• Advancing Health Equity for People Experiencing Homelessness Using Blockchain Technology for Identity Management:A Research Agenda
  • Tim Mercer, MD, MPH (bio) and Anjum Khurshid, MD, PhD (bio)
Abstract

People experiencing homelessness (PEH) are medically complex, with limited access to health care and unmet health-related social needs. People experiencing homelessness must access a wide range of health and social services, for which they must typically show proof of identity. Many PEH do not have original vital documents, which are highly susceptible to damage, loss, or theft. Lack of proof of identity is a major barrier to receiving services, and can exacerbate health inequities plaguing this population. Blockchain technology can be used to ensure secure and portable identity management in health care. Based on our clinical experience caring for this population, and implementation of a pilot blockchain-based identity management solution for PEH in our community, we believe blockchain can solve the identity management problem among PEH. We propose a research agenda that will help stakeholders determine how blockchain technology could be an innovative and effective techQuity solution for this pernicious problem.

Key words

Homelessness, identity, identity management, blockchain, technology, health equity, access to care, techQuity

"We are not concerned with the very poor. They are unthinkable, and only to be approached by the statistician or the poet."

—E.M. Forster

The Health Inequities of Homelessness

There are over half a million people experiencing homelessness in the United States.1 Compared with the general population, people experiencing homelessness (PEH) have higher rates of medical and mental health conditions, limited access to health care, higher utilization of costly acute care and crisis services, and unmet health-related social needs.26 People experiencing homelessness are victims of structural violence7 [End Page 262] and intersecting with homelessness in the United States is structural racism: in every state, African Americans are disproportionately more likely than Whites to experience homelessness.8 We know that housing is an important social determinant of health. In a 10-year prospective cohort study conducted in Boston (2000–2009), unsheltered homeless adults had an all-cause mortality rate 10 times higher than the general population, with a mean age of death of 53 years.9,10

Nameless Faces

In order to meet their needs, PEH must access a wide range of health and social services. However, two fundamental problems exist. First, to access these services, PEH must typically show proof of identity. However, many PEH do not have original vital documents, such as state-issued IDs or birth certificates, which are easily susceptible to damage, loss, or theft. As any homeless service provider or person experiencing homelessness themselves can tell you, this is an exceedingly common issue, and replacing vital documents or lost IDs is complex, burdensome, and time-consuming. Our prior study based on qualitative interviews with PEH in Austin, Texas, showed that at least one third of clients lacked a basic identity document when they entered the health and human services system in the city.11 A survey of homeless service providers conducted by the National Law Center on Homelessness and Poverty revealed that the lack of a photo ID prevented PEH from receiving food stamps, social security income (SSI) benefits, Medicaid, shelter or housing services, or medical services; furthermore, ever since September 11, 2001, federal and state laws and administrative policies have made it more difficult for PEH to obtain a photo ID.12 Second, health care and social services in the U.S. are fragmented and siloed, and in the absence of a truly person-centered and integrated approach, health care and social service systems lack interoperability and are unable to accurately collect, share, and verify even basic identity information for a person experiencing homelessness.6,13 This puts the burden on PEH to navigate complex, duplicative, and bureaucratic requirements just to prove their identity and begin the process of accessing services.14,15 Given these problems, PEH are often nameless faces, individuals among us in need of services but unable to benefit from them simply because they cannot prove who they are. Therefore, lack of proof of identity is a major barrier to receiving health care and social services, and can exacerbate the health inequities plaguing this population.

A Potential TechQuity Solution

Blockchain technology can be used to ensure secure and portable identity management in health care, and holds great promise to be a techQuity solution for the problem of identity management for PEH.11,14 Fundamentally, blockchain can be described as a distributed trust network that uses cryptography or encryption to share ledgers of transactions across a large number of nodes.16 Each piece of information must be verified by a consensus mechanism where all participants of the network agree on the truth of each transaction. Once verified the new transaction is attached to a block of information with other verified transactions. These verified blocks of information [End Page 263] are then linked to the previously verified blocks of information thus creating a chain. Any change in previously verified information in any block is therefore detected easily because it changes the cryptographic code (Figure 1).17

