Interoperability in Pervasive Health: Is It Tackled as a Priority?

Ana Dias

, Ana Isabel Martins

, Alexandra Queirós

and Nelson Pacheco Rocha

GOVCOPP, Department of Economics, Management, Industrial Engineering and Tourism, University of Aveiro,

Campo Universitário de Santiago, 3810-193 Aveiro, Portugal

IEETA, Department of Medical Sciences, University of Aveiro,

Campo Universitário de Santiago, 3810-193 Aveiro, Portugal

IEETA, Health Sciences School, University of Aveiro, Campo Universitário de Santiago, 3810-193 Aveiro, Portugal

Keywords: eHealth, Pervasive Health, Interoperability, Home Monitoring.

Abstract: For the electronic health record (EHR) to be considered a true clinical decision support system, it must be

possible to access and integrate the patients’ clinical information collected throughout their lives, guaranteeing

up-to-date, safe and congruent information, immediately accessible at the place of care. Moreover, there is a

considerable capacity to develop and manufacture personal health devices (PHD) highly integrated and

miniaturized, which facilitate the home monitoring of patients with chronic diseases. Since the information

collected by PHD should be integrated in existing EHR, interoperability is an essential requirement of eHealth

to allow the integration of care into a diversity of settings and care providers. The purpose of this systematic

review was to identify and analyse references related to the topic of home monitoring that reveal an explicit

concern with interoperability requirements. Regarding the results and considering the initial 2778 references,

only 2% (61 references) explicitly mentioned interoperability issues and, within these 61 references, only

eight reported end-to-end solutions that can be integrated and usable in care service provision. Therefore, the

issue of interoperability of PHD, both semantic and technological, a priority for the establishment of a remote

patient monitoring solution market, is discussed in this review.

1 BACKGROUNG

Progresses attained in the last decades in health

information technology (HIT) are undeniable;

however, some goals apparently have not yet been

achieved. Efforts to link and aggregate patients’

clinical information collected throughout the care

process have been hampered by factors such as

technological "heritage", proprietary technology,

obsolete regulation, incomplete specification of end-

to-end standards and financial concerns (Perlin,

2016). The design and implementation of HIT has not

yet reached its potential in terms of impact it can have

on health care provision and interoperability is

assumed as being an essential requirement to

integrate health care into a diversity of settings and

care providers (Kuziemsky et al., 2016).

In health care delivery, there is significant amount

of information available, so the problem is less the

volume and more the value that is created with the

available information. Major difficulties are related to

the aggregation of information from different sources,

with different formats and meanings, as well as the

lack of tools to recognise, within all the available

information, which is relevant for each particular

situation and to make it useful rather than just being

visible (Halevy, 2011).

Due to the growing importance of the eHealth

paradigm (Eysenbach, 2001) and related concepts

(e.g. connected health (Kvedar et al., 2014), holistic

health (Rossi et al., 2013) or pervasive health

(Connelly et al., 2017)), contexts regarding health

care delivery have evolved. Particularly, health care

delivery has evolved from hospital to home, and

home monitoring of patients’ clinical information

together with context information resulting from their

environment might be incorporated in the

characterization of their health conditions. In this

pervasive context, different groups of technologies

assume an important role, namely telecare, mobile

health (mHealth) and ambient assisted living (AAL):

telecare include solutions such as monitoring devices

or medical alert devices to support patients in their

environments (Emery et al., 2002) or rehabilitation

activities (Cruz et al., 2013; Teixeira et al., 2013);

Dias, A., Martins, A., Queirós, A. and Rocha, N.

Interoperability in Pervasive Health: Is It Tackled as a Priority?.

DOI: 10.5220/0006545400570065

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 5: HEALTHINF, pages 57-65

ISBN: 978-989-758-281-3

mHealth is related to the use of mobile

communication devices for the health care provision

(WHO, 2011); and AAL intends to respond to the

specific needs and major diseases of older adults in

their domestic spaces, increasing their autonomy,

confidence and participation ability (Queirós et al.,

2015).

