towards pervasive computing in health care - a literature orwat graefe, faulwasser_unknown
TRANSCRIPT
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Towardspervasivecomputinginhealthcare-aliteraturereview
CarstenOrwat1*,AndreasGraefe1*,TimmFaulwasser2*
1InstitutfrTechnikfolgenabschtzungundSystemanalyse(InstituteforTechnology
AssessmentandSystemsAnalysis),ForschungszentrumKarlsruheinderHelmholtz-
Gemeinschaft(KarlsruheResearchCentre,MemberoftheHelmholtzAssociation);
Address:P.O.Box3640,D-76021Karlsruhe,Germany.
2InstitutfrAutomatisierungstechnik(InstituteforAutomaticControl),Otto-von-
GuerickeUniversittMagdeburg(Otto-von-GuerickeUniversityMagdeburg);
Address:P.O.Box4120,D-39016Magdeburg,Germany.
*Theseauthorscontributedequallytothiswork.
Correspondingauthor
E-mailaddresses:
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Abstract
Background
Theevolvingconceptsofpervasivecomputing,ubiquitouscomputingandambient
intelligenceareincreasinglyinfluencinghealthcareandmedicine.Summarizing
publishedresearch,thisliteraturereviewprovidesanoverviewofrecent
developmentsandimplementationsofpervasivecomputingsystemsinhealthcare.It
alsohighlightssomeoftheexperiencesreportedindeploymentprocesses.
MethodsThereisnocleardefinitionofpervasivecomputinginthecurrentliterature.Thus
specificinclusioncriteriaforselectingarticlesaboutrelevantsystemswere
developed.Searcheswereconductedinfourscientificdatabasesalongsidemanual
journalsearchesfortheperiodof2002to2006.Articlesincludedpresentprototypes,
casestudiesandpilotstudies,clinicaltrialsandsystemsthatarealreadyinroutine
use.
Results
Thesearchesidentified69articlesdescribing67differentsystems.Inaquantitative
analysis,thesesystemswerecategorizedintoprojectstatus,healthcaresettings,user
groups,improvementaims,andsystemsfeatures(i.e.,componenttypes,data
gathering,datatransmission,systemsfunctions).Thefocusisonthetypesofsystems
implemented,theirfrequencyofoccurrenceandtheircharacteristics.Qualitative
analyseswereperformedofdeploymentissues,suchasorganizationalandpersonnel
issues,privacyandsecurityissues,andfinancialissues.Thispaperprovidesa
comprehensiveaccesstotheliteratureoftheemergingfieldbyaddressingspecific
topicsofapplicationsettings,systemsfeatures,anddeploymentexperiences.
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Conclusions
Bothanoverviewandananalysisoftheliteratureonabroadandheterogeneousrange
ofsystemsareprovided.Mostsystemsaredescribedintheirprototypestages.
Deploymentissues,suchasimplicationsonorganizationorpersonnel,privacy
concerns,orfinancialissuesarementionedrarely,thoughtheirsolutionisregardedas
decisiveintransferringpromisingsystemstoastageofregularoperation.Thereisa
needforfurtherresearchonthedeploymentofpervasivecomputingsystems,
includingclinicalstudies,economicandsocialanalyses,userstudies,etc.
Background
Pervasivecomputingandrelatedconcepts
Pervasivecomputing,ubiquitouscomputing,andambientintelligenceareconcepts
evolvinginaplethoraofapplicationsinhealthcare.Intheliterature,pervasive
computingislooselyassociatedwiththefurtherspreadingofminiaturizedmobileor
embeddedinformationandcommunicationtechnologies(ICT)withsomedegreeof
intelligence,networkconnectivityandadvanceduserinterfaces[1-5].Becauseofits
ubiquitousandunobtrusiveanalytical,diagnostic,supportive,informationand
documentaryfunctions,pervasivecomputingispredictedtoimprovetraditionalhealth
care[6,7].Someofitscapabilities,suchasremote,automatedpatientmonitoringand
diagnosis,maymakepervasivecomputingatooladvancingtheshifttowardshome
care,andmayenhancepatientself-careandindependentliving.Automatic
documentationofactivities,processcontrolortherightinformationinspecificwork
situationsassuppliedbypervasivecomputingareexpectedtoincreasethe
effectivenessaswellasefficiencyofhealthcareproviders.Forexample,inhospitals
pervasivecomputinghasthepotentialtosupporttheworkingconditionsofhospital
personnel,e.g.,highlymobileandcooperativework,useofheterogeneousdevices,or
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frequentalternationbetweenconcurrentactivities[8].Anywhereandanytimeare
becomingkeywordsadevelopmentoftenassociatedwithpervasivehealthcare[9,
10].Ontheotherhand,thesocial,economicandethicalconcernsregardingtheuseof
pervasivecomputingmaydetractfromitsacceptanceandsocietaldesirability,which
isequallyrelevanttohealthcare[11,12].
Purposeofthisreview
Pervasivecomputingenteredhealthcareinalmosteverysetting,makingitdifficultto
developanideaofitstypicalimplementationandmaintainanoverviewofrecent
developments.Weaddressthisdifficultybyprovidingasystematicoverviewand
analysisofsystemsdevelopmentsandimplementationsofpervasivecomputingin
healthcareandhighlightingexperiencesindeployment.Summarizingpublished
research,thisliteraturereviewprovidesaresourceforresearchers,scholars,or
practitionersdealingwithpervasivecomputing.Thatsaid,manysystems
developmentsandimplementationsarenotpublishedintheliterature.Therefore,this
articledoesnotfullycoverthefieldofpervasivecomputinginhealthcare.Rather,it
providesanoverviewofpeer-reviewedliteratureonthistopic.
Methods
Scopeofsystems
Asthetechnologyisstillevolving,thereisneitheranappropriatedefinitionof
pervasivecomputing[13]noranexactdistinctionfromsimilarterms,suchas
ubiquitouscomputing[14]orambientintelligence[15].Thisoftenleadssystems
developers,imprecisely,todeclaretheirsystemspervasiveorsimplynotuseanyof
theseterms.Therefore,forthisliteraturereviewasetofcriteriawhichdefinedthe
frameworkfortheselectionprocesshadtobedeveloped.Thecriteriaareminimum
featuresofpervasivecomputingregardedasnewanddistinctive.Thisselectionseeks
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Inclusioncriteriaforstudies
Prototypes,tests,pilotstudiesandcasestudiesconductedinhealthcaresettings,or
systemsinvolvingprospectiveendusers,clinicaltrialsaswellassystemsalreadyin
routineusewereincluded.Experimentsinnon-medicalsettingsaswellasmere
descriptionsofconcepts,designsorarchitectureswerenotincluded.Onlycomplete
functioningsystems,nocomponentsorparts,weretakenintoaccount.
Searchmethod
Thisliteraturereviewislimitedtopublishedworkthathasundergonescientificpeer-
reviewprocesses.Oursearchwasrestrictedtoarticlesinjournalsandchaptersof
periodicalswritteninEnglishandpublishedbetween2002and2006.Keyword
searcheswereconductedinPubMed,ISIWebofScience(ScienceCitationIndex
Expanded),IEEEXploreandINSPECbyusingthesearchstring("pervasive
computing"OR"ubiquitouscomputing"OR"ambientintelligence"OR"pervasive
healthcare")AND(healthcareOR"healthcare"ORmedic*).Thesedatabasescontain,
amongothersthings,literatureinthefieldsofmedicine,medicalinformatics,medical
technology,computerscienceandresearch,aswellaselectronicengineering.The
databasesearchesledto247distinctarticles.Asmanyauthorsdonotusetheterms
pervasivecomputing,ubiquitouscomputing,etc.,46periodicalsweresearched
manually(seeadditionalfile:Listofjournalsincludedinmanualsearch.pdf).The
journalswereselectedtorepresentthefieldsofmedicalinformaticsandpervasive
computingmostrelevanttothesubjectathand.
Forboththedatabasesearchandthemanualjournalsearch,thetitlesandabstractsof
eacharticlewerereadbyatleasttwoauthors,first,tocheckwhetherinclusioncriteria
weremet.Dubiousarticleswerenotexcludedimmediatelybutconsideredinthe
secondstep.Steponeresultedin98articlesfromdatabasesearchand291articles
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frommanualjournalsearch.Insteptwo,afterduplicateshadbeeneliminated,326
articleswerereadinfulllength,againbyatleasttwoauthors.Incaseofany
disagreementaboutinclusion,therespectivearticlewasreadbyathirdauthorwho
decidedaboutitsinclusionornon-inclusion.AsillustratedinFigure1,thefinal67
systemsdescribedin69articleswereincludedintheanalysis.Intheanalysisand
discussionsbelowreferenceismadetothesystems,nolongertothearticles.