The architecture of blockchain technology thus creates a set of features that ensure security and privacy along with an individual's control over their information, which is not easily established in existing health information systems.18 Blockchain technology's characteristics that make it a unique solution for managing identities of vulnerable individuals include a very strong cryptographic security, immutability, or inability to change any entry that has been verified by a consensus, distributed information that allows transparency of transactions, and the ability to audit each entry in the network records.19 Moreover, through the use of public and private keys it allows individuals to control when and where their information is shared.20

Despite being an evolving technology, blockchain technology is increasingly being used in solving real-world problems. Cryptocurrencies are being used by banks, governments, and private markets and the cryptocurrency sector is expanding rapidly.21 Bitcoin and other blockchain-based coins have had their ups and downs but are rapidly moving beyond the early adopters to more mainstream users.22,23 The government in Estonia has adopted blockchain technology as part of its secure identity management and transaction infrastructure for all its citizens.24,25 Major companies such as IBM, Walmart, Whole Foods, and Chemonics are using blockchain technology for supply chain management.26 Breakthroughs in achieving efficiency in these transactional processes are also being reported.27

Beyond finance and business, blockchain technology applications have also been making their mark in the social and health sectors. Blockchain applications in the social sector include the empowerment of rural farmers in Africa, Asia, and South America.28 Similarly, blockchain has been used in the pharmaceutical industry to address the issue of counterfeit drugs,29,30 and the FDA has a program to use blockchain for this purpose.31 Medical and informatics literature is increasingly describing applications of blockchain in health care.3234 From managing medical records to tracking COVID-19 patients, blockchain's technical capabilities are being found useful across the industry.3537

Recently, the City of Austin worked with the University of Texas at Austin Dell Medical School to test the feasibility of using blockchain technology to establish an identity management system for persons experiencing homelessness. The project involved social and health care service providers and patients with lived experience of homelessness.14 The results of the study showed that blockchain technology, using an Ethereum platform, allowed PEH to create accounts, upload documents, share documents with differentiated permissions, enable service providers to share documents and information, and allow an individual to hold their personal identity information as an asset in their blockchain account.11

One of the key features of blockchain that may provide some innovative ways to help address inequities in health is that its foundations are based on mathematical algorithms that can be scrutinized and audited to rectify any systematic discrimination or bias. While the concern of biased algorithms is being raised more widely now, the research to address these concerns is still in its early stages.38,39 As a peer-to-peer network, blockchain technology also allows individuals to conduct transactions without [End Page 264]

Figure 1. A conceptual model of blockchain's distributed ledger. Source: The authors, adapted from Khurshid and Gadnis, 2019 (Ref #14).
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Figure 1.

A conceptual model of blockchain's distributed ledger.

Source:

The authors, adapted from Khurshid and Gadnis, 2019 (Ref #14).

[End Page 265]

an intermediary who could impose any personal or institutional bias on the nature or scope of such transactions. The system works on agreed-upon principles or consensus and brings transparency and auditability that can prevent judgmental or stereotyped interpretation or implementation of rules. It also protects an individual's privacy and identity by sharing validated credentials without having to share complete identification records. For instance, if an individual must prove that they are over 18 years old, that information can be validated through blockchain's immutable record without having to share the full identity document or even date of birth.

Individual PEH preferences and comfort level with the various options for log-in mechanisms (password, QR codes, biometrics), affordable devices (e.g., Android, iOS), and literacy levels are factors that are important for future adoption of blockchain technology for health equity. Similarly, business process changes and acceptance of these trust mechanisms by institutions may be influenced by existing law and regulatory requirements that must be updated. Validation and verification of data and issuance of identity documents when multiple public and private agencies are engaged in multiparty transactions may have competing solutions.

Despite the promise of blockchain technology to address identity management in health care and social services, much remains unknown about the scope of the problem, how blockchain technology could be applied to address it, and how this might translate into addressing the health inequities that result from it. Therefore, we propose a research agenda that will help key stakeholders determine how blockchain technology could be an innovative and effective techQuity solution for the problem of identity management for PEH.

