Telemedicine Chapter 20: Telemedicine and Biotechnology

This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020

Systematic Reviews

Kristoffersson, Annica et al (2020) [Systematic Review] A Systematic Review on the Use of Wearable Body Sensors for Health Monitoring: A Qualitative Synthesis[1]

The use of wearable body sensors for health monitoring is a quickly growing field with the potential of offering a reliable means for clinical and remote health management. This includes both real-time monitoring and health trend monitoring with the aim to detect/predict health deterioration and also to act as a prevention tool. The aim of this systematic review was to provide a qualitative synthesis of studies using wearable body sensors for health monitoring. The synthesis and analysis have pointed out a number of shortcomings in prior research. Major shortcomings are demonstrated by the majority of the studies adopting an observational research design, too small sample sizes, poorly presented, and/or non-representative participant demographics: ie age, gender, patient/healthy. These aspects need to be considered in future research work.

Mohsin, AH et al (2020) [Systematic Review] Real-Time Remote Health Monitoring Systems Using Body Sensor Information and Finger Vein Biometric Verification: A Multi-Layer Systematic Review[2]

The development of wireless body area sensor networks is imperative for modern telemedicine. However, attackers and cybercriminals are gradually becoming aware in attacking telemedicine systems, and the black market value of protected health information has the highest price nowadays. Security remains a formidable challenge to be resolved. Intelligent home environments make up one of the major application areas of pervasive computing. Security and privacy are the two most important issues in the remote monitoring and control of intelligent home environments for clients and servers in telemedicine architecture. The personal authentication approach that uses the finger vein pattern is a newly investigated biometric technique. This type of biometric has many advantages over other types and is suitable for different human categories and ages. This study aims to establish a secure verification method for real-time monitoring systems to be used for the authentication of patients and other members who are working in telemedicine systems. The process begins with the sensor based on Tiers 1 and 2 [client side] in the telemedicine architecture and ends with patient verification in Tier 3 [server side] via finger vein biometric technology to ensure patient security on both sides. Multilayer taxonomy is conducted in this research to attain the study’s goal. In the first layer, real-time remote monitoring studies based on the sensor technology used in telemedicine applications are reviewed and analysed to provide researchers a clear vision of security and privacy based on sensors in telemedicine. An extensive search is conducted to identify articles that deal with security and privacy issues, related applications are reviewed comprehensively and a coherent taxonomy of these articles is established. ScienceDirect, IEEE Xplore and Web of Science databases are checked for articles on mHealth in telemedicine based on sensors. A total of 3064 papers are collected from 2007 to 2017. The retrieved articles are filtered according to the security and privacy of telemedicine applications based on sensors. Nineteen articles are selected and classified into two categories. The first category, which accounts for 57.89% (n = 11/19), includes surveys on telemedicine articles and their applications. The second category, accounting for 42.1% (n = 8/19), includes articles on the three-tiered architecture of telemedicine. The collected studies reveal the essential need to construct another taxonomy layer and review studies on finger vein biometric verification systems. This map-matching for both taxonomies is developed for this study to go deeply into the sensor field and determine novel risks and benefits for patient security and privacy on client and server sides in telemedicine applications. In the second layer of our taxonomy, the literature on finger vein biometric verification systems is analysed and reviewed. In this layer, we obtain a final set of 65 articles classified into four categories. In the first category, 80% (n = 52/65) of the articles focus on development and design. In the second category, 12.30% (n = 8/65) includes evaluation and comparative articles. These articles are not intensively included in our literature analysis. In the third category, 4.61% (n = 3/65) includes articles about analytical studies. In the fourth category, 3.07% (n = 2/65) comprises reviews and surveys. This study aims to provide researchers with an up-to-date overview of studies that have been conducted on user/patient authentication to enhance the security level in telemedicine or any information system. In the current study, taxonomy is presented by explaining previous studies. Moreover, this review highlights the motivations, challenges and recommendations related to finger vein biometric verification systems and determines the gaps in this research direction [protection of finger vein templates in real time], which represent a new research direction in this area.

Shuwandy, ML et al (2019) [Systematic Review] Sensor-Based mHealth Authentication for Real-Time Remote Healthcare Monitoring System: A Multilayer Systematic Review[3]

The new and groundbreaking real-time remote healthcare monitoring system on sensor-based mobile health authentication in telemedicine has considerably bounded and dispersed communication components. mHealth, an attractive part in telemedicine architecture, plays an imperative role in patient security and privacy and adapts different sensing technologies through many built-in sensors. This study aims to improve sensor-based defence and attack mechanisms to ensure patient privacy in client side when using mHealth. Thus, a multilayer taxonomy was conducted to attain the goal of this study. Within the first layer, real-time remote monitoring studies based on sensor technology for telemedicine application were reviewed and analysed to examine these technologies and provide researchers with a clear vision of security- and privacy-based sensors in the telemedicine area. An extensive search was conducted to find articles about security and privacy issues, review related applications comprehensively and establish the coherent taxonomy of these articles. ScienceDirect, IEEE Xplore and Web of Science databases were investigated for articles on mHealth in telemedicine-based sensor. A total of 3064 papers were collected from 2007 to 2017. The retrieved articles were filtered according to the security and privacy of sensor-based telemedicine applications. A total of 19 articles were selected and classified into two categories. The first category, 57.89% (n = 11/19), included survey on telemedicine articles and their applications. The second category, 42.1% (n = 8/19), included articles contributed to the three-tiered architecture of telemedicine. The collected studies improved the essential need to add another taxonomy layer and review the sensor-based smartphone authentication studies. This map matching for both taxonomies was developed for this study to investigate sensor field comprehensively and gain access to novel risks and benefits of the mHealth security in telemedicine application. The literature on sensor-based smartphones in the second layer of our taxonomy was analysed and reviewed. A total of 599 papers were collected from 2007 to 2017. In this layer, we obtained a final set of 81 articles classified into three categories. The first category of the articles [86.41% (n = 70/81)], where sensor-based smartphones were examined by utilising orientation sensors for user authentication, was used. The second category [7.40% (n = 6/81)] included attack articles, which were not intensively included in our literature analysis. The third category [8.64% (n = 7/81)] included ‘other’ articles. Factors were considered to understand fully the various contextual aspects of the field in published studies. The characteristics included the motivation and challenges related to sensor-based authentication of smartphones encountered by researchers and the recommendations to strengthen this critical area of research. Finally, many studies on the sensor-based smartphone in the second layer have focused on enhancing accurate authentication because sensor-based smartphones require sensors that could authentically secure mHealth.

