Blockchain Revolutionizing in Emergency Medicine: A Scoping Review of Patient Journey through the ED

Abstract

Background:
Blockchain technology has revolutionized the healthcare sector, including emergency medicine, by integrating AI, machine learning, and big data, thereby transforming traditional healthcare practices. The increasing utilization and accumulation of personal health data also raises concerns about security and privacy, particularly within emergency medical settings.

Method:
Our review focused on articles published in databases such as Web of Science, PubMed, and Medline, discussing the revolutionary impact of blockchain technology within the context of the patient journey through the ED.

Results:
A total of 33 publications met our inclusion criteria. The findings emphasize that blockchain technology primarily finds its applications in data sharing and documentation. The pre-hospital and post-discharge applications stand out as distinctive features compared to other disciplines. Among various platforms, Ethereum and Hyperledger Fabric emerge as the most frequently utilized options, while Proof of Work (PoW) and Proof of Authority (PoA) stand out as the most commonly employed consensus algorithms in this emergency care domain. The ED journey map and two scenarios are presented, exemplifying the most distinctive applications of emergency medicine, and illustrating the potential of blockchain. Challenges such as interoperability, scalability, security, access control, and cost could potentially arise in emergency medical contexts, depending on the specific scenarios.

Conclusion:
Our study examines the ongoing research on blockchain technology, highlighting its current influence and potential future advancements in optimizing emergency medical services. This approach empowers frontline medical professionals to validate their practices and recognize the transformative potential of blockchain in emergency medical care, ultimately benefiting both patients and healthcare providers.

Full text

Citation: Wu, T.-C.; Ho, C.-T.B.
Blockchain Revolutionizing in
Emergency Medicine: A Scoping
Review of Patient Journey through
the ED. Healthcare 2023,11, 2497.
https://doi.org/10.3390/
healthcare11182497
Academic Editors: Daniele Giansanti,
Frank Po Wen Lo and Bo Xiao
Received: 31 July 2023
Revised: 29 August 2023
Accepted: 6 September 2023
Published: 8 September 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
healthcare
Review
Blockchain Revolutionizing in Emergency Medicine: A Scoping
Review of Patient Journey through the ED
Tzu-Chi Wu 1,2,* and Chien-Ta Bruce Ho 1
1Institute of Technology Management, National Chung-Hsing University, Taichung 40227, Taiwan;
bruceho@nchu.edu.tw
2Department of Emergency Medicine, Show Chwan Memorial Hospital, Changhua 500009, Taiwan
*Correspondence: j10062008@hotmail.com or d109026105@mail.nchu.edu.tw
Abstract:
Background: Blockchain technology has revolutionized the healthcare sector, including
emergency medicine, by integrating AI, machine learning, and big data, thereby transforming
traditional healthcare practices. The increasing utilization and accumulation of personal health data
also raises concerns about security and privacy, particularly within emergency medical settings.
Method: Our review focused on articles published in databases such as Web of Science, PubMed,
and Medline, discussing the revolutionary impact of blockchain technology within the context of the
patient journey through the ED. Results: A total of 33 publications met our inclusion criteria. The
findings emphasize that blockchain technology primarily finds its applications in data sharing and
documentation. The pre-hospital and post-discharge applications stand out as distinctive features
compared to other disciplines. Among various platforms, Ethereum and Hyperledger Fabric emerge
as the most frequently utilized options, while Proof of Work (PoW) and Proof of Authority (PoA)
stand out as the most commonly employed consensus algorithms in this emergency care domain. The
ED journey map and two scenarios are presented, exemplifying the most distinctive applications of
emergency medicine, and illustrating the potential of blockchain. Challenges such as interoperability,
scalability, security, access control, and cost could potentially arise in emergency medical contexts,
depending on the specific scenarios. Conclusion: Our study examines the ongoing research on
blockchain technology, highlighting its current influence and potential future advancements in
optimizing emergency medical services. This approach empowers frontline medical professionals
to validate their practices and recognize the transformative potential of blockchain in emergency
medical care, ultimately benefiting both patients and healthcare providers.
Keywords: blockchain; emergency medicine; IoT; AI; telemedicine
1. Introduction
In recent years, the field of emergency medicine care has witnessed a significant
transformation in our conventional healthcare models due to the widespread adoption and
application of digital technologies, including artificial intelligence [
1
], machine learning [
2
],
big data [
3
], and the metaverse. With the increasing adoption of digital technologies and
the growth of healthcare services, there has been a significant increase in the types, velocity,
and volume of personal health data, leading to a greater demand for data exchange within
the healthcare ecosystem. While big healthcare data holds significant potential, striking
a balance between permissible data applications and maintaining security and patients’
rights to privacy presents a formidable challenge [4].
Data security and data ownership have become focal points in the healthcare system [
5
].
The issue of sensitive healthcare data breaches has become a recurring concern, as evidenced
by incidents like the largest healthcare data breaches of 2018, which resulted in the exposure
of 13 million total healthcare records and led to significant repercussions [
6
]. At the same
time, sensitive information such as medical history, social security numbers, and financial
Healthcare 2023,11, 2497. https://doi.org/10.3390/healthcare11182497 https://www.mdpi.com/journal/healthcare

Healthcare 2023,11, 2497 2 of 29
details faces potential risks. Additionally, with the emergence of personalized healthcare
and wearable devices, the ownership of individual healthcare data and the implementation
of access control mechanisms have gained paramount significance [
5
,
7
]. During this period,
it becomes crucial to implement trustworthy technologies while maintaining trust and
safety among ecosystem participants. As a result, healthcare institutions are in urgent need
of reviewing the current clinical applications and proposing novel and improved solutions
to maintain trust and enhance data security within the emergency healthcare ecosystem.
So far, there have been numerous reviews focusing on the applications of blockchain
in healthcare. However, across different specialized medical disciplines, unique healthcare
sectors and practice settings each possess their own distinct characteristics. Alongside
widely utilized electronic medical record applications, the domain of emergency medi-
cal care presents specific requirements, encompassing pre-hospital emergency services,
inter-hospital transfers, as well as prehospital care for trauma and critical illnesses. These
particular aspects have not received a thorough examination in previous literature reviews
and have often been overlooked in the majority of evaluations concerning the implementa-
tion of blockchain technology in the healthcare sector. Therefore, considering the increasing
adoption of blockchain technology, a better understanding of its application and current
status in emergency care systems is urgently needed. The study is structured as follows:
Section 2provides an introduction to the background knowledge of blockchain; Section 3
elaborates on the research methods used; Section 4presents the obtained results; Section 5
discusses the findings; Section 6addresses future challenges and limitations; and finally,
Section 7concludes the study.
2. Background
2.1. Blockchain
Blockchain technology, a groundbreaking innovation, has swiftly gained traction,
with transformative potential across diverse sectors such as finance, healthcare, informa-
tion systems, government services, and supply chain management [
8
,
9
]. At its core, a
blockchain is a decentralized and distributed ledger that enables secure and transparent
record-keeping. The emergence of Bitcoin as a cryptocurrency marked the inception of
blockchain 1.0 technology [
10
]. Blockchain 2.0 involves distributed ledgers with smart
contracts, whereas Blockchain 3.0 denotes the application of blockchain technology beyond
financial contexts, aiming to extend the trustless and decentralized characteristics to other
systems, particularly in the healthcare domain [
11
]. In the following section, we will review
the structure and architecture of blockchains, as well as the strengths and weaknesses of
various consensus algorithms and platforms in the context of healthcare.
2.2. The Structure of a Blockchain
The blockchain is composed of numerous blocks, which are linked together one by
one to create a blockchain. Each block contains two primary components of data: the block
header and the block body (Figure 1). The block header functions as metadata for each
block within the blockchain, holding critical information about the block. It comprises
elements such as the version number, timestamp, nonce, Merkle root, and previous block
hash. The version number indicates the protocol version of the block, which is mainly used
for protocol upgrades. The timestamp denotes the block’s creation time, while the nonce is
a numerical value utilized in proof of work to ensure the block’s hash meets a specified
difficulty target. The Merkle root represents a tree-like structure that allows us to obtain
the hash value of a sequence of data. Lastly, the previous block hash points to the unique
identifier of the preceding block. This connection guarantees a sequential order of blocks
and validates the accuracy of previous blocks.

