Blockchain in Healthcare TodayTM ISSN 2573-8240 online https://doi.org/10.30953/bhty.v2.98 Letter to the Editor | Open Access DMMS: A Decentralized Blockchain Ledger for the Management of Medication Histories Patrick Li1, Scott D. Nelson2, Bradley A. Malin3, You Chen4 1Computer Science, Saratoga High School, Saratoga, CA, USA; 2Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; 3Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; 4Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA Blockchain in Healthcare Today, January 4, 2019. © The Author(s). 2019 The original article was published in Blockchain in Healthcare Today. DOI: https://doi.org/10.30953/bhty.v2.38 Section: Use Cases/Pilots/Methodologies Keywords: Blockchain Ledger, Decentralized, Hyperledger Fabric Framework, Medication, Histories Dear Editor, We hereby appreciate you for publishing a unique journal dedicated to Healthcare Blockchain. We would like to mention some points on the latest paper published: “DMMS: A Decentralized Blockchain Ledger for the Management of Medication Histories”.1 It is a valuable text prototyping one of the most case requirements of healthcare suggesting that we should to move on peer-to-peer blockchain network, facilitating prescribing and patient history access. First, when we are trying to solve an issue, specifically in the health care; it would be better to plan a more comprehensive solution,2 what is called lean management.3 The prescription is not a stand-alone piece of software discrete of other administration and admission processes in hospitals. Experience has shown that stand-alone e- https://doi.org/10.30953/bhty.v2.38 Blockchain in Healthcare TodayTM ISSN 2573-8240 online https://doi.org/10.30953/bhty.v2.98 prescription has cost barriers to the system and also training of the staff.4,5 Therefore, a comprehensive and modular EHR could contain an e-prescription module. On page 4, “Public and private blockchain”, the first sentence parallels the public and private blockchain to permissionless and permissioned. Although the definitions are close together, they are different as described in chapter 23 of this APress book6 or this website7. On page 4, Hyperledger is mentioned as a private blockchain. However, it is a highly customizable platform that can be used for any type of blockchain.8–10 On page 5, research exemplified Etherium next to Bitcoin as a “Proof of Work” consensus blockchain. However, Etherium has switched to a mixed method “Proof of Concept” called Casper in recent years11,12 and has become more green and environmental friendly13 by reducing energy costs needed for mining. The other point to mention is about component naming (page 6). Although the system and component names are not visible to everyone, ethically it would be better not to categorize the patients as assets. Even some have suggested that we should not write the term patient in papers and that we should use the “participant” instead.14 However, as you have that for the physicians, you could simply call that “users”. On page 7 you have stated, “Machines will have a pre-installed client with a prescriber- type network card.” It was not clear to us what you mean at the first sight. It appears that the researcher has manufactured specific hardware that replaces computer network card for prescribers’ computer to join the developed blockchain network. The security part of the paper (page 8) starts with the sentence “In some breaches…”. Although using the word “breach” is not wrong here, as the research is published in an expertise blockchain journal, we have to consider that “breach” is specifically a type of insecurity issue15 that may lead to misunderstanding here. The other ethical issue (page 9) is that in a system developed by highly secure blockchain technologies, users trust and join as they are assured their data are safe and secured in the blockchain. Thus, how and in what case are the records queried and sent Blockchain in Healthcare TodayTM ISSN 2573-8240 online https://doi.org/10.30953/bhty.v2.98 to the third-party EHR vendors? In most cases, they do not store data in an encrypted format. Furthermore, (as described on page 10), the same issue happens for the private keys of the users unable to access smartphones. How are their private keys