Talal, Mohammed et al (2019) [Systematic Review] Smart Home-based IoT for Real-time and Secure Remote Health Monitoring of Triage and Priority System Using Body Sensors: Multi-driven Systematic Review[4]

The Internet of Things (IoT) has been identified in various applications across different domains, such as in the healthcare sector. IoT has also been recognised for its revolution in reshaping modern healthcare with aspiring wide range prospects, including economical, technological and social. This study aims to establish IoT-based smart home security solutions for real-time health monitoring technologies in telemedicine architecture. A multilayer taxonomy is driven and conducted in this study. In the first layer, a comprehensive analysis on telemedicine, which focuses on the client and server sides, shows that other studies associated with IoT-based smart home applications have several limitations that remain unaddressed. Particularly, remote patient monitoring in healthcare applications presents various facilities and benefits by adopting IoT-based smart home technologies without compromising the security requirements and potentially large number of risks. An extensive search is conducted to identify articles that handle these issues, related applications are comprehensively reviewed and a coherent taxonomy for these articles is established. A total number of (n = 3064) are gathered between 2007 and 2017 for most reliable databases, such as ScienceDirect, Web of Science and Institute of Electrical and Electronic Engineer Xplore databases. Then, the articles based on IoT studies that are associated with telemedicine applications are filtered. Nine articles are selected and classified into two categories. The first category, which accounts for 22.22% (n = 2/9), includes surveys on telemedicine articles and their applications. The second category, which accounts for 77.78% (n = 7/9), includes articles on the client and server sides of telemedicine architecture. The collected studies reveal the essential requirement in constructing another taxonomy layer and review IoT-based smart home security studies. Therefore, IoT-based smart home security features are introduced and analysed in the second layer. The security of smart home design based on IoT applications is an aspect that represents a crucial matter for general occupants of smart homes, in which studies are required to provide a better solution with patient security, privacy protection and security of users’ entities from being stolen or compromised. Innovative technologies have dispersed limitations related to this matter. The existing gaps and trends in this area should be investigated to provide valuable visions for technical environments and researchers. Thus, 67 articles are obtained in the second layer of our taxonomy and are classified into six categories. In the first category, 25.37% (n = 17/67) of the articles focus on architecture design. In the second category, 17.91% (n = 12/67) includes security analysis articles that investigate the research status in the security area of IoT-based smart home applications. In the third category, 10.44% (n = 7/67) includes articles about security schemes. In the fourth category, 17.91% (n = 12/67) comprises security examination. In the fifth category, 13.43% (n = 9/67) analyses security protocols. In the final category, 14.92% (n = 10/67) analyses the security framework. Then, the identified basic characteristics of this emerging field are presented and provided in the following aspects. Open challenges experienced on the development of IoT-based smart home security are addressed to be adopted fully in telemedicine applications. Then, the requirements are provided to increase researcher’s interest in this study area. On this basis, a number of recommendations for different parties are described to provide insights on the next steps that should be considered to enhance the security of smart homes based on IoT. A map matching for both taxonomies is developed in this study to determine the novel risks and benefits of IoT-based smart home security for real-time remote health monitoring within client and server sides in telemedicine applications.

Sanyal, Chiranjeev et al (2018) [Systematic Review] Economic Evaluations of eHealth Technologies: A Systematic Review[5]

Background: Innovations in eHealth technologies have the potential to help older adults live independently, maintain their quality of life, and to reduce their health system dependency and health care expenditure. The objective of this study was to systematically review and appraise the quality of cost-effectiveness or utility studies assessing eHealth technologies in study populations involving older adults. Methods: We systematically searched multiple databases (MEDLINE, EMBASE, CINAHL, NHS EED, and PsycINFO) for peer-reviewed studies published in English from 2000 to 2016 that examined cost-effectiveness or utility of eHealth technologies. The reporting quality of included studies was appraised using the Consolidated Health Economic Evaluation Reporting Standards statement. Results: Eleven full text articles met the inclusion criteria representing public and private health care systems. eHealth technologies evaluated by these studies includes computerized decision support system, a web-based physical activity intervention, Internet-delivered cognitive behavioral therapy, telecare, and telehealth. Overall, the reporting quality of the studies included in the review was varied. Most studies demonstrated efficacy and cost-effectiveness of an intervention using a randomized control trial and statistical modeling, respectively. This review found limited information on the feasibility of adopting these technologies based on economic and organizational factors.
Conclusions: This review identified few economic evaluations of eHealth technologies that included older adults. The quality of the current evidence is limited and further research is warranted to clearly demonstrate the long-term cost-effectiveness of eHealth technologies from the health care system and societal perspectives.

Randomised Controlled Trials

Steinberg, Christian et al (2020) A Novel Wearable Device for Continuous Ambulatory ECG Recording: Proof of Concept and Assessment of Signal Quality[6]

Diagnosis of arrhythmic disorders is challenging because of their short-lasting, intermittent character. Conventional technologies of noninvasive ambulatory rhythm monitoring are limited by modest sensitivity. We present a novel form of wearable electrocardiogram sensors providing an alternative tool for long-term rhythm monitoring with the potential of increased sensitivity to detect intermittent or subclinical arrhythmia. The objective was to assess the signal quality and R-R coverage of a wearable ECG sensor system compared to a standard 3-lead Holter. In this phase-1 trial, healthy individuals underwent 24-h simultaneous rhythm monitoring using the OMsignal system together with a 3-lead Holter recording. The OMsignal system consists of a garment [bra or shirt] with integrated sensors recording a single-lead ECG and an acquisition module for data storage and processing. Head-to-head signal quality was assessed regarding adequate P-QRS-T distinction and was performed by three electrophysiologists blinded to the recording technology. The accuracy of signal coverage was assessed using Bland-Altman analysis. Fifteen individuals underwent simultaneous 24-h recording. Signal quality and accuracy of the OMgaments was equivalent to Holter-monitoring (84% vs 93% electrophysiologists rating, p = 0.06). Signal coverage of R-R intervals showed a very close overlay between the OMsignal system and Holter signals, mean difference in heart rate of 2 5 bpm. The noise level of OMgarments was comparable to Holter recording. OMgarments provide high signal quality for adequate rhythm analysis, representing a promising novel technology for long-term non-invasive ECG monitoring.

Miscellaneous

Alwashmi, Meshari F (2020) [Review] The Use of Digital Health in the Detection and Management of COVID-19[7]

Digital health is uniquely positioned to enhance the way we detect and manage infectious diseases. This commentary explores the potential of implementing digital technologies that can be used at different stages of the COVID-19 outbreak, including data-driven disease surveillance, screening, triage, diagnosis, and monitoring. Methods that could potentially reduce the exposure of healthcare providers to the virus are also discussed.