Healthcare 2023,11, 2497 3 of 29
Healthcare 2023, 11, x FOR PEER REVIEW 3 of 29
Figure 1. Blockchain architecture.
The other component is the block body, which encompasses all the data contributing
to the block’s generation. In the context of the Bitcoin blockchain, these data include
transaction records. The block body holds the actual information stored within the block
and can be considered the block’s payload. A blockchain is established by linking blocks,
with each block containing vital metadata in its block header and the actual data in its
block body. The block header ensures the integrity and order of blocks within the
blockchain, while the block body stores specific data relevant to the blockchain’s purpose,
such as transaction records in the case of the Bitcoin blockchain [7,8,12].
2.3. Layered Architecture of Blockchain
In the context of blockchain technology, the architecture typically consists of several
key layers that collaborate to enable the functionality of the blockchain network. These
layers encompass the infrastructure layer, data layer, network layer, consensus
mechanism, and application layer (Figure 2).
Figure 2. Layered architecture of the blockchain.
The infrastructure layer lays the groundwork by providing the essential elements
that underpin the operation of the blockchain network. This encompasses components
like the foundational hardware, network connectivity, and data storage. The data layer
shoulders the responsibility of storing and managing the factual data recorded on the
blockchain. Meanwhile, the network layer serves as the conduit for communication
among nodes within the blockchain network. This layer facilitates the dissemination of
Figure 1. Blockchain architecture.
The other component is the block body, which encompasses all the data contributing
to the block’s generation. In the context of the Bitcoin blockchain, these data include
transaction records. The block body holds the actual information stored within the block
and can be considered the block’s payload. A blockchain is established by linking blocks,
with each block containing vital metadata in its block header and the actual data in its block
body. The block header ensures the integrity and order of blocks within the blockchain,
while the block body stores specific data relevant to the blockchain’s purpose, such as
transaction records in the case of the Bitcoin blockchain [7,8,12].
2.3. Layered Architecture of Blockchain
In the context of blockchain technology, the architecture typically consists of several
key layers that collaborate to enable the functionality of the blockchain network. These
layers encompass the infrastructure layer, data layer, network layer, consensus mechanism,
and application layer (Figure 2).
Healthcare 2023, 11, x FOR PEER REVIEW 3 of 29
Figure 1. Blockchain architecture.
The other component is the block body, which encompasses all the data contributing
to the block’s generation. In the context of the Bitcoin blockchain, these data include
transaction records. The block body holds the actual information stored within the block
and can be considered the block’s payload. A blockchain is established by linking blocks,
with each block containing vital metadata in its block header and the actual data in its
block body. The block header ensures the integrity and order of blocks within the
blockchain, while the block body stores specific data relevant to the blockchain’s purpose,
such as transaction records in the case of the Bitcoin blockchain [7,8,12].
2.3. Layered Architecture of Blockchain
In the context of blockchain technology, the architecture typically consists of several
key layers that collaborate to enable the functionality of the blockchain network. These
layers encompass the infrastructure layer, data layer, network layer, consensus
mechanism, and application layer (Figure 2).
Figure 2. Layered architecture of the blockchain.
The infrastructure layer lays the groundwork by providing the essential elements
that underpin the operation of the blockchain network. This encompasses components
like the foundational hardware, network connectivity, and data storage. The data layer
shoulders the responsibility of storing and managing the factual data recorded on the
blockchain. Meanwhile, the network layer serves as the conduit for communication
among nodes within the blockchain network. This layer facilitates the dissemination of
Figure 2. Layered architecture of the blockchain.
The infrastructure layer lays the groundwork by providing the essential elements that
underpin the operation of the blockchain network. This encompasses components like the
foundational hardware, network connectivity, and data storage. The data layer shoulders
the responsibility of storing and managing the factual data recorded on the blockchain.
Meanwhile, the network layer serves as the conduit for communication among nodes
within the blockchain network. This layer facilitates the dissemination of transactions and
blocks across the network. The consensus mechanism, on the other hand, establishes the
regulations and protocols that guide the nodes in reaching an accord on the blockchain’s
state. It ensures a unanimous consensus among nodes regarding the validity of transactions
and the sequence in which they are appended to the blockchain. There are several proposed

Healthcare 2023,11, 2497 4 of 29
and implemented consensus protocols, with the three most commonly used ones are Proof
of Work (PoW), Proof of Stake (PoS), and Proof of Authority (PoA) [13,14].
Among the consensus algorithms, Proof of Work (PoW) is the most well-known
and closely associated with block-chain technology, particularly due to its integration in
Bitcoin. Its strengths in healthcare include a well-established consensus algorithm that
is decentralized and highly secure, as it does not rely on a central authority to validate
transactions. However, it is highly energy-intensive and can be slow, requiring a significant
amount of time to validate transactions. Healthcare providers might need to bear higher
resource, cost, and time burdens, which could be a drawback, especially in acute care
settings. We have summarized the pros and cons of other types of consensus algorithms in
healthcare in Table 1.
Lastly, the application layer becomes the realm where developers construct and deploy
decentralized applications (DApps) atop the blockchain. This layer interacts with the
underlying strata to provide specific functionalities to end-users. These DApps encompass
a variety of utilities, such as smart contracts, token issuance, and supply chain tracking,
among others [
1
,
15
–
17
]. The use of smart contracts in the application layer ensures data
provenance and eliminates the need for intermediaries [
12
]. Smart contracts are self-
executing agreements where predefined provisions are encoded in the source code. As
these contracts are automatically enforced based on predetermined conditions, they operate
without the involvement of third parties or intermediaries. This not only eliminates the
need for intermediaries but also provides all stakeholders with a secure and immutable
transaction history [8,18].
Table 1. Strengths/weaknesses of consensus algorithms.
Consensus Algorithm Strength Weakness Ref.
Proof of Work
(PoW)
1. Well-established
2. Highly secure
3. Decentralized
1. Highly energy-intensive
2. Slow, requires time
3. Be vulnerable to centralization
[1,7,8,13,19]
Proof of Stake
(PoS)
1. Less energy-intensive
2. Require less computational
power
3. Faster (than PoW)
1. Less secure
2. Be vulnerable to centralization
3. Not tested in production
environments
Delegated Proof of Stake
(DPoS)
1. Faster (than PoW, PoS)
2. More scalable
3. More decentralized (than PoW,
PoS)
1. Less secure
2. Requires active voter
3. Limited scalability
Proof of Authority
(PoA)
1. Faster processing
2. Lower energy consumption
3. Ideal for private blockchains
1. Less decentralized, centralized
Practical Byzantine Fault
Tolerance
(PBFT)
1. High speed and efficiency
2. Suitable for permissioned
blockchain
3. Tolerates a certain number of
faulty nodes
1. Less secure
2. Vulnerable to attacks
3. Limited scalability

Healthcare 2023,11, 2497 5 of 29
2.4. Types of Blockchains
There are three types of blockchains: public, hybrid, and private (Figure 3). Public
blockchains, also known as permissionless blockchains, are exemplified by cryptocurrencies
like Bitcoin [
10
] and Ethereum [
20
], which are extensively employed. Hybrid blockchains,
alternatively referred to as consortium blockchains or federated blockchains, exhibit par-
tial centralization. On the other hand, private blockchains, recognized as permissioned
blockchains, uphold a distributed network that is frequently centralized [8].
Healthcare 2023, 11, x FOR PEER REVIEW 5 of 29
Public blockchains are open to anyone with internet access, allowing anyone to
participate in the network. However, they can be less private, slower, and less scalable,
particularly in healthcare applications. In contrast, private blockchains restrict
participation to known individuals or entities, ensuring controlled and limited access to
the blockchain network. Nevertheless, they may be more susceptible to aacks and
failures due to their lesser decentralization compared to other blockchain types.
Additionally, private blockchains could be burdensome for healthcare entities, as they
tend to be more expensive to set up. Hybrid blockchains offer the advantages of both
public and private blockchains, yet they are concurrently more intricate and more
susceptible to aacks [7,8,21].
Figure 3. Types of blockchains.
2.5. Blockchain Platform
There are numerous blockchain platform options available in the current landscape,
including Ethereum, Hyperledger, MedRec [22], and MultiChain [23], all of which have
been integrated into healthcare systems. Each platform possesses its own strengths and
weaknesses. Public blockchain platforms like Ethereum and private ones like Hyperledger
are well-known examples. Hyperledger encompasses various established projects,
including Hyperledger Fabric, Hyperledger Besu, and Hyperledger Indy, among others
[24]. Hyperledger Fabric, in particular, stands out as an enterprise-grade, authorized,
secure, and high-performance blockchain network. Functioning as a permissioned
blockchain platform, Hyperledger Fabric enables the establishment of private and secure
networks tailored for healthcare entities. Its noteworthy scalability makes it a viable
option for healthcare applications that involve a substantial volume of transactions.
However, it displays less decentralization compared to some other blockchain platforms,
which could potentially expose it to increased vulnerability to aacks and operational
limitations [24,25].
Conversely, Ethereum, a prominent public blockchain platform, is firmly established
with a substantial developer community and a wealth of tools and resources.
Nevertheless, it can experience slowness and restricted scalability, which can pose
challenges when dealing with a significant number of transactions [7,24,25]. The process
of selecting an appropriate off-the-shelf blockchain platform for a specific healthcare or
clinical application can be intricate. In previous reviews, a portion of healthcare
applications leaned towards the utilization of private or consortium (publicly
Figure 3. Types of blockchains.
Public blockchains are open to anyone with internet access, allowing anyone to partici-
pate in the network. However, they can be less private, slower, and less scalable, particularly
in healthcare applications. In contrast, private blockchains restrict participation to known
individuals or entities, ensuring controlled and limited access to the blockchain network.
Nevertheless, they may be more susceptible to attacks and failures due to their lesser
decentralization compared to other blockchain types. Additionally, private blockchains
could be burdensome for healthcare entities, as they tend to be more expensive to set up.
Hybrid blockchains offer the advantages of both public and private blockchains, yet they
are concurrently more intricate and more susceptible to attacks [7,8,21].
2.5. Blockchain Platform
There are numerous blockchain platform options available in the current landscape,
including Ethereum, Hyperledger, MedRec [
22
], and MultiChain [
23
], all of which have
been integrated into healthcare systems. Each platform possesses its own strengths and
weaknesses. Public blockchain platforms like Ethereum and private ones like Hyperledger
are well-known examples. Hyperledger encompasses various established projects, includ-
ing Hyperledger Fabric, Hyperledger Besu, and Hyperledger Indy, among others [
24
].
Hyperledger Fabric, in particular, stands out as an enterprise-grade, authorized, secure,
and high-performance blockchain network. Functioning as a permissioned blockchain plat-
form, Hyperledger Fabric enables the establishment of private and secure networks tailored
for healthcare entities. Its noteworthy scalability makes it a viable option for healthcare
applications that involve a substantial volume of transactions. However, it displays less
decentralization compared to some other blockchain platforms, which could potentially
expose it to increased vulnerability to attacks and operational limitations [24,25].

