Pervasive Health and Regulatory Frameworks

Alexandra Queirós

, Anabela Silva

, Hilma Caravau

, Alina Ferreira

, Margarida Cerqueira

Joaquim Alvarelhão

, Milton Santos

and Nelson Pacheco Rocha

Health Sciences School/IEETA, University of Aveiro, Aveiro, Portugal

Health Sciences School/CINTESIS, University of Aveiro, Aveiro, Portugal

IEETA, University of Aveiro, Aveiro, Portugal

Health Sciences Department/IEETA, University of Aveiro, Aveiro, Portugal

Keywords: Pervasive Computing, Pervasive Health, Mobile Health, Ambient Assisted Living, Regulatory Frameworks.

Abstract: Pervasive health deals with the application of pervasive computing for health and wellness management and

its developments should be subject of regulatory oversight. The paper presents a general overview of

pervasive health concepts and applications, and aims to verify the level of conformity of current

developments with existing regulatory frameworks.

1 INTRODUCTION

Pervasive health has emerged as a specialization of

eHealth and deals with the application of pervasive

computing (Cook et al., 2009) for health and

wellness management, aiming to make health care

more seamlessly to our everyday life (Korhonen and

Barddram, 2004).

A special attention should be given to eHealth

appliances and applications that, by nature and if

critical aspects are not safeguarded, have the

potential to be a source of harm in normal use or if

misused. This means pervasive health developments

should not merely consider a technological

perspective but must combine both the technological

and the societal requirements.

One of the most important requirements that

should be considered is the level of conformity with

regulatory frameworks. Therefore, the paper

presents a study based on literature review aiming to

systematize concepts related to pervasive health and

to verify the level of conformity of current

developments with regulatory guidelines and

requirements.

In addition to this section (Introduction), the

paper comprises three more sections: Literature

Review, Discussion and Conclusions.

2 LITERATURE REVIEW

During the last two decades, there was a

considerable increase in the capacity to develop and

manufacture systems that employ smart components

highly integrated and miniaturized (Cook and Das,

2012). As a consequence of this remarkable

development, pervasive computing is nowadays part

of our everyday and social life, and impacts our

surrounding environments. Pervasive computing is a

multidisciplinary research field aiming the

development of appliances and applications to allow

convenient access to relevant information and

services. It involves technologically oriented

research on topics like embedded hardware,

software, middleware, wireless communications or

cloud computing among others. There are three

important enabling technologies related to pervasive

computing: ubiquitous computing, ubiquitous

communication and ubiquitous user interaction

(Korhonen and Barddram, 2004).

According to the vision of Weiser (1993),

ubiquitous computing aims to enhance the computer

use by bringing computing devices into everyday

life (e.g. integration of computing power and sensing

features into anything, including everyday objects

like white goods, toys or furniture), making them

available throughout the physical environment in

such a way that the users would not notice their

presence. In turn, ubiquitous communication

comprises multiple technologies to allow the

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Queirós A., Silva A., Caravau H., Ferreira A., Cerqueira M., Alvarelhão J., Santos M. and Pacheco Rocha N..

Pervasive Health and Regulatory Frameworks.

DOI: 10.5220/0005249204940501

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2015), pages 494-501

ISBN: 978-989-758-068-0

 2015 SCITEPRESS (Science and Technology Publications, Lda.)

interaction among multiple devices anytime

anywhere. Finally, since ubiquitous computing

allows the individuals, within a single session, to

interact with multiple devices, user-friendly

interfaces are required. These should support natural

interaction (e.g. speech or gestures) and should

consider the preferences of the users.

A pervasive computing infrastructure, hence, is a

seamless environment of computing, networking,

and natural user interfaces to provide applications

supported by a wide range of appliances with

unobtrusive, continuous and reliable connectivity.

On the other hand, the Ambient Intelligence concept

(Augusto, 2008) shares with pervasive computing

the vision of technology being embedded and

invisible in our natural surroundings, available when

needed and providing an effortless interaction.

However, Ambient Intelligence also includes the

adaptation to the users and the capacity of providing

context awareness (Augusto et al., 2012). Therefore,

pervasive technologies together with artificial

intelligence are used to provide embedded intelligent

devices that can sense the environment state,

perceive the presence of human beings, track their

activities and learn their preferences. For that,

artificial intelligence technology is being used not to

emulate human intelligence, a goal of its

developments in the past, but to combine the

synergies of humans and pervasive technologies

(Mann, 2001).