Damen, Ida et al (2020) [Scoping Review] A Scoping Review of Digital Tools to Reduce Sedentary Behavior or Increase Physical Activity in Knowledge Workers[8]

Background: There is increasing interest in the role that technology can play in improving the vitality of knowledge workers. A promising and widely adopted strategy to attain this goal is to reduce sedentary behavior (SB) and increase physical activity (PA). In this paper, we review the state-of-the-art SB and PA interventions using technology in the office environment. By scoping the existing landscape, we identified current gaps and underexplored possibilities. We discuss opportunities for future development and research on SB and PA interventions using technology. Methods: A systematic search was conducted in the Association for Computing Machinery digital library, the interdisciplinary library Scopus, and the Institute of Electrical and Electronics Engineers Xplore Digital Library to locate peer-reviewed scientific articles detailing SB and PA technology interventions in office environments between 2009 and 2019. Results: The initial search identified 1130 articles, of which 45 studies were included in the analysis. Our scoping review focused on the technologies supporting the interventions, which were coded using a grounded approach. Conclusion: Our findings showed that current SB and PA interventions using technology provide limited possibilities for physically active ways of working as opposed to the common strategy of prompting breaks. Interventions are also often offered as additional systems or services, rather than integrated into existing office infrastructures. With this work, we have mapped different types of interventions and provide an increased understanding of the opportunities for future multidisciplinary development and research of technologies to address sedentary behavior and physical activity in the office context.

Muzny, Miroslav et al (2020) [Review] Wearable sensors with possibilities for data exchange: Analyzing status and needs of different actors in mobile health monitoring systems[9]

Background: Wearable devices with an ability to collect various type of physiological data are increasingly becoming seamlessly integrated into everyday life of people. In the area of eHealth, many of these devices provide remote transfer of health data, as a result of the increasing need for ambulatory monitoring of patients. This has a potential to reduce the cost of care due to prevention and early detection. Objective: The objective of this study was to provide an overview of available wearable sensor systems with data exchange possibilities. Due to the heterogeneous capabilities these systems possess today, we aimed to systematize this in terms of usage, where there is a need of, or users benefit from, transferring self-collected data to health care actors. Methods: We searched for and reviewed relevant sensor systems [ie devices] and mapped these into 13 selected attributes related to data-exchange capabilities. We collected data from the Vandrico database of wearable devices, and complemented the information with an additional Internet search. We classified the following attributes of devices: type, communication interfaces, data protocols, smartphone/PC integration, connection to smartphone health platforms, 3rd party integration with health platforms, connection to health care system/middleware, type of gathered health data, integrated sensors, medical device certification, access to user data, developer-access to device, and market status. Devices from the same manufacturer with similar functionalities/characteristics were identified under the same device family. Furthermore, we classified the systems in three subgroups of relevance for different actors in mobile health monitoring systems: EHR providers, software developers, and patient users. Results: We identified 362 different mobile health monitoring devices belonging to 193 device families. Based on an analysis of these systems, we identified the following general challenges: Conclusions: Few of the identified mobile health monitoring systems use standardized, open communication protocols, which would allow the user to directly acquire sensor data. Use of open protocols can provide mobile health application developers an alternative to proprietary cloud services and communication tools, which are often closely integrated with the devices. Emerging new types of sensors, often intended for everyday use, have a potential to supplement health records systems with data that can enrich patient care.

Palanica, Adam et al (2020) [Review] The Need for Artificial Intelligence in Digital Therapeutics[10]

Digital therapeutics is a newly described concept in healthcare which is proposed to change patient behavior and treat medical conditions using a variety of digital technologies. However, the term is rarely defined with criteria that make it distinct from simply digitizedversions of traditional therapeutics. Our objective is to describe a more valuable characteristic of digital therapeutics, which is distinct from traditional medicine or therapy: that is, the utilization of artificial intelligence and machine learning systems to monitor and predict individual patient symptom data in an adaptive clinical feedback loop via digital biomarkers to provide a precision medicine approach to healthcare. Artificial intelligence platforms can learn and predict effective interventions for individuals using a multitude of personal variables to provide a customized and more tailored therapy regimen. Digital therapeutics coupled with artificial intelligence and machine learning also allows more effective clinical observations and management at the population level for various health conditions and cohorts. This vital differentiation of digital therapeutics compared to other forms of therapeutics enables a more personalized form of healthcare that actively adapts to patients’ individual clinical needs, goals, and lifestyles. Importantly, these characteristics are what needs to be emphasized to patients, physicians, and policy makers to advance the entire field of digital healthcare.

Sust, Pol Perez et al (2020) [Review] Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak[11]

Digital health technologies offer significant opportunities to reshape current health care systems. From the adoption of electronic medical records to mobile health apps and other disruptive technologies, digital health solutions have promised a better quality of care at a more sustainable cost. However, the widescale adoption of these solutions is lagging behind. The most adverse scenarios often provide an opportunity to develop and test the capacity of digital health technologies to increase the efficiency of health care systems. Catalonia is one of the most advanced regions in terms of digital health adoption across Europe. The region has a long tradition of health information exchange in the public health care sector and is currently implementing an ambitious digital health strategy. In this viewpoint, we discuss the crucial role digital health solutions play during the COVID-19 pandemic to support public health policies. We also report on the strategies currently deployed at scale during the outbreak in Catalonia. Conflicts of Interest: All authors are public servants involved in the deployment of the digital health strategies mentioned in this paper.

Tsai, Tsai-Hsuan et al (2020) [Review] Technology anxiety and resistance to change behavioral study of a wearable cardiac warming system using an extended TAM for older adults[12]

With advances in technology, wireless and sensor technologies represent a method for continuously recording people’s biomedical signals, which may enhance the diagnosis and treatment of users’ everyday health conditions. These technologies mostly target older adults. In this study, we examine a smart clothing system targeting clinically high-risk patients, including older adults with cardiovascular disease and older adults in general to obtain an understanding of the patients’ perception of using wearable healthcare technologies. Cognizant that technology anxiety has been shown to affect users’ resistance to using new technology and that perceived ubiquity is considered a characteristic of wearable devices and other mobile wireless technologies, we included three external variables: technology anxiety, perceived ubiquity, and resistance to change, in addition to the traditional components of the technology acceptance model (TAM). The results of the hypothesized model showed that among older adults in general, technology anxiety had a negative effect on the perceived ease of use and perceived ubiquity. The perceived ubiquity construct affects both user groups’ perceived ease of use and perceived usefulness of wearing smart clothes. Most relationships among the original constructs of the TAM were validated in older adults in general. Interestingly, we found that perceived usefulness had an indirect effect on behavioral intention through attitude. These results further confirm the validity of the extended TAM in determining older users’ technology acceptance behavior.

Xin, Ming et al (2020) [Review] MXenes and Their Applications in Wearable Sensors[13]

MXenes, a kind of two-dimensional material of early transition metal carbides and carbonitrides, have emerged as a unique class of layered-structured metallic materials with attractive features, as good conductivity comparable to metals, enhanced ionic conductivity, hydrophilic property derived from their hydroxyl or oxygen-terminated surfaces, and mechanical flexibility. With tunable etching methods, the morphology of MXenes can be effectively controlled to form nanoparticles, single layer, or multi-layer nanosheets, which exhibit large specific surface areas and is favorable for enhancing the sensing performance of MXenes based sensors. Moreover, MXenes are available to form composites with other materials facilely. With structure design, MXenes or its composite show enhanced mechanical flexibility and stretchability, which enabled its wide application in the fields of wearable sensors, energy storage, and electromagnetic shielding. In this review, recent progress in MXenes is summarized, focusing on its application in wearable sensors including pressure/strain sensing, biochemical sensing, temperature, and gas sensing. Furthermore, the main challenges and future research are also discussed.

