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DIGITAL HEALTH

Wearable Technology Applications in Healthcare: A

Literature Review
by Min Wu, PhD and Jake Luo, PhD; Online Journal of Nursing Informatics Contributors

Abstract
Wearable technologies can be innovative solutions for healthcare
problems. In this study, we conducted a literature review of wearable
technology applications in healthcare. Some wearable technology
applications are designed for prevention of diseases and maintenance
of health, such as weight control and physical activity monitoring.
Wearable devices are also used for patient management and disease
management. The wearable applications can directly impact clinical
decision making. Some believe that wearable technologies could
improve the quality of patient care while reducing the cost of care,
such as patient rehabilitation outside of hospitals. The big data
generated by wearable devices is both a challenge and opportunity for
researchers who can apply more artificial intelligence (AI) techniques
on these data in the future. Most wearable technologies are still in
their prototype stages. Issues such as user acceptance, security,
ethics and big data concerns in wearable technology still need to be
addressed to enhance the usability and functions of these devices for
practical use.

Introduction
Wearable technologies enable the continuous monitoring of human
physical activities and behaviors, as well as physiological and
biochemical parameters during daily life. The most commonly
measured data include vital signs such as heart rate, blood pressure,
and body temperature, as well as blood oxygen saturation, posture,
and physical activities through the use of electrocardiogram (ECG),
ballistocardiogram (BCG) and other devices. Potentially, wearable
photo or video devices could provide additional clinical information.
Wearable devices can be attached to shoes, eyeglasses, earrings,
clothing, gloves and watches. Wearable devices also may evolve to
be skin-attachable devices. Sensors can be embedded into the
environment, such as chairs, car seats and mattresses. A
smartphone is typically used to collect information and transmit it to a
remote server for storage and analysis. There are two major types of
wearable devices that are used for studying gait patterns. Some
devices have been developed for healthcare professionals to monitor
walking patterns, including the accelerometer, multi-angle video
recorders, and gyroscopes. Other devices have been developed for
health consumers, including on-wrist activity trackers (such as Fitbit)
and mobile phone apps and add-ons. Wearable devices and data
analysis algorithms are often used together to perform gait
assessment tasks in different scenarios.

Wearable technologies can be innovative solutions for healthcare

problems. In this study, we conducted a literature review of wearable
technology applications in healthcare. Some wearable technology
applications are designed for the prevention of diseases and
maintenance of health, such as weight control and physical activity
monitoring. Wearable devices are also used for patient management
and disease management. The wearable applications can directly
impact clinical decision-making. Some believe that wearable
technologies could improve the quality of patient care while reducing
the cost of care, such as patient rehabilitation outside of hospitals. The
big data generated by wearable devices is both a challenge and
opportunity for researchers who can apply more AI techniques on that
data in the future.

A search in the PUBMED databases was performed in September

2018. All papers containing the terms “wearable technologies” or
“wearable devices” in the title or abstract were identified. In addition,
the search was limited to articles whose publication dates were within
10 years (from 2008 to 2018). The abstracts of these studies (n=1126)
were then inspected to ascertain whether they contained information
about the “wearable technology applications in healthcare.” The
authors then reviewed those studies for information regarding
wearable device applications and identified 67 relevant papers.

Results
To summarize the results of the literature review, the wearable
technology applications are grouped into three categories based on
their roles. For example, wearable devices designed for weight
control and physical activity monitoring are listed in the section
of prevention of diseases and maintenance of health. In addition,
there are sections of patient management and disease
management.

Prevention of Diseases and Maintenance of Health

Fall Identification and Prevention
In many countries, providing care to an aging population has become
a significant challenge. For example, the number of Americans 65 and
older will grow from about 49 million in 2018 to approximately 100
million in 2060 (Vespa, Armstrong, & Medina, 2018 ). The World
Health Organization expects that the global elderly population 60 or
older will rise to 2 billion by 2050 (World Health Organization (WHO),
2015). The aging population has increased risks for chronic
conditions, falls, disabilities and other adverse health outcomes
(Ambrose, Paul, & Hausdorff, 2013 ). Providing preventive
interventions to the aged population to improve health outcomes has
become an important research and development topic. Wearable
devices could be used to address some of the challenges related to
detecting and managing adverse health conditions in aging
populations. Wearable devices have great potential to be used in fall
prevention among older adults. Falls occur in 30% to 60% of older
adults each year, and 10% to 20% result in injury, hospitalization or
death (Rubenstein, 2006 ). For the elderly people in the USA, falls
lead to four to 12 days of hospital stay per fall (Bouldin et al., 2013 ).
Recent studies have focused on developing wearable devices and
associated algorithms to collect and analyze gait (manner of walking)
data for fall prevention (Awais et al., 2016 ).