The research related to pervasive computing and

the associated intelligent components has matured to

the point where tangible prototype test beds are

becoming a commonplace (Cook and Das, 2012).

2.1 Pervasive Health

One of the most important application areas of

pervasive computing is health care. Pervasive health

can contribute, with different roles, to personalize

health and wellness services promoting an evolution

from a medical approach to individual-centric

operational models, in which the individual becomes

an active partner in the care process (Korhonen and

Barddram, 2004). The term personalization can be

related to different concepts, such as personalized

medicine, i.e. individual customization of diagnosis

and therapy based on information related to the

genomic profile of each patient (Genet et al., 2011),

monitoring personalization (e.g. using wearable

sensors), or personalized care (i.e. care services

delivered independent of time and location

according to choice and preferences of the

individuals (Blobel, 2012; Rigby, 2012), allowing

them the possibility of being actively involved in

their health and care pathway).

2.1.1 Monitoring Applications

The advances on sensing technology make it

possible the development of mobile and wearable

sensors able to continuously monitor physiological

parameters, activities and behaviours in out-hospital

conditions. Additionally, the existing ubiquitous

communications make possible anywhere, anytime

transfer and access of health-related information

such as measurement data or medical knowledge.

Therefore, a typical pervasive health application

consists in monitoring health conditions or the

progress of some illness, namely chronic diseases.

For monitoring applications, sensors are required

to collect relevant physiological data. A wide range

of sensors, including pressure and thermal sensors,

might be used to measure blood pressure,

temperature of the body, blood glucose, heart sound,

heart rate, respiration, blood oxygen saturation or

perspiration. Some sensors are non-invasive, but

various biological signals require invasive sensors

such as electrodes. Non-invasive wearable and

textile devices present a considerable potential and,

for instance, they allow to measure physiological

parameters through the use of techniques such as

infrared or optical sensing (Rashidi and Mihailidis,

2013).

However, health conditions are influenced by a

wide range of factors distributed across different

levels of impact that interact with each other

continuously and in subtle ways (Glass and McAtee

2006). These include behavioural (e.g. data

associated with medication adherence), social (e.g.

data associated with activities and participation) and

environmental factors. For instance, a diet plan is

influenced by an individual's health conditions as

well as behavioural factors (e.g. physical activity)

and environmental factors that either hinder or

facilitate these behaviour factors (Alvarelhão et al.

2012). In this particular, it is important to consider

mobile and wearable sensors not only able to

monitor physiological parameters, but also to

monitor activities and behaviours (e.g. recognizing

social activity or identifying any changes in

activities might be an indicator of decline) (Queirós

et al., 2013a).

Monitoring physiological parameters, together

with monitoring daily activities (i.e. identifying

consistency and completeness in these activities), to

assess, in a naturalistic and continuous way, health

and cognitive status (Rashidi and Mihailidis, 2013;

PervasiveHealthandRegulatoryFrameworks

495

Suzuki et al., 2007) might help to automate

assistance and prevent accidents or disease

exacerbations.

Concerning emergency situations, monitoring

patients and providing alerts for health care

providers might facilitate prompt intervention. In

this respect, pervasive health applications might

improve access to care, particularly when time is

vital (e.g. in stroke or acute trauma).

As falls constitute an important cause of

morbidity and mortality in older adults, fall

detection is another application area (Rashidi and

Mihailidis, 2013). It can be envisaged various types

of fall detection systems based on wearable devices

(e.g. devices such as accelerometers and gyroscopes

to measure posture and motion), ambience sensors

(e.g. pressure or floor vibration detection sensors) or

real time video and audio analysis (Lai et al., 2011;

Rashidi and Mihailidis, 2013).

2.1.2 Other Applications

Considering the envisioning goal of personalized

care, pervasive health should be much more than

monitoring applications. Pervasive health also

includes a wide range of applications, namely

preventive applications, applications to enhance the

communication between care providers and patients

and between caregivers or applications to support

frail citizens, such as elderly people, to live

independently and with wellness.