The information is no longer stored and

exclusively managed by the electronic health records

(EHR) of the health care institutions. Although EHR

are adequate for the presentation of information from

patients, collected and aggregated in local HIT, the

reality is that the provision of health care is not

restricted to an institution or even to a single care

provision system (Queirós et al., 2013). All

caregivers need comprehensive, up-to-date, safe and

congruent information from the patient, immediately

accessible at the place of care, to ensure the highest

levels of clinical quality. For instance, when

considering the home monitoring of a patient with a

chronic disease (e.g. diabetes, heart failure or chronic

obstructive pulmonary disease), the resulting

monitoring information should be distributed within

an information network ranging from clinicians,

social care network, and family members to the

patients themselves. These requirements promote the

emergence of new technological approaches such as

personal health record (PHR) (Krukowski et al.,

2015) that aimed at electronic management of

information between the patients and their formal and

informal health care providers, and that might

contribute to the availability of the patients’ clinical

information that is collected throughout their lives

(Halevy, 2011).

However, the implementation of this vision is

bounded by a set of problems: for instance, clinical

information is blocked in HIT silos, generated and

stored in different systems that either do not

communicate with one another or are unable to

synthesize information to make it meaningful and

usable. Therefore, interoperability must be ensured,

in terms of communications protocols and semantic

normalization, between a wide range of information

sources and eHealth applications. Hence, initiatives

efforts carried out by international institutions such as

the Continua Health Alliance, the Health Care

Information and Management Systems Society

(HIMSS), the National Institute of Standards and

Technology (NIST), and the Integrating the

Healthcare Enterprise (IHE) are crucial to overcome

interoperability difficulties and to promote a

homogeneous eHealth ecosystem (Aragüés et al,

2011).

Given this background, the main purpose of the

systematic review reported in the present article was

to explore if interoperability is a real concern when

developing concrete pervasive solutions (e.g.

telehealth, mHealth or AAL applications) to gather

patients’ information, both clinical and contextual

information.

2 METHODS

The purpose of this systematic review was to identify

and analyse in more detail references related to home

monitoring, which reveal an explicit concern with

interoperability requirements. The general goals of

this systematic review were to identify, within the

selected references, how interoperability is addressed

in the solutions being proposed, how they are

validated and if there is effective technological and

semantic interoperability. The ultimate goal of this

analysis was to assess if, in addition to allowing

information sharing, the solutions proposed are able

to produce meaningful and contextualized

information that can be integrated into EHR, that is,

if the information they collect is qualified to be

integrated and usable in the care service provision.

Moreover, if this is the case, it is important to identify

standards that are most commonly used.

2.1 Study Design

Considered the aforementioned purposes, the

systematic review of the present study was informed

by the following research question: is there an explicit

concern related to interoperability during the

development of new eHealth applications to gather

patients’ information in their home environments?

Within references selected as expressing an

effective concern related to interoperability, some

sub-questions were raised:

▪ What are the problems being addressed?

▪ Which types of interoperability computational

support were provided?

▪ How the proposed solutions addressed

interoperability?

▪ Which technical implementation has been

used?

▪ Which methods were used to validate the

proposed interoperability implementations?

▪ Is the resulting information ready to be

integrated into the health care service

provision? If yes, which standards are being

used?

HEALTHINF 2018 - 11th International Conference on Health Informatics

To achieve these goals, initially, a systematic

review of literature published between 2011 and 2016

was performed.

Exclusively the references that had the keywords

“interoperability” or “interoperable” in title or

abstract were considered for further assessment and

classification, being excluded the first group of

references.

Subsequently, the references included for analysis

were assessed and some more were excluded

reflecting specified criteria, which is described

below. The remaining references were then

categorized according to the degree of significance to

answer the questions posed within this research, that

is to say the option was to analyse in greater detail the

references that proposed solutions in which it was

considered relevant that the information produced

could be integrated into the health care service

provision.

