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Although most digital twin (DT) applications for health care have emerged in precision medicine, DTs can potentially support the overall health care process. DTs (twinned systems, processes, and products) can be used to optimize flows, improve performance, improve health outcomes, and improve the experiences of patients, doctors, and other stakeholders with minimal risk.
This paper aims to review applications of DT systems, products, and processes as well as analyze the potential of these applications for improving health care management and the challenges associated with this emerging technology.
We performed a rapid review of the literature and reported available studies on DTs and their applications in health care management. We searched 5 databases for studies published between January 2002 and January 2022 and included peer-reviewed studies written in English. We excluded studies reporting DT usage to support health care practice (organ transplant, precision medicine, etc). Studies were analyzed based on their contribution toward DT technology to improve user experience in health care from human factors and systems engineering perspectives, accounting for the type of impact (product, process, or performance/system level). Challenges related to the adoption of DTs were also summarized.
The DT-related studies aimed at managing health care systems have been growing over time from 0 studies in 2002 to 17 in 2022, with 7 published in 2021 (N=17 studies). The findings reported on applications categorized by DT type (system: n=8; process: n=5; product: n=4) and their contributions or functions. We identified 4 main functions of DTs in health care management including safety management (n=3), information management (n=2), health management and well-being promotion (n=3), and operational control (n=9). DTs used in health care systems management have the potential to avoid unintended or unexpected harm to people during the provision of health care processes. They also can help identify crisis-related threats to a system and control the impacts. In addition, DTs ensure privacy, security, and real-time information access to all stakeholders. Furthermore, they are beneficial in empowering self-care abilities by enabling health management practices and providing high system efficiency levels by ensuring that health care facilities run smoothly and offer high-quality care to every patient.
The use of DTs for health care systems management is an emerging topic. This can be seen in the limited literature supporting this technology. However, DTs are increasingly being used to ensure patient safety and well-being in an organized system. Thus, further studies aiming to address the challenges of health care systems challenges and improve their performance should investigate the potential of DT technology. In addition, such technologies should embed human factors and ergonomics principles to ensure better design and more successful impact on patient and doctor experiences.
One of the fastest growing sectors of the global economy is the health care industry [
Meanwhile, a revolution toward an intelligent industry or “Industry 4.0” combining advanced technologies emerged in 2011 [
In this context, this rapid review aims to highlight what DTs have accomplished in correlation with health care management support. We intend to cover the interventions that used DTs (products, processes, systems) to improve the management of medical services. We report the DT type and its role in the system (function). This classification of DTs is adopted from Siemens, classifying DTs into 3 types, with 1 related to processes (eg, production), 1 related to product design, and 1 related to system performance (eg, performance) [
Types of digital twins.
We performed a rapid review of studies involving DT technology to improve health care services management. Rapid reviews are a form of evidence synthesis that can provide timelier decision-making information than standard systematic reviews. They are suitable for emerging research topics where systematic reviews are unpractical [
Our protocol was registered on January 28, 2022, with the Open Science Framework [
We searched PubMed, Web of Science, IEEE Xplore, Scopus, and ScienceDirect using “digital twin” and “health” as the keywords. The studies included journal and conference articles that covered only the health care applications of DTs (no industrial, manufacturing, or energy-related initiatives). We excluded the following types of studies: studies published in a language other than English; reviews, short communications, and briefs not reporting the impact of DTs through empirical studies and approaches; papers that are not peer-reviewed; studies that present an initiative to support a medical practice (precision medicine, organ transplant, etc).
Studies are discussed based on the contribution of DTs to improving user experience in health care from human factors and systems engineering perspectives, accounting for the type of impact (product, process, or performance/system level).
Of all the sources found, 72 papers were screened comprehensively, and 17 papers were included in this review. The screening process is summarized in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram shown in
Even though very few articles matched our scope, the research trend is evolving. The selected papers covered different application areas, including process development (n=5), a system improvement initiative (n=8), and developing/designing and testing a product (n=4). We adhered to conventions for narrative reviews by combining our results with interpretations and discussion in the Results and Discussion sections.
We identified 4 main functions that DTs perform in managing health care systems. We summarize the functions and their adopted definitions in
PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram of the article selection process.
Functions of digital twins identified in this study.
Function | Definition |
Safety management | Avoiding unintended or unexpected harm to people during the provision of health care processes; identifying crisis-related threats to a system and helping control the impacts |
Operational control | Ensuring high system efficiency levels by making sure that health care facilities run smoothly and offer high-quality care to every patient |
Information management | Ensuring privacy, security, and real-time information access to stakeholders |
Health management and well-being promotion | Empowering self-care abilities by enabling health management practices |
These technologies have the potential to avoid unintended or unexpected harm to people during the provision of health care processes and identify crisis-related threats to a system and help control the impacts, which we define as safety management. They are also used to ensure privacy, security, and real-time information access to all stakeholders, which can be considered information management. Another function identified is well-being promotion and health management, where DTs empower the self-care abilities of patients by enabling health management practices. The last function is operational control and management. This technology has the potential to ensure a high system efficiency level by ensuring that health care facilities run smoothly and offer high-quality care to every patient.