The preventive measures seek to act in several

dimensions (social, family and individual

dimensions), to contribute to the adoption of active

and healthy lifestyles, to give advice and to promote

adherence to long term therapies or to facilitate the

early detection of potential problems (Alcaniz et al.,

2009; Botella, 2009). Still, in terms of prevention,

the information provided by intelligent components

makes possible to tailor efficient interventions (e.g.

intelligent prediction of the moment and place when

intervention can optimally be delivered).

In some instances, pervasive health applications

might promote the engagement with primary care,

replace time-consuming visits and provide

rehabilitation care or assistance (Alcaniz et al.,

2009). This might benefit specialties that require

frequent follow-up care. For instance, specialized

training systems useful to treat stroke patients can be

controlled by remote physiotherapists with access to

the results, namely in terms of exercise levels

(Teixeira et al., 2013).

Furthermore, it should be understood how

pervasive health might facilitate the individuals to be

actively involved in their health and care pathway.

In patients with chronic diseases, applications might

allow them to receive information to better control

their diseases. For instance, educational information

about pain (e.g. general information, symptoms or

causes) can be provided, as well as information

relating to individual health conditions or pain relief

(e.g. relaxation techniques or pain reduction

techniques, such as acupressure), through a variety

of media, including images, video or animations

(Rosser and Eccleston, 2011). Furthermore,

applications can be used for cognitive rehabilitation

and to support older adults suffering from cognitive

decline (Cruz et al., 2014).

Other applications promote self-management,

namely lifestyle management, prescriptions

reminders, care appointments management, health

care record access (e.g. patients having the ability to

securely share their health information with

clinicians or others, as needed) or help the patients

to contribute with observations of their daily living

(e.g. Personal Health Records - PHR).

Within the pervasive health paradigm, different

groups of technologies, although focused in specific

aspects, can contribute to an idealized model of care

personalization. Among these groups, mobile health

(mHealth) (Boulos et al., 2014) and Ambient

Assisted Living (AAL) (i.e. the development of the

Ambient Intelligence concept to enable elderly with

specific demands to live longer in their natural

environment) (Queirós et al. 2013a; Rashidi and

Mihailidis, 2013) have been object of relevant

research. Although, there is a significant overlap

between the two concepts, i.e. there are applications

that can be classified as mHealth or AAL, mHealth

emphasizes mobility and considers applications to

support the care of the patients in their homes as

well as applications to be used in clinical

environments for professional activities (e.g. training

of medical students), while ALL might include static

devices and intends to support elderly living at home

not only in aspects related to health care but also

independent living.

2.2 Mobile Health

The World Health Organization has defined

mHealth as “medical and public health practice

supported by mobile devices, such as mobile phones,

patient monitoring devices, personal digital

assistants, and other wireless devices” (WHO, 2010:

6). Therefore, mHealth deals with the use of mobile

communication devices, such as smartphones or

tablets to support health services (Mosa, Yoo and

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Sheets, 2012), both in terms of disease and

wellbeing management.

Since health care services involve multiple

locations (e.g. clinics, outpatient’s services or

patients’ homes) they are highly mobile in nature

(Mosa, Yoo and Sheets, 2012). This means mHealth

might support communication and collaboration

among different health professionals in activities

related to disease diagnosis, drug reference, medical

calculations or literature search, among others.

The pervasive computing landscape includes

massive numbers of portable devices (e.g.

smartphones or tablets) that gather and store

information. Current smartphones are fairly robust,

truly pervasive and accessible, - they are accessible

to over 90% of the global population (Cook and Das,

2012; ITU, 2011) - and they provide ubiquitous user

interfaces and have the ability to collect, store and

communicate information (Cook and Das, 2012).

Therefore, they are considerable relevant to

mHealth. Furthermore, an interesting feature of

smartphone devices is the availability of short-

distance wireless data transmission, such as

Bluetooth (Mosa et al., 2012). This enables the

smartphone applications to work with a wide range

of hardware devices (e.g. glucose meters, pulse

oximeter or thermometers) from different vendors.

Concerning health care professionals,

smartphones are being used to perform mobile

diagnostic tests, to access Electronic Health Records

(EHR) and other patient information, to support

decisions related to drugs prescription or to provide

new means of medical education and teaching

(Boulos et al., 2014), among other activities.