Calvaresi, Davide et al (2019) [Review] Real-time multi-agent systems for telerehabilitation scenarios[14]

Telerehabilitation in older adults is most needed in the patient environments, rather than in formal ambulatories or hospitals. Supporting such practices brings significant advantages to patients, their family, formal and informal caregivers, clinicians, and researchers. This paper presents a focus group with experts in physiotherapy and telerehabilitation, debating on the requirements, current techniques and technologies developed to facilitate and enhance the effectiveness of telerehabilitation, and the still open challenges. Particular emphasis is given to 1. the body-parts requiring the most rehabilitation; 2. the typical environments, initial causes, and general conditions; 3. the values and parameters to be observed; 4. common errors and limitations of current practices and technological solutions; and 5. the envisioned and desired technological support. Consequently, it has been performed a systematic review of the state of the art, investigating what types of systems and support currently cope with telerehabilitation practices and possible matches with the outcomes of the focus group. Technological solutions based on video analysis, wearable devices, robotic support, distributed sensing, and gamified telerehabilitation are examined. Particular emphasis is given to solutions implementing agent-based approaches, analyzing and discussing strength, limitations, and future challenges. By doing so, it has been possible to relate functional requirements expressed by professional physiotherapists and researchers, with the need for extending multi-agent systems (MAS) peculiarities at the sensing level in wearable solutions establishing new research challenges. In particular, to be employed in safety-critical cyber-physical scenarios with user-sensor and sensor-sensor interactions, MAS are requested to handle timing constraints, scarcity of resources and new communication means, crucial to providing real-time feedback and coaching. Therefore, MAS pillars such as the negotiation protocol and the agent’s internal scheduler have been investigated, proposing solutions to achieve the aforementioned real-time compliance.

Gu, Dongxiao et al (2019) [Review] Visualizing the intellectual structure and evolution of electronic health and telemedicine research[15]

Background: In recent years, the development and application of emerging information technologies, such as artificial intelligence, cloud computing, Internet of Things, and wearable devices, has expanded the content of e-health. Electronic health has become a research focus, but few studies have explored its knowledge structure from a global perspective. Methods: To detect the evolution track, knowledge base and research hotspots of e-health, we conducted a series of bibliometric analyses on the retrieved 3,085 papers from the Web of Science core database in 1992-2017. We used several bibliometric tools, such as HistCite, CiteSpace, NetDraw, and NEViewer, to describe the evolution process, time-and-space knowledge map, and hotspots in e-health. Results: The research results are as follows: 1. the number of publications has been obviously increasing after 2005 and according to the trend line it is expected to continue increase exponentially in the future; 2. countries/regions conducting e-health research have close cooperative relationship, among which European countries have the closest cooperation; 3. electronic health records, mobile health and health information technology are research hotspots in electronic health. Moreover, scholars also pay attention to the hot issues such as privacy, security, and quality improvement. Conclusions: Electronic health is a large and growing field with quite a number of research articles in medical journals. This study provides a comprehensive knowledge structure of electronic health for scholars in the healthcare informatics field, which can help them quickly grasp research hotspots and choose future research projects.

Guo, Jingjing et al (2019) [Review] Soft and Stretchable Polymeric Optical Waveguide-Based Sensors for Wearable and Biomedical Applications[16]

The past decades have witnessed the rapid development in soft, stretchable, and biocompatible devices for applications in biomedical monitoring, personal healthcare, and human-machine interfaces. In particular, the design of soft devices in optics has attracted tremendous interests attributed to their distinct advantages such as inherent electrical safety, high stability in long-term operation, potential to be miniaturized, and free of electromagnetic interferences. As the alternatives to conventional rigid optical waveguides, considerable efforts have been made to develop light-guiding devices by using various transparent and elastic polymers, which offer desired physiomechanical properties and enable wearable/implantable applications in optical sensing, diagnostics, and therapy. Here, we review recent progress in soft and stretchable optical waveguides and sensors, including advanced structural design, fabrication strategies, and functionalities. Furthermore, the potential applications of those optical devices for various wearable and biomedical applications are discussed. It is expected that the newly emerged soft and stretchable optical technologies will provide a safe and reliable alternative to next-generation, smart wearables and healthcare devices.

Huzooree, Geshwaree et al (2019) [Review] Pervasive mobile healthcare systems for chronic disease monitoring[17]

Pervasive mobile healthcare system has the potential to improve healthcare and the quality of life of chronic disease patients through continuous monitoring. Recently, many articles related to pervasive mobile healthcare system focusing on health monitoring using wireless technologies have been published. The main aim of this review is to evaluate the state-of-the-art pervasive mobile healthcare systems to identify major technical requirements and design challenges associated with the realization of a pervasive mobile healthcare system. A systematic literature review was conducted over IEEE Xplore Digital Library to evaluate 20 pervasive mobile healthcare systems out of 683 articles from 2011 to 2016. The classification of the pervasive mobile healthcare systems and other important factors are discussed. Potential opportunities and challenges are pointed out for the further deployment of effective pervasive mobile healthcare systems. This article helps researchers in health informatics to have a holistic view toward understanding pervasive mobile healthcare systems and points out new technological trends and design challenges that researchers have to consider when designing such systems for better adoption, usability, and seamless integration.

Jeong, Yu Ra et al (2019) [Review] Stretchable, Skin-Attachable Electronics With Integrated Energy Storage Devices for Biosignal Monitoring[18]

The demand for novel electronics that can monitor human health, for example, the physical conditions of individuals, during daily life using different techniques from those used in traditional clinic diagnostic facilities is increasing. These novel electronics include stretchable sensor devices that allow various biosignals to be directly measured on human skin without restricting routine activity. The thin, skin-like characteristics of these devices enable stable operation under various deformations, such as stretching, pressing, and rubbing, experienced while attached to skin. The mechanically engineered design of these devices also minimizes the inconvenience caused by long-term wear owing to conformal lamination on the skin. The final form of a skin-attachable device must be an integrated platform with an independent and complete system containing all components on a single, thin, lightweight, stretchable substrate. To fabricate fully integrated devices, various aspects, such as material design for deformable interconnection, fabrication of high-performance active devices, miniaturization, and dense arrangement of component devices, should be considered. In particular, a power supply system is critical and must be combined in an electromechanically stable and efficient manner with all devices, including sensors. Additionally, the biosignals obtained by these sensors should be wirelessly transmitted to external electronic devices for free daily activity. This Account covers recent progress in developing fully integrated, stretchable, skin-attachable devices by presenting our strategies to achieve this goal. First, we introduce several integration methods used in this field to build stretchable systems with a special focus on the utilization of liquid gallium alloy. The unique characteristics and patterning process of liquid metal are summarized. Second, various skin-attachable sensors, including strain, pressure, with enhanced sensitivity and mechanical properties are discussed along with their applications for biosignal monitoring. Dual mode sensors that simultaneously detect temperature and pressure signals without interference are also introduced. Third, we emphasize supercapacitors as promising, efficient energy storage devices for power management systems in wearable devices. Supercapacitors for skin-attachable applications should have a high performance, such as high operation voltage, high energy and power densities, cyclic and air stability and water resistance. For this, strategies to select novel materials for electrode, electrolyte, and encapsulation are suggested. Several approaches to fabricate stretchable supercapacitor systems are also presented. Finally, we introduce recent examples of skin-attachable, stretchable electronics that integrate sensors, power management devices, and wireless data transfer functions on a single elastomer substrate. Conventional wireless technologies, such as near-field communications (NFC) and Bluetooth, are incorporated in miniaturized features on the devices. To date, much research has been performed in this field, but there are still many technologies to develop. The performance of individual devices and mass fabrication techniques should be enhanced. We expect that future electronic devices with fully integrated functions will include advanced human-machine interaction capabilities and expand the overall abilities of the human body.