Our findings are presented per the function of DTs (safety management, information management, health management and well-being promotion, and operational control). The operational control findings are presented in 5 subparts (process control of anomalies, scheduling of interventions, resource allocation, operation optimization, and strategy optimization). After presenting the state of the art of DT use, we present the challenges associated with the use and implementation of DTs, followed by the limitations of our study.
Functions and key findings.
Function and type of DTa | Key findings | ||
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System (Jovanović et al, 2021) [ |
The DT used allows management of the infection peak and development of precisely targeted vaccination strategies that allow targeting based on individuals' number of social contacts. | |
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System (Talukder, 2021) [ |
A DT architecture is proposed to ensure safety within an ecosystem disrupted by COVID-19. It mitigates the system challenges and increases patient safety in post–COVID-19 health care delivery. | |
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System (Alrashed et al, 2022) [ |
A DT was used to simulate the different possible strategies and scenarios to predict the spread of the COVID-19 virus and minimize the impacts while ensuring continuity in providing services to citizens. | |
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Product (Lutze, 2019) [ |
DTs embedded in wearable devices were used to gather personal information to make group or system decisions. | |
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System (Pang et al, 2021) [ |
A city DT was developed based on federated learning principles to serve as a local central server of information. It allows centralizing information, sharing knowledge, sharing local strategies, and sharing responses to adopted plans in real time among multiple cities. | |
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Product (Díaz et al, 2021) [ |
The DT developed (DTCoach) serves as not only an accompanying educator but also as a mentor that can be used on portable devices like smartphones. It enables web-based pose estimation and performance measurement by providing a person-centered digital coaching experience with a platform that serves as a coach, an accompanying educator, and a mentor who can help make the necessary adjustments based on the individuals' capabilities. | |
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Product (Liu et al, 2019) [ |
The suggested cloud-based system, ClouDTH, uses personal data from digitally twinned wearable medical devices to achieve interaction and convergence between physical and virtual medical spaces to facilitate personal health management for elderly patients. | |
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Product (Tröbinger et al, 2021) [ |
The DT product developed serves as an alternative to telemedicine solutions. It presents a new approach to the remote doctor visit. The dual doctor-patient twin paradigm involves 2 robotic systems (patient GARMI, doctor MUCKI). Control, interaction, and knowledge transfer are enhanced by artificial intelligence, visual motion, and facial expression analysis in the DT. Thus, it enables a transparent remote doctor visit and better-informed and robot-assisted telerehabilitation with bidirectional telepresence control. | |
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Process (Nonnemann et al, 2019) [ |
DTs of the processes in an ICUb station are integrated into a system (Health@Hand) to allow remote monitoring; it detects faults and anomalies immediately and will enable interventions at an early stage. | |
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Process (Chase et al, 2021) [ |
DTs of the processes are used to optimize the interventions in a medical ICU. They aim to optimize patient care by clinical staff at the enterprise level for more productivity and quality improvement. | |
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System |
The hospital's DT proposed developing a predictive decision support model that employs real-time services data drawn from these systems and devices. This model enables assessing the efficiency of existing health care delivery systems and evaluating the impact of changes in services without disrupting the daily activities of the hospital. It allows foreseeing the effectiveness of changes in the models before they are applied in reality. | |
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System (Augusto et al, 2018) [ |
The DT of an emergency unit is developed to optimize the pathway of patient care in the unit. The system accounts for various arrival processes to account for massive arrivals in case of a crisis and determine the best available leverages to optimize the operations of the system. | |
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Process (Mylrea et al, 2021) [ |
BioSecure DT monitors every step in the supply chain process to ensure good productivity and cybersecurity by applying Cyber-Informed Engineering. | |
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Process (Karakra et al, 2019) [ |
It predicts the near future and monitors the processes in real time through the HospiT'Win (DT) system. It allows detection of unexpected situations before problems occur in real life (delay, change in schedule, etc). It will enable the tracking of data flow from the real world to the virtual world. | |
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System (Karakra et al, 2020) [ |
Using discrete event simulation and DTs through a system called HospiT'Win allows tracking the pathways of patients inside the health care organization to manage growing demand and decrease waiting times and delays. The solution enhances resilience to sustain critical operations under expected and unexpected conditions. It conveys key information to decision-makers in real time. | |
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System (Rodríguez-Aguilar et al, 2020) [ |
The DT of the health care system is developed to better respond to contingencies and ensure optimal allocation of available resources in a DHPESc. | |
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Process (Croatti et al, 2020) [ |
A trauma DT is used to digitalize and support the process of severe trauma management, considering it as a physical asset that is mirrored by 2 DTs. |
aDT: digital twin.
bICU: intensive care unit.
cDHPES: Digital Health Public Emergency System.
