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J Med Internet Res

Object name is jmir_v21i9e13595_fig2.jpg" src="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6789420/bin/jmir_v21i9e13595_fig2.jpg">Case study: Application of developed framework in the pharmaceutical supply chain.Customer Perspective Customers are at the center of all decisions at PharmaChain Inc. PharmaChain Inc is committed to customer service and innovation, and these two values guide its decision to strengthen its pharmaceutical transportation services. The blockchain solution enables customers to track and trace their temperature-regulated pharmaceutical products, thereby increasing consumer confidence. As an additional benefit, the organization receives positive media attention regarding its commitment to safely transporting pharmaceutical products, which positively strengthens the company’s relationship with its customer base. Thus, the customer gains real-time access via mobile device or desktop computer to trustworthy information via the blockchain, and the need to contact customer service, which can be time consuming for the customer and costly for the company, is removed.Internal Perspective PharmaChain Inc explores various parts of the internal and external process to solve customer challenges. Blockchain aids in the reduction of lags in the internal processes between temperature measurement and timely corrective actions. Those lags may have otherwise resulted in increased liability, loss of product efficacy, and product destruction. This implementation facilitates the monitoring of the pharmaceutical products’ exposure to undesirable conditions (such as temperature extremes and delays in transit).External Perspective Conversely, blockchain delivers external process improvements leveraged to resolve legal and compliance issues more rapidly, ultimately allowing lifesaving medicine to reach patients more quickly by eliminating customary hold times in customs. A blockchain initiative was selected to improve visibility and facilitate trust among stakeholders (eg, manufacturers, distributors, transporters, government agencies, and pharmacies). If the freight forwarders do not produce and submit customs approval forms in a timely fashion, the pharmaceutical products cannot be released, with the duration of the hold potentially affecting the quality of the product and negatively affecting the customer experience. A trusted blockchain minimizes the standard 4- to 8-hour hold duration necessary to verify the validity of the customs approval submitted by the freight forwarder, and improved compliance also helps increase trust among external partners.Learning and Growth (Innovation) Perspective Blockchain applications support PharmaChain Inc in improving its learning capabilities by enabling it to analyze its business processes and optimize them. The learning capabilities can be extended beyond pharmaceutical products, resulting in organizational efficiencies. The growth opportunity within blockchain applications is enabling traceability along the supply chain journey. Traceability helps reduce fraud in the pharmaceutical supply chain, which is a major societal benefit. Encouraged by the success of the initiative, the organization is deploying blockchain across multiple business products, especially for high value activities and products like pet transportation and food items.Financial Perspective For PharmaChain Inc, pharmaceuticals represent one of its highest grossing revenue centers among all its shipping products. With a supply chain industry ripe for innovation, PharmaChain Inc accepts that a financial investment must be made to realize the key benefits of blockchain technology. Blockchain technology reduces the risk of theft and fraud as pharmaceutical products move through multiple warehouses along the supply chain, thus justifying the financial investment. The blockchain solution implemented by PharmaChain Inc positively impacts customer service and internal and external processes, increasing reliability and thereby reducing long-term costs. The risk of theft is minimized due to the automation of security controls, facilitated by the blockchain implementation. In addition, the cost of physical tracking of shipments is also minimized. The organization anticipates a lift of 10% in pharmaceutical sales over an 18-month period due to the initiative.Tradeoffs Between the Perspectives Transparency is one of the key characteristics of blockchain that helps to facilitate value within health care. Transparency helps ensure the authenticity of the pharmaceutical products while providing a lone source of the truth for the pharmacy supply chain network. However, transparency comes with tradeoffs between the value-based perspectives. For example, transparency replaces the concept of need to know that previously existed between the internal operational perspective and the customer perspective. Prior to the adoption of the blockchain solution, process improvements that were necessary to address internal operational failure were implemented only when the benefits outweighed the costs. With the introduction of blockchain, increased transparency may increase the exposure of failures in internal operations to the entire supply chain network, which, in turn, may reduce confidence in PharmaChain Inc. Therefore, any deficiencies identified in internal processes will be addressed more rapidly. While this increases the cost of the pharmacy product in the short term, it is likely to improve performance in the long term. Since blockchain in pharmaceuticals is transformational in providing trusted information, positive media attention that results from being an innovator in the industry provides additional opportunities for expanding the customer base.Thus, PharmaChain Inc needs to continuously balance competing demands to improve internal operations and to innovate. Blockchain