Healthcare 1.

0
With the evidence that the endemic disease was caused by contaminated drinking water sources,
the British Government started piping water to individual homes in 1830s. This evidence-based
measure had effectively prevented the occurrence and expansion of infectious diseases. Not long
after that and just within a few decades, the scientific basis of germ theory and vaccine
immunology was established. Vaccines become generally available and the epidemics of nasty
and dangerous infectious agents were prevented and controlled. The combined measures of
sanitation, germ controls, vaccination and epidemiology surveys had created a better
environment for a healthy life in the nineteenth century. Those were the days of healthcare 1.0 in
which major health problems were resolved with smart public health approaches.

Healthcare 2.0
The industrial machines kept running and changing. With the use of assembly lines, the concept
of mass production was introduced into the car industry in the early twentieth century to produce
cheaper products in large quantity. Big was the style of the time. The same environment grew in
healthcare. The supergiant pharmaceutical companies like Hoffmann-La Roche was formed a
few years before the end of nineteenth century. With the use of industrial mass production
technology, several antibiotics were introduced to the market just a few years later. It was at that
time that both basic science education and clinical training become equally important in medical
education. Hospitals grew bigger, serviced by more professionals, and physicians were trained
for specialties to deal with more patients and complicated conditions (e.g., Mayo Clinic became
an internationally medical center within 1890 to 1910). Mass structure was feature of the
healthcare 2.0

Healthcare 3.0
The progression went on and speeded-up. There came the microcontrollers in 1980s that allowed
manufacturing of smaller computers and facilities capable of speedy computations and large data
storage. With the fast advancing computer technology, the tomography leaped from single
images to reconstructed images, and doctors can examine the lesions with additional information
and identify the diseases earlier. Also, the internet changes the way we learn. Most medical
literatures can be downloaded from the e-libraries. This accelerated the development of
evidence-based medicine in which in the old time the investigators had to walk-in the library and
xerox-copy the papers or order them from other libraries. It is obvious that the information
technology had firmed the basis of healthcare 3.0.

The new brain and new hands in healthcare 4.0

Today, with automation and data exchange techniques, the Industrial Revolution has transformed
to its 4.0 version. Several hot topics like cyber-physical systems, internet of things, and cloud
computing always appear in newspaper and conference discussions. With these 4.0 industrial
inventions and new concepts, the healthcare has also transformed to 4.0 version - the era of smart
medicine (Fig. 1), featured by its new brain and new hands. The new brain consists of several
essential components. The precision medicine guides the treatment by using more
comprehensive molecular diagnoses, e.g., genotype, protein expression, and RNA expression.
The artificial intelligence and big data refine the diagnostic (e. g., enhance lesion boundary and
suggest diagnosis) and treatment procedures; the patients cooperate with doctors by shared
decision making. Telemedicine will make seeing or being seen easier, and of course, all these
will not happen without the internet of things. The new hands include robot, mini-laboratory,
wearable devices, customized materials and three dimensioned printing which are no longer
devices and scenes in fiction movies (Fig. 2). Moreover, every device operates faster and become
smaller; diseases can be diagnosed from a drop of blood within minutes; plates, screws and joint
implants for bone and joint surgery can be made customized, and bone scaffold can be prepared
by threedimensional printing. While most of these concepts and technologies are mature and
ready for dissemination, we still require time for artificial intelligence to become practically
useful because it needs to learn and, learn correctly. There are still rooms for all people to
negotiate and judge what are to be learnt and what are not. And, unless artificial intelligence can
be condensed into smaller devices, say, a robot that moves around or a simple home computer
without hiding in the cloud somewhere behind the investors, we can expect one or two decades
but not one or two hundred years before its take the major assisting role in medicine.

Era Tahun Agenda

1.0 1800s Public health approaches: the combined measures of

sanitation, germ controls, vaccination and epidemiology
surveys

2.0 1900s - Hoffmann-La Roche (The supergiant pharmaceutical

companies) was formed
- Industrial mass production technology → several
antibiotics were introduced to the market
- Hospitals grew bigger, serviced by more professionals,
and physicians were trained for specialties to deal with
more patients and complicated conditions
- Mayo Clinic became an internationally medical center

3.0 1980 Manufacturing of smaller computers and facilities capable

of speedy computations and large data storage → most
medical literatures can be downloaded from the e-libraries

4.0 2020 -‘Industrial Revolution’