Figure2providesanoverviewofthejournalswiththelargestnumbersofselected
articles.
Systemsandprojectswereanalyzedbythecategoriesofprojectstatus,healthcare
setting,users,improvementaims,componenttypes,datagathering,datatransmission,
systemsfunctions,anddeploymentissuesaswellascombinationsthereof.Forthe
analyses,theapproachofCruz-Correiaetal.[18]waspartlyadopted,whilethe
definitionofcategorieswaspartlyinfluencedbyotheroverviewsofthetopic[7,8,
19,20].
ResultsTable1displayssystemandprojectnames,countriesofimplementation,numberof
referencesaswellastheactualreferences.Whenanarticleincludestwoormore
systems,thesystemsarelistedseparately.Whendifferentarticlesrefertothesame
systemorproject,thereferencesarelistedtogether.Finally,67distinctsystemswere
identifiedforthereview.Thecountrieswiththelargestnumbersofsystemsinplace
areUSA(24systems),UK(8systems),France(4systems),Taiwan(4systems),
Australia(3systems),Denmark(3systems),Germany(3systems),Spain(3systems).
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Atotalof31systemswereimplementedintheEU.Twocommercialsystemsare
employedinternationally.
Statusofsystem
Threestagesofprojectstatusweredistinguished:prototypeorpilottesting,clinicalor
medicaltrials,andregularoperation.AsshowninTable2,mostsystemsare
presentedintheirprototypeorpilotstages(84%).Authorsreportedthatsixsystems
hadpassedclinicaltrials,fivesystemswerefoundtobeinregularoperation.This
informationrepresentsthestatusasdescribedinthearticles,ignoringanysubsequent
changes.
Healthcaresettings
Thetargetedhealthcaresettingsaredifferentiatedintoambulatory,homeandmobile,
clinical,careandrehabilitation.Mostsystems(57%)areintendedforuseinhome
andmobilesettings,followedbyclinics(36%)(Table3).Foursystemsareappliedin
theambulatorysetting.Sevensystemshaveusesinemergencymedicalservices.Five
systemsarededicatedtotheuseincaresettings,andnosystemisexplicitlyforeseen
forrehabilitation.
Users
Systemsusersaredividedintohealthcareprofessionals,(i.e.medicalpersonnel,
includingnursesandprofessionalcaregivers,paramedics,physicians)andlaypersons
(i.e.patientsandprivatecaregivers,suchasfamilymembers).Eventhough,inmost
cases,severalstakeholdersprofitfromanapplication(e.g.,patientsbenefitingfroma
betterdiagnosisbyphysiciansusingasystem),onlytheactiveusersoroperatorswere
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consideredasusers.AsTable4shows,nursesandcaregivers(51%)andphysicians
(54%)arenearlyequalasdesignatedusers.Paramedicsaretheusersoffivesystems.
Notsurprisingly,patientsarethelargestgroupofusers(72%).Inmanycases,theyare
supportedbylaycaregiversorfamilymembersinvolvedinninesystems.Four
systemsinvolveotherusertypes,i.e.exercisepartnersinanelderly-careinstitution
[21],pharmacists[22],institutionmanagement[23],oracallcenter[24].
Improvementaims
ThedevelopmentanddeploymentofITsystemsinhealthcareisusuallydrivenby
intentionstoimprovemedicalcareorworkflow.Therefore,thiscategoryisdivided
intoorganizationalimprovements(e.g.,improveddocumentationorprocess
automation)andmedicalimprovements.Medicalimprovementsarefurtherdividedas
follows:Therapyandrehabilitationdealswithsituationswherethegoalisthe
recoveryofthepatient,whilepreventionandcareencompassessituationswhereno
diseaseistreated,butadiseaseoritsfurtherprogressaretopreventedorcompensated
for.Thelatterincludescareforelderlyorsupportofpeoplewithspecialneeds.As
Table5shows,39%ofallsystemsseektoimprovetheorganizationofhealthcare
providers.12%ofallsystemsweredesignedtoimprovetherapyandrehabilitation,
while63%seektoenhancepreventionandcare.
Inaddition,medicalimprovementsarecategorizedaccordingtothebodysubsystem
anddiseasecategorizationoftheMedicalSubjectHeadingsoftheU.S.National
LibraryofMedicine[25].Categoriesencompassthecardiovascularsystem,
respiratorytract,endocrinesystem,sensoryorgans,nervoussystem,andothers.These
categorieswereselectedaccordingtothediseasesmentionedinthestudiesincluded.
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Alargepartofthesystemsrefertothenervoussystem(21%),dementiabeing
mentionedmostoften(Table6).Inaddition,18%ofthesystemsrefertothe
cardiovascularsystem,inparticulartoheartarrhythmiaorchronicheartdiseases.
Eightsystemstargettherespiratorytract,withchronicobstructivepulmonarydisease
(COPD)asthemostimportantcase.Twosystemsarededicatedtodiabetestreatment
(endocrinesystem).ThesevensystemsintheOtherscategorycover,forinstance,
inflammatoryboweldisease[26],cancer[27],orstress[28].Also,24%ofsystems
arefoundtohavenospecifictargeteddiseaseorpartofthebodysubsystem.Inmany
cases,systemsmonitormultiplephysiologicalparametersfordiversehealthcare
applications.Othersystemsprovidegeneralinformationaboutthestatusofpatientsor
inhabitants[23,29-31]ormonitorpresence,movementsorbehavioralpatternsof
residentsofcareinstitutions[23,32-40].TheDatagatheringSectionbelowprovides
moredetailsonthedifferenttypes.
Systemsfeatures
Fourvariableswhichcharacterizespecificsystemsfeatures,i.e.componenttypes,
typesofdatagathering,datatransmission,andsystemsfunctions,wereselected.
Componenttypes
Systemsareclassifiedintothosewithmobileandstationarycomponents.Systems
withmobilecomponentsweredifferentiatedasconventionalmobiledevices,
wearables,andimplanteddevices.Stationarydevicesarecomputer-enhancedphysical
environments,suchasbuildingsorfurniture.AsdepictedinTable7,51%ofsystems
arefoundtoutilizeconventionalmobiledevices.Stationarydevicesareusedequally
often(51%),inmanycasesinacomprehensive,integratedapplicationofsystems,
suchasinformationexchangesystemsinhospitalsorformonitoringincarefacilities.
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Aconsiderablefractionusewearables(42%)includingwrist-wornunits[31,41-45],
anelectronicvest[46],anelectronicglove[38]aswellasmobilemedicaldevices,
suchasabloodglucosemeter[22],bloodpressuremeter[47],spirometer[48],
asthmapeakflowmeter[49],electrocardiogram(ECG)orheartratemonitors[24,28,
50],ormulti-purposemeters[30,51,52].Alsoelectronicpersontagsorbadges[21,
23,39,53,54],electronicobjecttags[21,38,55,56]oracustomizablemodular
system[57]belongtothiscomponenttype.Onlytwosystemshaveimplanteddevices,
i.e.acardiacpacemakerwithamonitoringfunction[58]andanimplantable
haemodynamicmonitoringsystem[59].
Datagathering
Thesystemsareclassifiedbyfivetypesofdatagatheringordatainput:monitoringof
personsorobjects;localizationofpersonsorobjectsaswellasmanualinputor
requestbytheuser.AspresentedinTable8,mostsystemsmonitorpersons(63%),
typicallybygatheringphysiologicalorbehavioraldata.Forphysiologicaldataorvital
signs,respectively,systemsrangefrommeasuringasinglephysiologicalparameter,
i.e.ECG[24,50,60],lungfunction(asthma)[48,49],haemodynamictrends[59],
bloodglucose(diabetes)[22,57],heartrhythm[58],bloodpressure[47],orweight
[26],tosimultaneouslygatheringmultiplephysiologicaldata[28-31,42,45,46,51,
52,61-64].