stored? What has been done in the research puts the users in more danger in comparison to those that have access to smartphones. That’s the violation of ethical code “Justice”.16,17 Acknowledgements: The authors would like to thank Shiraz University of Medical Sciences, Shiraz, Iran and also Center for Development of Clinical Research of Nemazee Hospital and Dr. Nasrin Shokrpour for editorial assistance and also Dr. Maryam Shahpasand from Asia Pacific University of Technology & Innovation for her kind help. Sincerely, Amir Hossein Zolfaghari1, Mahdi Nasiri2, Roxana Sharifian3 1MSc Student of Medical Informatics, School of Management and Medical Information Sciences, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. E-mail: zolfaghari@sums.ac.ir; 2Assistant Professor, Health Human Resources Research Center, School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; 3Associate Professor, School of Management and Medical Information Sciences, Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. References 1. Li P, Nelson SD., Malin BA, Chen Y, Chen Y. DMMS: A decentralized blockchain ledger for the management of medication histories. Blockchain Healthcare Today 2019; 1. Available at URL: mailto:zolfaghari@sums.ac.ir Blockchain in Healthcare TodayTM ISSN 2573-8240 online https://doi.org/10.30953/bhty.v2.98 https://blockchainhealthcaretoday.com/index.php/journal/article/view/38 2. Zaccai G. Designing the future of healthcare. in Studies in Health Technology and Informatics 149, 49–57 (2009). 3. Lawal AK, Rotter T, Kinsman L, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Syst Rev. 2014 Sep 19;3:103. doi: 10.1186/2046-4053-3-103. 4. Porterfield A, Engelbert K. Coustasse A. Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. Perspect. Heal. Inf. Manag. 2014;11, 1g. 5. Lander L, Klepser DG. Cochran GL, Lomelin DE. Morien M. Barriers to electronic prescribing: Nebraska pharmacists’ perspective. J. Rural Heal. 2013; 29:119–24. 6. Drescher D. Kirk L. Blockchain basics : a non-technical introduction in 25 steps. Apress. 2017. 7. Blockchainhub.net. Types of Blockchains and DLTs (Distributed Ledger Technologies). https://blockchainhub.net/ Available at: https://blockchainhub.net/blockchains-and-distributed-ledger-technologies-in- general/. Accessed: 14th January 2019. 8. Hyperledger. Blockchain Technology Projects – Hyperledger. https://www.hyperledger.org/ Available at: https://www.hyperledger.org/projects. Accessed: 14th January 2019. 9. Hyperledger.org. GitHub - Hyperledger. http://www.hyperledger.org Available at: https://github.com/hyperledger/hyperledger. Accessed: 14th January 2019. 10. Moses SP. Hyperledger — Chapter 1 | Blockchain Foundation – The Startup – Medium. medium.com (2018). Available at: https://medium.com/swlh/hyperledger- chapter-1-foundation-7ad5bd94d452. Accessed: 14th January 2019. 11. Evan T. Types of Consensus Protocols Used in Blockchains – Hacker Noon. hackernoon (2018). Available at: https://hackernoon.com/types-of-consensus-protocols- used-in-blockchains-6edd20951899. Accessed: 14th January 2019. 12. Ethereum Github page. Proof of Stake FAQs · ethereum/wiki Wiki · GitHub. Github (2018). Available at: https://github.com/ethereum/wiki/wiki/Proof-of-Stake-FAQs. Accessed: 14th January 2019. Blockchain in Healthcare TodayTM ISSN 2573-8240 online https://doi.org/10.30953/bhty.v2.98 13. Tron Live. An easy to understand guide to PoW, PoS, DPoS, consensus mechanism and super representative. medium (2018). Available at: https://medium.com/tron- foundation/an-easy-to-understand-guide-to-pow-pos-dpos-consensus-mechanism-and- super-representative-eb1f5504a8e. Accessed: 14th January 2019. 14. Neuberger J. Do we need a new word for patients? Let’s do away with “patients.” BMJ 1999; 318:1756–7. 15. Kobus III, TJ. The A to Z of healthcare data breaches. J. Healthc. Risk Manag. 2012; 32:24–8. 16. Goodman, KW. Cambridge University Press. & Cambridge. Ethics, Computing, and Medicine : Informatics and the Transformation of Health Care. Cambridge University Press. 1997. doi:10.1017/CBO9780511585005 17. Gracyk T. Four fundamental principles of ethics. Minnesota State University Moorhead. 2012. Available at: http://web.mnstate.edu/gracyk/courses/phil 115/Four_Basic_principles.htm. 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