Specifying Blockchain Audit Infrastructure for Physician-Facing Electronic Health Record Governance

Abstract

Electronic health records enforce rules about who may open a patient's chart, but they cannot demonstrate that those rules were honored. A recent survey of physicians using a national record system found wide use alongside limited confidence in its privacy protections, and the stated concern was not the absence of access controls but the inability to verify that access was monitored and that its log had not been altered. Blockchain audit infrastructure, a tamper-evident record of access that no single party can change unilaterally, is increasingly proposed as the remedy. Proposing it is not the same as specifying it. Three decisions govern whether such a record earns clinical trust: what it stores, who maintains it, and who controls its rules. This commentary ties each decision to the trust deficit physicians report and argues that any blockchain proposal for clinical records should be required to resolve all three before it is taken seriously.