Healthcare 2023,11, 2497 6 of 29
Conversely, Ethereum, a prominent public blockchain platform, is firmly established
with a substantial developer community and a wealth of tools and resources. Nevertheless,
it can experience slowness and restricted scalability, which can pose challenges when
dealing with a significant number of transactions [
7
,
24
,
25
]. The process of selecting an
appropriate off-the-shelf blockchain platform for a specific healthcare or clinical application
can be intricate. In previous reviews, a portion of healthcare applications leaned towards
the utilization of private or consortium (publicly permissioned) blockchains. This trend is
understandable within the healthcare context due to the desire to retain control over access
and data recording on the blockchain. Allowing unrestricted writing (adding blocks to the
blockchain) or access is not conducive [
12
,
26
]. The decision between adopting public or pri-
vate blockchain networks within the healthcare sector may hinge on specific requirements,
regulatory considerations, and the levels of trust established among stakeholders. We have
summarized the pros and cons of platforms in healthcare in Table 2.
Table 2. Strengths/weaknesses of platforms.
Platform Strength Weakness Ref.
Hyperledger
1. Permissioned blockchain
platform
2. Supports smart contracts
3. Highly scalable
1. Less decentralized
2. Still being developed, smaller
developer community
3. Complex to set up
[1,7,23–25,27]
Ethereum
1. Well-established
2. Supports smart contracts
3. Supports dApps
4. Highly decentralized
1. Highly energy-intensive
2. Slow
3. Less scalable
4. High cost
MedRec
1. Permissioned blockchain
2. Interoperability
3. Secure and decentralized
platform for storing and sharing
medical records
1. Limited scalability
2. Compatibility
3. Challenges related to regulatory
compliance
4. Data standardization
MultiChain 1. Flexible
2. Customizable platform
1. Smaller developer community
2. High technical expertise to set up
and maintain
2.6. The Features of Blockchain
The important characteristics of blockchain, including auditability, anonymity, trans-
parency, immutability, decentralization, and autonomy, have the potential to play a crucial
role in ensuring that patients’ personal health information is collected, shared, and utilized
appropriately in the context of medical care (Figure 4) [
4
]. Blockchain’s auditability ensures
a tamper-proof ledger of all transactions, accessible for auditing and verification by any
network participant. Anonymity offers a heightened level of privacy, allowing users to
transact without disclosing their real-world identities, a particularly crucial aspect in sensi-
tive fields like healthcare. The transparency feature furnishes an open and clear record of
all transactions, accessible to all network participants. The immutability of the blockchain
guarantees an unalterable record of transactions, resistant to any changes or deletions once
recorded. Furthermore, its decentralized nature eliminates the reliance on a central author-
ity for transaction validation. Additionally, blockchain operates autonomously, requiring
minimal human intervention [7,28].

Healthcare 2023,11, 2497 7 of 29
Healthcare 2023, 11, x FOR PEER REVIEW 7 of 29
Figure 4. The key features of blockchain technology.
2.7. State-of-the-Art Application and Reviews of Blockchain for HealthCare
Blockchain technology emerges as a groundbreaking force, possessing substantial
untapped potential capable of catalyzing significant advancements across diverse
healthcare domains, thereby introducing unprecedented transformations. Notably, recent
strides in Internet of Things (IoT) technology have facilitated enhanced connectivity,
enabling seamless access to critical patient information, vital hospital resources, and
wearable devices. The integration of blockchain-driven healthcare further amplifies these
advancements. The expansion of health data collection, particularly in the context of
remote patient monitoring, encompasses a wide spectrum of health-related information,
thereby presenting intricate challenges pertaining to data sharing and accessibility that
extend beyond the confines of healthcare facilities. By affording patients complete
sovereignty over their historical health records, blockchain assumes a pivotal role in
substantially shaping healthcare efficiency and optimizing cost-effectiveness. The
empowerment of patients with comprehensive insights into their health records
culminates in a remarkable reduction of superfluous documentation and medically
redundant tests [5,29–31].
Drawing upon the insights gleaned from Table 3, the scholarly community has
exhibited a profound interest in probing the influence of blockchain technology within
the healthcare landscape. Numerous researchers have undertaken extensive
investigations, elucidating the multifaceted impact of blockchain, with a distinct emphasis
on its adoption and application across healthcare domains [32]. Furthermore, an array of
reviews has predominantly centered on scrutinizing electronic medical records (EMRs)
and electronic health records (EHRs) [32–34]. Notably, recent trends have showcased an
emergent inclination toward reviews that encompass the realms of IoT, AI, and
telemedicine applications. However, comprehensive evaluations specifically focusing on
blockchain remain relatively scarce, with specialized reviews primarily concentrating on
sectors such as dentistry [35], oncology [36], orthopedics [37], radiology [38], and
neuroscience [39]. Significantly, the exploration of adoption studies within the realm of
emergency care remains conspicuously underrepresented. Each specialized medical
discipline introduces unique care paradigms, underscoring the paramount importance
Figure 4. The key features of blockchain technology.
2.7. State-of-the-Art Application and Reviews of Blockchain for Healthcare
Blockchain technology emerges as a groundbreaking force, possessing substantial un-
tapped potential capable of catalyzing significant advancements across diverse healthcare
domains, thereby introducing unprecedented transformations. Notably, recent strides in
Internet of Things (IoT) technology have facilitated enhanced connectivity, enabling seam-
less access to critical patient information, vital hospital resources, and wearable devices.
The integration of blockchain-driven healthcare further amplifies these advancements. The
expansion of health data collection, particularly in the context of remote patient monitoring,
encompasses a wide spectrum of health-related information, thereby presenting intricate
challenges pertaining to data sharing and accessibility that extend beyond the confines of
healthcare facilities. By affording patients complete sovereignty over their historical health
records, blockchain assumes a pivotal role in substantially shaping healthcare efficiency
and optimizing cost-effectiveness. The empowerment of patients with comprehensive
insights into their health records culminates in a remarkable reduction of superfluous
documentation and medically redundant tests [5,29–31].
Drawing upon the insights gleaned from Table 3, the scholarly community has ex-
hibited a profound interest in probing the influence of blockchain technology within the
healthcare landscape. Numerous researchers have undertaken extensive investigations,
elucidating the multifaceted impact of blockchain, with a distinct emphasis on its adoption
and application across healthcare domains [
32
]. Furthermore, an array of reviews has
predominantly centered on scrutinizing electronic medical records (EMRs) and electronic
health records (EHRs) [
32
–
34
]. Notably, recent trends have showcased an emergent inclina-
tion toward reviews that encompass the realms of IoT, AI, and telemedicine applications.
However, comprehensive evaluations specifically focusing on blockchain remain relatively
scarce, with specialized reviews primarily concentrating on sectors such as dentistry [
35
],
oncology [
36
], orthopedics [
37
], radiology [
38
], and neuroscience [
39
]. Significantly, the
exploration of adoption studies within the realm of emergency care remains conspicuously
underrepresented. Each specialized medical discipline introduces unique care paradigms,
underscoring the paramount importance and exigency of conducting meticulous and
tailored literature reviews tailored to each respective subdomain.

Healthcare 2023,11, 2497 8 of 29
Table 3. Previous reviews on blockchain in healthcare.
Study Year Review Type Context
[26] 2018 Systematic Review Analysis of state-of-the-art blockchain research in the field of healthcare.
[27] 2019 Systematic Review Showcased the ongoing research into the application of blockchain
technology in the healthcare sector.
[40] 2019 Comprehensive Review Conducting a review to analyze and map the research landscape of
blockchain technologies, particularly their applications in healthcare.
[41] 2019 Review Presented the applications and challenges of blockchain technology faced
by the healthcare industry.
[42] 2019 Review Examine the concept of blockchain technology and the challenges
associated with its adoption, and a review of the recent implementations.
[24] 2019 Systematic Review Introduce healthcare and biomedical blockchain applications along with
their underlying platforms and compare popular platforms.
[43] 2019 Systematic Review Focus on blockchain-based electronic medical record systems.
[44] 2020 Systematic Literature Review Current implications for the use of blockchain technology for improving
healthcare processes.
[8] 2020 Scoping Review Provided a review of the utilization and proposal of blockchain to enhance
processes and services within the healthcare sector.
[31] 2020 Systematic Review Evaluate blockchain technology research for patient care and propose a
research agenda.
[32] 2020 Systematic Review Blockchain technology in electronic health records.
[45] 2020 Scoping Review Examine and classify the advantages and risks associated with
implementing blockchain technology in healthcare systems.
[36] 2020 Systematic Literature Review
Examine the motivations, advantages, limitations, and future challenges of
implementing advanced distributed ledger technology in the field of
oncology.
[33] 2021 Systematic Review Blockchain Personal Health Records
[46] 2021 Systematic Review
The potential of blockchain technology in healthcare applications, including
those related to COVID-19 and non-COVID-19 contexts.
[37] 2021 Systematic Review Blockchain technology in orthopedic healthcare.
[47] 2021 Narrative Review Summarizing current and future uses of blockchain in healthcare and
upcoming research directions.
[48] 2021 Review
Illustrate cases showcasing the practical application of blockchain
technology in the domain of telehealth and telemedicine and delve into the
associated challenges.
[49] 2021 Analytical Review To comprehend the full range of blockchain implementations and explore
the potential of blockchain solutions in healthcare.
[39] 2021 Review Blockchain technology in medicine and neurology.
[34] 2022 Scoping Review Highlight the potential and obstacles of incorporating blockchain
technology into EHR systems.
[38] 2022 Review Blockchain technology in radiology research and clinical practice.
[50] 2023 Scoping Review
Explores the benefits, challenges, and patient empowerment gaps in
integrating blockchain technology within the existing healthcare landscape,
particularly in the patient-centric blockchain-based framework of the EHR
paradigm.
[51] 2023 Review Examine the significance and constraints associated with the utilization of
blockchain technologies for enhancing healthcare operations.
[52] 2023 Systematic Review Concentrate on privacy-enhancing techniques utilizing blockchain and
federated learning in telemedicine.
[53] 2023 Systematic Review Summarizing existing studies on blockchain adoption in healthcare.
[35] 2023 Literature Review Blockchain technology in dental healthcare.
[54] 2023 Systematic Literature Review
Approaches involving the integration of blockchain and IoT are specifically
aimed at addressing certain security and privacy-related issues.