In research settings, the performance of fall detection using wearable

devices has already achieved considerable good results. For example,
one study developed a solution to recognize walking and activities
(González et al., 2015 ). The study used a genetic algorithm and two
triaxle accelerometer bracelets to detect walking patterns that could
lead to disruptive events, such as falling and seizure onset. Pannurat,
Thiemjarus, & Nantajeewarawat (2017 ) presented a method to
detect a fall at different phases using a wireless accelerometer and
classification algorithms. Their evaluation results showed an 86% and
91% accuracy for fall pre-impact and post-impact detection. Hsieh,
Liu, Huang, Chu, & Chan (2017 ) developed a novel hierarchical fall
detection system using accelerometer devices on the waist. The
results showed that the system achieved a high accuracy at 99% in
identifying fall events. Similarly, Gibson, Amira, Ramzan, Casaseca-
de-la-Higuera, & Pervez (2017 ) presented a fall detection system
using a database of fall and daily activities. Their method used the
Shimmer biomedical device on the chest to collect data. The detection
signals were extracted using compress sensing and principal
component analysis techniques. The obtained binary tree classifiers
achieved 99% precision in identifying fall events. These studies were
performed in research laboratory settings. A recent study (Awais et
al., 2016) compared and evaluated the performance of wearable
sensors in classifying physical activities for older adults in real-life and
in-lab scenarios. This study found that systems developed in a
controlled lab setting might not be able to perform well in real-life
conditions. Therefore, new systems should be tested in real-life
conditions.

Physical Activity and Interaction Monitoring

Prolonged sedentary behavior is associated with many adverse health
outcomes. To investigate whether reminders could change student
posture and positively influence their wellbeing, Frank, Jacobs, &
McLoone (2017 ) designed wearable device-based system to monitor
student activities. Vibration reminders were sent through the wearable
devices after 20 minutes of sitting. The results show that the strategy
was effective in changing student behavior, although the health effects
of this change were inconclusive.

Choo, Dettman, Dowell, & Cowan (2017 ) evaluated the effectiveness

of using wearable devices and smartphones for tracking language
patterns. The study conducted a Language Environment Analysis
(LENA) using a language-tracking wearable device to collect mother-
child communication data. The collected data were used to provide
feedback to mothers about the communication pattern. The after-study
evaluation showed that mothers had a positive response to the device
and felt that the communication data collected by the wearable device
provided useful information to improve mother-child communication.

Mental Status Monitoring

Developing wearable devices and algorithms to monitor mental
conditions is a relatively new domain. Some wearable devices are
equipped with sensors that can detect human physiology status, such
as heartbeat, blood pressure, body temperature, or other complex vital
signs (e.g. electrocardiograms). Using these signals, new systems can
be developed to monitor mental conditions. Stress detection is the
most common application of such systems.
To detect stress patterns of children, Choi, Jeon, Wang, & Kim
(2017) proposed a framework using wearable devices and machine
learning-based techniques. The wearable devices collected both audio
and heart rate signals for stress detection. The framework has a
potential to be used to remotely monitor child safety through stress
patterns. The study results showed that by combining audio and heart
rate signals, the system had a better performance in fighting noise
signals when compared with audio-only methods. Support Vector
Machine (SVM) is one machine learning method. The accuracy of the
best algorithm (SVM+Wrapper) is 93.47%. A study by Setz and
colleagues (2010 ) showed that even simple electrodermal activity
(EDA) sensors have the capacity to identify stress level. An EDA
sensor can measure skin conductance, which usually is correlated
with the stress level of a person. They described how a Swiss team
developed an EDA-based system called Emotion Board. The system
can collect and measure skin conductance signals. The collected
signals were processed using linear discriminant analysis (LDA) and
an SVM-based classifier was used to detect stress. The evaluation on
33 subjects showed that the maximum accuracy was 82.8%.

Sports Medicine
Wearable devices can help athletes or coaches to systematically
manage athletic training and matches. For example, Skazalski,
Whiteley, Hansen, & Bahr (2018 ) used commercially available
wearable devices as a valid and reliable method to monitor the jump
load of elite volleyball players and to measure jump-specific training
and competition load in the players’ jumps. The results of this study
also indicate that the devices showed excellent jump height detection
capacities. The wearable devices can monitor functional movements,
workloads, heart rate, etc., so they may be more widely used in sport
medicine to maximize performance and minimize injury.
Chen, Lin, Lan, & Hsu (2018 ) developed a method to monitor and
detect heat stroke. Heat stroke can harm people when they are doing
exercises in hot temperatures. The team proposed a fuzzy logic-based
method for inferencing signals collected from multiple wearable
devices, environmental temperatures and humidity sensors. The
experimental results showed that the system can be used to monitor
heat stroke risk and alert users.