Behavioraldatagatheringincludesmonitoringofpresence,movementsoractivities
[21,35,37,65,66],suchasmonitoringofActivitiesofDailyLiving(ADL)[38,67,
68],sleepingorovernightactivities[27,41],medicationadherence[27],presenceor
movementsinroomsorfacilities[21,36,39,53],socialorcommunicativebehavior
[40],ordetectionoffalls[33,34].Alsocombinationsofmonitoringmultiple
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physiologicalparametersandmovementdatacanbefound[23,69].Inonecase,the
purposeofpersonidentificationismentionedexplicitly[67].Ontheotherhand,
monitoringofobjectsislessfrequent(16%).Itincludes,forinstance,RFID-based
inventorycontrol[43],monitoringofbloodbagtemperature[55],checkingforlab
results[70,71]ormonitoringconditionsoractivitiesofpersons,suchasindicating
sleepingconditionsbybedsensors[68,72].
Thesecondmostfrequenttypeofdatainputislocalizationofpersons(31%).
Thisencompassesthelocalizationofmedicalpersonnelwithinhospitalsorcare
facilities,inmostcases,forcontext-awareorlocation-dependentinformation[13,73-
76].Mostsystemsfocusonthelocalizationofpatientsorresidentswithinfacilities
[23,27,32,35,37,39,40,43,44,63,67,68,77],orinlargergeographicalareasby
GPS[24].Localizationisalsousedtosupportpersonswithspecialneeds,for
instance,fordirectingblindpersons[53],ortoassistadhocgroupsofhelpersin
emergencysituations[60].Onlyonesystemfurnishesmultiplelocalizationsof
personnel,patients,andequipment[54]whilethreesystemslocalizeobjects,i.e.
medicalequipment[54,56]orRFID-taggedobjectsofdailylifeallowingconclusions
tobedrawnaboutactivitiesofthepersonsmonitored[38].
Alargepercentageofsystemsrequiremanualinputorrequestofdata(28%),mainly
inmobiledevices,suchasPDAsortabletPCs.Thedataisenteredbyhealthcareor
carepersonnel[63,74,75,78-84]orpatients[48,50,85],residentsofcarefacilities
[40]orpeoplewithspecialneeds[86].Inmanycases,manualinputorrequestisan
additionalchannelbesidesautomaticmonitoringorlocalization.Forinstance,manual
involvementconsistsoftransmittingpartsofthephysiologicalparametersor
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supportiveresultsofquestionnaires[50],supportivetelephonecallsbyanurse
paralleltoautomatictransmissionofmonitoringdata[62],ordataaccessthrougha
webinterface[59].Inothercases,speechrecognitionissupportedbymanualdata
input[73,87].
Datatransmission
Therearesystemstransmittingdatatoothersystemsorplayersandthosewhichdo
not.Withdatatransmission,thedataleavetheareaofcontrolbyaspecificuser,
whichmayhaveimplicationsonprivacyandsecurity(seebelow).Asisshownin
Table9,mostsystemstransmitdata(88%),forexample,forpurposesofdataanalysis,
forwarding,orstorage.Inmanycases,dataaretransmittedtoacentralserver.All
systemsdevelopedfordataexchangeamongmultipleusersdepend-bynature-on
datatransmission.About19%ofallsystemsdonotrelycompletelyondata
transmissionandareabletoperformfunctionsindependentlyandinadecentralized
fashion.Abouthalfofthosesystemsconsistofwearablesmonitoringpatienthealthor
activity[31,38,42,45,57],assistingtheuserbyprovidingsupportiveinformation
aboutthehealthstatusorbysuggestingcertainactivities.Somesystemscanperform
partsoftheirfunctionsbothwithandwithoutdatatransmission[31,40,41,45,48,
57,72].
Systemsfunctions
Thefunctionsprovidedbythesystemsaresubdividedintosixcategories:analytical
anddiagnosticsupport;alerting;medicaltreatment;supportactivities(e.g.,
remindingorguidance);processautomation;anddocumentationandinformation.As
isevidentfromTable10,about60%ofallsystemsprovideanalyticalanddiagnostic
functions,oftenincombinationwithautomaticalerting,whichisperformedby46%
ofallsystems.Mostofthesesystemsperformphysiologicalmonitoring,inparticular
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ofthecardiovascularsystem[28,29,41,50,61].Thereareotherdisease-specific
systems,forexample,fordiabetes[22,48]orasthma[49,57].Alargepercentageof
systemsdonotperformphysiologicalmonitoring,butobtainanalyticalanddiagnostic
supportfromtrackingtheactivitiesorbehaviorofpatients[27,65,67-69,77].The
supportactivitiescategory(34%)includesheterogeneousfunctions,suchas
providingremindersformedication[85],schedulingforsocialcontacts[21],
orientationinbuildings[53],oraproductbarcodetranslationforblindpeople[86].
Documentationandinformationisafunctionin31%ofallsystems.Itincludes
systemsprovidingcontext-awareinformationaboutpatientdataandlaboratory
reportsduringsurgicalinterventions[13,79]orinmorningrounds[76].Many
systemssupportingtheemergencytriageprocessstoredatafordocumentation
purposes[63,80-82].Severalsystemsmeasuringphysiologicalparametersalsostore
datafordocumentation[46,48,61,88].Onesystemprovidestrendinformationabout
thebehaviorofelderlypeoplereceivingcare[27].
About16%ofallsystemstargetprocessautomation,themostimportanttaskofwhich
istotrackingpersons[13,39,73,76],orinventories[56].Identificationofpersons
viaRFID[43,44],phonecallinterception[73]orelectronicprescriptiontransmission
[84]areotherexamplesinthiscategory.Nosystemisdedicatedtomedicaltreatment,
whichcouldbeconceivableascomputer-supportedandremotemedication.
Analysisofhealthcaresettings
Combinationsofthecategorieshealthcaresettings,improvementaims,functions,and
componenttypesalsoprovidecross-categoryanalysesinordertogainsomeinsight
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intotheuseofsystemsindifferenthealthcaresettings.Forthesecross-category
analyses,itmustbepointedoutthattheallocationsofsystemsrefertotheirfull
functionalities.Thus,multipleentriesunderdifferentcombinationsarepossible.
Healthcaresettingsandimprovementaims
Notsurprisingly,organizationalimprovements,achievedmostlybyautomationof
manualactivities,aretheprimarygoalintheclinicalsetting(24%),followedby
improvedpreventionandcare(15%)(Table11).Inthehomeandmobilesettings,
however,thesystemsprimarilyseektoprovidemedicalimprovementsmainlyin
preventionandcare(48%)followedbytherapyandrehabilitation(10%).Here,only
foursystemsaretoachieveorganizationalimprovements.
Healthcaresettingsandsystemsfunctions
Table12shedssomelightonthewayssystemsfunctionsareusedintherespective
healthcaresettings.Asexpected,analyticalanddiagnosticsupport(18%),alerting
(14%),andsupportactivities(11%)aremostpopularinhomeormobilesettings
whereasinformationanddocumentation(foursystems)orprocessautomationand
control(nosystem)playonlyanegligiblerole.Forclinicalapplications,thesystems
functionsaredistributedmoreevenly,informationanddocumentation(10%)being
mostpopular.
Healthcaresettingsandcomponenttypes
InTable13,itcanbeseenthatcomponentsimplementedmostfrequentlyinhomeor
mobilesettingarestationarydevices(33%)andwearables(28%),followedby
conventionalmobiledevices(21%).Intheclinicalsetting,conventionalmobile
devicesaremostprevalent(22%),followedbystationarydevices(15%),whileeight
systemsmakeuseofwearables.Thereisnosystemimplementingstationarydevices
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inemergencysettings,asmostofthesystemstakeadvantageofconventionalmobile
devices.
Analysisofsystemsfeatures
Systemsfunctionsandtypesofdatagathering
Table14providesinformationaboutthetypesofdatagatheringapproachesenabling
therespectivefunctionsofthesystems.Monitoringofpersonsisbyfarthemost
importanttypeofdatagatheringforanalyticalanddiagnosticsupport(48%),alerting
(36%)aswellassupportactivities(19%),followedbylocalizationofpersons.
Monitoringandlocalizationofobjectsgenerallyoccurlessfrequentlyandareapplied
intypicalactivitiesfororganizationalimprovements,suchasinformationand
documentationaswellasprocessautomationandcontrol.Forallfunctions,very
manysystemsrequiremanualdatainput,whichcouldindicatethatcomplete
automationmaynotyetbefullypossibleordesirable.