Healthcare 2023,11, 2497 9 of 29
2.8. Research Questions
To ensure comprehensive coverage of relevant literature on the topic of interest, we
formulated the following initial research questions:
1. What is the level of adoption of blockchain in the field of emergency healthcare, and
what are the current applications?
2.
From the perspective of the emergency department journey, what are the trends in the
application of blockchain in emergency healthcare?
3.
What are the specific elements of blockchain technology utilized in publications
related to emergency medicine?
From the perspective of the ED journey, we explore how blockchain can be integrated
into tracking the workflow of a patient from the pre-hospital stage to triage, treatment
planning, and post-discharge care.
3. Methodology
3.1. Research Protocol
This scoping review aimed to gain insights into the current development and ap-
plication of blockchain technology in emergency medicine. The review adheres to the
Preferred Reporting for Systematic Reviews and Meta-Analysis Extension for Scoping
Reviews (PRISMA-ScR) guidelines and is reported accordingly with the PRISMA-ScR
checklist [55].
3.2. Eligibility Criteria
To be eligible for inclusion in this review, papers needed to focus on the application
of blockchain technology in the field of acute medicine. The data sources encompassed
the Web of Science (WoS), PubMed, and Medline. The search strings were formulated in
accordance with the research domain and the specified research questions. The search
terms were as follows:
(Blockchain OR “block chain”) AND (Emergency medicine OR acute medicine OR acute
care OR ED)
To make the literature search more comprehensive, we also included other relevant
keywords related to the emergency department journey, such as pre-hospital, triage, inter-
hospital transfers, and disposition.
(Blockchain OR “block chain”) AND (pre-hospital)
(Blockchain OR “block chain”) AND (triage)
(Blockchain OR “block chain”) AND (inter-hospital transfers OR hospital transfers)
(Blockchain OR “block chain”) AND (disposition OR discharge disposition OR post discharge)
The selection of search terms for this scoping review was based on those commonly
used in previous reviews. The term “blockchain” was employed as a consistent search term
across all reviews. Additionally, another search term was chosen by the majority authors:
“healthcare or medicine OR Medical Management [
8
,
12
,
26
]”. Our choice aimed to narrow
the focus of healthcare to the context of emergency medical care within this scoping review.
To ensure a comprehensive scope of search, several intermediate stages of the emergency
care journey were also incorporated, seeking a more holistic understanding.
Regarding database selection, Web of Science (WOS) was chosen as a recognized
authoritative source for social sciences and technology-related information. PubMed and
Medline were included due to their coverage of all medical-related literature, establishing
them as standard data sources for research papers in health informatics. However, despite
the inclusion of these key databases, the comprehensiveness of the sources might have been
limited. This limitation will be acknowledged and discussed in the dedicated section. We
included studies from the years 2008 to 2023. The reason for choosing the year 2008 as the
beginning of the range is the introduction of Bitcoin in 2008, which was the first published
application of blockchain technology. The literature search was last updated on 30 June

Healthcare 2023,11, 2497 10 of 29
2023. All reference results were exported into EndNote, and duplicates were subsequently
removed.
3.3. Selection of Studies
Inclusion criteria:
1. Original research studies.
2. Publications related to blockchain technology in the acute medical care sector.
3.
Publications related to blockchain technology are used in the journey of emergency
medicine.
Exclusion criteria:
1. Papers without full-text availability.
2. Papers with a focus other than the use of blockchain in the acute medical care sector.
3. Duplicate papers.
4.
Editorials, prefaces, paper summaries, summaries of tutorials, correspondences, dis-
cussions, comments, readers’ letters, workshops, panels, and poster sessions in the
search results.
Two researchers conducted the evaluation collaboratively. The selection procedure
encompassed the assessment of titles, abstracts, and complete articles by the first reviewer
to ascertain the inclusion of pertinent papers. In cases where the initial reviewer had
uncertainties about certain articles, they were subjected to a second evaluation by a separate
reviewer. Both reviewers meticulously examined the retrieved articles and documented the
data using a pre-established matrix that they jointly formulated.
4. Results
A total of 328 articles were identified, out of which 47 were duplicates. After applying
the inclusion and exclusion criteria, 281 articles were reviewed, and 33 articles remained
for further analysis (Figure 5).
Healthcare 2023, 11, x FOR PEER REVIEW 10 of 29
the beginning of the range is the introduction of Bitcoin in 2008, which was the first
published application of blockchain technology. The literature search was last updated on
30 June 2023. All reference results were exported into EndNote, and duplicates were
subsequently removed.
3.3. Selection of Studies
Inclusion criteria:
1. Original research studies.
2. Publications related to blockchain technology in the acute medical care sector.
3. Publications related to blockchain technology are used in the journey of emergency
medicine.
Exclusion criteria:
1. Papers without full-text availability.
2. Papers with a focus other than the use of blockchain in the acute medical care sector.
3. Duplicate papers.
4. Editorials, prefaces, paper summaries, summaries of tutorials, correspondences,
discussions, comments, readers’ leers, workshops, panels, and poster sessions in the
search results.
Two researchers conducted the evaluation collaboratively. The selection procedure
encompassed the assessment of titles, abstracts, and complete articles by the first reviewer
to ascertain the inclusion of pertinent papers. In cases where the initial reviewer had
uncertainties about certain articles, they were subjected to a second evaluation by a
separate reviewer. Both reviewers meticulously examined the retrieved articles and
documented the data using a pre-established matrix that they jointly formulated.
4. Results
A total of 328 articles were identified, out of which 47 were duplicates. After applying
the inclusion and exclusion criteria, 281 articles were reviewed, and 33 articles remained
for further analysis (Figure 5).
Figure 5. PRISMA-ScR flow diagram.
The details of 33 articles are provided in Table 4. The findings reveal that data sharing
and documentation, including personal health records (PHR) and electronic health
records, are the primary areas where blockchain technology is applied. Notably, the pre-
hospital application stands out as a distinctive aspect compared to other disciplines,
encompassing hospital referrals, trauma scene alarm systems, secure drone information
Figure 5. PRISMA-ScR flow diagram.

Healthcare 2023,11, 2497 11 of 29
The details of 33 articles are provided in Table 4. The findings reveal that data sharing
and documentation, including personal health records (PHR) and electronic health records,
are the primary areas where blockchain technology is applied. Notably, the pre-hospital
application stands out as a distinctive aspect compared to other disciplines, encompassing
hospital referrals, trauma scene alarm systems, secure drone information dissemination,
and even the dispatch of emergency materials during disasters. Additionally, AI and deep
learning are the most commonly paired technologies with blockchain, while smart phones,
IoT, and IoMT have generated numerous emerging data sources.
Table 4. Overview of the included studies.
Id, (Year),
Reference Journey of ED Technic or
Application
Main
Chal-
lenge/Limitation
Consensus Al-
gorithm/Smart
Contracts
Types of
Blockchains
Blockchain
Platform
1. (2019) [56]Pre-hospital
(referral)
EMR, EHR
(medical
referral service)
Scalability
Proof of
Authority (PoA)
and PoET/Yes
Consortium
blockchain Go Ethereum
2. (2021) [57] Pre-hospital UAV
Privacy,
scalability,
security/cost,
and capacity
PoW/Yes Public
blockchain Ethereum
3. (2022) [58] Pre-hospital UAV Security and
effectiveness
Not de-
fined/hashed
time locked
contract
Not defined Not defined
4. (2022) [59] Pre-hospital IoT Trust and
transparency
Not
defined/Yes
Private
blockchain
Hyperledger
Fabric
5. (2023) [60] Pre-hospital
Dispatch of
emergency
materials
Automated,
reinforcement
learning
PoS, DPos,
authorization
proof,
PBFT/Yes
Public,
consortium,
and private
blockchain
Hyperledger
Fabric
6. (2023) [61] Pre-hospital
Internet of
Vehicles (IoV)
and IoMT
Data storage,
confidentiality,
and security
PoW/Yes Public and
consortium Ethereum
7. (2019) [62]Documentation,
data exchange
Personal Health
Record (blood
sugar)
Data privacy
regulations PoW/Yes Hybrid
blockchain Not defined
8. (2020) [63]Documentation,
data exchange EHR
Privacy,
scalability, and
availability
Not
defined/Yes
Consortium
blockchain
Hyperledger
Fabric
9. (2020) [64]Documentation,
data exchange
COVID-19 data
sharing, ML
Privacy,
integrity, and
scalability
Not
defined/Yes
Public-
permissioned
blockchain
MedRec
10. (2020) [65]Documentation,
data exchange EHR
Secure,
trustable data
sharing
PoW and
PBFT/Yes
Private
blockchain
Hyperledger
Fabric
11. (2021) [66]Documentation,
data exchange
IoMT, edge
computing,
MEdge-Chain
architecture
Efficient, secure
connectivity
Proof of Stake
(DPoS)/Yes
Permissioned
blockchain Not defined