Unanswered Questions Abound: A Research Agenda

While practical examples of blockchain applications in health care are being reported at an increasing rate, according to two recently published systematic reviews, very little empirical research has been conducted so far.18,40 Much of the published literature consists of opinion pieces discussing the fragmentation of electronic health records systems and the potential applicability of blockchain in solving this problem, drawing from its use in other sectors. Most of the empirical research has focused on the use of blockchain to strengthen health information technology (HIT) security or privacy, or to improve HIT interoperability across different health care systems. Only a very small minority of studies looked at whether blockchain technology could actually improve health care outcomes. While applications of blockchain technology have been reportedly used in rural Indonesia, Kenyan slums, and Syrian refugee camps for identity management, we are not aware of any empirical research, other than our own preliminary pilot work, that evaluates blockchain's applicability for identity management with PEH.11,14,28 Given this lack of empirical evidence for the use of blockchain technology for identity management to improve health equity, we propose a research agenda that can help answer critical questions. We derived this research agenda from three main sources: first, was a rationale, pragmatic set of questions that arose based on our own clinical work caring for this population as well as our own pilot project using blockchain technology; second, was a critical review of the literature described above, noting key research [End Page 266] gaps; and third, we drew constructs and questions from well-described theoretical frameworks concerning the adoption and uptake of new technologies, including the technology acceptance model (TAM) and the unified theory of acceptance and use of technology (UTAUT).41,42 Our proposed research agenda poses questions across five key domains: scope and burden of the problem; acceptability and feasibility of the solution; technology and infrastructure requirements; ethical, legal, and regulatory implications; and implementation and effectiveness (Box 1).

Scope and burden of the problem: What is the true scope and burden of the identity management problem among PEH, and what is its quantifiable impact on driving health inequities in this population?

Clinicians caring for PEH, and the social workers who often help them track down vital documents, can tell you anecdotally that identity management in this population is a pervasive problem. Our own pilot data show that photo IDs and other vital documents are required to access services at nearly every health care or homeless services agency in our community.11 We must better quantify this, in larger populations across multiple locales, particularly in terms of the associated costs (both time and money) that lost identity has on PEH and the systems that serve them. The next step will be to quantify the effect this has on access to medical and social services, and how this translates into driving poor health outcomes and/or perpetuating homelessness. This type of research will provide a clear baseline from which to benchmark future progress on blockchain's use in addressing this problem and narrowing health inequities.

Acceptability and feasibility of the solution: What are the perspectives of acceptability and feasibility among PEH, service providers, and policymakers on the use of blockchain technology for identity management?

While there is still very much a digital divide between PEH and the general population, there are some preliminary data to suggest that many PEH do have access to mobile phones43 and that mobile health technology (mHealth) interventions are both acceptable and feasible in this population.44,45 Our own preliminary work suggests that blockchain technology for identity management among PEH was generally acceptable, although this needs much more thorough vetting at scale.11 For instance, among passwords, QR codes, and biometrics, we would like to know what is the preferred method of validating identity and what challenges exist with different mobile phone plans and devices. Furthermore, many questions remain about the details of how service providers and policymakers would implement and use such a system. We must determine how much of a technology literacy gap must be overcome by PEH and service providers alike to understand what blockchain technology is, what it can and cannot do, and how it will be applied to solve the identity management problem. Furthermore, the perspective of policymakers and other regulators must be heard and incorporated in order for such a disruptive technology solution to be implemented. This will require both formative research and empirical evaluation of blockchain-based identity management systems.

Technology and Infrastructure Requirements: What technology and technology infrastructure would be needed to implement blockchain solutions for identity management among PEH? [End Page 267]

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[End Page 270]

Blockchain technology is neither homogeneous nor monolithic, and is rapidly evolving. As the number of use cases and industries testing this technology increase, more innovative blockchains are being developed. Concerns about the speed of transactions per second,46 high energy consumption for achieving consensus in a distributed network,47 and incentives for operators of the network, have been addressed with variations in the design and consensus mechanisms. The introduction of permissioned blockchains which usually allow a consortium of trusted entities to process transactions may provide some early adoption for businesses, such as health care organizations, that hesitate to put their data on a public ledger. In health care, where providers still resist openly sharing patient information, these technical innovations are important in the adoption of blockchain technology. Hyperledger Indy, for instance, has been developed as an open source permissioned platform by a consortium of some of the large tech companies to help manage distributed identities securely and can facilitate the creation of a potential identity management system.48,49 For a blockchain technology solution to be effective for identity management among PEH, it must be adopted and implemented by multiple health care and social services providers, interfacing with their own respective information management systems. We must map all the nodes, stakeholders, and technological requirements in a system involved in creating, procuring, reissuing, verifying, and using someone's identity. Fundamentally, we need to understand what technology infrastructure and capabilities must be in place, at both the individual level and the system level, in order for a blockchain-based identity management solution to be adopted and implemented. This may require solving unusual technological infrastructure problems, and uncovering and testing various interoperability issues.