Weight Control and Monitoring

Tracking physical activities using wearable devices has become a
popular method to help people assess activity intensity and calories
expended. There is a growing interest among health consumers to
use wearable devices, especially consumer wearable devices, to track
weight control activities and outcomes. A study by Dooley,
Golaszewski, & Bartholomew (2017 ) compared and validated three
major consumer devices for measuring exercise intensities. The study
devices included Fitbit Charge HR, Apple Watch, and Garmin
Forerunner 225. The project enrolled 62 participants aged 18-38 and
measured their heart rates and energy expenditures using all three
devices. A hypothetical ideal "gold standard" test had a sensitivity of
100% and a specificity of 100%. The study showed a high magnitude
of errors across all devices when compared to the gold standard. This
study indicated that these devices might be useful as a stimulus to
increase activity, but they have limitations as a tracking and outcome
measurement method.

Although there are studies that show that wearable devices can be
used as a stimulus mechanism to increase user activities, there is still
a lack of evidence-based studies to validate the use of wearable
device for the outcome of weight loss. A recent randomized clinical
trial was conducted in Korea to examine the effectiveness of using
wearable devices and smartphones to reduce childhood obesity (Yang
et al., 2017). The project aimed to enroll a thousand 5th- and 6th-
grade students to assess a wearable device-based intervention
system called “Happy Me.” The outcome measures of the trial were
behavioral changes (e.g. physical activity, healthy eating) and
anthropometric changes (e.g. body weight, body mass index, waist
circumference). The results of the study attempted to provide scientific
evidence for the effectiveness of using a wearable device system for
weight control.

Public Education
Medical and healthcare education is rapidly changing and is
influenced by many factors including the changing healthcare
environment, the changing role of health professionals, altered
societal expectations, rapidly changing medical science, and the
diversity of pedagogical techniques. Technologies such as podcasts
and videos with flipped classrooms, mobile devices with apps, video
games, simulations (part-time trainers, integrated simulators, virtual
reality), and wearable devices (google glass) are some of the
techniques available to address the changing educational
environment. These technologies should also be used to educate the
public about health-related topics.

Patient Management
Wearable technology can also improve patient management efficiency
in hospitals. Researchers hope to use wearable technology for the
early detection of health imbalances. Wireless communication in
wearable techniques enable researchers to design a new breed of
point-of-care (POC) diagnostic devices (Ghafar-Zadeh, 2015 ). For
example, garments integrated with wearable solutions, such as
commercial portable sensors and devices in the emergency medical
services (EMS), emergency room (ER) or intensive care unit (ICU)
environments, have facilitated the continuous monitoring of risks that
endanger patient lives. The system enables detection of patient
health-state parameters (heart rate, breathing rate, body temperature,
blood oxygen saturation, position, activity and posture) and
environmental variables (external temperature, presence of toxic
gases, and heat flux passing through the garments) to process data
and remotely transmit useful information to healthcare providers
(Curone et al., 2010 ).

Wireless wearable devices have supported mobility in patients.

Activity monitoring is used to manage chronic conditions of patients
(Chiauzzi, Rodarte, & DasMahapatra, 2015 ). Wearable device
activity tracking abilities provide a mechanism to allow health
consumers to enhance their self-management capacities. Many health
consumers are already tracking their weight, diet, or health routines in
some way. Wearable devices further improve the self-tracking ability
by providing sensor data as objective evidence.

Cancer Survivors
Endometrial cancer survivors are the least physically active of all
cancer survivor groups and exhibit up to 70% obesity (Basen-
Engquist et al., 2009 ) , but lifestyle interventions can result in
improved health outcomes. A study was conducted to evaluate the
acceptability and validity of the Fitbit Alta™ physical activity monitor
for sociocultural diverse endometrial cancer survivors (Rossi et al.,
2018). The study found that the Fitbits were well accepted by 25
participants and the physical activity data indicated an insufficiently
active population. Physical inactivity and sedentary behavior are
common amongst breast cancer survivors. Another study used
wearable activity trackers (WATs) as behavioral interventions to
increase physical activity and reduce sedentary behavior within this
population (Nguyen et al., 2017 ). They found that wearable technique
programs have the potential to provide effective, intensive, home-
based rehabilitation.

