Blockchain-Based Quality of Service for Healthcare System in the Gaza Strip

Electronic Health Records EHRs are critical, highly sensitive private information in healthcare, and need to be frequently shared among different parties for example patients, physicians and administration. Blockchain provides a shared, immutable and transparent health records of all the transactions to build applications with trust, accountability, and transparency. This provides a unique opportunity to develop a secure and trustable EHR data management and sharing system using blockchain. This study aims to develop the use of health records as well as finding the current status of EHRs by designing a checklist to measure the extent of use of health records in the Gaza Strip hospitals and exploring the possibilities of using blockchain technology to develop the use of the electronic health records to share accurate and complete health data between multiple parties such as patients, doctors, and managers in an effective, transparent and secure manner.


I INTRODUCTION
Actually, correct, accurate and timely information is the most important foundation for smart cities. Blockchain, big data and artificial intelligence are the most important technologies used in smart city applications [1][2][3]. One of the most important applications of smart cities is healthcare. EHR management system aims to provide a full history of a patient, that contains the right information in the right place in the right order, at the right time for the right person at the lowest cost, considering the security of patient data. There are no EHRs designed to manage multi-institutional, lifetime medical records. Many global healthcare systems are in crisis because of prohibitive costs, limited access to care, patient safety and privacy concerns, data breaches, and varying quality of care.
Patient's health record is an important part of information for the process of medical treatment of patients including personal data, personal medical profile, allergies, etc. Several hospitals adopt information communication and technology to manage patient medical records which are called Electronic Health Record System. The current EHR system in most countries is not very effective, as hospitals have used different programs. The EHR systems in hospitals are private and developed to use within the organization only, where some hospitals have developed their own system, while others have purchased ready-to-use application software. Thus, it is not connected to each other. If a patient transfers for any reason to another hospital, access to the patient's medical profile in the new hospital could not be done. As a result, patients receive limited bene-fits from the data in the private EHR system. Such problems make hospitals unable to transfer important information between the stakeholders in the system with confidence. As well as, patients are not confident about the security and privacy of their data [4].
As a result, advancement of blockchain technology is necessary to have the potential to accommodate an exchange of existing data safely. The operation of blockchain comprises information confidential, accurate and ready-to-use information [5]. Blockchain offers a potential solution; it enables us to put the patient at the center of the healthcare ecosystem and increases the security, auditability, and privacy of sensitive health data and interoperability of systems that contain such personal information. Therefore, doctors can diagnose symptoms precisely from the past medical treatment, and pharmacists can supply medicines correctly and accurately from the prescriptions through the system [6]. Additionally, it can provide the information accurately and timely for the strategic planning of the healthcare service providers more effectively [7].
Blockchain's success depends on whether all stakeholders are willing not only to adopt its technical infrastructure and its core principles but also to participate in healthcare standards development and ongoing governance of blockchainbased healthcare platforms. The need to increase the efficiency of healthcare delivery and reduce duplication and errors is essential to enable health organizations to meet the increasing demand for services in the future. Many countries experience identifies that adoption of a comprehensive EMR system will assist in achieving these objectives [7].
This study aims to investigate the availability, use and efficiency of the electronic health record in the Gaza Strip hospitals, and explore the possibility of applying blockchain technology to improve health care in it and standing on the obstacles that hinder the use of such technology in the field of EHRs. For this purpose, a checklist is designed and analyzed to achieve the above aim.

II THE STUDY QUESTIONS
Unleashing blockchain's potential in healthcare will require organizations to address significant challenges. Since its greatest benefits revolve around streamlining, the coordination among multiple providers, and patients, healthcare organizations will need to measure and study the current situation of EHRs and study how appropriate an EHR is to use and benefit from blockchain technology. This what research tries to address.
It also offers a new vision of smart healthcare, by potential formularization of effective healthcare policies for decision-makers, patients, health care providers with different health care institutions, and other stakeholders. In addition to, it tries to identify the reality of the EHR and its effectiveness in the providing of healthcare in the Gaza Strip, explore the possibility of applying blockchain technology to improve healthcare in its medical centers. Considering the Gaza Strip case study, study importance can be realized from answering the following key research questions.
 What are the capabilities of EHR?  How medical centers such as hospitals and clinics are ready for using blockchain technology?  What are the obstacles that obstruct the use of blockchain technology in the field of EHR?  What are the capabilities of the new blockchain technology in the field of healthcare and EHR?  What are the benefits of using blockchain technology for patients, medical staff, hospital management, and community?

