Towards Pervasive Computing in Health Care - A Literature Orwat Graefe, Faulwasser_Unknown

8/8/2019 Towards Pervasive Computing in Health Care - A Literature Orwat Graefe, Faulwasser_Unknown

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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:

CO: [email protected]

AG: [email protected]

TF: [email protected]


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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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75. SkovM,HeghRT:Supportinginformationaccessinahospitalwardbyacontext-awaremobileelectronicpatientrecord.PersonalandUbiquitousComputing2006,V10(4):205-214.

76. BardramJE:Activity-basedcomputing:supportformobilityandcollaborationinubiquitouscomputing.PersonalandUbiquitousComputing2005,9(5):312-322.

77. SteenkesteF,BanerjeeS,CourturierP:TelesurveillanceofGeriatricPatientsinaHospitalUsingPassiveInfra-redSensors.Journalof

InformationTechnologyinHealthcare2005,3(2):89-100.


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incriticalcare.JournaloftheAmericanMedicalInformaticsAssociation2005,12(4):398-402.

79. SchmidtA,AltF,D.W,NiggemannJ,FeussnerH:Experimentingwith

ubiquitouscomputingtechnologiesinproductiveenvironments.ElektrotechnikundInformationstechnik2006,123(4):135-139.

80. SchaechingerU,RockeleinW,PerkA,AsbachP,NerlichM:NOAH-amobileemergencycaresystem.StudiesinHealthTechnologyandInformatics2003,97:147-158.

81. MichalowskiW,SlowinskiR,WilkS,FarionKJ,PikeJ,RubinS:Designanddevelopmentofamobilesystemforsupportingemergencytriage.MethodsofInformationinMedicine2005,44(1):14-24.

82. MichalowskiW,SowiskiR,WilkS:METSystem:ANewApproachtom-HealthinEmergencyTriage.JournalonInformationTechnologyinHealthcare2004,2(4):237-249.

83. GururajanR:Astudyoftheuseofhand-helddevicesinanemergencydepartment.JournalofTelemedicineandTelecare2004,10(Supplement1):33-35.

84. GhineaG,AsgariS,MoradiA,SerifT:AJini-basedsolutionforelectronicprescriptions.IEEETransactionsonInformationTechnologyinBiomedicine2006,10(4):794-802.

85. ScherrD,ZweikerR,KollmannA,KastnerP,SchreierG,FruhwaldFM:Mobilephone-basedsurveillanceofcardiacpatientsathome.JournalofTelemedicineandTelecare2006,12(5):255-261.

86. NarasimhanP:Assistiveembeddedtechnologies.IEEEComputer2006,39(7):85-87.

87. ChangP,ShengYH,SangYY,WangDW,HsuYS,HouIC:Developingandevaluatingawirelessspeech-and-touch-basedinterfaceforintelligent

comprehensivetriagesupportsystems.StudiesinHealthTechnologyandInformatics2006,122:693-697.

88. deToledoP,JimnezS,delPozoF,RocaJ,AlonsoA,HernandezC:TelemedicineexperienceforchroniccareinCOPD.IEEETransactionsonInformationTechnologyinBiomedicine2006,10(3):567-573.

89. GrunwaldA:RationaleTechnikfolgenbeurteilung.KonzepteundmethodischeGrundlagen.Berlin,Heidelberg,NewYork:Springer;1999.

90. IntilleSS:Anewresearchchallenge:Persuasivetechnologytomotivate

healthyaging.IEEETransactionsonInformationTechnologyinBiomedicine2004,8(3):235-237.91. MorrisTJ,PajakJ,HavlikF,KenyonJ,CalcagniD:BattlefieldMedical

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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]


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]



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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]


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]


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]


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]


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


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]



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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]



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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]


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]



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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

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