Health care has evolved away from focusing solely on illness toward primary health care and health promotion, considering health care as a complex ecosystem [
The goal of the patient safety movement is to reduce adverse outcomes or injuries resulting from health care processes. It is imperative that these adverse outcomes are avoided, prevented, or minimized [
Our study found different DT applications (n=3) that contribute to patient and system safety management through system twinning and product twinning. For instance, an opportunity that DT developers seized was the COVID-19 safety crisis within the health care ecosystem [
Although the applications of DT technology in patient safety were inspired by COVID-19, it is essential to investigate its potential in other settings and crisis situations. In addition, this technology helps address safety issues in health care without interrupting day-to-day work; it can also be used to address other medical safety issues, such as surgical errors, workplace safety issues, and medical bias in diagnosis.
The American Health Information Management Association describes health information management as the process of collecting, analyzing, and securing digital and traditional medical records that are vital to providing quality patient care [
According to Lutze [
Another example of an information management DT was suggested by Pang et al [
Health and well-being goals are challenging to achieve for many individuals. In response to this challenge, a growing number of technologies are being developed to improve people's diet, physical activity, sleep, and mental health. By promoting behavior change and controlling health care costs through modern digital health interventions, people can maintain better health and a healthier lifestyle. Today, a variety of sensors are miniaturized and widely used to track basic physiological indicators on the move to help with better health and well-being management. Moreover, because smartphones are extremely easy to access, mobile health apps are currently considered the most beneficial platform for promoting healthy lifestyles and changing behavior [
In our review, we found that DTs were used for health management and well-being promotion (n=3). One such DT was introduced by Díaz et al [
Another example was ClouDTH, suggested by Liu et al [
Operating a health care facility on a day-to-day basis impacts patient experiences and organizational goals [
Detecting anomalies in processes is essential to prevent hazards and predict the corrective actions that need to be implemented. With some interventions, such as the solution suggested by Croatti et al [
Another example is Health@Hand, suggested by Nonnemann et al [
One of the challenges in health care is providing an optimized scheduling strategy that can effectively use the hospital's resources and prevent delays, errors, and long lengths of stay. An application in the same settings (ICU and process twins) was developed by Chase et al [
Another DT initiative called HospiT'Win was developed to manage the patients' pathways inside the hospitals [
Some operational strategies need to be implemented first to evaluate their efficiency. In hospitals, evaluating interventions would disrupt the daily services and activities of the units. This is where DTs could be most useful. Karakra et al [
Providing patients safe and high-quality care is a demanding process. A DT framework for a system is proposed by Augusto et al [
A DT system would provide patients with a safe and secure monitoring option; medical staff would have safe and secure monitoring methods, and authorities would be able to track extreme crisis scenarios in real time accurately. However, digital twinning is facing many challenges that are hindering its growth. The first obstacle is the infrastructure of data flow. For example, to prevent false positives in the digitally twinned sensors, we need a good understanding of the variability in the personal parameters and characteristics of the users [
DTs also have the potential to offer new important pathways for various care processes in health care. For instance, strategies to improve communication and patient-centered care can be implemented digitally to evaluate their effectiveness before adopting them in real life to avoid repetitive trials that may disturb patients' pathways. In addition, some patients are hard to deal with because of their critical medical situations. Digital twinning of the care processes for these patients can give more visibility to health care professionals to understand the best possible care strategy for these patients. Furthermore, usability studies are sometimes costly in terms of facilities, equipment, and time. DTs can facilitate remote usability testing across diverse populations, accounting for their lower literacy or health literacy and individuals with cognitive or physical disabilities. They can also help testers gain time, reduce effort, and earn money while providing real-time decision support by solving recruitment problems for surveys, interviews, and clinical trials.
As illustrated in
Finally, this study also has several limitations. The included studies largely reported postintervention data, so we could not determine the preintervention-to-postintervention change or ascertain whether the intervention groups were matched at baseline for key characteristics and outcome measure scores. In addition, we may have missed some articles in our screening because the research was limited to the following databases: PubMed, Web of Science, IEEE Xplore, Scopus, and ScienceDirect.
Framework of the impact classification of digital twins from human factors and systems perspectives.
DTs are replications of systems, products, or processes that bridge reality using data and expand the same to virtual models. In medical services, DTs are primarily used in personalized medicine; however, they also have the potential to be used at the system level. These applications vary from safety to information management, health and well-being promotion, and operations control. This rapid review shows that digital twinning for health care system management is still an emerging field with considerable potential that was also used during the COVID-19 pandemic. Therefore, interdisciplinary teams from various disciplines, including human factors and ergonomics, human-computer interaction, data science, and digital health, should further investigate the potential of this technology and address the challenges that may influence the design and adoption of this technology in the health care system.
Digital Health Public Emergency System
digital twin
intensive care unit
Both SE and OA conceptualized the study and participated in the literature review, finding interpretation, and manuscript writing. Both the authors have approved the final version of the manuscript.
None declared.