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New community-based arrangements and novel technologies can empower individuals to be active participants in their health maintenance, enabling people to control and self-regulate their health and wellness and make better health- and lifestyle-related decisions. Mobile sensing technology and health systems responsive to individual profiles combined with cloud computing can expand innovation for new types of interoperable services that are consumer-oriented and community-based. This could fuel a paradigm shift in the way health care can be, or should be, provided and received, while lessening the burden on exhausted health and social care systems.
Our goal is to identify and discuss the main scientific and engineering challenges that need to be successfully addressed in delivering state-of-the-art, ubiquitous eHealth and mHealth services, including citizen-centered wellness management services, and reposition their role and potential within a broader context of diverse sociotechnical drivers, agents, and stakeholders.
We review the state-of-the-art relevant to the development and implementation of eHealth and mHealth services in critical domains. We identify and discuss scientific, engineering, and implementation-related challenges that need to be overcome to move research, development, and the market forward.
Several important advances have been identified in the fields of systems for personalized health monitoring, such as smartphone platforms and intelligent ubiquitous services. Sensors embedded in smartphones and clothes are making the unobtrusive recognition of physical activity, behavior, and lifestyle possible, and thus the deployment of platforms for health assistance and citizen empowerment. Similarly, significant advances are observed in the domain of infrastructure supporting services. Still, many technical problems remain to be solved, combined with no less challenging issues related to security, privacy, trust, and organizational dynamics.
Delivering innovative ubiquitous eHealth and mHealth services, including citizen-centered wellness and lifestyle management services, goes well beyond the development of technical solutions. For the large-scale information and communication technology-supported adoption of healthier lifestyles to take place, crucial innovations are needed in the process of making and deploying usable empowering end-user services that are trusted and user-acceptable. Such innovations require multidomain, multilevel, transdisciplinary work, grounded in theory but driven by citizens’ and health care professionals’ needs, expectations, and capabilities and matched by business ability to bring innovation to the market.
Non-communicable chronic diseases (NCD), primarily cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, are responsible for 63% of all deaths worldwide (36 million out of 57 million global deaths). More than 9 million of all deaths attributed to chronic diseases actually occur before the age of 60 [
The body of research is clearly directing policy to a paradigm shift, away from traditional disease treatment towards a person-centered individualized coproduction of health [
Technological innovations may be key to tackling the next decade’s challenge of how to use our social and economic capital to empower and motivate individuals to engage in healthier personal lifestyle choices [
Well-being is a widely used term encompassing various constructs [
Dimensions and determinants of wellness according to models in the literature [
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Research has shown that interventions for change are likely to take place, not in the traditional health care system, but rather in what sociologists have labeled “enabling spaces” [
An ecological model of factors influencing life style behaviors [
We follow a bottom-up approach for the review of state-of-the-art and beyond state-of-the-art theory and practice on personalized technology and innovations for empowering individuals to self-perceived well-being and healthy lifestyles. The question we are trying to answer is the following: What are the main sociotechnical challenges that need to be successfully addressed in delivering state-of-the-art, ubiquitous eHealth and mHealth services in the 21stcentury, including citizen-centered wellness management services for the large scale ICT-supported adoption of healthier lifestyles?
Our goal is to generate evidence on community-based, citizen-centered interventions and review key enabling technologies that can support research and bridge the gap between ICT health and social care systems [
In more detail, this paper is structured as follows. First, we present the state-of-the-art technologies in the areas of personalized health monitoring systems, activity profiling, lifestyle capturing, and infrastructure supporting services, highlighting challenges in development and deployment of such technological solutions. Second, from the stakeholders’ standpoint, we present a vision on specific key concepts that would channel a leap forward, that is, person-centered ICT-based innovations, ushering in a new generation of services enabling changes at the personal level and a paradigmatic shift in health and social care systems. These technologies could be used to achieve personalized healthy lifestyles, wellness, and well-being through individual empowerment and engagement and effective self-management. We highlight and discuss specific innovations that would be able to support personalized healthy lifestyles and well-being for the public. Third, we discuss important drawbacks and pitfalls that must be addressed for the effective use of high-quality technological solutions that are able to serve people through secure, safe, and trustable innovative services to take place.