Systemsfunctionsandcomponenttypes
Table15illustratesthatthereisnooneparticulartypeofcomponentdominating
implementationofanalyticalanddiagnosticsupportaswellasalertingandsupport
activities,althoughthereisaslightprevalenceofconventionalmobiledevicesfor
analyticalanddiagnosticsupportaswellasofstationarydevicesforalerting.
Differencesarefoundforfunctionsaimedatachievingorganizationalimprovements.
Inthiscase,conventionalmobiledevicesaremostpopularforinformationand
documentationaswellasforprocessautomationandcontrol.
Systemsflexibilityandcomplexity
Next,theflexibilityofthesystemswillbeanalyzedinthelightofwhetheraparticular
systemperformsmorethanonesystemfunction.AsisshowninTable16,30systems
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(45%)areidentifiedwhichperformonefunctiononly:analyticalanddiagnostic
support(12systems),supportactivities(7systems),alerting(5systems),information
anddocumentation(4systems),andprocessautomationandcontrol(2systems).As
functionsincrease,systemsnaturallybecomemorecomplexwhilethenumberof
systemsactuallycapableofperformingmultiplefunctionsdecreases.Thisanalysis
revealed19systemsperformingtwofunctions,14systemswiththreefunctions,and
foursystemsabletoperformfourfunctions.
Inthecontextofthisstudy,systemscomplexityisexpressedbythenumberof
differenttypesofcomponentsinasystem.Adistinctionismadebetweensystems
usingasingledeviceormultipledevicesmadeupofone(57%)ormorethanone
componenttype(Table17).Amongthesesystemsusingonlyonetypeofcomponent,
stationarydevicesaremostfrequent(21%),mainlyascomprehensiveICT
infrastructureembeddedinfacilities.Theyarecloselyfollowedbyconventional
mobiledevices(19%)andwearables(15%).Inthecategoryofsystemscombining
twocomponenttypes(40%),thecombinationofconventionalmobiledeviceswith
stationarydevicesandwearableswasfoundmostfrequently(10and9systems,
respectively),followedbythecombinationofwearablesandstationarydevices(7
systems).Onlytwosystemswerefoundtoimplementasmanyasthreedifferenttypes
ofcomponents.
Deploymentissues
Underthisheading,thefocusisonorganizationalorpersonnelissues,privacyand
securityissues,andfinancialissues.Althoughtheseissuesarecrucialforthesuccess
ofpervasivecomputinginhealthcare,theyarerarelyaddressedintheliterature
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(Table18).Hence,noquantitativeanalysisofthesetopicswaspossible.The
qualitativeanalysisshownbelowrevealedsomeinterestingfindingsinarticlesabout
issuesofdeployment.
Issuesoforganizationandpersonnel
Issuesoforganizationorpersonnelaredescribedforonlysixsystems(Table18).
Positiveexperiencesarereportedfromaninterpersonalcommunicationservice
utilizingdigitalnoteswithinhospitalwards[74].Theauthorinvestigatesthe
integrationofthesystemintoregularclinicalactivities.Oneofthefindingsisthatthe
systemisbetteradaptedtoahighdegreeofmobilityandthehighlyevent-driven
workingpatternsofcliniciansthanconventionalcommunicationtechnology,suchas
telephoneorfax.Amongotherthings,digitalnoteshavetheadvantageofnot
interruptingworkroutinesandprovidinginformationinausecontext.
Theneedfororganizationalissuestobeseparatedintohomeapplicationsand
applicationsinclinicsisstressedbyDaddetal.inastudyofamonitoringsystem
[69].While,inahomesetting,monitoringisalong-termprocedurerelatively
unattended,monitoringinclinicstakesplaceinanenvironmentwheremanyhealth
professionals,technicalassistanceandsubstituteequipmentareavailable.The
organizationaldifferenceleadstovaryingtechnicaldesignrequirements.
Otherauthorswriteaboutorganizationalproblemstobesolvedforsuccessful
deploymentandregularoperation.Fortheimplementationofawirelessbiomedical
sensorforbloodpressuremeasurementduringsurgery,yrietal.[47]concludedthat
nursingeducationshouldincludeastrongerfocusonnursinginformatics.Since
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nursesplayedaroleinprotectingpatients,bettereducationcouldhelpthemovercome
potentiallyconservativeattitudestowardchange.
Organizationalproblemswithalertpagersinasurgicalintensivecareunitare
examinedbyReddyetal.[70].Thepagerautomaticallyalertsaboutcriticallab
results,potentialmedicationproblems,andcriticalpatienttrendinformation.One
problemisthateverymessageissentnotonlytoresidentsandfellows,but
simultaneouslytophysicianswhonormallywouldbeinformedonlyaboutimportant
clinicalevents.Theremovalofhierarchicalboundariesbyprovidinginformationto
everyone,thus,alsohasunintendednegativeconsequences.Moreover,the
unidirectionalnatureofpagerspreventsphysiciansfromrespondingtoaproblemin
thesameway.Physiciansalsocomplainofinformationoverload,aseverymessage
looksequallyimportant.Anotherorganizationalproblemisthatnurses,whoare
responsibleforsupplyingphysicianswithadequateinformation,donotknowwhether
physiciansarealreadyawareofinformationsentautomatically.Thus,nursesmight
additionallyinformphysiciansaboutevents.Severaltechnicalmeasuresareproposed
bytheauthorstobettermatchorganizationalneeds.
Hansenetal.[13]describeorganizationalissueswhichemergedinthedeploymentof
theiHospitalsystem,i.e.ahospitalschedulingandawarenesssystem.Thesystem
utilizeslocationtracking,videostreamingforcontextinformation,largeinteractive
displays,andmobilephones.Inordertoteachusers,someofthemarefamiliarized
withthesystem,encouragedinusingit,andaskedtopassoninformationand
experiencetoothers.Theprojectteamalsoreportedthatsystemscausingextra
workloadandmainlybenefitingothersarelikelytobenotused.Oneexampleisa
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trackingchiprequiringdailypickupandregistration.Theyalsopointtotheproblem
ofthemissingdefinitionofwhoisresponsibleforoccasionallytimeconsumingand
complexsystemssupportafterdeployment.Asimilarcaseispresentedbystbyeet
al.[56]asresultoffocusgroupsinvolvingnursingstaff.Nursesraisedconcernsabout
theadditionalworkloadduetotheimplementationofnewsystems,especiallywhena
systemisnoteasytouseornoadditionalstaffishiredforsystemsmaintenance.
Privacyandsecurityissues
Authorsreportaboutprivacy,securityandcontrolissuesfor11systems(Table18),in
somecasesonlybymentioningthatappropriatetechnicalmeasuresensuresystems
compliancewithdataprotectionlaws.Suchtechnicalmeasuresincludetheremovalof
useridentityfromdata[41]andencryptionandauthenticationstepspriortodata
transmissionaspartoftheGSM/GPRSprotocol[41,42],withasecureWAPsession
[50],orwithsessionkeyencryptionanddigitalsigningusingapublickeycertificate
[84].AnotherstudyofatelemedicinesystemforCOPDimplementsabroadsetof
securitymeasuresrangingfrompasswordlog-ins,PKIcertificates,tokens,SSL
encryptions,VPNtorestrictinguseonlytotheintranet[88].Inanothercase,itis
notedthattheencryptionlevelofthetagsusedtotrackpatients,equipmentandstaff
istooweakforregularoperation[54].Tocontrolaccesstostoredinformation,one
systemincludesasetoflayerswithdifferentaccessprivilegesfordifferentuser
groups[50].Inatrialofahand-heldcomputingdeviceinanemergencydepartment,
datasecuritywastobeachievedbyapolicyrequiringthatnopatientdatabestoredon
thehand-helddeviceandbedeletedimmediatelyaftertransmissiontoaserver.In
addition,thesystemsendsanalerttosecuritypersonnelwhenthehand-helddevice
crossescertainfacilityboundaries[83].