The methods used to conduct this systematic

review of literature as well as the subsequent

categorization of search results is described in the

following subsections.

2.2 Data Sources and Searches

The research was carried out using the Scopus, Web

of Science and IEEE Xplore Digital Library

databases, in the publications titles, abstracts and

keywords.

The keywords used in the search, simultaneously,

were: “monitoring” and “pervasive health”, since

these are the topics around which it is important to

evaluate the centrality of the interoperability issue.

Pervasive health is seen as a contribution to a more

personalized model of care allowing individuals to be

more actively involved in their care process. A classic

pervasive health care application is home monitoring

of health conditions, particularly patients with

chronic diseases. However, it is important to note that

pervasive health is more than monitoring applications

as it can also include preventive applications (e.g.

elderly people to live independently) (Queirós et al.,

2015).

The remaining keywords were: “mobile health”,

“mhealth” and “ambient assisted living”. These

keywords were combined so that at least one of them

corresponded to the subject of the search.

2.3 Inclusion and Exclusion Criteria

References with no author, no abstract, not written in

English, duplicates and editorials were excluded.

References selected for review were all written in

English and all who had a date of publication between

2011 and 2016. Then, all the references that did not

explicitly mention the “interoperability” or

“interoperable” keywords in tittle and/or in abstract

were also rejected.

Subsequently, within the references’ full texts

revised, those that corresponded to items out of ambit

of this systematic review were also excluded. Then,

in the group of references within the scope of this

systematic review, were also identified and excluded

those references that corresponded to categories to be

rejected in view of the objectives of this analysis,

specifically: overviews, political perspectives,

position papers, reviews and systematic reviews.

Then, the remaining references were clustered in

ascending order of importance for this study:

connection between devices; intermediate

components between devices and client applications

for handling the storage and sharing of the

information being gathered (e.g. architectures,

gateways, middleware or data hubs); intermediate

components but incorporating medical devices

specificities; and end-to-end solutions.

2.4 Study Selection

After the first screening, one author assessed all titles

for relevance. Those clearly not meeting the inclusion

criteria were removed.

Afterwards, the abstracts of the retrieved articles

were assessed against the inclusion and exclusion

criteria, by two authors. Any disagreements were

discussed with a third reviewer and resolved by

consensus. Abstracts were then subject to a first

classification and grouping.

Finally, the references that were selected by the

superior interest for this study were gathered and

analysed in more detail. Two authors, according to

the outlines criteria, then assessed again these full

texts thought to be of relevance, and any divergences

were also discussed with a third reviewer and agreed

by consensus.

3 RESULTS AND DISCUSSION

This systematic review followed the guidelines of the

Preferred Reporting Items for Systematic Reviews

and Meta-Analyses (PRISMA) (Moher et al., 2009)

as described in Figure 1.

A total of 2778 references were retrieved from the

initial search of the selected databases. Then, 2717 of

these references were rejected because they did not

Interoperability in Pervasive Health: Is It Tackled as a Priority?

explicitly mention “interoperability” or

“interoperable” in the tittle and/or in the abstract.

Figure 1: PRISMA flowchart.

Afterwards, by reviewing these 61 references’

full-texts, 31 were excluded: the first 17 references

grouped and classified are articles assumed as out of

the scope of this study; other cluster (n=14) are

references that, although within the ambit of the

present analysis, were also excluded because they

correspond to position papers (n=5), systematic

reviews (n=3), reviews (n=1), overviews (n=2) and

political standpoints (n=3).

The remaining 30 references were first clustered

in ascending order of importance for this study: five

references deal with the connection between devices;

14 references are related to the intermediate

components between different types of sensors and

the client applications for handling the storage and

sharing of the devices’ information; three references

are similar to the previous, but incorporating medical

devices specificities; and the latter cluster (eight

references) comprises the references that propose

end-to-end solutions.