Patients with Stroke

Stroke, predominantly a condition of advanced age, is a major cause
of acquired disability in the global population. Conventional treatment
paradigms in intensive therapy are expensive and sometimes not
feasible because of social and environmental factors. Researchers
used wearable sensors to monitor activity and provide feedback to
patients and therapists. In a study by Burridge and colleagues (2017),
the researchers developed a wearable device with embedded inertial
and mechanomyographic sensors, algorithms to classify functional
movement, and a graphical user interface to present meaningful data
to patients to support a home exercise program.

Patients with Brain and Spinal Cord Injuries

Patients with brain and spinal cord injuries need exercises to improve
motor recovery. Often, these patients are not qualified to monitor or
assess their own conditions and they need healthcare provider
guidance. Therefore, there is a need to transmit physiological data to
clinicians from patients in their home environment. Researchers like
Burns and Adeli (2017) are doing just that, by reviewing wearable
technology for in-home health monitoring, assessment and
rehabilitation of patients with brain and spinal cord injuries.

Chronic Pulmonary Patients

As a chronic illness, chronic obstructive pulmonary disease typically
worsens over time, so extensive, long-term pulmonary rehabilitation
exercises and patient management are required. A group of
researchers designed a remote rehabilitation system for a multimodal
sensors-based application for patients who have chronic breathing
difficulties (Tey, An, & Chung, 2017 ). The system included a set of
rehabilitation exercises specific for pulmonary patients, and provided
exercise tracking progress, patient performance, exercise
assignments, and exercise guidance. Patients in the study could
receive accurate pulmonary exercises guidance from the sensory
data. Further evaluation studies are needed to verify if the proposed
remote system can provide a comfortable and cost-effective option in
the healthcare rehabilitation system.

Disease Management
Significant progress in the development of wearable device systems
for healthcare applications has been made in the past decade.
Wearable technology can make disease management more effective
as outlined below.

Heart Disorders
Wearable devices have been developed to do cardiovascular
monitoring and enable mHealth applications in cardiac patients. Low-
power wearable ECG monitoring systems have been developed
(Winokur, Delano, & Sodini, 2013 ). Some wearable devices can
monitor heart rate variability (HRV). In a study, a wearable patch-style
heart activity monitoring system (HAMS) was developed for recording
the ECG signal (Yang et al., 2008 ). The wearable devices can be
used efficiently as health monitoring system during daily routines in
many places and situations.

Wearable technology can assess patient heart activity outside of a

laboratory or clinical environment. It is possible to perform heart
assessments during a wide range of everyday conditions without
interfering with a patient's activity tasks. For example, researchers
designed a textile-based wearable device for the unobtrusive
recording of ECG, respiration and accelerometric data and to assess
the 3D sternal seismocardiogram (SCG) in daily life. Researchers also
designed a portable and continuous ballistocardiogram (BCG) monitor
that is wearable in the ear (Da He, Winokur, & Sodini, 2012 ). The ear
devices can reveal important information about cardiac contractility
and its regulation.

The wearable cardioverter defibrillator (WCD) was introduced into

clinical practice in 2001, and indications for its use are currently
expanding. The WCD represents an alternative approach to prevent
sudden arrhythmic death until either Implantable Cardioverter
Defibrillator (ICD) implantation is clearly indicated, or the arrhythmic
risk is considered significantly lower or even absent (Klein et al.,
2010).

Hernandez-Silveira and colleagues (2015 ) studied the feasibility of

using a wireless digital watch as a wearable surveillance system for
monitoring the vital signs of patients. The researchers compared the
wearable system with traditional clinical monitors. The results showed
that the tested wearable device provided reliable heart rate value for
about 80% of the patients and the overall agreement between the new
device and clinical monitor was satisfactory because the comparison
was statistically significant. A similar study by Kroll, Boyd, & Maslove
(2016) showed that a wrist-worn personal fitness tracker device can
be used to monitor the heart rate of patients even though the collected
heart rates were slightly lower than the standard of continuous
electrocardiographic (cECG) monitoring.

As well, heat stroke can be potentially damaging for people while

exercising in hot environments. To prevent this dangerous situation, a
researcher designed a wearable heat-stroke-detection device (WHDD)
with early notification ability. If a dangerous situation was detected, the
device activated the alert function to remind the user to avoid heat
stroke (Chen et al., 2018 ).