Personalized health systems and pervasive mobile monitoring can enable sensing, mining, and learning of human behaviors and intentions. Examples include personalized mobile information delivery, context aware social networking, device and environment customization, serious games and entertainment, education, safety, and mobile business [
Smartphones are rapidly becoming the central computing, sensing (large number of sensors embedded), and communication platform for deploying personalized wellness mobile apps and services [
Existing research [
Sensor-enabled mobile phones have the potential to collect
Advances in human-centric sensing are being fueled by the combination of sensor data and classification models to recognize human activities [
A major challenge is to develop innovative personalized technologies that can help individuals maintain healthy lifestyles and wellness by keeping track of their everyday activities. Today, we have a plethora of apps and services supported by modern smartphones and mobile apps using embedded or external sensing devices. Most of these smart well-being tracking systems focus on capturing physical activity, fitness, and sleep patterns [
A recent study analyzed the content of many popular free apps related to physical activity and compared them against existing guidelines and fitness principles already established by the American College of Sports Medicine (ACSM) [
Human activity recognition is a challenging problem for context-aware systems and apps. Research in this field has mainly adopted techniques based on supervised learning algorithms, but these systems suffer from scalability issues with respect to number of processed activities and richness of contextual data [
Recent research has shown that emotions can now be recognized more accurately by machine learning algorithms than by laypersons [
In recent years, there have been many developments in the area of natural user interfaces, from touch screens to assistants integrating dialogue capabilities. Intelligent assistants that interact with users via conversational natural spoken language can provide them with meaningful and easily understandable information and advices (eg, about their prescribed medications) [
Large amounts of data currently sit in different silos within health and social care systems. If these data were to be released in an appropriate manner and used effectively, they could transform the way care is provided [
Nevertheless, cloud computing is also benefiting the health care sector and the wellness management domain [
The benefits that motivate organizations to move towards this direction include higher productivity and better time management. Health care providers are willing to store and share electronic medical records via the cloud and hence remove the geographical dependence between health care provider and patient [
However, the cloud is susceptible to privacy and security attacks, many of which occur from within the cloud providers themselves as they have direct access to stored data [
With the adoption of electronic health services, an opportunity exists for the creation of longitudinal health records that span many decades and aggregate data from multiple health care organizations’ source for delivering care. The need for standards for the representation and exchange of medical information becomes apparent. As defined by the Health Information Management Systems Society, an electronic health record (EHR) “is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.” According to the report of the National Institutes of Health (National Center for Research Resources) on EHRs, three main organizations create standards related to EHRs: the Health Level Seven (HL7), the Comité Européen de Normalisation - Technical Committee (CEN TC) 215, and the American Society for Testing and Materials (ASTM). HL7, which operates in the United States, develops the most widely used health care‒related electronic data exchange standards in North America. CEN TC 215, which operates in 19 European member states, is the preeminent organization developing health care information technology (IT) standards in Europe. Both HL7 and CEN collaborate with the ASTM, which is mainly used by commercial laboratory vendors. EHRs today use both technical and clinical standards. However, EHR vendors have implemented only some standards, while having a great deal of variation in their implementations, which results in systems that cannot interoperate and for which secondary use of data, for example, research and epidemiology, is difficult. Current EHR systems, due to their evolution over time, are often just an electronic representation of the previously used paper records. They are highly idiosyncratic, vendor-specific realizations of patient record subsets. They adopt few, if any, health information standards and very rarely accommodate controlled terminologies where they might be sensible.
A variety of health care communication standards has also been developed during the last decade. Their goal is to improve the interoperability and the connectivity among devices, computerized systems, tablets, smartphones, and health information systems, standardizing the content and structure of the information exchanged. Within the EU region, qualified medical devices and software depend on whether or not the device or software falls within the scope of the Medical Devices Directive (ie, 2007/47/EC). Currently, the directive states that software can indeed be qualified as a medical device, but unfortunately it does not specify what exact kind of software will meet the medical device definition per se.