Jeong, In Cheol et al (2019) [Review] Wearable Devices for Precision Medicine and Health State Monitoring[19]

Wearable technologies will play an important role in advancing precision medicine by enabling measurement of clinically-relevant parameters describing an individual’s health state. The lifestyle and fitness markets have provided the driving force for the development of a broad range of wearable technologies that can be adapted for use in healthcare. Here we review existing technologies currently used for measurement of the four primary vital signs: temperature, heart rate, respiration rate, and blood pressure, along with physical activity, sweat, and emotion. We review the relevant physiology that defines the measurement needs and evaluate the different methods of signal transduction and measurement modalities for the use of wearables in healthcare.

Khan, Saleem et al (2019) [Review] Recent Developments in Printing Flexible and Wearable Sensing Electronics for Healthcare Applications[20]

Wearable biosensors attract significant interest for their capabilities in real-time monitoring of wearers’ health status, as well as the surrounding environment. Sensor patches are embedded onto the human epidermis accompanied by data readout and signal conditioning circuits with wireless communication modules for transmitting data to the computing devices. Wearable sensors designed for recognition of various biomarkers in human epidermis fluids as well as physiological indicators have potential applications both in medical diagnostics and fitness monitoring. The rapid developments in solution-based nanomaterials offered a promising perspective to the field of wearable sensors by enabling their cost-efficient manufacturing through printing on a wide range of flexible polymeric substrates. This review highlights the latest key developments made in the field of wearable sensors involving advanced nanomaterials, manufacturing processes, substrates, sensor type, sensing mechanism, and readout circuits, and ends with challenges in the future scope of the field. Sensors are categorized as biological and fluidic, mounted directly on the human body, or physiological, integrated onto wearable substrates/gadgets separately for monitoring of human-body-related analytes, as well as external stimuli. Special focus is given to printable materials and sensors, which are key enablers for wearable electronics.

Loncar-Turukalo, Tatjana et al (2019) [Review] Literature on Wearable Technology for Connected Health: Scoping Review of Research Trends, Advances, and Barriers[21]

Background: Wearable sensing and information and communication technologies are key enablers driving the transformation of health care delivery toward a new model of connected health (CH) care. The advances in wearable technologies in the last decade are evidenced in a plethora of original articles, patent documentation, and focused systematic reviews. Although technological innovations continuously respond to emerging challenges and technology availability further supports the evolution of CH solutions, the widespread adoption of wearables remains hindered. Objective: This study aimed to scope the scientific literature in the field of pervasive wearable health monitoring in the time interval from January 2010 to February 2019 with respect to four important pillars: technology, safety and security, prescriptive insight, and user-related concerns. The purpose of this study was multi-fold: identification of 1. trends and milestones that have driven research in wearable technology in the last decade; 2. concerns and barriers from technology and user perspective; and 3. trends in the research literature addressing these issues. Methods: This study followed the scoping review methodology to identify and process the available literature. As the scope surpasses the possibilities of manual search, we relied on the natural language processing tool kit to ensure an efficient and exhaustive search of the literature corpus in three large digital libraries: Institute of Electrical and Electronics Engineers, PubMed, and Springer. The search was based on the keywords and properties to be found in articles using the search engines of the digital libraries. Results: The annual number of publications in all segments of research on wearable technology shows an increasing trend from 2010 to February 2019. The technology-related topics dominated in the number of contributions, followed by research on information delivery, safety, and security, whereas user-related concerns were the topic least addressed. The literature corpus evidences milestones in sensor technology (miniaturization and placement), communication architectures and fifth generation (5G) cellular network technology, data analytics, and evolution of cloud and edge computing architectures. The research lag in battery technology makes energy efficiency a relevant consideration in the design of both sensors and network architectures with computational offloading. The most addressed user-related concerns were (technology) acceptance and privacy, whereas research gaps indicate that more efforts should be invested into formalizing clear use cases with timely and valuable feedback and prescriptive recommendations.
Conclusions: This study confirms that applications of wearable technology in the CH domain are becoming mature and established as a scientific domain. The current research should bring progress to sustainable delivery of valuable recommendations, enforcement of privacy by design, energy-efficient pervasive sensing, seamless monitoring, and low-latency 5G communications. To complement technology achievements, future work involving all stakeholders providing research evidence on improved care pathways and cost-effectiveness of the CH model is needed.

Majumder, Sumit et al (2019) [Review] Smartphone Sensors for Health Monitoring and Diagnosis[22]

Over the past few decades, we have witnessed a dramatic rise in life expectancy owing to significant advances in medical science and technology, medicine as well as increased awareness about nutrition, education, and environmental and personal hygiene. Consequently, the elderly population in many countries are expected to rise rapidly in the coming years. A rapidly rising elderly demographics is expected to adversely affect the socioeconomic systems of many nations in terms of costs associated with their healthcare and wellbeing. In addition, diseases related to the cardiovascular system, eye, respiratory system, skin and mental health are widespread globally. However, most of these diseases can be avoided and/or properly managed through continuous monitoring. In order to enable continuous health monitoring as well as to serve growing healthcare needs; affordable, non-invasive and easy-to-use healthcare solutions are critical. The ever-increasing penetration of smartphones, coupled with embedded sensors and modern communication technologies, make it an attractive technology for enabling continuous and remote monitoring of an individual’s health and wellbeing with negligible additional costs. In this paper, we present a comprehensive review of the state-of-the-art research and developments in smartphone-sensor based healthcare technologies. A discussion on regulatory policies for medical devices and their implications in smartphone-based healthcare systems is presented. Finally, some future research perspectives and concerns regarding smartphone-based healthcare systems are described.