Healthcare 2023,11, 2497 12 of 29
Table 4. Cont.
Id, (Year),
Reference Journey of ED Technic or
Application
Main
Chal-
lenge/Limitation
Consensus Al-
gorithm/Smart
Contracts
Types of
Blockchains
Blockchain
Platform
12. (2021) [67]Documentation,
data exchange
Personal Health
Record
Data
integration,
data ownership,
and privacy
Proof of elapsed
time consensus
algorithm/Yes
Private
blockchain
Hyperledger
Fabric
13. (2022) [68]Documentation,
data exchange
Personal Health
Record
(PHR)
Retrieve
cross-hospital
medical data,
low adoption
rate
Proof of
Authority
(PoA)/Yes
Consortium
blockchain
iWellChain
Frame-
work/Ethereum
14. (2022) [69]Documentation,
data exchange
Patient data
sharing and
storage
Legal
ramifications,
delayed
transactions,
and costs
Proof of
Authority
(PoA)/Yes
Private
blockchain Ethereum
15. (2022) [70]Documentation,
data exchange
Transfer from
EHR to patient
PHR
Performance
and energy
consumption
Proof of
Authority
(PoA)/Yes
Private
blockchain Ethereum
16. (2023) [71]Documentation,
data exchange
IoMT, deep
learning, AI Data security Not
defined/Yes Not defined Not defined
17. (2023) [72]Documentation,
data exchange
IoMT,
healthcare
smartphone
Security,
reliability PBFT/Yes Consortium
blockchain
Hyperledger
Fabric
18. (2022) [73] Medical care Supply chain of
medicines
Solid, secure,
decentralized,
transparent
Not
defined/Yes
Private/public
blockchain
Hyperledger
Fabric
19. (2021) [74] Medical care Telemedicine Scalable issue Proof of work
(PoW)/No Not defined Not defined
20. (2020) [75] Medical care
Supply chain
for medical
supplies
Transparency,
improving
efficiency
Not
defined/No Not defined Not defined
21. (2022) [76] Medical care
Acute
craniocerebral
trauma
anesthesia
Medical data
sharing
Not
defined/No Not defined Not defined
22. (2022) [77] Medical care
Stroke care
information
management
Decreasing wait
times, secure
Not
defined/No Not defined Not defined
23. (2022) [78] Medical care
CNN for
COVID image
detection
Data security Proof of Work
(PoW)/No
Permissioned
blockchain Not defined
24. (2022) [79]
Medical care
(blood pressure
sensor)
Fog computing,
IoMT
Packet error
rate, reliability,
and throughput
Proof of Work
(PoW)/Yes
Private
blockchain Ethereum

Healthcare 2023,11, 2497 13 of 29
Table 4. Cont.
Id, (Year),
Reference Journey of ED Technic or
Application
Main
Chal-
lenge/Limitation
Consensus Al-
gorithm/Smart
Contracts
Types of
Blockchains
Blockchain
Platform
25. (2023) [80] Medical care
Blockchain with
IoT, supply
chain
management
Quality
assurance,
tracing,
transparency,
and security
Proof of Work
(PoW)/Yes
Public
blockchain Ethereum
26. (2020) [81] Disposition
COVID
surveillance
and case
tracking system
Standardization
and
interoperability
Proof of
Authority
(PoA)/No
Private
blockchain Ethereum
27. (2021) [82] Disposition IoMT, machine
learning
Limited
information
Not
defined/No Not defined Not defined
28. (2021) [83] Home
IoMT, transfer
personal data to
hospital system
Decreased time,
precise, and
cost-effective
Proof of Work
(PoW)/Yes
Public/Private
Blockchain Ethereum
29. (2021) [84] Home
IoT,
interplanetary
file system
(IPFS)
Security and
privacy
Not
defined/Yes
Hybrid
blockchain Not defined
30. (2021) [85] Home AI, IoT Privacy and
security
Not
defined/No Not defined Not defined
31. (2021) [86] Home IoT data and
AIoT Cost Not
defined/No Not defined Not defined
32. (2018) [87] Others
Health
Professions
Education
Trust and
transparency
Not
defined/No Not defined Not defined
33. (2019) [88] Others Clinical trials Policy change Not
defined/No Not defined Not defined
Among the various platforms, Ethereum (n = 10) and Hyperledger Fabric (n = 7)
emerge as the most frequently utilized ones in this domain. Regarding the type of
blockchain, several papers failed to define their approach, especially in the journey of
medical care and post-disposition, but it appears that public blockchains and consortiums
are the preferred types, especially in pre-hospital domains. As for the consensus algorithm,
the most frequently used consensus algorithm in the included publications was PoW, ac-
counting for 27% (9/33) of the published works, followed by PoA, which accounted for
15% (5/33).
Regarding smart contracts, 66.7% (22/33) of the included studies utilized them for
various functionalities, while the remaining studies did not specify if smart contracts were
employed or not. Privacy, security, access control, and interoperability are all important
issues addressed in these publications. Interoperability, data integrity consistency, and cost
could be challenges in the future for the emergency medicine journey.

Healthcare 2023,11, 2497 14 of 29
5. Discussion
In our review, we have observed a growing number of blockchain applications in
emergency medical care. The most prevalent application involves medical record manage-
ment, followed by healthcare delivery, post-discharge monitoring, and pre-hospital care.
The former has rapidly developed due to its universal demand across the medical field,
and there is a gradual increase in the adoption of blockchain in specialized emergency care
applications. With the advancement of IoT and 5G technologies, post-discharge monitoring
and pre-hospital care hold the potential to significantly benefit from blockchain technology.
Regarding the utilization of consensus algorithms, each consensus method possesses
its own strengths and weaknesses, dependent on specific characteristics [
13
]. Among
these methods, Proof of Work (PoW) and Proof of Authority (PoA) stand out as the most
commonly employed consensus algorithms in our review. The notable strength of PoW lies
in its security, which is a critical and prioritized factor in healthcare applications. However,
PoW’s energy-intensive and slow nature might pose challenges in healthcare scenarios that
demand swift and efficient data processing. Similarly, PoS algorithms are well-established
but offer relatively lower security. Consequently, they may not align well with healthcare
applications that demand both security and speedy transaction processing in the future.
PoA, on the other hand, presents opportunities through its attributes of speed, lower energy
consumption, and privacy. It streamlines the consensus process, enhances energy efficiency,
and restricts participation to predefined authorities or validators, making it suitable for
healthcare settings [19].
Similar to the findings of previous reviews, Ethereum and Hyperledger Fabric are
the primary platforms of focus. Ethereum’s strength lies in its well-established nature,
flexibility, and user friendliness, which facilitate smooth applications in acute medical
care. However, in the future, challenges may arise due to its potential to be slower, more
energy-intensive, and less scalable compared to other blockchain platforms. As the volume
of real-time individual data increases in pre-hospital care and post-discharge IoT scenarios,
healthcare will face greater challenges. On the other hand, Hyperledger Fabric boasts high
scalability, making it particularly suitable for healthcare applications with a significant
transaction load. Its standout feature is its emphasis on privacy and security, allowing
organizations to maintain control over data and transaction access, which proves to be
a significant advantage in healthcare applications. Nonetheless, Hyperledger Fabric’s
complexity and higher learning curve present challenges and signify areas where efforts
can be directed for future emergency medical education and promotion.
Next, we have created an emergency department journey map (Figure 6) and allocated
the “ID Numbers” of selected studies to their respective stages within the journey. The emer-
gency department (ED) map illustrates a patient’s journey, commencing with pre-arrival
incidents like car accidents or heart attacks, advancing to pre-hospital care or transfers,
followed by the arrival at the emergency entrance for triage, subsequent assessment and
treatment, disposition, and ultimately returning home. The inclusion of ID numbers along
this pathway signifies the placement and relevance of blockchain applications along the
emergency department journey. This aids in providing a clearer comprehension of the
current status and potential growth of blockchain applications at different phases of the
journey. In the forthcoming discussion, we will delve into the current scenario and future
prospects of blockchain applications based on the emergency department journey map. Fi-
nally, we will provide examples focused on two distinctive scenarios in emergency medical
care: pre-hospital and disposition at home.

Healthcare 2023,11, 2497 15 of 29
Healthcare 2023, 11, x FOR PEER REVIEW 14 of 29
Figure 6. Emergency department journey map (ID Number of the included studies in Table 4).
Figure 6. Emergency department journey map (ID Number of the included studies in Table 4).

