnarkar, A.A.; Uke, N.; Deshpande, S.D.; Futane, P.R.; Alkhayyat, A.;
Alhayani, B. Integration of Healthcare 4.0 and blockchain into secure cloud-based electronic health records
systems. Applied Nanoscience 2023, 13, 2329–2342.
143. Khanna, D.; Jindal, N.; Singh, H.; Rana, P.S. Applications and Challenges in Healthcare Big Data: A
Strategic Review. Current Medical Imaging 2023, 19, 27–36.
144. Guo, C.; Chen, J. Big data analytics in healthcare. In Knowledge Technology and Systems: Toward Establishing
Knowledge Systems Science; Springer, 2023; pp. 27–70.
145. El Khatib, M.; Hamidi, S.; Al Ameeri, I.; Al Zaabi, H.; Al Marqab, R. Digital Disruption and Big Data in
Healthcare-Opportunities and Challenges. ClinicoEconomics and Outcomes Research 2022, pp. 563–574.
146. Khan, M.I.; Loh, J. Benefits, challenges, and social impact of health care providers’ adoption of social
media. Social Science Computer Review 2022, 40, 1631–1647.
147. Jacob, C.; Sezgin, E.; Sanchez-Vazquez, A.; Ivory, C. Sociotechnical factors affecting patients’ adoption of
mobile health tools: systematic literature review and narrative synthesis. JMIR mHealth and uHealth 2022,
10, e36284.
148. Siyal, A.A.; Junejo, A.Z.; Zawish, M.; Ahmed, K.; Khalil, A.; Soursou, G. Applications of blockchain
technology in medicine and healthcare: Challenges and future perspectives. Cryptography 2019, 3, 3.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 19 September 2023 doi:10.20944/preprints202308.0867.v2

39 of 39

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those
of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s)
disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or
products referred to in the content.