Smartphone patient oriented applications might

deliver health care services for patients with chronic

conditions (Mosa, Yoo and Sheets, 2012). Examples

of chronic disease management applications include

self-management (e.g. self-management of the

chronic obstructive pulmonary disease) (Marshall et

al., 2008), expert feedback to patients based on their

input (e.g. helping diabetic patients by calculating

the dose of insulin based on carbohydrate intake,

pre-meal blood glucose, and anticipated physical

activity reported) (Charpentier et al., 2011), support

to rehabilitation programs (e.g. real-time remote

monitoring of the heart rate during rehabilitation

exercises), measurement of physical activity level

(Bexelius et al., 2010), integration of data from

wearable health sensors (Boulos et al., 2011) or even

helping patients to practice meditation (Mosa et al.,

2012; Sarasohn-Kahn, 2010).

Furthermore, the scientific literature refers a

considerable number of fall detection applications

using smartphones together with wearable tri-axial

accelerometers (Mosa, Yoo and Sheets, 2012) and

applications being used for pain management

(Boulos et al., 2014; Mosa et al., 2012; Rosser and

Eccleston, 2011).

Smartphone technology has the potential to

provide real-time pain reporting, which is relevant,

since pain is a diverse and prevalent state that is

often hard for patients to describe and, therefore,

difficult for caregivers to diagnose and treat (Mosa,

Yoo and Sheets, 2012). A systematic review of

smartphone applications conducted by Rosser and

Eccleston (2011) analyses 111 smartphones-based

application targeting various types of pain and

different health conditions with pain implications,

including applications that provide basic

measurement of pain level (either using visual

analogue scales or Wong-Baker pain faces scales) or

diary tracking applications (Rosser and Eccleston,

2011). The focus of these applications can be

divided into general pain (i.e. unspecified generic

pain), specified pain syndromes (e.g. headache and

back, neck, chest, dental or menstrual pain) or

chronic pain (e.g. specific long-term health

conditions such as fibromyalgia, arthritis and

degenerative disc disease). Predominantly the

purpose of the reported applications was pain relief

or educational information about pain (e.g. general

information, symptoms or causes). Additionally,

some applications present pain reduction techniques

(e.g.

information on acupuncture, acupressure

tutorials and headache prevention), relaxation

techniques (e.g. meditation or massage tutorials) and

skills training exercises for relieving tension, while

others employ attributes of the smartphones to

reduce pain (e.g. use of the vibration capacity of the

smartphone as a relaxation mechanism) (Rosser and

Eccleston, 2011).

2.3 Ambient Assisted Living

AAL is an emerging field that had attracted global

interest, both in academia and industry, for the

potential of its solutions, namely in terms of health

care applications (Augusto et al., 2012). AAL

concerns and developments are in line with the

World Health Organization active ageing framework

(WHO, 2002). Active ageing emphasizes an

enabling positive thinking. While a disabling

perspective leads to isolation and dependence and

increases the needs of older people, an enabling

view focuses on maintaining the older adults'

functioning and expanding their participation in all

aspects of the society. Enabling instruments such as

PervasiveHealthandRegulatoryFrameworks

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ALL are essential, considering the fact that as people

age their quality of life (i.e. perception of the

position in life in the context of the surrounding

culture and value system) is largely determined by

their ability to maintain autonomy (i.e. ability to

control, cope with and make personal decisions on a

day-to-day basis) and independence (i.e. the ability

to perform functions related to daily living with no

or little help from others) (WHO, 2002).

AAL intends to address needs of older adults and

respective major diseases (Heath, 2008):

cardiovascular disease, hypertension, stroke,

diabetes, cancer, chronic obstructive pulmonary

disease, musculoskeletal conditions, mental health

conditions or blindness and visual impairment.

Meeting the specific individual needs, namely

providing care services at the home of the

individuals together with intelligent applications, is

one of the main strategies to guarantee independent

living of older people (Kleinberger, 2007).

Considering this context, important AAL goals are

to promote personal (e.g. medication reminder) and

distance support (e.g. tele rehabilitation programs)

or to provide the caregiver with accurate, up to date

information so that the right care at the right time

can be delivered (e.g. continuous monitoring of

physiological parameters or behaviours, emotions

and activities) (Kapoor, 2010; Mirarmandehi, 2010).

These goals can contribute to the overall effort to

provide personalized and affordable access to

essential services with efficacy and efficiency

(Queirós et al., 2013b).

A combination of conventional service provision

together with intelligent applications have been

designed in a considerable number of AAL projects

(Queirós et al., 2013a) to contribute for independent

living.