The group of references related to the connection

between devices (n=5) include those that describe

solutions providing communication protocols to

network sensors. The remaining three categories have

an ascendant interest to answer the questions raised in

this systematic review, going from ways to guarantee

connection between sensors to end-to-end solutions.

The group of 14 references contains articles that

report solutions with different designations (e.g.

architectures, gateways, middleware or data hubs) but

with the same purpose, which is to aggregate data

from various sources to provide it in an integrated

way to client applications. These references, although

being related to health care applications, they do not

allude to interoperability standards used in health care

applications. As for the three references incorporated

in the other cluster, they describe the same type of

solutions proposed in the last group, but explicitly

referring the use of health care standards.

Finally, the references that were selected by the

superior interest for this study (n=8), because

referring to end-to-end applications, allowing

connections to EHR and based on standards such as

Health Level Seven (HL7), were analysed in more

detail in the study reported by the present article.

3.1 Characteristics of the Studies

Within the 30 references selected and categorized

according to the degree of relevance for this

systematic review, there are several aspects to be

highlighted and analysed in this section.

Five references (Elsaadi et al, 2016; Escobar et al.,

2015; Fong, 2011; Grossi et al, 2012, Palma et al.,

2016) describe solutions providing communication

protocols to connect a large number of sensors.

Fourteen references report solutions to aggregate

data from various sources to provide it in an

integrated way to client applications (Carr et al.,

2013; Costa et al., 2014; Denkovski et al, 2015; Ding

et al. 2016; Ferreira et al., 2012; Kilintzis, et al., 2013;

Norgall et al., 2013; Pradilla et al, 2015; Rossi et al.,

2014; Ruiz-Zafra et al., 2013; Smirek, et al., 2016; Su

et al., 2011; Xiao et al., 2016; Woznowski et al.,

2015). These articles, though being related to health

care applications, they do not allude to

interoperability standards used in health care,

inhibiting the information that is produced from being

integrated into the health care service provision.

However, what is described in the type of solutions

proposed in three references (Damas et al., 2013;

Norgall et al., 2012; Pereira et al., 2014), explicitly

refer the use of health care standards, considering the

specificity of medical devices (e.g. the already

established ISO/IEEE 11073 standards-based

Continua personal health ecosystem - X73 protocol

(Damas et al., 2013)).

The main problem being addressed here is the lack

of interoperability among different levels of available

technologies which restricts a wider deployment

among intermediate and end-users (Pereira et al.,

2014), therefore the demand for interoperability

among devices is emphasized as most commercially

available devices include their own software and

communication protocols, which cause serious

problems and hinder the application of a standard

(Damas et al., 2013). Therefore, the shortfalls of

Included

Eligibility

Screening

Identification

Articles found in Scopus, Web of Science and

IEEE Xplore Digital Library (n=2778):

Articles underwentfullreview (n=61).

Excluded based on the full review (n=31).

Total number of articles (n=30).

Articles excluded based on the review of

their titles and abstracts (n=2717).

HEALTHINF 2018 - 11th International Conference on Health Informatics

dominating insulated available products are

highlighted (Norgall et al., 2012).

To address interoperability, the references

reported different communication protocols,

including Bluetooth Health Device Profile (HDP)

(Pereira et al., 2014) and Open Services Gateway

initiative (OSGi), a framework for modular systems

that simplifies building, deploying, and managing

complex applications. OSGi is complemented with

the X73 standard data model, which allowed, for

instance, the modelling of the information being

gathered (Damas et al., 2013) so that the information

resulting from different AAL systems might be

integrated (Norgall et al., 2012).