Blood Disorders
Wearable trackers have drawn interest from health professionals
studying blood disorders. Overall, the U.S. prevalence of hypertension
among adults was 29.0% during 2015–2016 (Fryar, Ostchega, Hales,
Zhang, & Kruszon-Moran, 2017 ). Wearable devices can detect
hypertension with physiological signals (Ghosh, Torres, Danieli, &
Riccardi, 2015 ). Some of the most widely used wearable devices are
applications for evaluating and monitoring blood pressure, including
cuff-less blood pressure sensors, wireless smartphone-enabled upper
arm blood pressure monitors, mobile applications, and remote
monitoring technologies. They have the potential to improve
hypertension control and medication adherence through easier
logging of repeated blood pressure measurements, better connectivity
with health-care providers, and medication reminder alerts (Goldberg
& Levy, 2016 ).

The study of blood flow is called hemodynamics. Patients with

orthostatic hypotension have pathologic hemodynamics related to
changes in body posture. Researchers designed a new cephalic laser
blood flowmeter that can be worn on the tragus to investigate
hemodynamics upon rising from a sitting or squatting posture. This
new wearable cerebral blood flow (CBF) meter is potentially useful for
estimating cephalic hemodynamics and objectively diagnosing
cerebral ischemic symptoms of patients in a standing posture
(Fujikawa et al., 2009 ). In another study, researchers detected site-
specific blood flow variations in people while running, using a
wearable laser doppler flowmeter (Iwasaki et al., 2015 ).
Diabetes Care Management
Patients and healthcare providers need to track many factors that
influence blood glucose dynamics (e.g., medication, activity, diet,
stress, sleep quality, hormones, and environment) to effectively
manage diabetes. Recent consumer technologies are helping the
diabetic community to take great strides toward truly personalized,
real-time, data-driven management of this chronic disease
(Heintzman, 2016 ). These consumer technologies include
smartphone apps, wearable devices and sensors. One well-known
example is the wearable artificial endocrine pancreas for diabetes
management, which is a closed-loop system formed by a wearable
glucose monitor and an implanted insulin pump (Dudde, Vering,
Piechotta, & Hintsche, 2006 ). Closed-loop control (CLC) for the
management of type 1 diabetes (T1D) is a novel method for optimizing
glucose control. More studies of CLC were conducted recently. For
example, overnight CLC improved glycemic control in a multicenter
study of adults with type 1 diabetes (Brown et al., 2017 ). Researchers
also explored the possibilities of using Google Glass to simplify the
daily life of people with diabetes mellitus (Hetterich, Pobiruchin,
Wiesner, & Pfeifer, 2014 ).

With the increasing cost of healthcare, wearable devices and systems

could have potential to facilitate self-care through monitoring and
prevention. For instance, a wearable bioelectronic technology was
developed to provide non-invasive monitoring of sweat-based glucose
level (Lee et al., 2017 ).

Parkinson’s Disease
To manage Parkinson’s disease, wearable devices offer huge
potential to collect rich sources of data that provide insights into the
diagnosis and the effects of treatment interventions. Ten-second
whole-hand-grasp action is widely used to assess bradykinesia
severity, since bradykinesia is one of the primary symptoms of
Parkinson's disease. Researchers developed a wearable device to
assess the severity of the Parkinsonian bradykinesia (Lin, Dai,
Xiong, Xia, & Horng, 2017 ). Many assessments of dyskinesia
severity in Parkinson's disease patients are subjective and do not
provide long-term monitoring. In another study an objective dyskinesia
score was developed using a motion capture system to collect patient
kinematic data (Delrobaei, Baktash, Gilmore, McIsaac, & Jog,
2017). The portable wearable technology can be used remotely to
monitor the full-body severity of dyskinesia, necessary for therapeutic
optimization, especially in the patients’ home environment.
The Parkinson@home study (de Lima et al., 2017 ) showed the
feasibility of collecting objective data using multiple wearable sensors
during daily life in a large cohort.

Autism
It is important for autistic children to recognize and classify their
emotions, such as anger, disgust, fear, happiness, sadness and
surprise. Daniels and colleagues (2018) conducted a project that used
Google Glass to study the feasibility of a prototype therapeutic tool for
children with autism spectrum disorder (ASD) to see if the children
would wear such a device. The feasibility study supported the utility of
a wearable device for social affective learning in ASD children and
demonstrated subtle differences in how ASD affected neurotypical
controls children perform on an emotion recognition task.

Depression
Wearable technology can also assist with the screening, diagnosis
and monitoring of psychiatric disorders, such as depression. The
analysis of cognitive and autonomic responses to emotionally relevant
stimuli could provide a viable solution for the automatic recognition of
different mood states, both in normal and pathological conditions.
Researchers explored a system based on wearable textile technology
and instantaneous nonlinear heart rate variability assessment to
characterize the autonomic status of bipolar patients (Valenza et al.,
2015). In another study, a wearable depression monitoring system
was proposed with an application-specific system-on-chip (SoC)
solution. The system accelerated the filtering and feature extraction of
heart-rate variability (HRV) from an electrocardiogram (ECG) (Roh,
Hong, & Yoo, 2014 ) to improve the accuracy of successfully
recognizing depression.