Ethical, legal, and regulatory implications: What are the legal, regulatory, compliance, and ethical considerations in using blockchain technology for identity management among PEH?

Blockchain technology purports to be able to create a secure, private, accessible, portable, and immutable transaction ledger for disparate systems to share protected health information.50 However, what information is available on the chain and what is linked to off-chain databases will determine the regulatory and legal compliance with existing health information privacy and security requirements.51 Due to the limited number of studies to evaluate the legal and ethical issues on this topic, there are significant research questions that still remain unanswered for widespread adoption of this technology.32 Several states have started developing blockchain legislation but they are mostly focused on financial sector applications rather than health care.52 Multidisciplinary teams must work together to thoroughly vet and address the legal, regulatory, and ethical issues at system, organizational, and individual levels to ensure that the blockchain can meet the security needs of organizations and the privacy needs of PEH.

Implementation and effectiveness: How do we best implement, test, and scale a blockchain technology solution for identity management among PEH and evaluate whether it enhances health equity?

Much of the research to answer the four questions above will be formative in nature, from characterizing the baseline scope and burden of the problem, to answering questions of acceptability and feasibility, to understanding the technological [End Page 271] infrastructure required as well as the legal and ethical considerations of implementing such a solution. However, two fundamental questions remain. First, does blockchain technology actually solve the problem of identity management for PEH? Second, does this promote health equity for PEH, by increasing access to services, improving health, and reducing homelessness? Answering these questions will require both efficacy and effectiveness research, using progressively more rigorous study designs including pre-/post-intervention studies and individual or cluster randomized trials.

Conclusion

People experiencing homelessness experience grave health inequities. The identity management problem faced by this population is a major driver of these inequities by fundamentally cutting off their access to necessary health care and social services. Urgent and innovative solutions are needed to address health inequities in this and other vulnerable populations. We propose that blockchain technology has the potential to be an innovative and effective techQuity solution that can solve the identity management problem for PEH and ultimately help reduce the health inequities that disproportionately affect this population.

However, blockchain is still an emerging and relatively untested technology. While it is seeing increased applications across the health care and social sectors, this is still largely uncharted territory, and a myriad of questions remain unanswered. In the case of using blockchain technology for identity management and improving health equity among PEH, we propose a research agenda consisting of five key questions that span defining the baseline problem, addressing acceptability and feasibility, mapping technology infrastructure requirements, understanding legal and ethical considerations, and rigorously testing the effectiveness of such a solution. Without addressing the first four research questions, interventions may be implemented that are not acceptable to PEH or service providers, that do not account for the requisite technology considerations, or that have untoward legal or ethical ramifications. Without rigorously testing the fifth question, we may risk implementing yet another trendy technology that at best falls short of addressing inequities, and at worst continues to perpetuate the systems and structures driving the inequities in the first place. If the research community does not rigorously explore the legal, ethical, operational, and equity implications of this technology, the tech industry may start implementing these solutions independently in an attempt to solve problems that traditional systems have been unable to solve. Therefore, there is urgency to the imperative that researchers get involved early to ensure that the implementation of this technology does not further isolate, stigmatize, and disempower those who are already experiencing inequities in our society. In partnership with PEH and other key stakeholders, we believe this research agenda has the potential to chart the path for blockchain technology to truly become a techQuity solution by solving the identity management problem for PEH. [End Page 272]

Tim Mercer and Anjum Khurshid

TIM MERCER is affiliated with the Division of Global Health and the Departments of Population Health and Internal Medicine at The University of Texas at Austin Dell Medical School and the CommUnityCare Federally Qualified Health Centers and the Health Care for the Homeless Program. ANJUM KHURSHID is affiliated with the Department of Population Health at The University of Texas at Austin Dell Medical School .

Please address all correspondence to Tim Mercer, The University of Texas at Austin Dell Medical School, 1601 Trinity St., Bldg B., Austin, TX, USA 78712; ph: 512-495-5393; email: tim.mercer@austin.utexas.edu.