innovations require financial and human capital investments, which compete with the demands to improve existing internal systems. Thus, at least in the short term, increased quality of services provided to the customer (for example, via the ability to track and trace pharmaceutical products) may negatively affect the financial metrics. However, the benefits are expected to significantly increase financial performance in the long term as the blockchain technology enables PharmaChain Inc to offer superior services in comparison to its competition, thus providing PharmaChain Inc the opportunity to strengthen its competitive position in the industry.DiscussionThus, we provide a comprehensive framework that can be used to evaluate blockchain implementation in the value-based health care context, and our study contributes to research streams on blockchain technology, the balanced scorecard framework, and value-based care.First, our framework can help decision makers in health care organizations evaluate the feasibility and utility of various blockchain proposals that seek to address the health IT chasm reported in prior research [1]. We examined the health IT chasm from three stakeholder perspectives to identify how blockchain-based solutions can resolve these issues based on existing use cases (Multimedia Appendix 1). However, because this disruptive technology is still in its infancy, having a holistic view of the value of blockchain applications is critical to making informed strategic investment decisions [55,81]. Our framework will aid health care organizations in holistically considering the implications of blockchain technology from five critical perspectives. While prior literature has identified three groups of stakeholders central to the delivery of value-based care [1], our study additionally highlights the critical role of external stakeholders and regulations.In addition, our study extends the BSC framework by emphasizing the importance of the external perspective within the health care domain. The health care domain is a dynamic environment marked by changing regulations as well as competitive forces that are charting the course of the industry more rapidly than ever before. Regulatory compliance and value-based provision of services and products are two salient considerations in the health care industry. While value can be created through external partnerships, interoperability among IT systems and regulatory compliance are two areas of concern that constrain such partnerships. Blockchain’s inherent characteristics, such as transparency, immutability, and traceability, facilitate interoperability and enable health care organizations to both cocreate value with their external stakeholders and comply with regulations. Considering the influence of the external environment on a health care organization’s existence, our framework enables the examination of the external perspective when evaluating the performance of blockchain-based HIT solutions.Third, with their emphasis on value-based care, health care organizations need to develop integrated health care IT infrastructure that can improve services and reduce medical errors. Blockchain, with its inherent trust- and security-promoting qualities, has the potential to significantly affect various areas of value provision for patients in health care. While many performance evaluation solutions exist, our study demonstrates the unique aspects of BSC in evaluating IT initiatives for enabling value-based care. The BSC framework enables the consideration of both financial and nonfinancial dimensions of IT initiatives in the short term as well as the long term. When compared with other performance evaluation solutions (such as Zachman’s framework, the HCI framework, or the technology-centric framework), our extended BSC framework facilitates consideration of the external perspective. It also defines and assesses performance against operational metrics for each of the five critical perspectives. In addition, our approach highlights the importance of the interrelationships among the perspectives, thus offering another critical extension of the BSC approach. The BSC, however, is limited in its ability to build intuitive and interactive systems like those that HCI and other frameworks provide. Thus, we recommend combining the BSC approach with other appropriate framework(s) to meet an organization’s unique needs.Finally, our case study illustrates how the proposed framework can be utilized to evaluate a health care blockchain application in the for-profit sector. Our approach can also be extended to not-for-profit organizations, which prioritize social goals over financial goals. In such organizations, the financial perspective can be modified to focus on financial sustainability by establishing metrics such as cost reduction, revenue growth, and cost of stakeholder engagement. Similarly, the customer perspective may be widened to include additional stakeholders, such as donors, funding sources, community, volunteers, and employees, that are critical to such organizations [82].AbbreviationsBMPLSBlockchain-Based Multi-level Privacy-Preserving Location Sharing SchemeBSCBalanced ScorecardEHRelectronic health recordEFQMEMEuropean Foundation Quality Management Excellence ModelGDPREuropean General Data Protection RegulationHCIhuman-computer interactionHITHealth Information TechnologyISInformation SystemsITInformation TechnologyONCOffice of the National Coordinator for Health Information TechnologyROIreturn on investmentTQMtotal quality managementAppendixMultimedia Appendix 1How blockchain can empower value-based care.Multimedia Appendix 2Assessment of performance evaluation frameworks.Multimedia Appendix 3Metrics (KPIs) per perspectives.Multimedia Appendix 4Relationship matrix among perspectives.FootnotesConflicts of Interest: None declared.References1. 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