Discussion
Most wearable technologies are still in their prototype stages. Issues
such as user acceptance, security, ethics, and big data concerns in
wearable technology still need to be addressed to enhance the
usability and functions of these devices for practical use.

User Acceptance
User preferences need to be considered to design devices that will
gain acceptance both in a clinical and home setting. Sensor systems
become redundant if patients or clinicians do not want to work with
them. A body-worn sensor system should be compact, embedded and
simple to operate and maintain. It also should not affect daily
behavior, nor seek to directly replace a healthcare professional. It
became apparent that despite the importance of user preferences,
there is a lack of high-quality studies in this area. Researchers should
be encouraged to focus on the implications of user preferences when
designing wearable sensor systems. These issues become
increasingly important if they seek to obtain measurements over
longer time periods, for example, in monitoring chronic diseases, or
during activity levels where the data collection is essential but not
necessarily lifesaving (Bergmann & McGregor, 2011 ).

One concern about older adult use of wearable device applications is

their acceptance and interest in using consumer-wearable devices for
personal health purposes. A recent review by Kekade and colleagues
(2018) of 31 studies shows that more than 60% of elderly people were
interested in the future use of a wearable device for improving
physical and mental health. However, not many elderly people were
currently using wearable devices because generally there is a lack of
awareness among the older generations. The study showed that
wearable devices should be tested to determine if they meet the
needs of elderly people, especially sick and female participant groups
(Kekade et al., 2018). The study also indicated that older populations
could benefit from using wearable devices; however, more work
should be done to increase the awareness of the technology use.

Security
Patient confidentiality and data security are major concerns when
using wearable devices since it can be challenging to ensure
compliance with HIPAA regulations. The communication security of
the collected data in Wireless Body Area Networks (WBAN) is a major
concern (Ali & Khan, 2015 ). Encryption is a key element of
comprehensive data-centric security. Encrypted data and the use of
encryption as an authentication mechanism within an organization's
network is generally trusted, but direct access to keys and certificates
allows anyone to gain elevated privileges. Key management is vital to
security strength. The dependability of cryptographic schemes for key
management has become an important aspect of this security.
However, the extremely constrained nature of biosensors has made
designing key management schemes a challenging task. For this
reason, many lightweight key management schemes have been
proposed to overcome these constraints. Because the physiological
data are transmitted over the WiFi, there is a need for secure WBAN
communications to prevent eavesdropping and the interrupting of
personal information. This security can be achieved by using a
cryptographic scheme to ensure basic security services like
confidentiality, integrity and authenticity. However, most cryptographic
schemes require secret keys. Because the security of these
cryptographic schemes depends upon the keys, there is a need for
secure key agreement and distribution among the nodes in the
network. Security must be evaluated based on the stringent HIPAA
principles for information privacy and security.

Ethical Issues
Mobile technology is increasingly being used to measure individuals'
moods, thoughts and behaviors in real time. Current examples include
the use of smartphones to collect ecological momentary assessments
(EMA); wearable technology to passively collect objective measures of
participants' movement, physical activity, sleep, and physiological
response; and smartphones and wearable devices with global
positioning system (GPS) capabilities to collect precise information
about where participants spend their time. Although advances in
mobile technology offer exciting opportunities for measuring and
modeling individuals' experiences in their natural environments, they
also introduce new ethical issues. A study by Roy (2017) in Chicago
discussed ethical challenges specific to the methodology (e.g.,
unanticipated access to personal information) and broader concerns
related to data conceptualization and interpretation (e.g., the ethics of
"monitoring" low-income youth of color). Lessons can be learned from
the collection of GPS coordinates and EMAs done in this study to
measure mood, companionship and health-risk behavior with a
sample of low-income, predominantly racial/ethnic minority youth living
in Chicago area. While Roy (2017) encouraged researchers to
embrace innovations offered by mobile technology, the discussion
highlighted some of the many ethical issues that also need to be
considered in the process.

Big Data
Wearable devices may collect very large amounts of personal data
due to their capacity for continuous data recording at high frequencies
coupled with potential large population use. The collected data fits into
the big data domain by meeting the four “V” characteristics (volume,
variety, veracity, velocity) of big data. Because wearable devices can
collect highly personalized data among large populations, the
collected information not only could be used to improve personalized
intervention, but also used for population pattern discovery.
Researchers in nursing science explored new ways of symptom
science research in the era of big data (Corwin, Jones, & Dunlop,
2019) . They reviewed the concepts of an interdisciplinary approach
and team science, as well as their benefits and challenges.