The Continua Health Alliance guidelines [
People do not experience technology. They experience services, made available by technology [
The Semantic Web aims at a machine interpretable view of the World Wide Web. It focuses on structuring the Web based on content categorization to improve aspects such as automatic discovery, composition, invocation, and interoperation of services. The Semantic Web stack includes a number of technologies and standards aimed at this purpose (eg, Resource Description Framework or Web Ontology Language (OWL), SPARQL).
In the domain of health and wellness, a state-of-the-art example using semantic description is the GoPubMed [
One key problem with working with ontologies is that application ontologies tend to jeopardize the aim of ontology-based semantic interoperability to work with generalized references in the given domain. With respect to the biomedical arena, a suite of quality-checked, interoperable domain ontologies is being developed [
In this section, we discuss person-centered developments for the adoption of healthier lifestyles that are beyond the state-of-the-art. We emphasize the perspective of overarching ICT-supported innovations to influence the way health is maintained. Acquire, profile, represent, persuade, assess, manage, connect, and respond are some of the essential capabilities/functions/services needed to create innovative user-centered approaches.
A change toward healthier lifestyles is both attainable and urgent, given the current situation in most western world economies. Research shows that ICT resources and health behavior interventions can be brought together to make it feasible and effective, improve health outcomes, and bring down costs [
In order to go beyond the state-of-the-art, the user must be brought in as an active participant to care processes and related decision-making processes. To allow informed decision making, we need to advance intelligent user profiling and understandable instruction information to users. We need to enable interaction with Internet-of-Things (IoT) resources and services to retrieve and transmit information to users in simple everyday devices, such as mobile phones, smart watches, and home appliances [
Healthy lifestyle change is attainable but not always easy to achieve, and sustaining behaviors, including use of ICT-based health-related programs, might be particularly challenging. Crucial evolution is needed in the process of making the essential information available and usable for the users, helping a person make a decision, and developing and deploying usable empowering end-user services that are accepted and enjoyed [
Many techniques have been proposed to automatically recognize human activities. Most important approaches use either statistical or symbolic reasoning. However, to date, these methods have mainly been considered separately. Proposed statistical activity recognition techniques differ on the kind and number of used sensors, activities considered, learning algorithms adopted, and many other parameters. One research direction focuses on using video with sound, image, and scene recognition software [
One of the main limitations of these early systems was the fact that they did not consider contextual information (eg, current location, environmental conditions, and surrounding objects) that could be used to derive user activity. On the other hand, the recognition of complex activities like social ones (eg, work meetings, friendly chat) is particularly challenging and is hard to achieve by the use of solely statistical methods. Indeed, complex activities can be better recognized by considering constraints and relationships among context data that can be neither directly acquired from sensors nor derived through statistical reasoning alone.