References

1. Culhane D, Henry M, Watt R, et al. The 2019 Annual Homeless Assessment Report (AHAR) to Congress Part 1: Point-in-Time Estimates of Homelessness. Washington, DC: Office of Community Planning and Development, 2020. Available at: https://www.huduser.gov/portal/sites/default/files/pdf/2019-AHAR-Part-1.pdf.
2. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014 Oct 25;384(9953):1529–40. https://doi.org/10.1016/S0140-6736(14)61132-6
3. Kertesz SG, McNeil W, Cash JJ, et al. Unmet need for medical care and safety net accessibility among Birmingham's homeless. J Urban Health. 2014 Feb;91(1):33–45. https://doi.org/10.1007/s11524-013-9801-3 PMid:23620012
4. Baggett TP, O'Connell JJ, Singer DE, et al. The unmet health care needs of homeless adults: a national study. Am J Public Health. 2010 Jul;100(7):1326–33. https://doi.org/10.2105/AJPH.2009.180109 PMid:20466953
5. Baggett TP, Chang Y, Porneala BC, et al. Disparities in cancer incidence, stage, and mortality at Boston health care for the homeless program. Am J Prev Med. 2015 Nov;49(5):694–702. https://doi.org/10.1016/j.amepre.2015.03.038 PMid:26143955
6. Bharel M, Lin WC, Zhang J, et al. Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act. Am J Public Health. 2013 Dec;103 Suppl 2 (Suppl 2):S311–7. https://doi.org/10.2105/AJPH.2013.301421 PMid:24148046
7. Magwood O, Leki VY, Kpade V, et al. Common trust and personal safety issues: a systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness. PLoS One. 2019 Dec 30;14(12):e0226306. https://doi.org/10.1371/journal.pone.0226306 PMid:31887152
8. Moses J. New data on race, ethnicity, and homelessness. Washington DC: National Alliance to End Homelessness, 2019. Available at: https://endhomelessness.org/new-data-on-race-ethnicity-and-homelessness/
9. Baggett TP, Hwang SW, O'Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013 Feb 11;173(3):189–95. https://doi.org/10.1001/jamainternmed.2013.1604 PMid:23318302
10. Roncarati JS, Baggett TP, O'Connell JJ, et al. Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000–2009. JAMA Intern Med. 2018 Sep 1;178(9):1242–8. https://doi.org/10.1001/jamainternmed.2018.2924 PMid:30073282
11. Khurshid A, Rajeswaren V, Andrews S. Using blockchain technology to mitigate challenges in service access for the homeless and data exchange between providers: qualitative study. J Med Internet Res. 2020 Jun 4;22(6):e16887. https://doi.org/10.2196/16887 PMid:32348278
12. Tompkins S. Photo identification barriers faced by homeless persons: the impact of September 11. Washington DC: National Law Center on Homelessness & Poverty, 2004. Available at: https://nlchp.org/wp-content/uploads/2018/10/ID_Barriers.pdf.
13. Cameron A, Abrahams H, Morgan K, et al. From pillar to post: homeless women's experiences of social care. Health Soc Care Community. 2016 May;24(3):345–52. https://doi.org/10.1111/hsc.12211 PMid:25721440
14. Khurshid A, Gadnis A. Using blockchain to create transaction identity for persons experiencing homelessness in America: policy proposal. JMIR Res Protoc. 2019 Mar 6;8(3):e10654. https://doi.org/10.2196/10654 PMid:30839279
15. Gundlapalli A, Hanks M, Stevens SM, et al. It takes a village: a multidisciplinary model for the acute illness aftercare of individuals experiencing homelessness. J Health Care Poor Underserved. 2005 May;16(2):257–72. https://doi.org/10.1353/hpu.2005.0033 PMid:15937390
16. Hancock M, Vaizey E. Distributed ledger technology beyond blockchain. London, United Kingdom: The Government Office for Science, 2016. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/492972/gs-16-1-distributed-ledger-technology.pdf.
17. Engelhardt M. Hitching healthcare to the chain: an introduction to blockchain technology in the healthcare sector. TIM Rev. 2017 Oct;7(10):22–34. https://doi.org/10.22215/timreview/1111