Dependency is strongly related to the ability to

perform Activities of Daily Living (ADL). The

impossibility of performing basic ADL (e.g.

personal hygiene, dressing and undressing, self-

feeding or ambulation) and instrumental ADL (e.g.

housekeeping, managing money, shopping or

clothing, use of telephone and other forms of

communication or transportation within the

community) usually implies that the individual

(although, in some circumstances, living alone) is on

the border of dependency and needs help and

support. It is clear that technology cannot supply

these needs completely, but it can mitigate the

dependency impacts by means of specialized

solutions (e.g. a nutritional adviser or an electronic

commerce solution for shopping) with the general

aim of increasing the performance of older adults in

their activities and participation.

All these AAL applications can maintain, or even

increase, the confidence of the individual in their

domestic spaces and thus increase their well-being at

home in general. However, assistance applications

must also address less tangible values such as

participation. In particular, they should consider, in a

comprehensive way, the possibility of the

technologies facilitate social, religious, civic and

political participation of older citizens.

3 DISCUSSION

Pervasive health has a huge potential in terms of

innovative solutions that might mitigate, in political,

economic and social terms, the consequences of the

contemporary demographic ageing.

A relevant finding of the study is that the

developments related to pervasive health are still

focused on technology and often potential users,

both patients and professionals, are not conveniently

involved.

For instance, the systematic review conducted by

Rosser and Eccleston (2011) reports a significant

percentage of applications (86%) with no health-care

professional involvement, either as the application

creator or as a source of information or evaluation of

the application content. Furthermore, a systematic

literature review related to AAL (Queirós et al.,

2013a) shows a high percentage of articles on

specific components (87%) when compared to the

percentage (13%) related to full systems. This

review also shows that a considerable number of the

articles describing systems focus on how technology

can be used in the AAL context instead of looking at

the users’ needs and proposing ways to address

them.

In order to solve this identified problem, it is

required that research teams should be composed of

professionals with different backgrounds and skills

such as health or social professionals and engineers

and that all the stakeholders, including potential

users, should be actively involved in all the stages of

the applications developments and evaluation

processes, including the conceptualization phase.

The studies reviewed also show the applications

are subject to very little or absolutely no regulatory

oversight, with a small percentage of articles

reporting evaluations or trials. However, pervasive

health solutions deal with sensitive health-related

aspects of a person’s life and this should put strong

demands in the development of these technologies.

Therefore, it is necessary to consider the risks

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associated with pervasive health appliances and

applications, including the possibility of the

individuals being misled. This is reinforced by the

fact that, often, the potential users are fragile and

vulnerable individuals, or their families, desperately

seeking solutions to acute problems. Thus, even for

appliances or applications that appear to be

extremely useful, there should be a concern for their

efficacy and efficiency, or for possible adverse

effects when being used.

3.1 Regulatory Frameworks

The obligation of an appliance or application being

classified as a medical device depends on its

functions and the corresponding level of patient

risks. For instance, a device able to measure heart

rate as a fitness tool is not a medical device, but it is

definitively a medical device if the resulting

information is sent to a health care professional

(FDA, 2013).

Worldwide, a wide range of organisms, including

the Food and Drug Administration (FDA) of the

United States and the European Medicines Agency

(EMA) of the European Union, have the mission to

safeguard the interests of the citizens by establishing

standards for the development, manufacture and

marketing of medical devices.

In 2013, the FDA issued a guidance concerning

the regulation of mobile medical applications (FDA,

2013). It considers that all the applications that

transform a mobile platform into a medical device

by using attachments, display screens, sensors, or

other such methods, regardless of the mechanism

behind the transformation, should be regulated

(FDA, 2013). Furthermore, FDA intends to exercise

enforcement discretion for mobile applications that

(FDA, 2013): help patients self-manage their disease

or conditions without providing specific treatment or

treatment suggestions; provide patients with simple

applications to organize and track their health

information; provide easy access to information

related to patient's health conditions or treatments;

help patients to document, show or communicate

potential conditions to health care providers;

automate simple tasks for health care providers; or

enable patients or health care providers to interact

with health care record systems (e.g. EHR).