Olatinwa, Damilola D. et al (2019) [Review] A Survey on LPWAN Technologies in WBAN for Remote Health-Care Monitoring[23]

In ubiquitous health-care monitoring (HCM), wireless body area networks (WBANs) are envisioned as appealing solutions that may offer reliable methods for real-time monitoring of patients’ health conditions by employing the emerging communication technologies. This paper therefore focuses more on the state-of-the-art wireless communication systems that can be explored in the next-generation WBAN solutions for HCM. Also, this study addressed the critical issues confronted by the existing WBANs that are employed in HCM. Examples of such issues include wide-range health data communication constraint, health data delivery reliability concern, and energy efficiency, which are attributed to the limitations of the legacy short range, medium range, and the cellular technologies that are typically employed in WBAN systems. Since the WBAN sensor devices are usually configured with a finite battery power, they often get drained during prolonged operations. This phenomenon is technically exacerbated by the fact that the legacy communication systems, such as ZigBee, Bluetooth, 6LoWPAN, and so on, consume more energy during data communications. This unfortunate situation offers a scope for employing suitable communication systems identified in this study to improve the productivity of WBANs in HCM. For this to be achieved, the emerging communication systems such as the low-power wide-area networks (LPWANs) are investigated in this study based on their power transmission, data transmission rate, data reliability in the context of efficient data delivery, communication coverage, and latency, including their advantages, as well as disadvantages. As a consequence, the LPWAN solutions are presented for WBAN systems in remote HCM. Furthermore, this research work also points out future directions for the realization of the next-generation of WBANs, as well as how to improve the identified communication systems, to further enhance their productivity in WBAN solutions for HCM.

Ranjan, Yatharth et al (2019) RADAR-Base: Open Source Mobile Health Platform for Collecting, Monitoring, and Analyzing Data Using Sensors, Wearables, and Mobile Devices[24]

Background: With a wide range of use cases in both research and clinical domains, collecting continuous mobile health (mHealth) streaming data from multiple sources in a secure, highly scalable, and extensible platform is of high interest to the open source mHealth community. The European Union Innovative Medicines Initiative Remote Assessment of Disease and Relapse-Central Nervous System (RADAR-CNS) program is an exemplary project with the requirements to support the collection of high-resolution data at scale; as such, the Remote Assessment of Disease and Relapse (RADAR)-base platform is designed to meet these needs and additionally facilitate a new generation of mHealth projects in this nascent field.
Objective: Wide-bandwidth networks, smartphone penetrance, and wearable sensors offer new possibilities for collecting near-real-time high-resolution datasets from large numbers of participants. The aim of this study was to build a platform that would cater for large-scale data collection for remote monitoring initiatives. Key criteria are around scalability, extensibility, security, and privacy. Methods: RADAR-base is developed as a modular application; the backend is built on a backbone of the highly successful Confluent/Apache Kafka framework for streaming data. To facilitate scaling and ease of deployment, we use Docker containers to package the components of the platform. RADAR-base provides 2 main mobile apps for data collection, a Passive App and an Active App. Other third-Party Apps and sensors are easily integrated into the platform. Management user interfaces to support data collection and enrolment are also provided. Results: General principles of the platform components and design of RADAR-base are presented here, with examples of the types of data currently being collected from devices used in RADAR-CNS projects: Multiple Sclerosis, Epilepsy, and Depression cohorts. Conclusions: RADAR-base is a fully functional, remote data collection platform built around Confluent/Apache Kafka and provides off-the-shelf components for projects interested in collecting mHealth datasets at scale.

Yang, Jun Chang et al (2019) [Review] Electronic Skin: Recent Progress and Future Prospects for Skin-Attachable Devices for Health Monitoring, Robotics, and Prosthetics[25]

Recent progress in electronic skin or e-skin research is broadly reviewed, focusing on technologies needed in three main applications: skin-attachable electronics, robotics, and prosthetics. First, since e-skin will be exposed to prolonged stresses of various kinds and needs to be conformally adhered to irregularly shaped surfaces, materials with intrinsic stretchability and self-healing properties are of great importance. Second, tactile sensing capability such as the detection of pressure, strain, slip, force vector, and temperature are important for health monitoring in skin attachable devices, and to enable object manipulation and detection of surrounding environment for robotics and prosthetics. For skin attachable devices, chemical and electrophysiological sensing and wireless signal communication are of high significance to fully gauge the state of health of users and to ensure user comfort. For robotics and prosthetics, large-area integration on 3D surfaces in a facile and scalable manner is critical. Furthermore, new signal processing strategies using neuromorphic devices are needed to efficiently process tactile information in a parallel and low power manner. For prosthetics, neural interfacing electrodes are of high importance. These topics are discussed, focusing on progress, current challenges, and future prospects.

Bayo-Monton, Jose-Luis et al (2018) [Review] Wearable Sensors Integrated with Internet of Things for Advancing eHealth Care[26]

Health and sociological indicators alert that life expectancy is increasing, hence so are the years that patients have to live with chronic diseases and co-morbidities. With the advancement in ICT, new tools and paradigms are been explored to provide effective and efficient health care. Telemedicine and health sensors stand as indispensable tools for promoting patient engagement, self-management of diseases and assist doctors to remotely follow up patients. In this paper, we evaluate a rapid prototyping solution for information merging based on five health sensors and two low-cost ubiquitous computing components: Arduino and Raspberry Pi. Our study, which is entirely described with the purpose of reproducibility, aimed to evaluate the extent to which portable technologies are capable of integrating wearable sensors by comparing two deployment scenarios: Raspberry Pi 3 and Personal Computer. The integration is implemented using a choreography engine to transmit data from sensors to a display unit using web services and a simple communication protocol with two modes of data retrieval. Performance of the two set-ups is compared by means of the latency in the wearable data transmission and data loss. PC has a delay of 0.051 ± 0.0035 s (max = 0.2504 s), whereas the Raspberry Pi yields a delay of 0.0175 ± 0.149 s (max = 0.294 s) for N = 300. Our analysis confirms that portable devices (p < < 0 . 01) are suitable to support the transmission and analysis of biometric signals into scalable telemedicine systems.

Dunn, Jessilyn et al (2018) [Review] Wearables and the Medical Revolution[27]

Wearable sensors are already impacting healthcare and medicine by enabling health monitoring outside of the clinic and prediction of health events. This paper reviews current and prospective wearable technologies and their progress toward clinical application. We describe technologies underlying common, commercially available wearable sensors and early-stage devices and outline research, when available, to support the use of these devices in healthcare. We cover applications in the following health areas: metabolic, cardiovascular and gastrointestinal monitoring; sleep, neurology, movement disorders and mental health; maternal, pre- and neo-natal care; and pulmonary health and environmental exposures. Finally, we discuss challenges associated with the adoption of wearable sensors in the current healthcare ecosystem and discuss areas for future research and development.