18. Vazirani AA, O'Donoghue O, Brindley D, et al. Implementing blockchains for efficient health care: systematic review. J Med Internet Res. 2019 Feb 12;21(2):e12439. https://doi.org/10.2196/12439 PMid:30747714
19. Bond S. Transforming digital identity into trusted identity. New York, NY: IBM, 2020. Availabe at: https://www.ibm.com/blockchain/solutions/identity.
20. Dimitrov DV. Blockchain applications for healthcare data management. Healthc Inform Res. 2019 Jan;25(1):51–6. https://doi.org/10.4258/hir.2019.25.1.51 PMid:30788182
21. Howell ST, Niessner M, Yermack D. Initial coin offerings: financing growth with cryptocurrency token sales. Rev Financ Stud. 2020 Sep;33(9):3925–74. https://doi.org/10.1093/rfs/hhz131
22. Koksal I. The rise of Crypto as payment currency. Jersey City, NJ: Forbes, 2019. Available at: https://www.forbes.com/sites/ilkerkoksal/2019/08/23/the-rise-of-crypto-as-payment-currency/?sh=1534e66926e9.
23. Scott B, Loonam J, Kumar V. Exploring the rise of blockchain technology: towards distributed collaborative organizations. Briefings in Entrepreneurial Finance. 2017 Sep;26(5):423–8. https://doi.org/10.1002/jsc.2142
24. Goede M. E-Estonia: The e-government cases of Estonia, Singapore, and Curaçao. Archives of Business Research. 2019 Feb;7(2).216–27. https://doi.org/10.14738/abr.72.6174
25. Heller N. Estonia, the digital republic. New York, NY: The New Yorker, 2017. Available at: https://www.newyorker.com/magazine/2017/12/18/estonia-the-digital-republic.
26. Yiannas F. A new era of food transparency powered by Blockchain. Innov Technol Gov Glob. 2018 July;12(1–2):46–56. https://doi.org/10.1162/inov_a_00266
27. The LINUX Foundation Projects. Case study: how Walmart brought unprecedented transparency to the food supply chain with Hyperledger fabric. San Francisco, CA: The LINUX Foundation Projects, 2019. Available at: https://www.hyperledger.org/resources/publications/walmart-case-study.
28. Gadnis A. Opinion: Blockchain offers poorest a real economic identity—and a shot at the SDGs. Washington DC: Devex, 2016. Available at: https://www.devex.com/news/opinion-blockchain-offers-poorest-a-real-economic-identity-and-a-shot-at-the-sdgs-89071.
29. Haq I, Muselemu Esuka O. Blockchain technology in pharmaceutical industry to prevent counterfeit drugs. IJCA. 2018 Nov;180(25):8–12. https://doi.org/10.5120/ijca2018916579
30. Kumar R, Tripathi R. Traceability of counterfeit medicine supply chain through blockchain. In: 2019 11th International Conference on Communication Systems & Networks (COMSNETS), Bengaluru (India), January 7–11, 2019:568–70. Piscataway, NJ: Institute of Electrical and Electronics Engineers (IEEE) https://doi.org/10.1109/COMSNETS.2019.8711418
31. US Food and Drug Administration (FDA). FDA takes new steps to adopt more modern technologies for improving the security of the drug supply chain through innovations that improve tracking and tracing of medicines. Silver Spring, MD: FDA, 2019. Available at: https://www.fda.gov/news-events/press-announcements/fda-takes-new-steps-adopt-more-modern-technologies-improving-security-drug-supply-chain-through.
32. Gordon WJ, Catalini C. Blockchain technology for healthcare: facilitating the transition to patient-driven interoperability. Comput Struct Biotechnol J. 2018 Jun 30;16: 224–30. https://doi.org/10.1016/j.csbj.2018.06.003 PMid:30069284
33. Mertz L. (Block) Chain reaction: a blockchain revolution sweeps into health care, offering the possibility for a much-needed data solution. IEEE Pulse. May–Jun 2018;9(3):4–7. https://doi.org/10.1109/MPUL.2018.2814879
34. Roman-Belmonte JM, De la Corte-Rodriguez H, Rodriguez-Merchan EC. How blockchain technology can change medicine. Postgrad Med. 2018 May;130(4):420–7. https://doi.org/10.1080/00325481.2018.1472996 PMid:29727247
35. Kuo TT, Kim HE, Ohno-Machado L. Blockchain distributed ledger technologies for biomedical and health care applications. J Am Med Inform Assoc. 2017 Nov 1;24(6):1211–20. https://doi.org/10.1093/jamia/ocx068 PMid:29016974