Concerning the type of interoperability

computational support, different solutions’

designations are reported although they pursue the

same objective, which is the aggregation of data from

multiple sources to provide them in an integrated way

to client applications, namely: architectures (Costa et

al., 2014, Ding et al., 2016, Norgall et al., 2013, Ruiz-

Zafra et al., 2013; Xiao et al., 2016; Woznowski et al.,

2015), gateways (Costa et al., 2014, Denkovski et al,

2015, Ding et al., 2016, Smirek, et al., 2016),

middleware (Carr et al., 2013, Kilintzis, et al., 2013)

or data hub (Woznowski et al., 2015).

Regarding the validation of the proposed

interoperability solution, the following methods are

reported: prototype (Ruiz-Zafra et al., 2013; Xiao et

al., 2016), case study (Kilintzis, et al., 2013; Pradilla

et al, 2015), proof of concept (Costa et al., 2014) and

scenarios implementation (Su et al., 2011).

3.2 Interoperability

The results presented and discussed in this section

relate to the eight articles (within the 61 references

assessed for inclusion) that have been highlighted by

this systematic review. These eight articles

correspond to end-to-end solutions and they report an

effective concern related to the interoperability issue,

proposing concrete solutions to ensure that the

information produced could be integrated into the

health care provision, as summarized in Tables 1, 2

and 3.

Concerning Table 1, it gives a global perspective

on how the subject of interoperability is addressed in

the references analysed herein, namely the problems

to be solved, the interoperability computational

support and the proposed technical solutions. In

particular, and with regard to the problems addressed

in literature, one of them are the difficulties

experienced in the sharing of information between

personal health devices (PHD) and care providers.

This reinforces the need to provide data in proven

standard form (Mihaylov et al., 2015), as well as the

requirement to ensure the interoperability of various

PHD and EHR for continuous self-management of

chronic disease patients. However, reliability,

interoperability, and scalability between different

PHD imply additional costs during the healthcare

applications development (Park et al., 2016). Another

difficulties that were tackled in literature was the need

to integrate data from different eHealth applications,

for instance to maximize the access to better therapies

and advanced medical devices (Torres Zenteno et al.,

2016) as well as the demand for the information

sharing between the PHR and the EHR, namely to

allow patients to alert health care professionals

automatically in real time when necessary (Galligioni

et al., 2015).

Considering the references which were subject to

a depth analysis (Alberts et al., 2014; Galligioni et al.,

2015; Gietzelt et al., 2014; Jung et al., 2014; Lee et

al., 2013; Mihaylov et al., 2015; Park et al., 2016;

Torres Zenteno et al., 2016), in all the solutions

reported the focus is on guaranteeing integration of

information, being reported in every case that the

resulting information is ready to be integrated in the

health care service provision. However, concerning

this issue, in some cases this is more explicit and

detailed (Lee et al., 2013; Mihaylov et al., 2015; Park

et al., 2016; Torres Zenteno et al., 2016) than others

(Alberts et al., 2014; Galligioni et al., 2015; Gietzelt

et al., 2014; Jung et al., 2014).The integration of

information from existing eHealth applications to

provide integrated data analysis is a central concern

(Alberts et al., 2014).

In particular the demand to ensure interoperability

of various PHD and EHR for continuous monitoring

and self-management of patients with chronic

diseases (Galligioni et al., 2015; Gietzelt et al., 2014;

Jung et al., 2014; Lee et al., 2013; Mihaylov et al.,

2015; Park et al., 2016; Torres Zenteno et al.,

2016).The need to provide sensor data in proven

standard form is denoted, as the existing coding

systems do not appear to be sufficient to encode the

data resulting from a variety of sensors (Gietzelt et

al., 2014). Thus, current solutions are considered to

lack interoperability and obstruct the establishment of

a remote patient monitoring solution market

(Mihaylov et al., 2015).

Interoperability in Pervasive Health: Is It Tackled as a Priority?

Table 1: Problem addressed, solution and computational support.

Problem addressed

Interoperability

computational support

Proposed solutions

Lee et al., 2013

Sharing of information from

PHD to care providers.

Middleware

A multi-agent platform that transmits patient clinical

data for services based on interoperability standards.