Healthcare 2023,11, 2497 16 of 29
5.1. Pre-Hospital
In the application of blockchain, pre-hospital emergency medical care stands out as the
most distinctive aspect compared to other specialties. It comprises two major components:
emergency medical services (EMS) and inter-hospital transfers (IHTs), with the former
being particularly noteworthy. EMS serves a paramount role in preserving human lives
and reducing mortality and morbidity rates [
89
]. Various studies have demonstrated that
accurate and early detection by EMS plays a crucial role in timely hospital management and
admission for emergencies such as ST-elevation myocardial infarction, acute stroke, and
trauma [
90
]. In the context of EMS, it involves the collection of pre-hospital individual data
and assessment results, which may be transmitted to data centers or cloud systems through
the internet. These data could be accessed by hospitals or individuals with different needs.
Additionally, with the increasing popularity of electronic transmission technologies and
social platforms, some social media platforms have been utilized as channels for data
transmission, effectively reducing treatment time [90].
Consequently, there is a growing body of research utilizing artificial intelligence
(AI) algorithms based on deep learning to enhance the quality of pre-hospital emergency
care. Many studies have confirmed that AI in emergency medicine improves accuracy
and efficiency, and reduces time-to-treatment for the detection of out-of-hospital cardiac
arrests (OHCA), stroke detection [
91
], and EKG interpretation for ST-elevation myocardial
infarction (STEMI) [
92
]. Unfortunately, most of the data obtained from the aforementioned
scenarios may not have been adequately protected.
In these processes, various forms of data such as patients’ basic information, medical
records, clinical images, audio recordings, and video footage are often collected, stored,
and accessed for further data analysis. The security of structured, semi-structured, and
unstructured data obtained from patients, including considerations related to storage, ac-
cess, management personnel, application usage, and data disposal, is often underestimated.
Furthermore, the utilization of social media as a transmission platform raises concerns
about data ownership, the rights of social media platforms to access and use personal data,
as well as the monitoring of individuals who have access to such data. Additionally, the
application of artificial intelligence involves direct data collection from individuals, leading
to uncertainties and ambiguity regarding the scope of data collection and sharing with
third parties, which may not be clear to patients.
At this juncture, blockchain technology can unleash its powerful capabilities, en-
compassing secure storage and protection of patients’ personal health data to prevent
unauthorized access or tampering. Additionally, it facilitates improved data sharing and
access control mechanisms, limited to authorized personnel within the EMS system or the
intended receiving hospital. This ensures sensitive data can only be accessed by those with
authorization. Furthermore, blockchain can be employed to track and verify the origin and
authenticity of data collected outside the hospital, guaranteeing the accuracy and credibility
of such data. This, in turn, aids healthcare providers in making precise medical decisions
based on the trustworthy information gathered beyond hospital premises.
So far, from the moment a car accident occurs, blockchain technology has been put to
use. Amel Ksibi et al. propose a system that combines the Internet of Vehicles (IoV) and the
Internet of Medical Things (IoMT) concepts with blockchain technology, enabling emer-
gency vehicles to arrive at the accident scene promptly and speeding up interventions in
emergency cases. Additionally, this system ensures the security of patient data [
61
]. More-
over, blockchain technology has already been applied in conjunction with fifth-generation
wireless networks in the context of newborn emergency transport [
93
]. Fang et al. leverage
blockchain technology to ensure data security and immutability, while exploring how
blockchain can enable trusted data sharing and collaboration among multiple stakeholders
to enhance the efficiency and accuracy of emergency transport [
93
]. We have partially
combined the instances mentioned earlier and are now providing examples of blockchain
utilization in pre-hospital care (Figure 7).

Healthcare 2023,11, 2497 17 of 29
Healthcare 2023, 11, x FOR PEER REVIEW 16 of 29
Figure 7. Examples of blockchain usage scenarios in pre-hospital care.
Inter-hospital transfers (IHTs) play a crucial role in healthcare systems by enhancing
access and efficiency in care delivery [94]. However, in many countries, such as England,
patients often receive treatment from multiple hospital trusts that utilize different record
systems, resulting in significant barriers to inter-hospital data sharing and interoperability
[95]. Furthermore, the exchange of personal health data among hospitals faces
technological and individual obstacles, including resistance to information sharing,
privacy concerns, and divergent interests [74,96]. Some hospital trusts still rely on paper
records, in-house-developed electronic health record (EHR) systems, or disparate
electronic systems. The lack of secure and transparent personal health data poses
concerns, considering that effective IHTs are integral to improving access, reducing costs,
and allocating resources appropriately within healthcare systems [94].
Systematic review studies indicate that research on blockchain technology in
healthcare has increased, and one of the most commonly used applications is for data
sharing, which aligns with our findings [26]. To address these challenges, an example
solution is proposed by Hasavari and Song, who propose a solution based on blockchain
technology, utilizing a secure file transfer protocol (FTPS) for secure file transfer, coupled
with blockchain as the ultimate data source [7]. In this approach, emergency-relevant
medical data of patients are securely uploaded to a TLS server integrated with the Fabric
blockchain, using advanced tools for scheduling and automating the uploading process.
Once stored on the ledger, the data are replicated and distributed to other authorized
network members, such as hospitals or healthcare personnel, based on predefined
policies, ensuring a consistent and comprehensive view of the patient’s health data [7].
Numerous similar frameworks have been proposed, and by leveraging blockchain
technology, improvements can be made in facilitating coordination among electronic
health record systems, developing targeted approaches to enhance interoperability, and
improving the effectiveness and efficiency of data sharing between hospitals [95]. In the
realm of pre-hospital care, there exists a scarcity of pertinent reviews at present. We
contend that velocity, cost, and real-time responsiveness will emerge as the foremost
challenges in the future, while compatibility stands as a primary concern for potential
inter-hospital transfers.
Figure 7. Examples of blockchain usage scenarios in pre-hospital care.
Inter-hospital transfers (IHTs) play a crucial role in healthcare systems by enhancing
access and efficiency in care delivery [
94
]. However, in many countries, such as Eng-
land, patients often receive treatment from multiple hospital trusts that utilize different
record systems, resulting in significant barriers to inter-hospital data sharing and interop-
erability [
95
]. Furthermore, the exchange of personal health data among hospitals faces
technological and individual obstacles, including resistance to information sharing, privacy
concerns, and divergent interests [
74
,
96
]. Some hospital trusts still rely on paper records,
in-house-developed electronic health record (EHR) systems, or disparate electronic systems.
The lack of secure and transparent personal health data poses concerns, considering that
effective IHTs are integral to improving access, reducing costs, and allocating resources
appropriately within healthcare systems [94].
Systematic review studies indicate that research on blockchain technology in healthcare
has increased, and one of the most commonly used applications is for data sharing, which
aligns with our findings [
26
]. To address these challenges, an example solution is proposed
by Hasavari and Song, who propose a solution based on blockchain technology, utilizing a
secure file transfer protocol (FTPS) for secure file transfer, coupled with blockchain as the
ultimate data source [
7
]. In this approach, emergency-relevant medical data of patients are
securely uploaded to a TLS server integrated with the Fabric blockchain, using advanced
tools for scheduling and automating the uploading process. Once stored on the ledger,
the data are replicated and distributed to other authorized network members, such as
hospitals or healthcare personnel, based on predefined policies, ensuring a consistent and
comprehensive view of the patient’s health data [
7
]. Numerous similar frameworks have
been proposed, and by leveraging blockchain technology, improvements can be made
in facilitating coordination among electronic health record systems, developing targeted
approaches to enhance interoperability, and improving the effectiveness and efficiency of
data sharing between hospitals [
95
]. In the realm of pre-hospital care, there exists a scarcity
of pertinent reviews at present. We contend that velocity, cost, and real-time responsiveness
will emerge as the foremost challenges in the future, while compatibility stands as a primary
concern for potential inter-hospital transfers.
5.2. ED Triage
The triage process is crucial to effectively managing modern emergency depart-
ments [
97
]. The information gathered during triage assists medical personnel in assessing
the condition of patients and determining appropriate treatment. However, in our review,

Healthcare 2023,11, 2497 18 of 29
there was no specific focus on blockchain research in triage. Nevertheless, there has been a
growing trend in the application of various digital technologies in this area. For example,
various digital technologies have been applied, including digitally-automated pre-hospital
triage in the USA [
98
], a computerized triage system known as the automated triage system
in Malaysia, decision-making support systems (DMSS) for triage, triage chatbots, and the
application of AI in triage [
99
–
102
], which are used to aid assessment and improve the
accuracy and efficiency of triage. Many personal data, including audio, some images, and
even videos, are transmitted, stored, and analyzed. However, security and privacy concerns
arise when collecting and processing such data, particularly regarding the confidentiality
of patients’ personal health information.
By storing clinical images/videos or their hashes on a blockchain, they can be easily
shared among different healthcare systems and providers. Integrating pre-hospital data
with ED triage, the blockchain serves as a mechanism to authenticate requesting parties,
such as emergency department physicians, specialist physicians, or dispatch centers, ensur-
ing their authorization to access specific data based on a permissioned list. In the future,
the utilization of blockchain technology has the potential to facilitate secure storage and
sharing of vast amounts of data during triage, resulting in enhanced security and reliability
of the information [103].
5.3. Documentation and Data Exchange
Accurate and complete medical data, including electronic medical records (EMRs) and
electronic health records (EHRs), are valuable assets for patients and healthcare providers.
With the development of electronic technology in recent years, there have been advance-
ments not only in storage formats and security but also in recording methods. The method
of medical record recording has also evolved, transcending traditional computer typing
or handwriting, with the integration of natural language processing artificial intelligence
systems capable of automatically drafting a health record based on a recording of a patient-
emergency physician interaction as it occurs [
104
]. In the past, healthcare settings and
providers have been hesitant to share medical data due to security concerns. Additionally,
conventional healthcare systems often employ inadequate security measures or systems,
resulting in potential risks to overall system security, especially with the introduction of
some digital technologies, such as AI, which significantly increase the risks.
Blockchain presents a promising opportunity in this context, as data sharing is highly
secure and verifiable through cryptographic principles [
12
]. Currently, similar to past
research, the most prevalent applications of blockchain technology in healthcare primarily
revolve around electronic medical records [
105
]. Many review articles emphasize that
electronic health records (EHR) and personal health records (PHR) are the primary areas
targeted for blockchain implementation [
8
]. These serve as a digital record of a patient’s
medical history, and blockchain technology efficiently addresses the limitations of tradi-
tional systems by offering reliable, accurate, and secure data storage and exchanges [106].
In general, a patient-centric node on a permissioned blockchain, which operates based
on business logic, requires robust identity management, accountability, access control, and
authorization [
7
]. Healthcare providers need to obtain enrollment and transaction certifi-
cates to connect to and access resources on the Fabric network. By leveraging blockchain
and smart contracts, the system empowers patients to efficiently enforce permission-based
access control policies for their data and enables the sharing of previous health records with
emergency doctors in critical situations. The execution steps involve a doctor or hospital
initiating an emergency request to the medical center’s infrastructure, which then processes
the data at the edge services. Subsequently, the data are formatted and identified for
transactional purposes. Additionally, when an emergency request is initiated, the system
sends the request information to the transaction manager for storage and enters a waiting
state. Finally, the request is processed with an approval status, granting access to the
patient’s database to the doctor and other healthcare providers [
7
,
107
]. When emergency
physicians evaluate patients and record their cases, blockchain technology can be applied