With significant growth of the internet, mobile devices and cloud

computing, the Wearable Internet of Things (Wearable IoT) has
become an emergent topic of research and applications (Hiremath,
Yang, & Mankodiya, 2014 ). A network of sensors will generate even
more complex and larger data sets. Such data also creates new
opportunities, such as the development of IoT sensing-based health
monitoring and management (Hassanalieragh et al., 2015 ),
generating new models to define human behavior (Paul, Ahmad,
Rathore, & Jabbar, 2016 ), analyzing connection communities (Sun,
Song, Jara, & Bie, 2016 ), and developing new mobile health
applications (Lv, Chirivella, & Gagliardo, 2016 ).
For example, in blood transfusions, big data have been used for
benchmarking, detecting transfusion-related complications,
determining patterns of blood use, and defining blood order schedules
for surgery. More generally, rapidly available information can monitor
compliance with key performance indicators for patient blood
management and inventory management leading to better patient care
and reduced use of blood (Pendry, 2015 ).

Integrating multimodal and multiscale big health data from wearable

sensors is a great challenge since heterogeneous data need to be
processed to generate unified and meaningful conclusions for clinical
diagnosis and treatment. Health data accompanied with a large
amount of noisy, irrelevant and redundant information also give
spurious signals in clinical decision support systems (Zheng et al.,
2014).

Future Trends
Interoperability
There is further work required regarding interoperability challenges.
For example, the fifth generation of wireless networking technology
(5G) enables us to connect many times more hospital devices to the
network at once and to gain remote access at home. Australia’s
Commonwealth Scientific and Industrial Research Organization
(CSIRO) developed a project called the Hospital Without Walls, which
aimed to provide continuous monitoring of patients in certain
diagnostic categories (Wilson et al., 2000 ). The key technology used
was a miniature, wearable, low-power radio that could transmit vital
signs and activity information to a home computer, and data was sent
by telephone line and the Internet to appropriate medical
professionals. The initial clinical scenario for this work was monitoring
elderly patients who had presented to hospitals following repeated
falls. Accelerometers built into the radio sets monitored activity and
detected and characterized falls. Simultaneous measurement of heart
rate also provided information about abnormalities of cardiovascular
physiology at the time of a fall. It is believed that with these future
developments, unobtrusive and wearable devices could advance
health informatics, lead to fundamental changes of how healthcare is
provided, and help to reform underfunded and overstretched
healthcare systems.

New Devices
Hemoglobin is a red protein responsible for transporting oxygen in the
blood. Wearable technologies provide portable, noninvasive point-of-
care ways to measure hemoglobin concentration. The wearable
devices have the potential to increase the quality of care.
Unfortunately, a study showed that widely available noninvasive point-
of-care hemoglobin monitoring devices were systematically biased
and too unreliable to guide transfusion decisions (Gayat et al., 2011 ).
Wearable devices with better accuracy are needed. For future
development, wearable devices should also play a role in disease
intervention through integration with actuators that are implanted
inside/on the body. New wearable drug delivery systems for blood
pressure management are likely to be developed in the future.

AI
The advancement of wearable technology and the possibilities of
using AI in healthcare is a concept that has been investigated by
many studies. The availability of the smartphone and wearable sensor
technology are leading to a rapid accumulation of human subject data,
and machine learning is emerging as a technique to map those data
into clinical predictions.
For instance, seizure prediction can increase independence and allow
preventative treatment for patients with epilepsy. A study by Kiral-
Kornek and colleagues (2018 ) presented a proof-of-concept for a
seizure prediction system that would be accurate, fully automated,
patient-specific, and tunable to an individual's needs. A deep learning
classifier was trained to distinguish between preictal and interictal
signals. This study demonstrated that deep learning in combination
with neuromorphic hardware can provide the basis for a wearable,
real-time, always-on, patient-specific seizure warning system with low
power consumption and reliable long-term performance.

Another study aimed to automatically score Parkinsonian tremors by

proposing machine-learning algorithms to predict the Unified
Parkinson's Disease Rating Scale (UPDRS) (Jeon et al., 2017 ). In
this study, the tremor signals of 85 patients with Parkinson's disease
(PD) were measured using a wrist-watch-type wearable device
consisting of an accelerometer and a gyroscope. Nineteen features
were extracted from each signal, and the pairwise correlation strategy
was used to reduce the number of feature dimensions. With the
selected features, a decision tree (DT), support vector machine
(SVM), discriminant analysis (DA), random forest (RF), and k-nearest-
neighbor (kNN) algorithm were explored for automatic scoring of the
Parkinsonian tremor severity. The performance of the employed
classifiers was analyzed using accuracy, recall and precision and was
compared to findings in similar studies.