Alberts et al., 2014

Information sharing between

eHealth applications.

Middleware

An Integrated eHealth platform that consists of two

sub-platforms: the health integration and analysis sub-

platform and the communications sub-platform.

Jung et al., 2014

Information sharing between

PHR and EHR.

Application

A mHealth application that interfaces with hospital

EHR

Gietzelt et al., 2014

Information sharing between

eHealth applications.

Architecture

Centralized registration of placeholder-documents

together with a decentralized data storage at peoples’

home.

Galligioni et al., 2015

Information sharing between

PHR and EHR.

Architecture

Web-based, multi-tier architecture with the following

components: electronic oncological patient record

(eOPR), RFID bar code reader, bar-coded drug labels,

disposable RFID bracelets for patients, RFID tags for

nurses and a mobile device.

Mihaylov et al., 2015

Sharing of information from

PHD.

Application

Design and implementation of an interoperable,

intelligent caring home system offering personalized

context-aware applications.

Torres Zenteno et al., 2016

Information sharing between

eHealth applications.

Platform

A technological platform that supports the predefined

process following an interoperability model based on

standards and implemented by a service-oriented

architecture.

Park et al., 2016

Sharing of information from

PHD.

Application

The application for continuous self-management of

chronic disease patients that communicates with PHD.

Table 2: Standards being reported.

Standards used for integration

Alberts et al., 2014; Jung et al., 2014; Galligioni et al., 2015

Not reported

Gietzelt et al., 2014

HL7 CDA; HL7 Arden syntax; SNOCAP-HET; MQTT

protocol

Lee et al., 2013

HL7 V2.5 Messages

Mihaylov et al., 2015

HL7 V3 CDA; X73

Park et al., 2016

HL7 V2.6; CCR; CCD; X73; HDP

Torres Zenteno et al., 2016

CEN/ISO 13606; IHE

Table 3: Validation.

Validation

Alberts et al., 2014; Jung et al., 2014

Not reported

Galligioni et al., 2015

Laboratory tests

Gietzelt et al., 2014

Future work

Lee et al., 2013

Meaningful use

Mihaylov et al., 2015

Proof of concept

Park et al., 2016

Clinical trial

Torres Zenteno et al., 2016

Simulation

HEALTHINF 2018 - 11th International Conference on Health Informatics

Three references are particularly focused on the

need to find more advanced solutions to guarantee

interconnection with the EHR as well as to improve,

optimize and reduce the time in care in particular

pathologies, specifically diabetes (Jung et al., 2014),

cancer (Galligioni et al., 2015) and stroke (Torres

Zenteno et al., 2016).

In order to address interoperability, the reported

solutions include, for instance: an application, the

Self-Management mobile PHR that communicates

with PHD (e.g. blood pressure monitor or pulse

oximeter) that have implemented standard protocols

so that stored vital signs are converted to HL7 and are

transmitted to PHR (Park et al., 2016); a PHR service,

interconnected with mHealth applications that use

clinical information from the EHR system of a

tertiary hospital to provide services to support

patients with chronic diseases, such as diabetes

patients (Jung et al., 2014); an architectural approach

to integrate Home-Centred Health-Enabling

Technology into Regional Health Information

Systems, a centralized registration of placeholder-

documents with a decentralized data storage at

patients’ home, using the Systematic Nomenclature

for Contexts, Analysis methods and Problems in

Health Enabling Technologies (SNOCAP-HET),

which is a nomenclature to describe the context of

sensor-based measurements in health-enabling

technologies (Gietzelt et al., 2014).