Healthcare 2023,11, 2497 19 of 29
to store all patient medical histories in a centralized location, facilitating faster and more
transparent access for authorized parties and reducing manual errors [
108
]. In this manner,
we can effectively integrate personal medical information that is dispersed across multiple
hospitals, enabling patients to access and utilize their health records freely in both their
daily lives and during emergencies [67].
Based on our review, it is evident that interoperability, scalability, and access control
constitute the principal challenges in the forthcoming landscape of electronic health records
(EHR) and personal health records (PHR). This observation aligns with the outcomes of the
majority of analogous systemic reviews conducted in the past [
32
,
33
]. Allowing patients
to have certain control and autonomy over their data is crucial, enabling them to decide
which nodes to grant access to. Additionally, the transparency of data in the blockchain
ensures reliable and accessible information, instilling confidence in patients during inter-
hospital transfers or when seeking a second opinion from another doctor [
105
,
109
]. A
secure and interoperable health system built on blockchain technology has the potential
to facilitate intelligent and optimized exchange of medical data among diverse entities,
such as hospitals of different levels, thereby reducing redundant medical procedures and
resource wastage [66].
5.4. Treatment
5.4.1. Drugs and Medical Devices
After the evaluation by the emergency physician, the physician will issue medical
orders for treatment, which may include the use of medications and procedures. In terms
of blockchain and supply chain management, medication safety is a primary application
area. Counterfeit drugs have presented a significant challenge to the global pharmaceutical
industry, with pharmaceutical companies facing difficulties in tracking their products
throughout the supply chain process [
110
]. The pharmaceutical supply chain has become
increasingly complex due to its involvement in life-saving treatments and the participation
of various stakeholders, including pharmaceutical manufacturers, dealers, distributors,
patients, information service providers, and regulatory agencies [
18
,
111
]. In this context,
blockchain technology emerges as a solution. Blockchain can trace and track the drug
delivery at every phase, from the supplier’s raw materials to manufacturing, distribution,
hospitals, and patients. For instance, Modum.io is a startup that utilizes IoT sensor devices
and blockchain technology to ensure the immutability of data and public accessibility of
temperature records, while also reducing operational costs in the pharmaceutical supply
chain [
112
]. In the context of medicinal drug supply chain management, blockchain
provides a crucial and secure platform to mitigate vulnerabilities, address fraudulent
attacks, enhance data transparency, and improve product traceability [80,105].
Many medical devices also face similar challenges, but relevant applications in emer-
gency medical care are currently less common. The lack of collaboration among enterprises
in the medical device logistics service supply chain and the absence of unified data manage-
ment norms and standards for data collection among logistics enterprises have resulted in
fragmented supply chain processes [
113
]. As a result, medical devices or supplies face sig-
nificant challenges regarding storage and transportation conditions, logistics environment,
timeliness, end-to-end tracking and monitoring, as well as the management capabilities
of logistics service providers [
113
,
114
]. Yu and Fu proposed a comprehensive medical
equipment management information system that integrates blockchain technology with
the full life cycle theory [
115
]. Such applications not only ensure quality control for medical
devices or supplies but also integrate with existing hospital nodes and patient nodes.
In the clinical treatment of patients, blockchain technology has been applied in other
specialties for monitoring and tracking certain implanted medical devices. We believe
there is an opportunity to securely record and track vital information related to implanted
medical devices, such as central venous catheters (CVC), endotracheal tubes, or Foley
catheters, at the emergency department in the future [
103
]. This includes details such as the
device model, placement date, and longevity, ensuring accurate and reliable documentation

Healthcare 2023,11, 2497 20 of 29
throughout the patient’s healthcare journey. Furthermore, this application of blockchain
technology facilitates seamless continuity of care as patients transition between different
healthcare settings. To sum up, the system has the opportunity to track the usage of
specific medications or devices by individual patients, providing valuable insights into
the production and transportation processes of raw materials and enhancing the overall
quality of care for emergency patients.
5.4.2. Consent
During the treatment process, consent forms are often utilized. However, in our
review, we didn’t find any relevant literature on this topic. This could be attributed to the
search terms used or the fact that current research is more conceptual in nature rather than
specifically focusing on emergency care. Nevertheless, the implementation of blockchain
in consent forms still holds great potential, including its application in informed consent
documents, do-not-resuscitate (DNR) directives, and the shared decision-making process
between healthcare providers and patients [
116
]. Blockchain-based informed consent,
combined with smart contracts, simplifies the process of obtaining informed consent,
enhances identity management, and improves data quality. This technology enables the
digitization of paper consent forms and facilitates the signing of digital medical consent
forms [
117
]. The general procedure involves patients registering their authentic identities
and receiving validation from a third-party verifier. They can then utilize blockchain
certificates and private keys to complete and sign the consent forms. The signed content is
securely stored within the blockchain network, ensuring the integrity of the signing records.
In contrast to traditional paper consent forms, digital consent forms offer advantages such
as immutability and long-term preservation. They also overcome geographical limitations
by allowing for remote signing. Furthermore, timestamps are an essential feature of the
blockchain. They enable the recording of signing time and sequence among various roles,
which is not achievable with paper consent forms [118].
5.5. Disposition
After receiving treatment, patients may have various options, such as discharge,
admission, or transfer, depending on their medical condition and the risk assessment con-
ducted by the emergency physician. They may also need to proceed with medical expense
payments. Our review indicates that there are already some blockchain applications in
post-discharge vital signs monitoring and readmission prediction that are utilized to protect
patient data security. For instance, the blood sample-based ED return technology is imple-
mented in the ED of a hospital in South Korea, combining big data cloud, machine learning,
and blockchain to predict ED return probability [
82
]. Direct application of payment and
insurance in the emergency department is scarce, but there have been some conceptual
studies in other fields that have great potential for future applications.
Not only does blockchain have the potential to integrate billing and payment systems,
it can also potentially synchronize insurance underwriting with hospital operations. This
integration can provide the latest information to patients, healthcare providers, and insur-
ance companies, and it also offers an opportunity to avoid health insurance fraud [
119
]. It
comprehensively scrutinizes each payment transaction while also predicting the insurance
amount, thereby alleviating the workload of insurance auditors [
30
]. Furthermore, through
patient-authorized access, insurance companies can directly receive the necessary docu-
ments for insurance claims, streamlining the entire claims process. Taking Taiwan as an
example, the current process for filing insurance claims after receiving emergency medical
care requires patients to first apply for a diagnosis report and relevant documents from
the hospital, which are then submitted to the insurance company. After assessment by the
insurer, the underwriting process can proceed, which may take one to two months. If the
use of blockchain for reimbursement purposes is implemented in the future, it is believed
that it can significantly improve patient satisfaction with emergency medical care.

Healthcare 2023,11, 2497 21 of 29
Finally, in terms of the payment system, there are currently no specific applications
focusing on post-emergency department payment journeys. However, blockchain-based
payment systems have been proposed in other fields. In current healthcare systems, pay-
ment settlement between patients and healthcare providers often relies on centralized
third-party services. However, these centralized methods are associated with slow pro-
cessing times, inefficiency, and a lack of transparency [
48
]. To overcome these limitations,
blockchain platforms offer the opportunity for cryptocurrency-based payment systems that
can provide a fast, secure, transparent, and auditable payment environment following an
emergency department visit.
5.6. Home
After the patient’s discharge, care continues at home and transitions back into the
community’s healthcare system. The use of wearable devices is becoming increasingly
common, including applications in IoT, AIoT, and telemedicine. These technologies are
extending the reach of emergency care into the community. Additionally, the use of
blockchain technology is also on the rise. In the subsequent sections, we will delve into
the applications of IoT, AI, and telemedicine during the final phase of the emergency
department journey, which is the patient’s return home. Additionally, we will present
illustrative scenarios showcasing the utilization of blockchain technology in this stage of
the emergency care journey (Figure 8).
Healthcare 2023, 11, x FOR PEER REVIEW 20 of 29
providers, and insurance companies, and it also offers an opportunity to avoid health
insurance fraud [119]. It comprehensively scrutinizes each payment transaction while also
predicting the insurance amount, thereby alleviating the workload of insurance auditors
[30]. Furthermore, through patient-authorized access, insurance companies can directly
receive the necessary documents for insurance claims, streamlining the entire claims
process. Taking Taiwan as an example, the current process for filing insurance claims after
receiving emergency medical care requires patients to first apply for a diagnosis report
and relevant documents from the hospital, which are then submied to the insurance
company. After assessment by the insurer, the underwriting process can proceed, which
may take one to two months. If the use of blockchain for reimbursement purposes is
implemented in the future, it is believed that it can significantly improve patient
satisfaction with emergency medical care.
Finally, in terms of the payment system, there are currently no specific applications
focusing on post-emergency department payment journeys. However, blockchain-based
payment systems have been proposed in other fields. In current healthcare systems,
payment selement between patients and healthcare providers often relies on centralized
third-party services. However, these centralized methods are associated with slow
processing times, inefficiency, and a lack of transparency [48]. To overcome these
limitations, blockchain platforms offer the opportunity for cryptocurrency-based payment
systems that can provide a fast, secure, transparent, and auditable payment environment
following an emergency department visit.
5.6. Home
After the patient’s discharge, care continues at home and transitions back into the
community’s healthcare system. The use of wearable devices is becoming increasingly
common, including applications in IoT, AIoT, and telemedicine. These technologies are
extending the reach of emergency care into the community. Additionally, the use of
blockchain technology is also on the rise. In the subsequent sections, we will delve into
the applications of IoT, AI, and telemedicine during the final phase of the emergency
department journey, which is the patient’s return home. Additionally, we will present
illustrative scenarios showcasing the utilization of blockchain technology in this stage of
the emergency care journey (Figure 8).
Figure 8. Examples of blockchain usage scenarios in disposition and home.
Figure 8. Examples of blockchain usage scenarios in disposition and home.
5.6.1. IOT
IoT (Internet of Things) serves as a prominent method of collecting data from various
networked resources and interconnected devices. In the realm of healthcare, IoT devices
play a crucial role in providing real-time sensory data from patients, which is recognized
as an extension of healthcare. It is also the major application of blockchain in the stage
of home. They offer efficient components for coordinating care between hospitals and
community services in the management of both acute and chronic patients [
120
]. In acute
medical care, IoT holds the potential to extend emergency healthcare by enabling post-
discharge monitoring of patients who may require extended observation or are at a higher
risk of disease. Through wearable devices, personal health records and vital signs can
be transmitted to the hospital, enabling relevant personnel to remotely monitor patients’
health. This not only contributes to reducing overcrowding in the emergency department
but also addresses the issue of prolonged stays.