Koydemir, Hatice Ceylan et al (2018) [Review] Wearable and Implantable Sensors for Biomedical Applications[28]

Mobile health technologies offer great promise for reducing healthcare costs and improving patient care. Wearable and implantable technologies are contributing to a transformation in the mobile health era in terms of improving healthcare and health outcomes and providing real-time guidance on improved health management and tracking. In this article, we review the biomedical applications of wearable and implantable medical devices and sensors, ranging from monitoring to prevention of diseases, as well as the materials used in the fabrication of these devices and the standards for wireless medical devices and mobile applications. We conclude by discussing some of the technical challenges in wearable and implantable technology and possible solutions for overcoming these difficulties.

Sonawane, Apurva et al (2017) [Review] Stability of Enzymatic Biosensors for Wearable Applications[29]

Technological evolution in wearable sensors accounts for major growth and transformation in a multitude of industries, ranging from healthcare to computing and informatics to communication and biomedical sciences. The major driver for this transformation is the new-found ability to continuously monitor and analyze the patients’ physiology in patients’ natural setting. Numerous wearable sensors are already on the market and are summarized. Most of the current technologies have focused on electrophysiological, electromechanical, or acoustic measurements. Wearable biochemical sensing devices are in their infancy. Traditional challenges in biochemical sensing such as reliability, repeatability, stability, and drift are amplified in wearable sensing systems due to variabilities in operating environment, sample/sensor handling, and motion artifacts. Enzymatic sensing technologies, due to reduced fluidic challenges, continue to be forerunners for converting into wearable sensors. This paper reviews the recent developments in wearable enzymatic sensors. The wearable sensors have been classified in three major groups based on sensor embodiment and placement relative to the human body: 1. on-body; 2. clothing/textile-based biosensors; and 3. biosensor accessories. The sensors, which come in the forms of stickers and tattoos, are categorized as on-body biosensors. The fabric-based biosensor comes in different models such as smart-shirts, socks, gloves, and smart undergarments with printed sensors for continuous monitoring.

Erdmier, Casey et al (2016) [Review] Wearable Device Implications in the Healthcare Industry[30]

This manuscript analyses the impact of wearable device technology in the healthcare industry. The authors provide an exploration of the different types of wearable technology that are becoming popular or are emerging into the consumer market and the personal health information and other user data these devices collect. The applications of wearable technology to healthcare and wellness are discussed, along with the impact of these devices on the industry. Finally, an analysis is provided, describing the current regulations in the US and UK that govern wearable devices and the impact of these device regulations on users and healthcare professionals.

Ghamari, Mohammad et al (2016) [Review] A Survey on Wireless Body Area Networks for eHealthcare Systems in Residential Environments[31]

Current progress in wearable and implanted health monitoring technologies has strong potential to alter the future of healthcare services by enabling ubiquitous monitoring of patients. A typical health monitoring system consists of a network of wearable or implanted sensors that constantly monitor physiological parameters. Collected data are relayed using existing wireless communication protocols to a base station for additional processing. This article provides researchers with information to compare the existing low-power communication technologies that can potentially support the rapid development and deployment of WBAN systems, and mainly focuses on remote monitoring of elderly or chronically ill patients in residential environments.

Khan, Yasser et al (2016) [Review] Monitoring of Vital Signs With Flexible and Wearable Medical Devices[32]

Advances in wireless technologies, low-power electronics, the Internet of things, and in the domain of connected health are driving innovations in wearable medical devices at a tremendous pace. Wearable sensor systems composed of flexible and stretchable materials have the potential to better interface to the human skin, whereas silicon-based electronics are extremely efficient in sensor data processing and transmission. Therefore, flexible and stretchable sensors combined with low-power silicon-based electronics are a viable and efficient approach for medical monitoring. Flexible medical devices designed for monitoring human vital signs, such as body temperature, heart rate, respiration rate, blood pressure, pulse oxygenation, and blood glucose have applications in both fitness monitoring and medical diagnostics. As a review of the latest development in flexible and wearable human vitals sensors, the essential components required for vitals sensors are outlined and discussed here, including the reported sensor systems, sensing mechanisms, sensor fabrication, power, and data processing requirements.

Trung, Tran Quang et al (2016) [Review] Flexible and Stretchable Physical Sensor Integrated Platforms for Wearable Human-Activity Monitoringand Personal Healthcare[33]

Flexible and stretchable physical sensors that can measure and quantify electrical signals generated by human activities are attracting a great deal of attention as they have unique characteristics, such as ultrathinness, low modulus, light weight, high flexibility, and stretchability. These flexible and stretchable physical sensors conformally attached on the surface of organs or skin can provide a new opportunity for human-activity monitoring and personal healthcare. Consequently, in recent years there has been considerable research effort devoted to the development of flexible and stretchable physical sensors to fulfill the requirements of future technology, and much progress has been achieved. Here, the most recent developments of flexible and stretchable physical sensors are described, including temperature, pressure, and strain sensors, and flexible and stretchable sensor-integrated platforms. The latest successful examples of flexible and stretchable physical sensors for the detection of temperature, pressure, and strain, as well as their novel structures, technological innovations, and challenges, are reviewed first. In the next section, recent progress regarding sensor-integrated wearable platforms is overviewed in detail. Some of the latest achievements regarding self-powered sensor-integrated wearable platform technologies are also reviewed. Further research direction and challenges are also proposed to develop a fully sensor-integrated wearable platform for monitoring human activity and personal healthcare in the near future.


[1] Kristoffersson A, Lindén M. A Systematic Review on the Use of Wearable Body Sensors for Health Monitoring: A Qualitative Synthesis. Sensors (Basel). 2020;205.:1502. Published 2020 Mar 9. doi:10.3390/s20051502

[2] Mohsin AH, Zaidan AA, Zaidan BB et al Real-Time Remote Health Monitoring Systems Using Body Sensor Information and Finger Vein Biometric Verification: A Multi-Layer Systematic Review. J Med Syst. 2018;42(12):238. Published 2018 Oct 16. doi:10.1007/s10916-018-1104-5

[3] Shuwandy ML, Zaidan BB, Zaidan AA, Albahri AS. Sensor-Based mHealth Authentication for Real-Time Remote Healthcare Monitoring System: A Multilayer Systematic Review. J Med Syst. 2019;432.:33. Published 2019 Jan 6. doi:10.1007/s10916-018-1149-5

[4] Talal M, Zaidan AA, Zaidan BB et al Smart Home-based IoT for Real-time and Secure Remote Health Monitoring of Triage and Priority System using Body Sensors: Multi-driven Systematic Review. J Med Syst. 2019;433.:42. Published 2019 Jan 15. doi:10.1007/s10916-019-1158-z

[5] Sanyal C, Stolee P, Juzwishin D, Husereau D. Economic evaluations of eHealth technologies: A systematic review. PLoS One. 2018;136.:e0198112. Published 2018 Jun 13. doi:10.1371/journal.pone.0198112

[6] Steinberg C, Philippon F, Sanchez M et al A Novel Wearable Device for Continuous Ambulatory ECG Recording: Proof of Concept and Assessment of Signal Quality. Biosensors (Basel). 2019;91.:17. Published 2019 Jan 21. doi:10.3390/bios9010017