In the European Union, the European Medical

Device Directive (MDD 93/42/EEC) defines a

medical device as any instrument, apparatus,

appliance, software, material or other article that

when used alone or in combination with accessories,

including specific software, aims to prevent,

diagnose, treat, monitor, or alleviate an illness or

injury in humans (EC, 1993). The CE mark assigned

to a device guarantees to users and health

professionals that the device complies with all

guidelines provided by all the applicable regulatory

frameworks.

Medical devices are divided into risk classes

according to different criteria, namely, the intended

purpose, potential risks arising either from its

technical conception and in its manufacturing

methods, duration of contact with the human body

(temporary, short or long period), invasiveness of

the human body (invasive, invasive of bodily

orifices, surgically invasive, implantable and

implantable absorbable) or the anatomy affected by

the use of the device.

As part of the technical documentation, the

developers also need to perform controlled tests and

risk assessment to demonstrate that their products

might improve any existing process used for the

same purpose. This implies the need to assess the

validity (validity refers to the degree of accuracy of

measurements or actions taken by an appliance or

application, i.e. if they actually measure or perform

what they intend to measure or to perform) and the

reliability (reliability refers to the consistency of the

measurements or the actions over time) of the

appliances and applications, which might be

supported by observational clinical trials involving

human subjects that, like all the clinical trials, must

comply with the ethical principles established by the

Declaration of Helsinki (WMA, 2013) and must

follow good clinical practices. These trials can

provide evidence to conclude that the measurements

and actions performed by the appliances or

applications are, respectively, consistent with the

measurements and actions associated with existing

similar appliances and applications.

Despite all the regulations, it is perhaps

surprising that relatively little research has been

undertaken so far to investigate the validity and the

reliability of pervasive health developments (Mosa

et al., 2012; Rosser and Eccleston, 2011).

3.2 Clinical Evidence

Besides the assessment of validity and reliability,

there is a need to understand the quality of the

available solutions and their clinical usefulness. This

requires interventional clinical trials to provide

clinical evidence of efficacy and efficiency of the

pervasive health applications.

Despite a high level of technological innovation

and implementation, and promising early results,

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499

most of the developments aimed the design,

development and evaluation of prototypes (i.e.

proof-of-concept). In contrast, evidence-based

medicine is supported on statistical and clinical

significance and the new developments are required

to show they are able to make a difference and are

cost-effective (Korhonen and Barddram, 2004).

Furthermore, high-quality efficacy and efficiency

evidence must also adequately address usability,

accessibility, readability (reading with

understanding) or health literacy needs of target

audiences, since they might have different and

unique usability requirements related to ageing and

physical or cognitive impairments. This requires

adequate development and evaluation methodologies

(Martins, 2012).

Collecting this kind of evidence requires

interventional clinical trials. These demands

considerable resources to integrate new applications

with daily care delivery, to be used by thousands of

users, both patients and health professionals, and

running over long periods of time (Rashidi and

Mihailidis, 2013).

Examples of questions that must be answered by

interventional clinical trials are: Is the information

being provided beneficial in clinical practice to

guide diagnosis, decision making or intervention? Is

that appliance or application going to have an impact

on patients or health care provider's? Is that change

beneficial for the patient in any way? Is the use of

the appliance or application making the diagnosis,

the decision or the intervention processes any better?

Multidisciplinary large-scale collaboration with

technology developers, companies, policy makers,

patient organizations and health professionals is

essential for pervasive health surpass this

methodological challenge (Korhonen and Barddram,

2004).

3.3 Limitations of the Study

The study was not based on a systematic literature

review. Therefore, the degree of generalization of

the study findings needs to be evaluated through

further research. Presently, the authors are

conducting a systematic literature review to support

this exploratory study.

4 CONCLUSIONS

The pervasive health paradigm has a huge potential

in terms of innovative solutions that might mitigate,

in political, economic and social terms, the

consequences of the contemporary demographic

ageing. However, their development should not be

seen merely from the technological point of view

because there is a wide range of ethical and

organizational issues that need to be considered.

In particular, in this paper the authors focused on

the need to complement the pervasive health

developments with strong evidence of their validity,

reliability and clinical usefulness. For that it is

necessary to implement strict evaluation processes

according to regulatory frameworks, which requires

observational and interventional clinical trials

involving patients and care providers.

ACKNOWLEDGEMENTS

This work was supported by COMPETE - Sistema

de Incentivos à Investigação e Desenvolvimento

Tecnológico, Projectos de I&DT Empresas em co-

promoção, under QREN TICE.Healthy.

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