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AsreportedbyHansenetal.[13]fortheimplementationoftheiHospitalsystem,the
projectteamfoundlessprivacyconcernsamongparticipantsthanexpected,although
privacy-sensitivedatafromvideomulticastandlocationtrackingareprocessed.The
authorshadconcludedfrominterviewsandobservationthattheuserswouldtrustthe
systembecauseofthechosendesign,inparticular,thelow-resolutionvideostreams
andonlypartiallocationtracking,whichlefttrackingfreeareas,suchasthecoffee
room,cafeteria,andbathrooms.Theissueofsurveillanceofmedicalstaffisalso
mentionedbystbyeetal.[56]inacasestudyofanequipmenttrackingsystem.In
thatcase,nursingstaffvoicedconcernsaboutsurveillanceoftheirworkpatternsonce
thesystemwouldbeusedmorewidely.
Hauptmannetal.[67]presentapervasivecomputingsystemforelderlycarewhichis
abletotrackpeopleoverlongperiodsoftime,identifyindividuals,andcharacterize
humanactivities,suchaseatingorpersonalhygiene.IntheopinionofHauptmanet
al.,activityobservationanddetectionisfeasibleaslongasthebenefitsofmonitoring
forcarepurposesarenotoutweighedbyprivacyconcerns.
Sixsmithetal.[34]providesomefindingsbyfocusgroupsinvolvingusersofinfrared
monitoringsystemsfordetectingfallsinanelderly-caresetting,inwhichconcerns
aboutintrusivenessareraised.Theauthorsreportthatlackofunderstandingthe
technologyispartlyresponsibleforprivacyconcerns,asthesystemwouldnotbeable
toreconstructanimageforviewing.Theyconcludethatadequateinformationabout
technologyisimportantduringdeployment.Whateverthepracticalbenefitsmight
be,usersmightnotacceptthetechnologyiftheybelieveitimpingesontheirprivacy
andlifestyle[34].
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Inonecasestudy[24],theauthorsclearlystatethatthetreatmentoflocationdatain
thiscase,areal-timeremoteheartarrhythmiamonitoringsystemisanunsolved
privacyissue.Recommendationsfortheappropriatecollection,use,andretentionof
thesedataarestillmissing(e.g.,thefrequencyoflocationdataacquisitionand
transmission,orcoordinateaccuracy).Theauthorsdescribethepotentialofmisuse
stemming,inparticular,fromcombinationsofdatabasescontaininghearthealth
indicatorswithcontinuous,time-stampedlocationdata.Theauthorsconcludethat
telemedicinecommunityandmedicalcommunityshouldparticipateindefining
privacy-relatedrulesandguidelines.Theyalsopointtoanotherunsolveddilemma:
encryptionofdatafortransmissioncould...sacrificepreciousminutesduringheart
attack[24].
Financialissues
Authorsmentionfinancialissuesforonlytensystems(Table18).Noauthorprovides
aprofoundanalysisofcostsandbenefitsineconomicterms.Themostdetailed
analysisisbystbyeetal.[56]foranequipmenttrackingsystemforbeds,sequential
compressiondevices,andinfusionpumps.Theyreportabouttheimpactonequipment
useand,thus,equipmentchargecapture,butshownopositiveresultsforallobjects
tracked.
Somecasestudiesonlyprovideroughestimationsorbriefnotes,suchasreferenceto
theparticipationofbusiness[36]ortoanexpectedlargemarketforthesystem[34].
ForatelemedicinesystemforCOPD,deToledoetal.[88]presentaroughestimateto
theeffectthatsignificantlyshorterhospitalizationwouldleadtofastamortizationof
thesystem.Somecasestudiesonlymentionthecostsofsystemcomponents[39,53]
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indicatingthatscalinguptoregularwidespreadoperationwouldchangethecost
structure(e.g.,duetootherlicensefeeswithmoreusers)[39].Authorsalsoassume
thatchangesinreimbursementsystems,suchastheintroductionoftheDiagnosis
RelatedGroupssystem,wouldhaveaconsiderableimpactonfinance[30].
Thecasestudiesalsocontaininformationaboutpossiblecostreductions.Hanadaetal.
[55]estimatethatonlysubstantialpricereductionsofbloodbagtagswouldmakethe
systemprofitable.Thepotentialsavingoffinanciallossesinayeardueto
inappropriatetemperaturemanagementthenwouldoffsetthecostoftheentireblood
bagmonitoringsystem.Costreductionsareexpectedtoariseinparticularfromthe
useofcommercialoff-the-shelftechnologies.AsdescribedbyNarasimhan[86],the
Trinetrasystem,whichsupportsblindshoppersinreadingproductbarcodesinstores,
isaresultofcostsconsiderations.Itutilizesoff-the-shelftechnology,i.e.amobile
phone,abarcodescanningpen,andaBluetoothheadset.Asnoinvestmentis
requiredfromstoreowners,thechancethatthesystemwillbeusedregularlyis
considerablybetter.Hansenetal.[13]reportaboutthehighcostsofacommercial
locationtrackingsystem,whichwouldmakethesolutionfinanciallyunattractivefor
theentirehospital.Therefore,theyestablishtheirlocationtrackingtechnologyonthe
basisofmobilephonesownedbyphysiciansorpatients.
DiscussionAlthoughforgoingmeredescriptionsofsystemsarchitecturesorconceptsand
focusinginsteadonprototypes,experiments,pilotstudies,clinicaltrialsinvolving
intendedendusersaswellassystemsalreadyinregularoperation,thearticlescover
lessdeploymentissuesthanexpected.Thepartlyqualitativeanalysisthuscanonly
indicatepotentialdeploymentproblemsrequiringfurtherconsideration.Weassume
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thatmanyauthorsdonotwishtoreportoncriticalornegativeissues.However,as
mostsystemsidentifiedwereintheprototypestage,suchexperienceswouldbe
particularlyvaluableinordertoleveragepervasivecomputingandtransfermore
systemsintoroutineoperation.
Findingsinthecasestudiesrevealed,forinstance,thatprivacyprotectionisnotonly
anissueintherelationbetweenhealthcareproviderandpatientwhichcurrentlyis
themainfocusofacademicandpublicdebates,butisalsoaninternalconcernof
healthcarestaff.Whencoupledwithorganizationalandpersonnelconcerns,
pervasivecomputinginnovationscouldwellbestifledbystaffworriesabout
surveillance.Also,theregulatoryframeworkforreimbursementandfinancingcanbe
decisiveforpervasivecomputingsystemstobeacceptedinroutineuse.Therearealso
indicationsthattheuseofoff-the-shelftechnologiesispromisingbecauseofpossible
costsreductions.Although34%ofthesystemsreviewedalreadyuseconventional
mobiledevices,weexpecttheirnumbertoincreasefurther,asthesedevicesare
becomingmoreandmorepowerful.
Thecasestudiesalsorevealthatdevelopersoftenthinkabouttechnicalmeasuresto
protectprivacy.Weconsiderinstitutionalmeasuresandpoliciesasequallycrucialnot
onlyforindividualacceptancebutforsocietalacceptability[89].Thislatter
distinctioniscrucial,sincetheindividualacceptanceofprivacy-relatedapplications,
forexample,byasufferingpatientoradependenthealthcareemployeeisexpectedto
bemuchgreaterthanthelevelofacceptabilitydemandedbysocietyandits
representativesinbalanceddecisions.Thisisrelevant,forinstance,todeterminethe
pointwherethebenefitsofmonitoringareoutweighedbythreatstoprivacy
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protection.Thispointshouldbedefinedinageneralmannerbyguidelinesand
policiesandcannotbedeterminedincasestudiesinvolvingpatientsoremployees.
Generalbindingdecisionsaboutthetypesofdatagatheredbypervasivecomputing
applicationsaswellasrulesaboutwherethedataareused,bywhomandinwhat
form,shouldbedeveloped,communicated,adopted,andenforced.Pervasive
computingmayimplythatmoreplayersareinvolvedincarerelationsandthe
managementofpersonaldata,suchassystemsorserviceproviders,relatives,or
multiplemedicalorcareprovidersincomplexhealthcaresituations,suchas
integratedhealthcare.
Inthecasestudiesexamined,privacy-enhancingtechnicalmeasuresmostlyhavean
add-oncharacter,suchasencryptionaddedtodatatransmission.Instead,anumber
ofsystemsdonotrequiredatatransmissiontoothersystemsorplayers.Data
transmissioninvolvesotherparties,thusinevitablyraisingprivacyconcerns.