Regarding the standards applied in the proposed

solutions (Table 2), the choice of HL7 was made in

most of the solutions in which standardized solutions

are reported (Gietzelt et al., 2014; Lee et al., 2013;

Mihaylov et al., 2015; Park et al., 2016): X73 with

HL7 V2.6 was used in two cases (Mihaylov et al.,

2015; Park et al., 2016), being stated others such as

Continuity of Care Document (CCD) and Continuity

of Care Record (CCR) (Park et al., 2016), Message

Queue Telemetry Transport protocol (MQTT)

(Gietzelt et al., 2014) and the CEN/ISO 13606, which

has been designed to support the semantic

interoperability of the communications between EHR

(Torres Zenteno et al., 2016). The standards applied

were not reported in three cases (Alberts et al., 2014;

Galligioni et al., 2015; Jung et al., 2014).

Finally, concerning the methods used to validate

the proposed interoperability solutions (Table 3): in

one of the cases, the evaluation was carried out by

meaningful use (Lee et al., 2013); in another case,

after laboratory tested, it was adopted as a routine in

two hospitals, having also been investigated its

usability and acceptance within professionals using

the system (Galligioni et al., 2015); and in other cases

the options were the proof of concept (Mihaylov et

al., 2015), simulation (Torres Zenteno et al., 2016)

and clinical trial (Park et al., 2016). In the remaining

three cases (Alberts et al., 2014; Gietzelt et al., 2014;

Jung et al., 2014) the validation methods were not

reported.

As an example, a clinical trial was carried out to

evaluate the transmission error rate for the measured

vital signs transmitted from PHD to a mHealth

application and from this to PHR Systems (Park et al.,

2016). Another case was the technological platform

that was tested with clinician staff, researchers,

electronic support staff and actors playing patients

role, having been defined several scenarios to test the

technological structure, being stated that, after this

phase, the platform would be tested with patients

suffering from clinical suspicion of stroke (Torres

Zenteno et al., 2016).

4 CONCLUSIONS

The first relevant conclusion concerning the retrieved

references is that in all the solutions reported the

focus is on guaranteeing integration of information,

being stated in every case that the resulting

information is ready to be integrated in the health care

service provision, although in only half of the cases

the details concerning this issue, are given more

objectively. The integration of information from

existing eHealth applications to provide integrated

data analysis is a central concern and current

solutions are considered to lack interoperability and

obstruct the establishment of a remote patient

monitoring solution market.

The design and implementation of eHealth

applications has not yet reached its potential in terms

of impact it can have on health care provision, and

interoperability is assumed as being an essential

requirement of HIT for the need to integrate patient

care into a diversity of settings and care providers.

Therefore, EHR systems should not only provide

access to patients’ clinical information, but also as a

true clinical decision support method, have the ability

to access and integrate patients’ clinical information

that is collected throughout their lives.

This is particularly important when dealing with

home monitoring of clinical and non-clinical

parameters recorded in daily life using various PHD.

So that the provision of remote medical services is

possible, the PHD should be connected in conjunction

with the institutional EHR systems as the occasion

demands.

This envisaged scenario is constrained by the lack

of implementations based on standardized

Interoperability in Pervasive Health: Is It Tackled as a Priority?

information models that have same information

content and transmission purposes.

The results of the systematic review presented in

this article show that interoperability is not the major

concern of a significant number of current

technological developments. Indeed, it should be

emphasized that of the 2778 initial references only

2% (61 references) explicitly mentioned the issue of

interoperability. Moreover, within these 61

references assessed for inclusion, only eight

corresponded to end-to-end solutions, since the

information produced could be integrated into the

health care service provision, where interoperability

was considered an effective concern. Furthermore,

within these eight references only one refers

standards specifically related to semantic

interoperability, used in a system whose validation is

not yet reported.

So, and despite the developments that have been

made in this area, there seems to be a lack of

integration in the care chain, which may indicate the

need to give greater priority to the issue of

interoperability of PHD, both semantic and

technological.

ACKNOWLEDGEMENTS

This work was partially supported by COMPETE

2020 - Programa Operacional Competitividade e

Internacionalização, Sistema de Incentivos à

Investigação e Desenvolvimento Tecnológico (SI

I&DT), under the project Social Cooperation for

Integrated Assisted Living (SOCIAL).

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