As a result of these constraints, there is a growing interest in the use of ontology-based techniques to automatically recognize complex context data such as human activities. While most activity recognition systems rely on data-driven approaches, the use of knowledge-driven techniques is gaining increasing interest. Research in this field has mainly focused on the use of ontologies to specify the semantics of activities and ontological reasoning to recognize them based on context information. In particular, in the area of pervasive computing, OWL DL has been used to build activity ontologies and to recognize activities based on context data [
Intelligent user profiling [
User context is of great importance in the area of health, healthy lifestyles, and wellness management to characterize a situation of an entity [
To obtain and build a user profile, the information can be provided explicitly by the user or be obtained through implicit observation of user actions. The simplest way of obtaining information about users is through the data they submit via forms or other user interfaces provided for this purpose. Especially for patients, their profile information is commonly assessed by patient-reported outcome measures (PROMs) including health-related quality of life information. PROMs can be defined as “reports coming directly from patients about how they function or feel in relation to a health condition and its therapy, without interpretation of the patients’ responses by physician or anyone else” [
Adopting healthy lifestyles is one of the biggest opportunities for preventing chronic diseases. A great interest among researchers is how to explore the use of ICT to change behaviors, a field that has been baptized persuasive technology [
Early findings suggest that combining tracking and statistical learning, user’s psycho-emotional characteristics and context information, could personalize persuasive technology [
Lifestyle choices greatly affect healthy aging. Still, accurate quantitative diagnostic tests assessing neurodegenerative diseases and cognitive function remain a challenging problem [
New care models incorporating advanced ICTs have the potential to provide service platforms able to improve health care, personalization, inclusion, and empowerment of the individual [
In an Ambient Intelligence environment, various wireless and wired sensor technologies can be integrated, allowing the user to control and interact with the environment. Such innovative systems [
Future health informatics for personalized eHealth services rely on innovative technologies for transparent and continuous collection of evidence-based medical information at any time, from anywhere and despite the coverage and availability of communication means. In light of this transformation and change, ICT serves as the catalyst for accelerating the preparedness of all traditional players and to assist all actuators to evolve in envisaged future health care models and systems. Disruption and delay tolerant networking is a novel approach for next-generation eHealth information services where end-to-end homogeneous networking connectivity is not always available [
Personal health record (PHR) systems are an important, innovative, and constantly evolving area that empowers patients to take a more active role in their own health and make informed decisions. One of the most promising aspects of PHRs is to improve health care delivery and reduce costs. The primary goal of a PHR system is to provide the patient with the ability to maintain and manage their PHR, a “systematic collection of information about an individual’s health and health care, stored in electronic format” [
Technological innovations to foster personalized healthy living and wellness could dramatically improve our ability to sense, monitor, and manage our health status and contribute to a change of paradigm in health care. Yet, misuse of technology and, above all, personal data generated through them, may lead to substantial deleterious effects. Below, we discuss important drawbacks and pitfalls that must be addressed for the use of services supported in such technologies to be perceived as secure, safe, and trustable and to be adopted at a greater level than today.
The objective of a secure system is to protect sensitive health information from unauthorized access, manipulation, and misuse. The protection goals that ascribe the requirements of a secure system are defined by the following objectives: authentication, authorization, confidentiality, integrity, accountability, and non-repudiation. It is essential that intelligent pervasive health care solutions are developed and correctly integrated to assist health care professionals in delivering high levels of patient care [
The face of health care is changing as new technologies are being incorporated into the existing infrastructure. The population of new technologies could possible dramatically improve our ability to detect, monitor, and address lifestyles and wellness but also could cause substantial deleterious effects. Adoption of technological innovation to support personalized healthy lifestyles and well-being depends on the extent that public concerns about privacy, confidentiality, and security of online data are addressed. Today there is a rapidly growing market of online apps and social media tools for health, with little focus on the issues of ownership and protection of data [
A huge volume of data is generated and is expected to increase by the use of future services either intentionally by users or automatically by networked devices, such as information appliances and sensors. Product developers and policy makers will need to proactively balance public concerns about privacy protection with the information-sharing needs of some business models and public health programs. Policies, regulatory and otherwise, will need to keep pace with technologic innovation.
A cloud infrastructure, for example, is susceptible to many privacy and security attacks [
In order to foster trust, users must receive clear and objective information about the benefits and risks associated with the use of the new systems and services. Since sensitive health and lifestyle data are going to be processed, measures must be taken in order to protect the data, stored and in transit, against unauthorized disclosure or access, accidental or unlawful destruction, or accidental loss or alteration according to Article 17 (1) of the Data Protection Directive (Directive 95/46/EC). When one considers the requirements imposed by standards or other regulations, such as the requirements for the fair and lawful processing of data established by the European Data Protection Directive [
Many of these innovations will be complex and would need to be networked to and operate in conjunction with other existing services and applications. Ensuring interoperability is fundamental in order to minimize the risk of disruption when integrating heterogeneous services. This can be achieved by using quality and evaluation processes throughout the development life cycle and stable architectural description plans [
Advances in the theory of the brain, neuroscience and the mechanisms of behavior modification [
ICT offers a promising new approach toward wellness throughout the lifespan, by fostering and supporting the active and meaningful participation of individuals in their health management. At the same time, it can maximize the information flow with clinicians and open new horizons for individualized medicine approaches based on multilevel personal data.