-Several hot topics like cyber-physical systems, internet of
things, and cloud computing always appear in
newspaper and conference discussions
-The precision medicine guides the treatment by using
more comprehensive molecular diagnoses, e.g.,
genotype, protein expression, and RNA expression
 -The artificial intelligence and big data refine the
diagnostic (e. g., enhance lesion boundary and suggest
diagnosis) and treat- ment procedures; the patients
cooperate with doctors by shared decision making
-Telemedicine will make seeing or being seen easier, and
of course, all these will not happen without the internet
of things
-artificial intelligence can be condensed into robot, mini-
laboratory, wearable devices, customized materials and
three dimensional printing (Moreover, every device
operates faster and become smaller; diseases can be
diagnosed from a drop of blood within minutes; plates,
screws and joint implants for bone and joint surgery
can be made customized, and bone scaffold can be
prepared by three-dimensional printing)

5.0 Future - advance in IT enables the digitalization of

information on human biometrics and
physiological function. Utilizing these massive
data resources will generate a diverse array of new
value
- advances in biotechnology allow more-elaborate
temporal and spatial observations of biological
forms and fuctions. Advances in IT enables
analysis of life forms as complex, integrated
systems
Digitalisation in Medicine
The term Medicine 4.0 is closely related to Industry 4.0; it describes the fourth stage in the
development of medicine. Modern medicines which emerged around 150 years ago are
undergoing a digital journey with the help of robotics, internet and artificial intelligence. The
introduction of AI systems in medicine is one of the most important modern trends in world
healthcare. Modern medical treatments cannot achieve their full potential without using
advanced computing technologies. AI technologies are fundamentally changing the global
healthcare system, allowing a radical redesign of the system of medical diagnostics, the
development of new drugs, advanced analysis, testing, and treatment to enable advances in the
field of transplantation surgeries. Computational simulation using finite element analysis (FEA)
is a crucial part of the digitalisation process in medicine. FEA allows medical
engineers/industrial designers to study many inter-related concepts including, for instance,
device stability and durability (e.g., predicting end-of-life of patient-specific implants). FEA
enables modelling of stresses within a material under different thermodynamic conditions. In an
FEA model, the part is simulated and analyzed using representative physical behavior. Such an
approach demonstrates weak areas of the part, and it allows enhancement of the design.
Digitalisation and AI generally improve the quality of healthcare services while reducing costs
for medical clinics. Figure 4 highlights key technologies enabling digitalisation of medicine.
On-Demand Healthcare
According to Fox et al., consumers are increasingly using online platforms to obtain medical
information due to the following reasons:
• 47% wish to know more about their doctor.
• 38% would like to check a hospital and its medical facilities.
• 77% would prefer online medical appointments.
In the new regime of digital economy, medical professionals, just like freelance professionals,
can provide their skills, talents, and expertise directly to the patients. Several healthcare
companies provide an online marketplace that connects medical workers directly with the
required medical facilities. This results in a much more effective way to provide on-demand
medical procedures and services to consumers. In turn, healthcare workers have now become a
part of the digital healthcare industry providing patient-oriented treatments .
Telemedicine
Telemedicine is a rather modern trend that became especially popular during the COVID-19
pandemic. Such an approach enables support and care of patients in a noncrucial state.
Telemedicine minimise the number of contacts between ill patients. Moreover, such educational
support is important for chronic patients, and to prevent diseases. According to the data of John
Hopkins, before the first global lockdown in March 2020, the number of televisi. It was
approximately 50–70 per month. By May 2020, this number radically increased to 94,000.
Moreover, after healthcare services were broadly reopened, the number of monthly televisits
remained about 35,000. Technologically, this kind of telecommunication provided the direct
transmission of medical information in various formats (medical history, laboratory data, X-ray
images, CT scan results, video images, ultrasound, etc.), as well as real-time video conferencing
between medical institutions or a doctor and patients. The use of telemedicine enabled the
provision of consultative medical services in those areas where patients do not have the
opportunity to receive the help of focused specialists directly at a medical institution.
Telemedicine is of no less importance even in developed countries. With its incorporation,
treatment costs have significantly reduced, the quality of diagnostics has improved, and remote
monitoring of health has become accessible. This is especially important for elderly patients and
patients with chronic diseases. For example, St. Luke University Health Network in
Pennsylvania regularly hosts video conferencing to help elderly patients. They recognize that this
social group is less likely to use mobile applications and is more comfortable with technologies
that target desktops or laptops. According to the Global Telemedicine Market Outlook, the
global telemedicine market reached USD 56.2 billion in 2020 and is expected to reach USD
175.5 billion by 2026. The annual growth rate is about 19.2%. Patient telemonitoring accounts
for the main share of 32–48% of the world market. The leading countries in terms of spending on
telemedicine and the development of the telemedicine technology market are China and the
United States.