[7] Alwashmi MF. The Use of Digital Health in the Detection and Management of COVID-19. Int J Environ Res Public Health. 2020;178.:2906. Published 2020 Apr 23. doi:10.3390/ijerph17082906

[8] Damen I, Brombacher H, Lallemand C et al A Scoping Review of Digital Tools to Reduce Sedentary Behavior or Increase Physical Activity in Knowledge Workers. Int J Environ Res Public Health. 2020;172.:499. Published 2020 Jan 13. doi:10.3390/ijerph17020499

[9] Muzny M, Henriksen A, Giordanengo A et al Wearable sensors with possibilities for data exchange: Analyzing status and needs of different actors in mobile health monitoring systems. Int J Med Inform. 2020;133:104017. doi:10.1016/j.ijmedinf.2019.104017

[10] Palanica A, Docktor MJ, Lieberman M, Fossat Y. The Need for Artificial Intelligence in Digital Therapeutics. Digit Biomark. 2020;41.:21‐25. Published 2020 Apr 8. doi:10.1159/000506861

[11] Pérez Sust P, Solans O, Fajardo JC et al Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill. 2020;62.:e19106. Published 2020 May 4. doi:10.2196/19106

[12] Tsai TH, Lin WY, Chang YS, Chang PC, Lee MY. Technology anxiety and resistance to change behavioral study of a wearable cardiac warming system using an extended TAM for older adults. PLoS One. 2020;151.:e0227270. Published 2020 Jan 13. doi:10.1371/journal.pone.0227270

[13] Xin M, Li J, Ma Z, Pan L, Shi Y. MXenes and Their Applications in Wearable Sensors. Front Chem. 2020;8:297. Published 2020 Apr 21. doi:10.3389/fchem.2020.00297

[14] Calvaresi D, Marinoni M, Dragoni AF, Hilfiker R, Schumacher M. Real-time multi-agent systems for telerehabilitation scenarios. Artif Intell Med. 2019;96:217‐231. doi:10.1016/j.artmed.2019.02.001

[15] Gu D, Li T, Wang X, Yang X, Yu Z. Visualizing the intellectual structure and evolution of electronic health and telemedicine research. Int J Med Inform. 2019;130:103947. doi:10.1016/j.ijmedinf.2019.08.007

[16] Guo J, Yang C, Dai Q, Kong L. Soft and Stretchable Polymeric Optical Waveguide-Based Sensors for Wearable and Biomedical Applications. Sensors (Basel). 2019;19(17):3771. Published 2019 Aug 30. doi:10.3390/s19173771

[17] Huzooree G, Kumar Khedo K, Joonas N. Pervasive mobile healthcare systems for chronic disease monitoring. Health Informatics J. 2019;252.:267‐291. doi:10.1177/1460458217704250

[18] Jeong YR, Lee G, Park H, Ha JS. Stretchable, Skin-Attachable Electronics with Integrated Energy Storage Devices for Biosignal Monitoring. Acc Chem Res. 2019;521.:91‐99. doi:10.1021/acs.accounts.8b00508

[19] Jeong IC, Bychkov D, Searson PC. Wearable Devices for Precision Medicine and Health State Monitoring. IEEE Trans Biomed Eng. 2019;665.:1242‐1258. doi:10.1109/TBME.2018.2871638

[20] Khan S, Ali S, Bermak A. Recent Developments in Printing Flexible and Wearable Sensing Electronics for Healthcare Applications. Sensors (Basel). 2019;195.:1230. Published 2019 Mar 11. doi:10.3390/s19051230

[21] Loncar-Turukalo T, Zdravevski E, Machado da Silva J, Chouvarda I, Trajkovik V. Literature on Wearable Technology for Connected Health: Scoping Review of Research Trends, Advances, and Barriers. J Med Internet Res. 2019;21(9):e14017. Published 2019 Sep 5. doi:10.2196/14017

[22] Majumder S, Deen MJ. Smartphone Sensors for Health Monitoring and Diagnosis. Sensors (Basel). 2019;19(9):2164. Published 2019 May 9. doi:10.3390/s19092164

[23] Olatinwo DD, Abu-Mahfouz A, Hancke G. A Survey on LPWAN Technologies in WBAN for Remote Health-Care Monitoring. Sensors (Basel). 2019;19(23):5268. Published 2019 Nov 29. doi:10.3390/s19235268

[24] Ranjan Y, Rashid Z, Stewart C et al RADAR-Base: Open Source Mobile Health Platform for Collecting, Monitoring, and Analyzing Data Using Sensors, Wearables, and Mobile Devices. JMIR Mhealth Uhealth. 2019;78.:e11734. Published 2019 Aug 1. doi:10.2196/11734

[25] Yang JC, Mun J, Kwon SY, Park S, Bao Z, Park S. Electronic Skin: Recent Progress and Future Prospects for Skin-Attachable Devices for Health Monitoring, Robotics, and Prosthetics. Adv Mater. 2019;31(48):e1904765. doi:10.1002/adma.201904765

[26] Bayo-Monton JL, Martinez-Millana A, Han W, Fernandez-Llatas C, Sun Y, Traver V. Wearable Sensors Integrated with Internet of Things for Advancing eHealth Care. Sensors (Basel). 2018;186.:1851. Published 2018 Jun 6. doi:10.3390/s18061851

[27] Dunn J, Runge R, Snyder M. Wearables and the medical revolution. Per Med. 2018;155.:429‐448. doi:10.2217/pme-2018-0044

[28] Koydemir HC, Ozcan A. Wearable and Implantable Sensors for Biomedical Applications. Annu Rev Anal Chem (Palo Alto Calif). 2018;111.:127‐146. doi:10.1146/annurev-anchem-061417-125956

[29] Sonawane A, Manickam P, Bhansali S. Stability of Enzymatic Biosensors for Wearable Applications. IEEE Rev Biomed Eng. 2017;10:174‐186. doi:10.1109/RBME.2017.2706661

[30] Erdmier C, Hatcher J, Lee M. Wearable device implications in the healthcare industry. J Med Eng Technol. 2016;404.:141‐148. doi:10.3109/03091902.2016.1153738

[31] Ghamari M, Janko B, Sherratt RS, Harwin W, Piechockic R, Soltanpur C. A Survey on Wireless Body Area Networks for eHealthcare Systems in Residential Environments. Sensors (Basel). 2016;166.:831. Published 2016 Jun 7. doi:10.3390/s16060831

[32] Khan Y, Ostfeld AE, Lochner CM, Pierre A, Arias AC. Monitoring of Vital Signs with Flexible and Wearable Medical Devices. Adv Mater. 2016;28(22):4373‐4395. doi:10.1002/adma.201504366

[33] Trung TQ, Lee NE. Flexible and Stretchable Physical Sensor Integrated Platforms for Wearable Human-Activity Monitoring and Personal Healthcare. Adv Mater. 2016;28(22):4338‐4372. doi:10.1002/adma.201504244