III BLOCKCHAIN AND EHR CONCEPTS
A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounteras well as supporting other care-related activities directly or indirectly via interfaceincluding evidence-based decision support, quality management, and outcomes reporting [8].
An EMR, Electronic Medical Record, is an application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. This environment supports the patient's electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage healthcare delivery within a Care Delivery Organization (CDO). The data in the EMR is the legal record of what happened to the patient during his or her encounter at the CDO and is owned by the CDO [8].
Conceptually, blockchain can be easily explained as a type of database for recording and confirming transactions. Each transaction is verified, recorded and combined with other transactions to produce a new block in the ledger that is then copied to peer nodes in the participating network, thus creating a distributed ledger of sorts. These transactions can range from moving data to transferring money, and even relating The Electronic Health Record and confidential personal information, etc. Salha et al. [9] discuss in depth the concept of blockchain in terms of definitions from different perspectives related multiple uses of stakeholders by different domains and applications.
Healthcare is one of the most important areas that is suitable to be effectively used in emerging blockchain technology and healthcare initiatives. In less than a decade, blockchain has surged from a technology with narrow applications related to digital currencies, to one with important applications in many domains especially in healthcare, so, drawing attention to policymakers at different levels too. EHRs are never designed to manage multi-institutional, lifetime medical records. Patients leave data scattered across various organizations. Thus they lose easy access to past data, as the provider, not the patient, generally retains primary stewardship on EHR. Patients thus interact with records in a fractured manner that reflects the nature of how these records are managed [10]. Table 1 presents the most important advantages of EHRs and their challenges.

TABLE 1
Advantages and Challenges of EHRs.
Advantages of EHRs [11] Challenges to EHRs Adoption [12,13] • Blockchain technology can enhance EHRs efficiency that are essential in fields of health care. At its core, blockchain relies on a decentralized, digitalized and distributed ledger model. By its nature, this is more robust and secure than the centralized models which are currently used in the health care ecosystem. Blockchain technology creates a viable, decentralized record of EHRs transactionsthe distributed ledgerwhich allows the substitution of a single master database. It keeps an immutable record of all transactions, back to the originating point of a transaction. This is also known as the provenance, which is essential in health care, allowing health care institutions, stakeholders and patients to review all transaction steps and reduce the risk of fraud, prevents changing and tampering with the data of the electronic health record of the patients. Table 2 shows current issues within the smart healthcare industry.

TABLE 2
Current Issues Within the Smart Healthcare Industry [14].

Healthcare Data Interchange
Data must pass between healthcare providers to necessary third parties, insurers, and patients while meeting data protection regulation in the healthcare sector.

Nationwide Interoperability
Having a single standard for patient data exchange allows for ease of passing data between healthcare providers, which legacy systems often do not provide.

Medical Device Tracking
Medical device tracking from supply chain to decommissioning allows for swift retrieval of devices, prevention of unnecessary repurchasing, and fraud analytics.

Drug Tracking
As with medical devices, blockchain offers the capability to track the chain of custody from supply chain to patients, allowing for tracking any transaction and prevention of counterfeit drugs.