Healthcare 2023,11, 2497 22 of 29
The utilization of wearable devices and personal health data brings substantial and
growing value to the emergency healthcare sector. However, it also presents challenges
such as single points of failure, mistrust, data manipulation, tampering, and privacy
concerns [
121
]. The combination of blockchain and IoT holds immense potential and can
yield significant benefits in distributed applications involving sensitive patient data [
122
].
These events can be securely sent to patients and healthcare providers, giving patients
the individual right to select who can access and view their medical information [
123
].
However, in our review, there remains a significant disparity among each study. The design
of the pre-built or theoretical part of the IoT network necessitates the consideration of
numerous parameters. Therefore, a consortium blockchain with additional features will be
essential to accommodate IoT requirements. As highlighted by Zubaydi et al., consensus
algorithms stand out as a primary limitation or drawback in such models, as the utilization
of generalized algorithms hampers the system’s ability to function at its full potential [
54
].
Ensuring the secure and convenient sharing of personal health data is crucial for
enhancing interaction and collaboration within and beyond the healthcare industry [
124
].
Simi´c et al. demonstrate how IoT devices can be utilized as data sources for real-time or
near-real-time data collection, with blockchain ensuring secure access and data exchange
between institutions [
122
]. Additionally, Liang et al. propose a user-centric medical
data exchange solution that leverages a mobile application to gather data from wearable
devices. This collected data are then shared with healthcare providers, insurance companies,
and research institutes through a permissioned blockchain network [
5
,
117
]. By utilizing
such an autonomous network with distributed storage, built upon the foundation of
blockchain, it extends its reach to connect emergency healthcare with post-discharge care,
home healthcare, and personalized precision medicine [30].
5.6.2. AI
The inclusion of artificial intelligence (AI) in the discussion is primarily due to its
wide-ranging applications in emergency healthcare in recent years. AI has been extensively
utilized throughout the emergency department (ED) journey, encompassing pre-hospital
EMS, emergency department triage, diagnosis by emergency physicians, medical record
documentation, disease outcome prediction, and even post-discharge monitoring. Big data
not only empowers AI but also mandates its utilization for data interpretation, compre-
hension, and decision-making to maximize favorable outcomes [
125
,
126
]. However, many
AI implementations depend on centralized datasets and servers, which expose them to
the risks of data alteration and loss, consequently leading to potentially unreliable and
untrustworthy outcomes [
103
]. Integrating blockchain databases with AI and IoT not only
enhances data security but also improves the performance of machine learning models,
achieving a win-win situation in terms of security, usability, and scalability [1].
5.6.3. Telemedicine
Telemedicine is considered one of the most significant innovative responses during
the COVID-19 pandemic, and its importance has been gradually increasing in recent
years. In the field of emergency medicine, telemedicine extends beyond the assessment of
confirmed patients during the pandemic and encompasses pre-hospital emergency services,
teleconsulting, as well as post-discharge monitoring and readmission prevention [
127
].
However, traditional telemedicine systems mostly rely on outdated methods for storage and
maintenance [
48
]. The centralization of existing telemedicine systems presents a significant
challenge as it introduces the risk of a single point of failure [
128
]. Additionally, medico-
legal concerns have raised questions regarding the relevance and clarity of communication
during the informed consent process, as well as data security issues. These challenges are
expected to be addressed through the application of blockchain technology.
In the healthcare sector, the readiness to embrace blockchain technology is still at an
early stage. Ahmad et al. demonstrate the practicality of blockchain technology in the
telehealth domain, which can bring about significant improvements in terms of reliability,

Healthcare 2023,11, 2497 23 of 29
traceability, immutability, and transparency [
48
]. However, limited research has been
conducted specifically to explore the perspectives and adoption trends of emergency
medicine professionals regarding blockchain. In general, emergency physicians routinely
manage critical patient data in situations where time is of the essence. In such a context,
blockchain holds significant promise not only for enhancing decision-making processes but
also for safeguarding patient privacy and data security. Nevertheless, there are challenges
that must be overcome, not only the ones mentioned in the previous review but also
scalability and interoperability issues. These hurdles must be tackled before blockchain
can effectively establish itself as a viable tool within our dynamic and rapidly evolving
emergency healthcare landscape.
6. Challenges and Limitations
The integration of blockchain technology into healthcare offers a viable solution, yet
it is still in its early stages and faces specific limitations and challenges. Some of these
challenges include cost, complexity, the emerging nature of the technology, the absence of
established security and privacy standards, as well as concerns regarding security [48].
To begin with, implementing a blockchain system in emergency care or hospital set-
tings involves significant costs due to the substantial number of transactions that need
to be processed in such environments. Speed is also a factor to consider, particularly in
emergency medical situations where platforms like Ethereum and consensus algorithms
such as Proof of Work (PoW) might encounter limitations in real-time applicability due
to their slower processing speeds. Secondly, the complex nature of diverse blockchain
implementations that utilize varying underlying technologies can impede seamless col-
laboration among different systems. Standardization becomes a critical issue that needs
attention to ensure smooth data exchange and cooperation across various healthcare sys-
tems. This is especially crucial in emergency units that need to interact with pre-hospital,
EMS systems, community healthcare groups, and patients, highlighting the challenge of
achieving compatibility. It’s only through compatibility that frontline emergency med-
ical personnel can genuinely be assisted rather than hindered. Thirdly, while pursuing
efficiency, cost-effectiveness, and scalability, concerns about privacy and confidentiality
arise. This also leads to different platforms and algorithms having varying applicability
in different scenarios. Public blockchains offer advantages such as high decentralization
but are vulnerable to exposing stored information if vulnerabilities are detected in their
underlying encryption schemes [
127
]. Lastly, security is a significant concern, as the loss
of a private key could render data permanently unreadable. Moreover, these systems are
inherently susceptible to a type of attack known as the 51% attack [129].
Through our review, we have compiled the current status of blockchain applications in
emergency medical care and presented blockchain-based scenarios, particularly in various
domains within this field. Many of these solutions have been successfully implemented
in real-world emergency medical contexts, while others remain promising concepts that
are either still hypothetical or in the theoretical stage. However, our study does have
certain limitations. Firstly, methodological decisions have introduced constraints in the
research process, including the utilization of specific search terms and queries to gather
evidence and a focused approach on emergency medicine, which may not encompass all the
features of blockchain. Secondly, the potential incompleteness of databases could hinder
the representation of the comprehensive landscape of current blockchain applications.
Thirdly, the majority of studies are proof-of-concept trials that require additional supporting
evidence. Future research could concentrate on applications before hospital admission and
after discharge to optimally leverage the value of emergency care medicine. Additionally,
investigations into treatment, informed consent, and educational applications remain
limited, underscoring the need for greater attention and involvement from professionals in
the field of emergency medicine.

Healthcare 2023,11, 2497 24 of 29
7. Conclusions
The scoping review examines and discusses significant applications of blockchain
technology within the realm of emergency medicine. A notable aspect that sets emergency
medicine apart from other fields is the utilization of blockchain in pre-hospital and post-
discharge contexts. Consensus algorithms, blockchain platforms, and types of blockchains
lack a universal advantage; their effectiveness varies depending on the distinct demands
of different emergency care scenarios, each possessing unique strengths, weaknesses, and
requirements. Presently, blockchain implementation primarily revolves around electronic
health records (EHR) and personal health records (PHR), yet potential challenges loom,
including scalability, interconnecting disparate systems, and inadequate system interoper-
ability. The integration of blockchain with the Internet of Things (IoT) is gaining traction,
broadening the scope and services of emergency medical care, particularly during the
“home” phase of the emergency department journey.
Healthcare providers must deeply comprehend the existing challenges and pre-
requisites in acute medical care, a vital foundation for productive collaboration with
blockchain experts and the successful deployment of blockchain solutions. The shift
towards patient-centered, blockchain-enabled care is increasingly apparent. The amalga-
mation of blockchain technology into emergency medicine holds the promise of enhancing
patient-centered interoperability and optimizing overall efficiency and security in health-
care data management. This potential is further exemplified by the streamlined access to
patient data and the facilitation of real-time communication among patients, emergency
physicians, and other specialists. Furthermore, the inherent attributes of auditability and
transparency confer significant advantages in ensuring the secure and trustworthy ex-
change of medical data among various stakeholders, encompassing patients, healthcare
providers, and insurance entities. Looking ahead, focused endeavors should be channeled
towards addressing challenges like costs, scalability, security, access control, and standard-
ization, depending on the demands of different scenarios. These endeavors will contribute
to the widespread integration of blockchain in acute medical care.
Author Contributions:
T.-C.W. drafted the manuscript. T.-C.W. and C.-T.B.H. revised it critically
for important intellectual content. 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:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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