In order to realize this paradigm shift towards citizen empowerment and engagement in health and well-being production, it is clear that a new generation of ubiquitous and convergent network and service infrastructures is required. Their function will be to sustain the construction and the deployment of highly personalized, scalable, flexible, manageable, context-aware, dependable, and secure services incorporating resources in a holistic seamless ecosystem [
Enormous challenges remain and multidisciplinary approaches are required to engineer an information infrastructure that ensures privacy and supports intelligent and personalized user-computer interaction, innovative conversional agents and assistants with emphasis on a citizen’s engagement and empowerment. Computer-delivered interventions can lead to better behavioral health outcomes, post-intervention improvements in health-related knowledge, attitudes, and intentions as well as positive changes in health behaviors such as dietary intake, tobacco use, substance use, safer sexual behavior, binge/purging behaviors, and general health maintenance [
The primary challenge for relevant future innovations is to utilize and modify existing technology with an emphasis on mobile communication technology and devices to (1) create new models of impact on chronic disease development able to empower individuals to adopt and sustain changes towards healthy choices (eg, nutritional habits, physical activity, stress management, sleep, anxiety, depression, meaningful social interaction, and networking) and to inform decisions makers and funding bodies on the best available choices; (2) create positive and personally motivating marketing strategies for individuals to become engaged and motivated to improve their own health on the following pillars: sensing and assessing individualized health behaviors and status, providing feedback tailored to psychosocial profiles, incorporating end users in the development of the technology, creating strong relationships for ownership and empowerment, and connecting the individual to community-based support/capacity structures to boost, encourage, sustain, and integrate their own self-regulating efforts; (3) use and improve available health supporting services for sensing and early detection of risky health behaviors; (4) develop an ecosystem of community-based capacity to support individuals who choose to be coproducers of healthy lifestyles in all levels of health care delivery (primary, secondary, tertiary); (5) provide a “proof of concept” of this model of integrated person-centered healthier lifestyle and well-being through ICT; and (6) create appropriate business models of community-integrated elements for health coproduction across cultural milieu, able to foster the scaling up of results and to bring social and technological innovation to the market.
In achieving such a paradigmatic shift, it is critical to provide smart ubiquitous services and systems advancing the current state-of-the-art in a number of domains relevant for risk factors that may influence directly or indirectly an individual’s wellness and well-being and lifestyle behaviors: (1) smart and ubiquitous sensor fusion and Internet of things services to allow health-related information to be aggregated and transmitted for remote monitoring and response, to support personalized/individualized multilevel patient/citizen-centered health care services; (2) assistant/coaching services for wellness management enabling citizens to manage their health and well-being; (3) intelligent decision-making support services through the combination of understanding with the ability to influence decisions by communicating subjective values, helping to select interventions, assessing outcomes, and providing feedback to the user; (3) novel mechanisms and services to support self-efficacy confidence that the individual can perform a given behavior, including decision making and a belief in their ability to change the situation; (4) ubiquitous just-in time support services with mechanisms that incorporate known principles of health behavior change, based on the user’s biopsychosocial profiling with representations of motivation cues and techniques for overcoming barriers to change; (5) ecosystems and personalized health promoting services managing multilevel information and medical data from multidisciplinary domains, including the health and social care systems; (6) service infrastructures able to support unified data access, management, presentation, sharing, and security, based on specific user requirements and engagement; (7) linkage services, able to connect government agencies and authorities to allow official public health structures to use the coming innovation for preventing diseases and promoting health through organized efforts and informed societal choices of public and private organizations, communities, and individuals; (8) train for the health and social care workforce in the utility of ICT; and (9) programs able to generate large population-based evidence on the efficacy and cost effectiveness of this paradigm shift.