IV RELATED WORK
A problem facing healthcare record systems is how to share the medical data with more stakeholders for various purposes without sacrificing data privacy and integrity. Blockchain as a promising technology to manage the transactions has been gaining popularity in the domain of healthcare. It has also the potential of securely, privately, and comprehensively manage patient health records.
Zhang M. and Ji Y. [15] discuss the latest status of blockchain technology and how it could solve the current issues in healthcare systems. They evaluated the blockchain technology from the multiple perspectives around healthcare data, including privacy, security, control, and storage. They reviewed the current projects and researches of blockchain in the domain of healthcare records and provide the insight into the design and construction of next generations of blockchain-based healthcare systems.
Conceic A. et al. [16] discuss how blockchain technology, and smart contracts, could help in some typical scenarios related to data access, data management and data interoperability for the specific healthcare domain. They propose the implementation of a large-scale information architecture to access EHRs based on smart contracts as information mediators. The main contribution for this study is the framing of data privacy and accessibility issues in healthcare and the proposal of an integrated blockchain based architecture.
Park et al. [17] confirm that it is possible to exchange EHR data in a private blockchain network. They concluded that to develop a blockchain-based EHR platform that can be used in practice, many improvements are needed, including reductions in data volume, improved protection of personal information, and reduced operating costs.
Ekblaw et al. [18] propose a novel and decentralized record management system to handle the EHRs, using the blockchain technology. Their system gives patients a comprehensive, immutable log and easy access to their medical information across the providers and treatment sites.
Xiao Yue et al. [19] propose centric access model ensures the patients to control their healthcare data on their own; simple, unified indicatorcentric schema makes it possible to organize all kinds of personal healthcare data practically and easily. Their method also indicates the fact that MPC (Multi-Party Computing) is one promising solution to enable an interested third party to conduct computation over patient data without violating privacy. Zhang et al. [20] address the adoption of blockchain in social network domain but not fully explores the benefits of the blockchain.

V EHRS IN THE GAZA STRIP A The Study Area
Gaza Strip constitutes the south west part of Palestinian coastal plain of Mediterranean Sea and it is confined between the Mediterranean Sea in the west, Sinai of Egypt in the south, Negev desert in the east and green line in the north. The Gaza strip area is about 365 km 2 . The length is about 41 km on the western Mediterranean coast and the width varying from 7 to 12 km, Figure 1. It is located on a latitude of 31˚ 16´ to 31˚ 45´ North and 34˚ 20´ to 34˚ 25´ East [21]. The population density of Palestine is generally high at 826 persons/km 2 , particularly in the Gaza Strip, where it is 5,453 persons/km 2 compared to a lower population density in the West Bank of 528 persons/km 2 in mid-2019 [22].

B Healthcare in the Gaza Strip
Healthcare sector in the Gaza Strip is composed of; (a) primary healthcare represented in clinics; (b) secondary healthcare represented in hospitals [23]. Ministry of Health (MOH) is considered the main provider of secondary healthcare in the Gaza Strip. It defines hospital as a place prepared to receive patients for more than one day for diagnosis or treatment [24]. There are 30 hospitals in the Gaza Strip; 13 hospitals supervised by MOH, 14 hospitals supervised by NGOs, and 3 hospitals supervised by Ministry of Interior (MOI). Private sector and the United Nation Relief and Works Agency for Palestine and Refugees in Near East (UNRWA) do not operate hospitals in the Gaza Strip [25]. The distribution of healthcare facilities according the supervision agency is showed in Table 3.

C Diseases Status
Vaccination coverage levels are one of the best indicators of the health system performance. Therefore, MOH provides all the needed services to ensure that immunizations for each child according to the national immunization schedule are granted. Figure 2 shows number of communicable diseases status in the Gaza strip of the year 2018 [26].
As shown in Table 4, non-communicable diseases NCDs such as ischemic heart disease is ranked the first (40%) from reported chronic diseases in the Gaza Strip in 2010. Whereas, cancer is ranked the second (20%), followed by cerebrovascular disease CVD (13%). Respiratory disease is ranked the fourth (10.4%) among reported chronic diseases in the Gaza Strip population.

TABLE 4
Non Communicable Diseases in the Gaza Strip [27].

D EHRs Challenges
Challenges facing the development of EHRs in the Gaza Strip involve [26]:  Interoperability  Lack of adoption of uniform standards and interoperability.  Privacy and confidentiality.  Social and organizational barriers.  Technology limitations.  Preserving electronic records.  The legal status of EMR

VI CHECKLIST ANALYSIS AND DISCUSSION
A checklist is designed to assess the performance of EHR and the potential using of blockchain at governmental and NGOs hospitals in the Gaza Strip. This design is highly accepted to assist to meet the study purposes. The target population of this study is hospital managers and IT managers who are working in governmental and NGOs hospitals in the Gaza strip. The total number of healthcare providers is 84, and thus, the target community in the study consists of 84 samples. The survey is conducted over six weeks. The checklist has been distributed to hospital administrators, and if the IT department is available, the head of the IT department is asked to answer the checklist.
Ethical approval is obtained from the Islamic University of Gaza as well as the official approval from the General Directorate of Human Resource Department in MOH -Gaza. Every participant in the study received a complete explanation of confidentiality and research purposes.