Social Robots
Robotics has made it possible to introduce social robots (SRs) in both remote rehabilitation and
assistance as a valid support in several sectors both as a direct and practical support and as a
mediator. The SR also stands as one of the key tools in rehabilitation through robotics as
highlighted in the special issue Rehabilitation and Robotics: Are They Working Well Together? ,
of which this study aims to be a part. It is natural that with this evolution, it is important to reflect
on new professional figures or at least on the remodeling of already existing professional figures.
One of the key figures in physical rehabilitation and assistance is that of the physiotherapist, who
stands between the physician of physical medicine and rehabilitation and the patient, entering
with greater contact with the patient. New models of care emerged, during the COVID-19
pandemic, based on technologies that allow greater social distancing between the patient and the
therapist. Based on this, an expansion of the job description of many figures involved in
rehabilitation and assistance is emerging. This is closely related to the remodeling of the work-
flow that SRs have the potential to modify. Changes in the work-flow have a direct impact on the
job description of the worker and therefore on the tasks he or she must perform, which are
regulated by operational prescriptions in the workplace. Among the figures involved in this
change and expansion of the job description, we find the figure of the physiotherapist. Regarding
the figure of the physiotherapist, since the COVID-19 pandemic, it is preferred that when we
mention a therapist with extended tasks toward digital in person or remotely (for example in
remote therapy), we refer to the augmented physiotherapist (APT) or digital physiotherapist
(DPT). This figure must be rethought starting from the new interaction tasks emerging in the
COVID-19 era with the looming social distancing. Furthermore, the physical and rehabilitative
medicine sector is moving in this direction. For some years now, there has been talk of new
forms of therapy delivery in this area in virtual mode through remote digital communication or
using new tools such as the SRs. For example, Alam Le has focused on this and analyzed the
critical issues highlighted in the current pandemic and the previous pandemic experiences,
analyzed the changes already requested by some key figures of the health system in relation to
technologies due to new intervention models consolidated during the current epidemic, and
reported some consensus studies on digital rehabilitation focused around the new figure of the
DPT without forgetting the ethical and curricular aspects.

SRs are bursting into health systems and playing a key role in many sectors, including
rehabilitation [2]. The recent pandemic has accelerated this process [1]. It is foreseeable that in
the coming years, many professionals in the health sector will have to deal with these devices
through new working models based on SRs [26,27]. These systems involve and will involve
figures who have to do with the elderly [6–9], frail, and handicapped individuals with motor and
communication problems [10–15]. These systems involve and will involve figures who have to
do with the elderly, frail, and handicapped individuals with motor and communication problems.
Physiotherapists are certainly among the key figures, and recently, and in the pandemic period,
they have had to deal more and more with digitization processes [5]. In this study, we focused on
the figure of the physiotherapist, and we prepared a survey focused on the consensus and opinion
of the use of this device. This study involved submitting an electronic survey on two statistically
independent samples to collect and analyze the data automatically. The survey showed a
consistency of the results on the investigated sample from which interesting considerations
emerge. Contrary to stereotypes that report how AI-based devices put jobs at risk;
physiotherapists are not afraid of these devices. Physiotherapists believe that SRs can be reliable
co-workers who do not judge. They believe that yes, SRs have weaknesses such as the lack of
empathy and they risk creating false relationships, but they also believe that artificial intelligence
on the one hand and wise professional use on the other will help overcome these limits.
Physiotherapists also believe that SRs will remain a complementary tool and that their role will
be of the utmost importance as an operational manager of its use and in performance monitoring.
These professionals also believe that the device will allow an increase in working capacity and
facilitate integration with other professionals. All those involved in the study believe that the
proposed electronic survey has proved to be a useful and effective tool that allows an
instantaneous creation of virtual focus groups. They believe in this tool and believe that it can be
useful as a periodic monitoring tool and useful for scientific societies.

References:
1. Chen C, Loh EW, Kuo KN, Tam KW. The Times they Are a-Changin' - Healthcare 4.0 Is
Coming! J Med Syst. 2019 Dec 23;44(2):40. doi: 10.1007/s10916-019-1513-0. PMID:
31867697.
2. Popov VV, Kudryavtseva EV, Kumar Katiyar N, Shishkin A, Stepanov SI, Goel S.
Industry 4.0 and digitalisation in healthcare. Materials. 2022 Mar 14;15(6):2140.
3. Simeoni R, Colonnelli F, Eutizi V, Marchetti M, Paolini E, Papalini V, Punturo A, Salvò
A, Scipinotti N, Serpente C, Barbini E. The Social Robot and the Digital Physiotherapist:
Are We Ready for the Team Play?. InHealthcare 2021 Oct 27 (Vol. 9, No. 11, p. 1454).
MDPI.