This paper focuses on innovative and meaningful ways to empower and engage individual citizens into sharing knowledge and awareness and becoming coproducers of their health and wellness through the adoption of eHealth and mHealth technology. This personal choice to being coproducer of one’s own health and wellness will have a ripple effect in both the way health is produced and maintained as well as on the kind of models and enterprises that can sprout in the communities of individual users.
Despite the innovative approach and expected results, such a paradigmatic shift cannot happen by overriding existing wellness and chronic disease management practices and services. Change needs to happen with and within current arrangements. In order to support and strengthen such movement, a number of trends would need to be supported by future research: (1) Evidence depends on the implementation of large-scale solutions based on innovative services, by means of a patient-centered approach that must also address the issue of comorbidities and their management; (2) Outcomes must be validated, strengthening the evidence for chronic disease management, through robust health technology assessment for effectiveness, quality, and continuity of care, personalization, cost-efficiency, satisfaction of the users, and transferability; (3) The rollout of services should be preceded by the development of guidelines to identify profiles of patients who may benefit from the provision of such services (condition, age, severity of the condition, comorbidity, socioeconomic status, and any other relevant factors); (4) Conditions for building on top of existing solutions and reuse, when possible, established and scientifically validated methodologies must be studied, and public national and regional authorities that act today as eHealth service providers must be involved; (5) Scale-up will depend on the dissemination and exploitation of good practices and coaching of early adopters and followers on how to effectively connect to the existing traditional health care system; (6) Assuring security and privacy in digital environments through stronger and transparent mechanisms, as predecessors of safety and trust, is of fundamental importance; providers need to realize that trust is a factor perceived by the user based on a dynamic process and it must be cared over time; and (7) The complex, changing needs of a mobile society will increasingly push for an agenda where all the above aspects will meet under cross-border deployment of health and wellness management services, and issues of interoperability, quality, and care standards will regain importance.
The challenge today is to facilitate the adoption and use of ICT tools that go beyond the current state-of-the-art, as described in this paper, not only by the engaged young population but also by the unengaged older people who are in urgent need of behavior change towards healthier life habits. We need health data to flow back to its owners so they can manage their own health and improve their own health metrics. The evidence so far suggests that these services need to be easily accessible, enjoyable, connected to people’s everyday life activities, and adapted to the end-user’s physiological and age-related changes. It is also important to educate the medical and social systems on the use and benefits of these technologies for achieving the desired health outcomes. By introducing such innovations within the health care system, we can promote community capacity and social engagement through better and healthier behavior and lifestyle of individuals.
American College of Sports Medicine
American Society for Testing and Materials
Comité Européen de Normalisation - Technical Committee
electronic health record
global positioning system
health device profile
Health Level Seven
information and communication technology
information technology
non-communicable chronic diseases
service-oriented architecture
service-oriented device architecture
This study is part of the work being conducted by some of MISTRAL (Multimodal Interventions Supported by Information and Communication Technology Building Resilience for Frailty Prevention) partners, in the context of the commitment participation and contribution to the European Innovation Partnership on Active Healthy Aging (EIPAHA). The work was partially supported from MyHealthAvatar project (FP7-ICT-2011.5.2) funded by the European Commission under the 7th Framework Programme, and SpeechXRays project (H2020-DS-2014-2015 No. 653586) funded by the European Commission under the H2020-DS-2014-1 Framework Programme.
EGS and SS have contributed to conception and design, acquisition of data, analysis and interpretation of data, drafting or revising the manuscript critically for important intellectual content, and final approval of the version to be published. MT, VS, KM, JHJ, HdJ, and AT have contributed, by order of names in the list of authors, to the analysis and interpretation of data and revising the manuscript. CT has contributed to the conception and design, acquisition of data, analysis and interpretation of data, and drafting or revising the manuscript critically for important intellectual content, especially from the medical point of view.
None declared.