A Checklist Design
The checklist has been prepared on the subject of the study and consists of two sections. Section one includes the demographic data such as personal, general and technical data of the respondent like institution's name, city name, name of governorate, institution level, supervising authority, institution age, etc. On the other hand, section two involves fifth dimensions which are: 

B Checklist Validity and Reliability
Content validity refers to the extent to which the paragraphs in the checklist, or the measuring tool, represent the content that has been chosen for inclusion in the test, by presenting the checklist to the arbitrators for their opinions. The check-list is presented to a number of experts as shown in Table 5. The arbitrators' opinions are taken into consideration and the amendment is made in light of the submitted proposals, thus the checklist is finalized. Internal consistency is a check to ensure all of the test items are measuring the concept they are supposed to be measuring. Table 6 shows the internal consistency performed using Cronbach's Alpha to verify the reliability of each dimension. Cronbach's Alpha test for all checklist variables is 0.964.  Figure 3 summarizes the demographic data analysis of the checklist. Figure 3-a shows, that Gaza Governorate comes first in terms of number of hospitals and clinics in the governorates of the Gaza Strip. This is due to its high population as well as the presence of governmental, educational, economic and other institutions.  Figure 3-c shows that 53.8% of the sample use EHR in the past 0-5 years. This indicates that the use of EHR is relatively recent and it may not meet all the needs of patients in the health sector. It also appeared from the study that there are a number of health institutions that do not have EHR. Figure 3-d clearly shows that 73.3% of the sample who responded to the study hold a bachelor's degree in computer science, 19.2% a master's degree and 7.7% a doctoral degree. These results confirm once again that the health sector has the scientific and technical personnel ability to develop the EHR and improve healthcare.

C Demographic Data Analysis
It can be observed as in Figure 3-e that 46.2% of the respondents are heads of computer departments in health institutions, as well as the same percentage 46.2% of respondents are managers of health institutions, and this matches the importance and accuracy of the information that can be obtained about EHR for this study.
Figure 3-f indicates that 46.2% of EHR technology used is one or more products developed internally, and 38.5% is a combination of ready-made products and internally developed. That means that there are different groups of health systems technology. Consequently, there may be incompatibilities between these different systems, as well as non-interoperability between these systems.

D Analysis of Checklist Paragraphs
The cross-tabulation is used to analyze the paragraphs of the checklist's dimensions, where cross tables are appropriate to the analysis of this kind of data, which consists of dichotomies. Table 7 summarizes the analysis result of the first dimension. It indicates, for example, the sum of those agreeing to paragraph No. (2) "It is possible to order medical checks and follow up laboratory results through EHR" is 91.7%. This means that radiology, medical and laboratory examinations are conducted and followed widely on most health institutions, through the EHR. This occurs in most health facilities separately, and not between them through an international, regional, or even local network. This answers the first question of this research, about the capabilities of the electronic health record for hospitals and clinics in the Gaza Strip.

Dimension One: The capabilities of the current EHR
The same result is obtained where the total of those who agree with the paragraph (7) is 12.5% that says "Patient allowed to access his health record electronically or share it with other specialists in the patient's case". Therefore, this indicates that the patient cannot share or view his EHR through the Internet. Here, blockchain technology can greatly help to connect health institutions and stakeholders, especially patients, so patients can view their data on the health record.
Respondents to paragraph No. (8) report that 12.5% agree with this paragraph which says that "There is an alarm system in EHR when results for a medical analysis appear to need an urgent intervention". This indicates that the EHR in the health institutions has not an alarm system. Hence, there is an urgent need to use Blockchain technology to develop the use of the EHR, to provide true, accurate and up-to-date information anytime and anywhere for the patient through the EHR. Thus, the second and third questions in this study are answered about the capabilities of the electronic health record, and the capabilities and benefits of blockchain technology in the healthcare field, especially in the Gaza Strip.  sector. This means that it must be ensured that the EHR has the capacity and competence to meet the basic needs in order to enter data correctly and accurately.