36. Dubovitskaya A, Xu Z, Ryu S, et al. Secure and trustable electronic medical records sharing using blockchain. AMIA Annu Symp Proc. 2017;2017:650–9.
37. Khurshid A. Applying blockchain technology to address the crisis of trust during the COVID-19 pandemic. JMIR Med Inform. 2020 Sep 22;8(9):e20477. https://doi.org/10.2196/20477 PMid:32903197
38. Ibrahim SA, Charlson ME, Neill DB. Big data analytics and the struggle for equity in health care: the promise and perils. Health Equity. 2020;4(1):99–101. https://doi.org/10.1089/heq.2019.0112 PMid:32258961
39. Obermeyer Z, Powers B, Vogeli C et al. Dissecting racial bias in an algorithm used to manage the health of populations. Science. 2019 Oct 25;366(6464):447–53. https://doi.org/10.1126/science.aax2342 PMid:31649194
40. Durneva P, Cousins K, Chen M. The current state of research, challenges, and future research directions of blockchain technology in patient care: Systematic Review. J Med Internet Res. 2020 Jul 20;22(7):e18619. https://doi.org/10.2196/18619 PMid:32706668
41. Kim J, Park HA. Development of a health information technology acceptance model using consumers' health behavior intention. J Med Internet Res. 2012 Oct 1;14(5):e133. https://doi.org/10.2196/jmir.2143 PMid:23026508
42. Venkatesh V, Thong J, Xu X. Consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology. MIS Quarterly. 2012 March;36(1).157–78. https://doi.org/10.2307/41410412
43. Moczygemba LR, Cox LS, Marks SA, et al. Homeless patients' perceptions about using cell phones to manage medications and attend appointments. Int J Pharm Pract. 2017 Jun;25(3):220–30. https://doi.org/10.1111/ijpp.12321 PMid:27896909
44. Moczygemba LR, Thurman W, Tormey K, et al. Feasibility of a GPS-enabled mHealth intervention to enhance care coordination among people experiencing homelessness. Presented at: AcademyHealth Annual Research Meeting, Virtual Conference, July 28–August 6, 2020.
45. Thurman W, Moczygemba LR, Hilbelink M. Smartphones and transportation as tools to meet the health and social needs of people experiencing homelessness. Presented at: AcademyHealth National Health Policy Conference, Washington (DC), Feb 10–11, 2020.
46. Lin T, Yang X, Wang T, et al. Implementation of high-performance blockchain network based on cross-chain technology for IoT applications. Sensors (Basel). 2020 Jun 8;20(11):3268. https://doi.org/10.3390/s20113268 PMid:32521762
47. Sedlmeir J, Buhl HU, Fridgen G, et al. The energy consumption of blockchain technology: beyond myth. Business and Information Systems Engineering. 2020 Jun;62: 599–608. https://doi.org/10.1007/s12599-020-00656-x
48. Lim SY, Fotsing PT, Almasri A, et al. Blockchain technology the identity management and authentication service disruptor: a survey. International Journal on Advanced Science, Engineering and Information Technology. 2018 Sep;8(4–2):1735–45. https://doi.org/10.18517/ijaseit.8.4-2.6838
49. Kondova G, Erbguth J. Self-sovereign identity on public blockchains and the GDPR. Proceedings of the 35th Annual ACM Symposium on Applied Computing, 2020 Mar:342–5. https://doi.org/10.1145/3341105.3374066
50. Shi S, He D, Li L, et al. Applications of blockchain in ensuring the security and privacy of electronic health record systems: a survey. Comput Secur. 2020;97:101966. https://doi.org/10.1016/j.cose.2020.101966 PMid:32834254
51. Charles WM, Marler NE, Long L, et al. Blockchain compliance by design: regulatory considerations for blockchain in clinical research. Frontiers in Blockchain. 2019 Nov 8;2(18). https://doi.org/10.3389/fbloc.2019.00018
52. Eyassu SE. Overview of blockchain legislation and adoption: status and challenges. Issues in Information Systems. 2019;20(1).

Additional Information

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1548-6869
Print ISSN
1049-2089
Pages
262-277
Launched on MUSE
2021-05-01
Open Access
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