Approachestoself-supported[17]pervasivecomputingrequiringneitherdata
transmissionnortheuseofcentralandexternalhardwareandsoftwareinfrastructures
areaninterestingoptioninpersonalhealthcareandpersonalsupportofhealthcare
staff.Forinstance,someofthesystemsmentionedaboveprovidesupportive
informationabouthealthstatusormakecertainsuggestionswithoutincludingdata
transmission[31,38,42,45,57].Thiscancontributetothedevelopmentof
persuasivecomputinginhealthcare[90].Furthertechnologicaldevelopments,
particularlyimprovementsindatastorageandprocessingcapabilitiesofmobile
devicesandwearables,canaccomplishpervasivecomputingwithoutdata
transmission.Thesewillenableashiftofanalytical,alerting,guidingandother
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functionsfromcentralserverstomobileandwearabledevices.Lessuserworryabout
surveillancecouldbearesult.
LimitationsThereisagapbetweenthesystemsweanalyzedinourliteraturereviewandthefull
fieldofpervasivecomputinginhealthcare.First,manysystemsdevelopmentsand
implementationsmightneverhaveundergonescientificpeer-reviewand,therefore,
cannotbecoveredbyourreviewoftheliterature.Second,beinglimitedtotheperiod
of2002to2006,theliteraturestudieddoesnotincorporatethemostrecent
developmentsincomputerscience,medicalinformatics,andengineering.In
particular,progressinmobilecomputingtechnologyissubstantial,forinstancein
location-basedservices.Weareawarealsooftheprevalenttimelagsbetweensystem
development,systemdescription,submissionandpublicationofarticles.
Ourapproachdoesnotallowdrawingconclusionsonwhethertheresultspresentedin
thisreviewarealteredbytechnologicalprogress.Inaddition,wecannotconclude
whethertheresultswouldbesimilarforsystemsnotcoveredbytheliterature.
Therefore,ageneralizationofconclusionsdrawnfromthisliteraturereviewisnot
possible;allconclusionsdiscussedaredrawnfromthecasestudiesreviewed.
Furthermore,althoughtheinclusioncriteriaforsystemsmentionedabovearebroadly
definedandbasedonpreviousresearch,otherpervasivecomputingexperts,authors,
usersetc.mayregardotherfeaturesasdecisive.
ConclusionsThisreviewprovidesanoverviewoftheliteratureonabroadandheterogeneous
rangeofpervasivecomputingsystemsrelatedtohealthcare.Mostsystemsare
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describedintheirprototypestagesinwhichdevelopersonlyrarelyreportabout
deploymentissues.Sincetheidentifyingandsolvingsuchissuesisdecisiveforthe
diffusionofpromisingsystems,aneedforfurtherfocusedresearchintothe
deploymentofpervasivecomputingsystemsinhealthcareisidentified.Future
researchshouldfocusonorganizationalaswellaspersonnelimplications,privacy
concernsorfinancialissues.Systematicevaluationsoftheeffectivenessand
efficiencyofpervasivecomputingsystemsareregardedasinevitabletoensureuser
acceptance,societalacceptabilityandfinancing.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authors'contributionsCO,AG,andTFcontributedequallytothestudydesign,literaturesearch,reading,
categorizingandanalyzing.COandAGpreparedthemanuscript,whileTFrevisedit
critically.COwastheinitiatoroftheliteraturereviewandadditionallyperformed
supervisorytasks.Allauthorsreadandapprovedthefinalmanuscript.
AcknowledgmentsWewouldliketothankthelibrariansoftheForschungszentrumKarlsruhe(Karlsruhe
ResearchCentre),especiallySusanneHill,fortheirprofessional,reliableandfast
supportinsearchingandobtainingliterature.Inaddition,wearegratefulforthe
helpfulcommentsbythetworeferees,KennethMandlandTorstenEymann,aswell
asforthelanguageimprovementsbyRalfFrieseandCindyKim.KnudBhle,Ulrich
RiehmandArndWebermakehelpfulcomments.SpecialthanksgotoCarsten
Holtmann,AsarnuschRashid,MandyScheermesser,andMichaelaWlkofthe
PerCoMedprojectteamforfruitfuldiscussionsandinsights.Theliteraturereviewis
partofthePerCoMed-PervasiveComputingindervernetztenmedizinischen
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Versorgung(PervasiveComputinginNetworkedMedicalCare)researchproject,
whichisfinanciallysupportedinpartbytheBundesministeriumfrBildungund
Forschung(GermanFederalMinistryofEducationandResearch)intheInnovations-
undTechnikanalyse(InnovationandTechnologyAnalysis)program
(Foerderkennzeichen16I1546).
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Figurelegends
Figure1-Methodusedinselectingarticlespublishedbetween2002and2006
Figure2-Periodicalsincludingmostofthearticlesselected
Tables
Table1-Systemsincludedinthereview
System/ProjectName Countries Numberof
Publications
YearsofPublication
References
ABC(Activity-BasedComputing)Framework,Aarhus Denmark 1 2005 [76]
ActivitiesofDailyLiving(ADL)MonitoringSystem,St.Paul USA 1 2006 [68]ActivityTrackingandAmbientDisplays USA 1 2003 [21]
AdaptiveCoachingthroughSequentialRoutines USA 1 2003 [21]
AdvancedCareandAlertPortableTelemedicalMonitor(AMON)Project
Switzerland,Israel,France
2 2004,2005
[41,42]
Airmed-CardioSystem Spain 1 2005 [50]
AllocationandGroupAwarePervasiveEnvironment(AGAPE)System
Italy 1 2006 [60]
Asset-TrackingSystem,Durham USA 1 2003 [56]
AsthmaMonitoringSystem,Oxford UK 1 2005 [49]AutomatedSurveillanceSystem,LaTronche France 1 2003 [32]BattlefieldMedicalInformationSystem-Tactical(BMIST)System USA 1 2006 [91]BloodBagMonitoringSystem,Shimane Japan 1 2003 [55]
CareintheCommunityProject UK 1 2004 [37]
CareMediaProject USA 1 2004 [67]
ChronicCareTelemedicineSystem,Madrid Spain 1 2006 [88]CyberCrumbSystem USA 1 2004 [53]
DiabetesTelemedicineSystem,Oxford UK 1 2005 [22]DiaBetNet USA 1 2004 [57]
EliteCareBusiness USA 1 2002 [23]
ENABLEProject,CookerMonitor UK,Lithuania,Ireland
1 2004 [72]
ENABLEProject,NightLight UK,Lithuania,Ireland
1 2004 [72]
GrontologieAssisteparlaRechercheetleDiagnosticdesIncidentsetdesErrancesNocturnes(Gardien)System
France 1 2005 [77]
Hand-HeldDecisionSupportSystem,Sydney Australia 1 2005 [78]
Hand-HeldDevicesinEmergencyDepartment,WesternAustralia Australia 1 2004 [83]HealthFeedbackDisplays USA 1 2005 [40]HomeAsthmaTelemonitoring(HAT)System USA 1 2004 [48]
HomeAutomatedTelemanagement(HAT)System USA 1 2006 [26]
HomeMonitoringofImplantedCardioverterDefibrillators,Aachen Germany 1 2006 [58]
Home-MonitoringSystemforCardiacPatients,Graz Austria 1 2006 [85]
HospitalWardwithVirtualNotes,Trondheim Norway 1 2006 [74]HospitalWithoutWallsProject Australia 1 2002 [69]iHospitalSystem,Horsens Denmark 1 2006 [13]
ImplantableHaemodynamicMonitoringSystem,Minneapolis USA 1 2005 [59]
IntegratedHomeTelehealthCareSystem,Seoul Korea 1 2005 [45]
IntelligentEmergencyRespose(IERS)System Canada 1 2005 [33]IST@HOMEProject EU 1 2004 [30]Karma2Project Italy 2 2004, [51,52]
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2005
LifeShirtSystem International
1 2004 [46]
MASCALSystem USA 1 2005 [54]
MIThrilSystem USA 1 2004 [57]
MobileEmergencyTriage(MET)System Canada 2 2004,2005
[81,82]
MobileWardSystem Denmark 1 2006 [75]
NASAArrhythmiaMonitoringSystem USA 1 2004 [24]NotfallOrganisations-undArbeitshilfe(NOAH)System Germany 1 2003 [80]
PervasiveSensorandActivityTracking(SevereCognitiveImpairment)
USA 1 2003 [21]
ProactiveActivityToolkit(PROACT) USA 1 2004 [38]
QuietCareSystem USA 1 2006 [27]
RealTimeLocationSystem,Antwerp Belgium 1 2006 [39]
Real-TimeWirelessPhysiologicalMonitoringSystem(RTWPMS),Taipei
Taiwan 1 2006 [64]
RemoteMonitoringSystem,Toulouse France 2 2002 [65,66]SafetyPortal,Taipei Taiwan 2 2005,
2006[43,44]
SenseWearSystem International
1 2005 [31]
SmartInactivityMonitorUsing
Array-BasedDetectors(Simbad)Project
UK 1 2004 [34]
TeleCAREProject Spain 1 2004 [35]
TriageandCasualtyInformaticsTechnology(TACIT)System USA 1 2006 [63]TriageSupportSystem,Taipei Taiwan 1 2006 [87]
TrinetraSystem USA 1 2006 [86]
TumorBoardProject Germany 1 2006 [79]VirtualEye(VI)System Saudi
Arabia,UAE
1 2006 [29]
WearableSystemsinNursingHomeCare,Lulea Sweden 1 2006 [73]WestSurreyTelemedicineMonitoringProject UK 1 2003 [62]
WirelessAlertsPagers,LosAngeles USA 2 2003,2005
[70,71]
WirelessElectronicPrescription(EPS)System,London UK 1 2006 [84]
WirelessIntelligentSensors(WISE),Huntsville USA 1 2003 [28]
WirelessPhysiologicalMonitoring,Taipei Taiwan 1 2004 [61]
WirelessSensorsinHealthandCare(WSHC)Project Norway 1 2006 [47]WorkerInteractiveNetworking(WIN)Project USA 1 2006 [36]
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Table2-Statusofsystems
Systemorprojectstatus n(%) References
Prototype/pilot study 56(84%) [13,21,24,26-30,32-45,47-58,60-69,72-77,79,80,83-87]
Clinicaltrials 6(9%) [22,57,59,78,81,82,88]
Inregularoperation 5(7%) [23,31,46,70,71,91]
Note:Systemsareassignedtoonestatuscategoryonly.Thepercentagesrefertoall67systemsexamined.