Dimension Two: Challenges facing the use of EHR
Phrase No. (5), which is "Is there a mobile application that allows monitoring of electronic health records (by the doctor, patient or family of the patient) or requesting medical examinations?", 29.2% agree on this phrase, all respondents are from government health institutions, and the percentage of respondents from private health institutions is 0%. There may be lack of clarity among respondents, as there is a special program for the Ministry of Health, but this program does not include functions for the EHR that can be viewed by the patient or doctor via the Internet.
Thus, it can be said that the healthcare system needs to develop a mobile program to enable patient stakeholders and doctors to view the patient's health record details according to the health law as well as the validity and privileges of each user. Here, the answer to the second and third question from the study is confirmed in terms of the capabilities of the EHR. The urgent need to use blockchain technology to link all governmental and private health institutions is also evident.

Dimension Four: Audit log and metadata properties approved in the EHR.
Dimension Four scene is summarized in Table 10 to Table  12, where the most important paragraphs are presented in Table 10 and details of phrases No. (2) and (3) are illustrated in Table 11 and Table 12 respectively. For example, paragraph No. (3), which says that "Audit log include the following data" reveals that 50% of all respondents who agree to this paragraph are head computer departments. This clearly indicates the presence of highly qualified medical and technical cadres to deal with the EHR project.
Pargraph No. (4) "Internet Protocol (IP)/ Media Access Control (MAC) address" in Table 12 is one of the most important phrases. The approval rate of the computer department heads is 35.7%. Likewise, they are high in the rest of the paragraphs. This indicates the importance of the fourthdimension data in terms of documenting the movement of access to EHR data. The same idea applies to paragraph (2) of Table 12. Paragraph No. (6) in Table 10 "Can the audit record be deleted?", the total of those approving it is 14.3%. This percentage indicates that there is an important basis in maintaining the audit record from deletion or change, and this saves the patient's EHR from alteration and manipula-tion and thus protect the patient's rights. Thus, blockchain technology is needed to enhance the documentation of movement to access the EHR, where the patient's health information is provided through the EHR for both the patient, the doctor, stakeholders and society. This is the answer of the fifth question of this study.  Table 11 ** Details are in Table 12 Dimension Five: Approved EHR technology features for patients' access to their data.
The important paragraphs in Dimension Five are shown in Table 13. Regarding the barriers, paragraph (4) "Concerns about the patient's security and privacy" indicates that 64.7% agree with this paragraph and consider it one of the most important obstacles in preventing patients from accessing their data through the EHR. of these, 17.6% are to the medical complex, 29.4% to the hospital and 17.6% to the clinic. This means that the issue of maintaining the privacy and security of patient information is a very important component, and must be addressed at the level of health laws, policies, and procedures before addressed on electronic health records. Also, paragraph (8) "Concerns with EHR system performance", 29.4% of respondents agree to this paragraph, out of this percentage 11.8% for medical complex, 17.6% for the hospital, and 0% for the clinic.  This means 70.6% of the respondents do not agree with this paragraph, and they consider the performance of the EHR system is good, but it may need improvement, and this is considered a strong point in the electronic health system.
As for the second part of Table 13, which talks about procedures to check a patient's EHR data, paragraph (2) "Veri-fying identity based on information an individual can verify (e.g., address, date of birth)", reveals that 91.7% of the respondents agreed to it. The distribution of this percentage is 29.2% medical complex, 50.0% hospital and 12.5% clinic. On the other hand, paragraph (3) "biometric identification", the percentage of approval of respondents is 12.5%. This means that the procedures used to verify the patient's EHR are the same as those in the old system, and these procedures and tools need to be developed to fit into the electronic health system. This axis addresses the obstacles facing the EHR, which are the same obstacles that face the implementation of blockchain technology, which can be resolved by enacting laws and legislation and implementing measures that maintain the privacy and security of health information, also developing procedures for identifying the personality of the patient who is trying to access its own EHR and other procedures that enhance confidence in the EHR. Here, the answer to the third question of the study is emphasized.