As machine-learning algorithms are increasingly used to support

clinical decision-making, reliably quantifying their prediction accuracy
is vital. Inaccurate results can mislead both clinicians and data
scientists. Cross-validation (CV) is the standard approach where the
accuracy of such algorithms is evaluated on a part of the data the
algorithm has not seen during training. A study compared two popular
CV methods: record-wise and subject-wise approaches (Saeb, Lonini,
Jayaraman, Mohr, & Kording, 2017 ). Using both a publicly available
dataset and a simulation, researchers found that record-wise CV often
massively overestimates the prediction accuracy of the algorithms.

In summary, various designs of wearable technology applications in

healthcare are discussed in this literature review. Further evaluation
studies for those applications are needed to confirm the benefits of
wearable technologies for the future.

Citation: Wu, M. & Luo, J. (Fall, 2019). Wearable technology

applications in healthcare: A literature review. Online Journal of
Nursing Informatics (OJNI), 23(3)

The views and opinions expressed in this blog or by commenters are

those of the author and do not necessarily reflect the official policy or
position of HIMSS or its affiliates.

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Tags: Digital Health , Technology

Published on November 25, 2019

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Introduction:Cardiovascular diseases (CVDs) are the leading cause of death worldwide, accounting for more than 17 million deaths
annually. Early detection and continuous monitoring of vital signs such as blood pressure, heart rate, and oxygen saturation are
crucial for the management and prevention of CVDs. Wearable biosensor systems have emerged as a promising solution for real-
time monitoring of vital signs in cardiovascular disease patients. However, there is a lack of research on the integration of IoT and
self-powering capabilities into these systems. Additionally, there is a need for further investigation into the effectiveness and
feasibility of using such a system for real-time monitoring of vital signs in cardiovascular disease patients. Research Gap:1.
Integration of IoT and self-powering capabilities:The integration of IoT and self-powering capabilities into wearable biosensor
systems can provide numerous benefits, such as real-time data transmission, reduced power consumption, and extended battery
life. However, there is a lack of research on the development and implementation of such systems for monitoring vital signs in
cardiovascular disease patients. Most existing wearable biosensor systems rely on Bluetooth or Wi-Fi connectivity for data
transmission, which can be unreliable in certain environments. Additionally, the use of batteries as a power source can limit the
duration of continuous monitoring. Therefore, there is a need for research on the development of self-powered wearable biosensor
systems that can integrate with IoT platforms for real-time data transmission. 2. Effectiveness and feasibility of real-time monitoring:
While wearable biosensor systems have shown promising results in monitoring vital signs in
cardiovascular disease patients, there is a need for further investigation into their effectiveness and
feasibility for real-time monitoring. Most existing studies have focused on the accuracy and reliability of
the sensors, but there is a lack of research on the impact of real-time monitoring on patient outcomes.
Additionally, there is a need for research on the feasibility of implementing such systems in clinical
settings and their acceptance by patients and healthcare providers.

3. Integration with existing healthcare systems:

The integration of wearable biosensor systems with existing healthcare systems can provide numerous
benefits, such as improved patient outcomes and reduced healthcare costs. However, there is a lack of
research on the integration of such systems with electronic health records (EHRs) and clinical decision
support systems (CDSSs). Additionally, there is a need for research on the development of
interoperability standards and protocols for seamless integration with existing healthcare systems.
 4. Ethical and privacy concerns:

The use of wearable biosensor systems for real-time monitoring of vital signs in cardiovascular disease
patients raises ethical and privacy concerns. There is a need for research on the development of ethical
guidelines and privacy policies for the use of such systems. Additionally, there is a need for research on
the impact of real-time monitoring on patient autonomy and the potential for data breaches and misuse.

Conclusion:

In conclusion, the development of a wearable biosensor system with IoT and self-powering capabilities
for real-time monitoring of vital signs in cardiovascular disease patients has the potential to revolutionize
healthcare delivery. However, there are several research gaps that need to be addressed, including the
integration of IoT and self-powering capabilities, the effectiveness and feasibility of real-time monitoring,
the integration with existing healthcare systems, and ethical and privacy concerns. Addressing these
research gaps can provide valuable insights into the development and implementation of such systems
and pave the way for improved patient outcomes and reduced healthcare costs.