Table3-Healthcaresettings
Healthcaresettings n(%) References
Ambulatory 4(6%) [31,46,84,91]
Home/mobile 38(57%) [21-24,26-28,30,31,33-38,40-42,45,48-53,57-59,62,65,66,68,69,72,85,86,88]
Emergency 7(10%) [24,54,60,63,80,87,91]Clinical 24(36%) [13,29,32,41-44,46,47,53-56,61,64,70,71,74-79,81-83,87,88]
Care 5(7%) [39,64,67,69,73]
Rehabilitation 0(0%)
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table4-Users
Users n(%) References
Medicalprofessionals
Nurses/caregivers 34(51%) [13,22,23,27,29-31,34,37,39,41-45,47,51,52,54-56,59,62,64-71,73-77,83,87,88]
Paramedics 5(7%) [24,54,63,80,91]
Physicians 36(54%) [13,22,23,29,31,32,41-52,54,55,58-61,63,64,69-71,74,76,78-85,88,91]
Laypersons
Patients 48(72%) [21-24,26-33,35-54,57-62,64,67-69,72,84-86,88]
Privatecaregivers/family
9(13%) [21,23,30,34-36,40,65,66,72]
Others 4(6%) [21,41,68,76]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table5-Improvementaims
Improvementaims n(%) References
Organizationalimprovements 26(39%) [13,21,23,29,39,43,44,47,54-56,63,70,71,73-76,78-84,87,91]
Medicalimprovements
Therapyandrehabili tation 8(12%) [22,31,46,50-52,57,85]
Preventionandcare 42(63%) [21,23,24,26-42,45,46,48,49,53,58-62,64-69,72,77,86-88]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
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Table6-Medicalimprovementsbybodysubsystems
BodySubsystems n(%) References
CardiovascularSystem 12(18%) [24,28,41,42,45,46,50,58-61,64,85]
RespiratoryTract 8(12%) [41,42,45,46,48,49,62,88,91]
EndocrineSystem 2(3%) [22,57]
SensoryOrgans 1(1%) [86]
Nervoussystem 14(21%) [21,46,51-53,57,65-67,72,77,86,91]
Others 7(10%) [26-28,46,57,68,91]
Nospecificdisease 16(24%) [23,29-40,43,44,69,87]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table7-Componenttypes
Componenttypes n(%) References
Conventionalmobiledevice 34(51%) [13,22,26,28-30,36,40,43,44,48-50,54,57,60,61,63,64,69-71,73-76,78,80-88,91]
Wearables 28(42%) [21-24,28,30,31,38,39,41-57,60,62,73]
Implanteddevices 2(3%) [58,59]
Stationarydevices 34(51%) [13,21,23,27,28,30,32-40,45,53,59,61,64-69,72,74-77,79,84]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table8-Typesofdatagathering
Typeofdatagathering n(%) References
Monitoringofpersons 42(63%) [21-24,26-31,33-36,39-42,45-53,57-69,88,91]
Monitoringofobjects 11(16%) [21,27,40,43,44,55,68,70-72,79,86]
Localizationofpersons 21(31%) [13,23,24,27,32,35,37,39,40,43,44,53,54,60,63,67,68,73-77]
Localizationofobjects 3(4%) [38,54,56]
Manualinputorrequest 19(28%) [40,48,50,59,62,63,73-76,78-87]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table9-Datatransmission
Datatransmission n(%) References
Withdatatransmission 59(88%) [13,21-24,26-31,34-36,39-77,79-86,88,91]
Withoutdatatransmission 13(19%) [21,31-33,38,40-42,45,48,57,72,87]
Notdescribedwellenough 2(3%) [37,78]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table10-Systemsfunctions
Functions n(%) References
Analyticalanddiagnosticsupport 40(60%) [22-24,26-32,35,37,41,42,45-52,57-62,64-69,77,79-82,85,87,88,91]
Alerting 31(46%) [13,21-24,27,29,30,33-36,39,41-45,47,48,58,60-62,64,68-72,77,83,85,88]
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Supportactivities 23(34%) [13,21-23,26,30,35,38,40,45,48,53,57,60,70-74,76,81,82,85,86]
Informationanddocumentation 21(31%) [13,23,27,43,44,46,48,54,55,61,63,64,74-76,78-83,88,91]
Processautomation 11(16%) [13,39,43,44,55,56,73,76,79,81,82,84,91]
Medicaltreatment 0
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table11-Healthcaresettingsandimprovementaims
Healthcaresettings
AmbulatoryHome/mobile
Clinical Care Emergency
n(%) 2(3%) 4(6%) 16(24%) 2(3%) 5(7%)Organizationalimprovements
References [84,91] [21,23] [13,29,43,44,47,54-56,
70,71,74-76,78,79,81-83,
87]
[39,73] [54,63,80,87,91]
Medicalimprovements
n(%) 2(3%) 7(10%) 1(1%) 0 0Therapyandrehabilitation
References [31,46] [22,31,50-52,57,85]
[46]
n(%) 2(3%) 32(48%) 10(15%) 4(6%) 3(4%)Preventionandcare
References [31,46] [21,23,24,26-28,30,31,33-38,40-42,45,48,49,53,58,59,62,65,66,68,69,72,
86,88]
[29,32,41,42,46,53,61,64,77,87,88]
[39,64,67,69]
[24,60,87]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
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Table12-Healthcaresettingsandfunctions
Healthcaresettings
Functions Ambulatory Home/mobile Clinical Care Emergency
n(%) 3(2%) 26(18%) 12(8%) 3(2%) 5(3%)Analyticaland
diagnosticsupport References [31,46,91] [22-24,26-28,30,31,35,37,41,42,45,48-52,57-59,62,65,66,68,69,
85,88]
[29,32,41,42,46,47,61,64,77,79,81,82,
87,88]
[64,67,69] [24,60,80,87,91]
n(%) 0 20(14%) 11(7%) 3(2%) 2(1%)Alerting
References [21-24,27,30,33-36,41,42,45,48,58,62,68,69,72,85,
88]
[13,29,41-44,47,61,64,70,71,77,83,88]
[39,64,69] [24,60]
n(%) 0 16(11%) 6(4%) 1(1%) 1(1%)Supportactivities
References [21-23,26,30,
35,38,40,45,48,53,57,72,
85,86]
[13,53,70,71,
74,76,81,82]
[73] [60]
n(%) 2(1%) 4(3%) 15(10%) 1(1%) 4(3%)Informationanddocumentation
References [46,91] [23,27,48,88] [13,43,44,46,54,55,61,64,74-76,78,79,81-83,88]
[64] [54,63,80,91]
n(%) 2(1%) 0 7(5%) 2(1%) 1(1%)Processautomationandcontrol
References [84,91] [13,43,44,55,56,76,79,81,
82]
[39,73] [91]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
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Table13-Healthcaresettingsandcomponenttypes
Healthcaresettings
Componenttypes Ambulatory Home/mobile Clinical Care Emergency
n(%)2(3%) 14(21%) 15(22%) 3(4%) 6(9%)
Conventional
mobiledevices
References [84,91] [22,26,28,30,36,40,48-50,57,69,85,86,
88]
[13,29,43,44,54,61,64,70,71,74-76,78,81-83,87,
88]
[64,69,73] [54,60,63,80,87,91]
n(%) 2(3%) 19(28%) 8(12%) 2(3%) 3(4%)Wearables