VII DISCUSSION
Based on the checklist results, there are some strengths at the current EHR in the Gaza Strip, which involves qualified medical and technical cadres, experience in the field of EHR that extends for many years, as well as the infrastructure of health systems from using computer technology and networks.
EHRs systems need to develop legislation, laws, and procedures in line with modern technology. Developing tools to improve the quality of health services through the use of blockchain technology to improve the use of the EHR by linking government and private health institutions to a unified network so that the patient can finally have permanent access to his medical data through the electronic health record anytime and anywhere.
Setting a roadmap to improve the performance of EHR using blockchain in the health sector in the Gaza Strip should include:  Digitization of all health institutions, where it is found that there are some health institutions still operating on the basis of the paper system.  Unifying medical terms by setting clear and specific standards to achieve high efficiency in the performance of the EHR.  Developing laws, legislations, and health procedures to suit modern technology and improve the performance of the EHR through blockchain technology.  Ensuring that the current EHR meets all the requirements for entering the patient's medical and demographic data and health institutions. where there are no EHRs were designed to manage multiinstitutional, lifetime medical records.  Addressing issues related to patient information privacy and security.  Connecting all health facilities to a unified network through blockchain technology to enable the patient, doctor and stakeholders to access the electronic health record anytime and anywhere.  Improving the performance of EHR programs to deal with a large amount of health data, which is significantly enlarged.  Developing and enhancing procedures to verify the identity of the patient who is trying to access his medical data through the EHR. In addition, enhancing public confidence in the electronic health record.  Developing model to improve performance of the current EHR Gaza strip using blockchain.  Developing software for mobile that allows the patient, doctor, and stakeholders to access the EHR anytime and anywhere.  Setting a road map to awareness the public society and medical society the importance of EHR for the patient and all stakeholders. In addition, enhancing confidence in the information of EHR.

VIII CONCLUSION
This study shows that the use of EHR in the Gaza Strip is relatively recent, with 50% of respondents using the electronic health record 0-5 years ago. And it may not meet all the needs of patients in the health sector. It also reveals that there are number of health institutions that do not have EHR. The study also shows that 70.6% of respondents believe that the performance of the EHR system is good, but it may need improvement, and this is considered a strong point in the electronic health system. The procedures used to verify the patient's access to EHR are the same as those in the old paper system, and these procedures and tools need to be developed to fit into the EHR. The study indicates that the issue of maintaining the privacy and security of patient information is a very important component, and must be addressed at the level of health laws, policies, and procedures before addressed on electronic health records. It also illustrates that conducting radiology report, medical examinations and laboratory data follow-up on a large scale in most health institutions, through the EHR. This occurs in most health facilities separately, not between them through an international, regional, or even local network. This confirms the presence of important patient-specific medical data distributed among different and independent health institutions, as the patient does not benefit from it through the EHR that was designed on the basis of the paper-based medical system, and not on the basis of computer use. The study concludes that the patient cannot share or view the EHR online. Here, blockchain technology can greatly help connect health institutions and stakeholders, especially patients, so that patients can display their data in the health record. In addition to, there are different software for the EHR, which differ from one health institution to another, some of these software are ready-made, some are internally developed, and some are a mixture internally developed and ready-made, and thus, the problem of incompatibility between these programs, and the inability to interoperate between it. Therefore, the urgent need to use blockchain technology to solve these problems. EHR in health institutions do not have an alarm system when results for medical analysis appear to need urgent intervention. Consequently, there is an urgent need to use blockchain technology to develop EHR use, to provide true, accurate, and up-to-date information anytime, anywhere to the patient through EHR. The study shows that the health care system needs to develop a mobile program to enable stakeholders and doctors to view patient health record details in accordance with the health law as well as the validity and privileges of each user. Finally, it is concluded that there is a strong need for blockchain technology to link public and private health institutions to one another, address the deficiencies and problems present in EHR, and allow the patient, physician, and stakeholders to access the patient health record.