References [31,46] [21-24,28,30,31,38,41,42,45,48-53,57,
62]
[41-44,46,47,53-56]
[39,73] [24,54,60]
n(%) 0 2(3%) 0 0 0Implanteddevices
References [58,59]
n(%) 1(1%) 22(33%) 10(15%) 4(6%) 0Stationarydevices
References [84] [21,23,27,28,30,33-38,40,45,53,59,65,66,68,69,72]
[13,32,53,61,64,74-77,79]
[39,64,67,69]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
Table14-Systemsfunctionsanddatagathering
Systemsfunctions
DatagatheringAnalyticalanddiagnosticsupport
AlertingSupportactivities
Informationand
documentation
Processautomationandcontrol
n(%) 32(48%) 24(36%) 13(19%) 9(13%) 2(3%)Monitoringofpersons
References [22-24,26-31,35,41,42,45-52,57-62,64-69,88,91]
[21-24,27,29,30,33-36,39,41,42,45,47,48,58,60-62,64,68,69,88]
[21-23,26,30,35,40,45,48,53,57,60]
[23,27,46,48,61,63,64,88,
91]
[39,91]
n(%) 3(4%) 5(7%) 5(7%) 4(6%) 3(4%)Monitoringofobjects
References [27,68,79] [27,43,44,68,70-72]
[21,40,70-72,86]
[27,43,44,55,79]
[43,44,55,79]
n(%) 10(15%) 10(15%) 9(13%) 9(13%) 5(7%)Localization
ofpersons References [23,24,27,32,35,37,60,67,
68,77]
[13,23,24,27,35,39,43,44,60,68,77]
[13,23,35,40,53,60,73,74,
76]
[13,23,27,43,44,54,63,74-
76]
[13,39,43,76],[44,73]
n(%) 0 0 1(1%) 1(1%) 1(1%)Localizationofobjects
References [38] [54] [56]
n(%) 9(13%) 4(6%) 8(12%) 10(15%) 5(7%)Manualinputorrequest
References [48,50,59,62,79-82,85,87]
[48,62,83,85] [40,48,73,74,76,81,82,85,
86]
[48,63,74-76,78-83]
[73,76,79,81,82,84]
Note:Multipleentriesindifferentcategoriesarepossible.Thepercentagesrefertoall67systemsreviewed.
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Table15-Systemsfunctionsandcomponenttypes
Systemsfunctions
ComponenttypesAnalyticalanddiagnosticsupport
AlertingSupportactivities
Informationanddocumentation
Processautomationand
control
n(%) 19(28%) 15(22%) 15(22%) 16(24%) 7(10%)Conventionalmobiledevices
References [22,26,28-30,48-50,57,60,61,64,69,80-82,85,87,
88,91]
[13,22,29,30,36,43,44,48,60,61,64,69-71,83,85,88]
[13,22,26,30,40,48,57,60,70,71,73,74,76,81,82,85,
86]
[13,43,44,48,54,61,63,64,74-76,78,80-83,88,91]
[13,43,44,73,76,81,82,84,
91]
n(%) 18(27%) 13(19%) 11(16%) 6(9%) 5(7%)Wearables
References [22-24,28,30,31,41,42,45-52,57,
60,62]
[21-24,30,39,41-45,47,48,
60,62]
[21-23,30,38,45,48,53,57,
60,73]
[23,43,44,46,48,54,55]
[39,43,44,55,56,73]
n(%) 17(25%) 17(25%) 13(19%) 9(13%) 5(7%)Stationarysystems
References [23,27,28,30,32,35,37,45,59,61,64-69,77,79]
[13,21,23,27,30,33-36,39,45,61,64,68,
69,72,77]
[13,21,23,30,35,38,40,45,53,72,74,76]
[13,23,27,61,64,74-76,79]
[13,39,76,79,84]
Note:Implanteddevicesarenotincludedinthetable.Multipleentriesindifferentcategoriesarepossible.The
percentagesrefertoall67systemsreviewed.
Table16Systemsflexibility
n(%) References
One-functionsystems 30(45%)
Analyticalanddiagnosticsupport 12(18%) [28,31,32,37,49-52,57,59,65-67,87]
Alerting 5(7%) [21,33,34,36,72]
Supportactivities 7(10%) [21,38,40,53,72,86]
Informationanddocumentation 4(6%) [54,63,75,78]
Processautomationandcontrol 2(3%) [56,84]
Two-functionsystems19(28%) [24,26,29,39,41,42,46,47,55,57,58,62,68-71,73,74,77,80,
83]
Three-functionsystems 14(21%) [22,27,30,35,43-45,60,61,64,76,79,85,88,91]
Four-functionsystems 4(6%) [13,23,48,81,82]
Note:Nomultipleentries.Theallocationofsystemsisunique.
Table17Systemscomplexity
n(%) References
Single-componentsystem 38(57%)
Conventionalmobiledevices 13(19%) [26,29,63,70,71,78,80-83,85-88,91]
Wearables 10(15%) [24,31,41,42,46,47,51,52,55-57,62]
Implanteddevices 1(1%) [58]
Stationarydevices 14(21%) [21,27,32-35,37,65-68,72,77,79]
Two-componentsystem 27(40%)
Conventionalmobiledevicesandwearables 9(13%) [22,43,44,48-50,54,57,60,73]
Conventionalmobileandstationarydevices 10(15%) [13,36,40,61,64,69,74-76,84]
Wearablesandstationarydevices 7(10%) [21,23,38,39,45,53]
Implantedandstationarydevices 1(1%) [59]
Three-componentsystem
Conventionalmobileandstationarydevicesandwearables 2(3%) [28,30]Note:Nomultipleentries.Theallocationofsystemsisunique.
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Table18-Deploymentissues
Deploymentissues References
Organizationalorpersonnelissues [13,47,56,69-71,74]
Financialissues [13,30,34,36,39,53,55,56,86,88]
Privacy,security,andcontrolissues [13,24,34,41,42,50,54,56,67,83,84,88]
Nodeploymentissues [23,26,28,29,32,33,35,37,38,41-44,57,61,64-66,68,80,87]
Note:Multipleentriesindifferentcategoriesarepossible.
AdditionalfilesAdditionalfile1Listofjournalsofincludedinthemanualsearch
TheadditionalListofjournalsincludedinmanualsearch.pdfPDFfilecontains
journalssearchedmanuallyintheliteraturereview.Thefilelistsjournalnamesand
linkstotheirwebsites.Whereavailable,furtherlinkstoPubMedreferencesaswellas
OpenAccessversionsofjournalsatPubMedCentral(PMC)areprovided.
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Web of KnowledgeIEEE Xplore INSPEC Pubmed
153 articles 66 articles 47 articles 41 articles
Eliminating duplicates
247 articles
98 articles
Reading titles and abstracts
291 articles
Eliminating duplicates
326 articles
Reading full papers
69 articles included
Manual journal search
Reading titles and abstracts
46 journals
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3
8
9
11
11
0 2 4 6 8 10 12
Number of articles included
IEEE Computer
IEEE Pervasive Computing
E Transactions on Information Technology in Biomedicine
Studies in Health Technology and Informatics
Journal of Telemedicine and Telecare
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Additional files provided with this submission:
Additional file 1: additional file - list of journals included in the manual search,109Khttp://www.biomedcentral.com/imedia/1552325145167656/supp1.pdf