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Date of publication xxxx 00, 0000, date of current version xxxx 00, 0000.
Digital Object Identifier 10.1109/ACCESS.2017.Doi Number

Enabling Technologies for the

Internet of Health Things
1 2 2
Joel J. P. C. Rodrigues , Senior Member, IEEE, Dante B. R. Segundo , Heres A. Junqueira ,
2 2 3 4
Murilo H. Sabino , Rafael M. Prince , Jalal Al-Muhtadi , and Victor Hugo C. de Albuquerque
1
National Institute of Telecommunications (Inatel), Santa Rita do Sapucaí, MG, Brazil; Instituto de Telecomunicações, Portugal;
ITMO University, Saint Petersburg, Russia; University of Fortaleza (UNIFOR), Fortaleza, CE, Brazil
2
National Institute of Telecommunications (Inatel), Santa Rita do Sapucaí, MG, Brazil
3
College of Computer and Information Sciences (CCIS), King Saud University, Riyadh 12372, Saudi Arabia
4
Graduate Program in Applied Informatics, Laboratory of Bioinformatics, University of Fortaleza (UNIFOR), Fortaleza, CE, Brazil
Corresponding author: Joel J. P. C. Rodrigues (e-mail: [email protected]).
This work was supported by the Research Center of College of Computer and Information Sciences, King Saud University; by the National Funding from
the FCT - Fundação para a Ciência e a Tecnologia through the UID/EEA/50008/2013 Project; by the Government of Russian Federation, Grant 074-U01;
by the Brazilian National Council for Research and Development (CNPq) via Grant No. 301928/2014-2, and by FINEP, with resources from Funttel, Grant
No. 01.14.0231.00, under the Centro de Referência em Radiocomunicações - CRR project of the Instituto Nacional de Telecomunicações (Inatel), Brazil.
The authors are grateful for this support.

ABSTRACT The Internet of Things (IoT) is one of the most promising technologies for the near future.
Healthcare and well-being will receive great benefits with the evolution of this technology. This work
presents a review of techniques based on IoT for healthcare and ambient assisted living, defined as the
Internet of Health Things (IoHT), based on the most recent publications and products available in the
market from industry for this segment. Also, this work identifies the technological advances made so far,
analyzing the challenges to be overcome and provides an approach of future trends. Though selected works,
it is possible notice that further studies are important to improve current techniques and that novel concept
and technologies of Internet of Health Things are needed to overcome the identified challenges. The
presented results aim to serve as a source of information for healthcare providers, researchers, technology
specialists, and the general population to improve the Internet of Health Things.

INDEX TERMS Ambient Assisted Living, Internet of Things, Internet of Health Things, Mobile Health,
Remote Healthcare Monitoring, Wearable.

I. INTRODUCTION industry domains, such as transportation [3], healthcare [4],

A new network infrastructure is being planned and proposed smart home [5], industry automation [6], smart grid [7],
considering continuous increment of the number of among others [8].
connected devices. The academy and industry proposed a Many research companies present perspectives and trends
new vision of the Internet with the Internet of Things (IoT), for the future of IoT as well as research community proposes
considering the next generation of the Internet. IoT offers a Future Internet of Things [9]. International Data
intelligence to objects by adding them the capacity to collect Corporation (IDC) predicts that IoT will reach about a US$
and store data from different types of sensors, to perform 1.7 trillion market by 2020. Gartner expects 25 billion
actions autonomously based on actuators, coordinate connected devices by 2020 while Cisco mentions about 50
functions, and share information considering the connectivity billion. And Harvard Business Review expects 28 billion
among nodes, for example, [1, 2]. To illustrate the IoT “things” connected to the Internet [10].
vision, one can imagine a home heating system being Healthcare industry is among the fastest to embrace IoT-
controlled by a smartphone or a car driving its user to his/her based solutions. It is being considered one of the key industry
work autonomously. This scenario describes a simple remote drivers and a special concept for it, considering the IoT
control and a machine-to-machine (M2M) communications application on e-Health, aka Internet of Health Things
that also support IoT. These applications can be suited in (IoHT). There is also a 2020 projection made for IoHT.

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“MarketsAndMarkets” predicts that IoHT will be worth US$ visits a medical doctor, he/she can easily access the clinic
163.2B, commercial report claims a spending of $117B, and history of the patient. Figure 1 presents an illustration of an
McKinsey estimates an economic impact of more than US$ IoHT-based solution.
170B. All this caused by cost savings, quality of life
improvement for patients with chronic disease, and health
monitoring, which prevents disease complication [10]. It is a
fact that IoHT will create a big economy impact in the world.
Then, given this scenario, this review will present a detailed
study of the literature and relevant proposals from industry
on IoHT. The main contributions of this work are the
following: (i) review of the main available contributions
proposed by the research community and industry, (ii)
discussion about the stage of deployment of IoHT in the
world, and, (iii) identification of open issues to be explored
in further research works. Thus, this review has adopted
aspects related to the scientific fields of Internet of Things,
Biomedical Engineering, and Medicine as well as the real
needs in the daily life of a hospital, clinic, or homecare
environments, for example. Thus, due to the approach
adopted in this review, it can be considered by both a
beginner and experienced researchers, professors, specialists,
hobbyists, as well as health professionals who wishes to FIGURE 1. Illustration of an IoHT-based solution architecture.

know the latest and recent techniques studied in the IoHT.

IoHT can support many medical conditions including care
The rest of the paper is organized as follows. Section 2
for pediatric and elderly patients, the supervision of chronic
elaborates on Internet of Health Things and reviews the most
diseases, and the management of private health and fitness,
relevant proposals available in the literature. Section 3
among others. For a better study of this extensive topic, this
presents the most relevant IoHT industry proposals. Section 4
review classifies the IoHT in four generic categories: i)
presents a discussion considering both academic and industry
remote healthcare monitoring; ii) healthcare solutions based
research proposals. Section 5 concludes the work and
on smartphones; iii) ambient assisted living; and iv) wearable
suggests further research works to explore on the topic.
devices. Next sub-sections elaborate on each one.
II. INTERNET OF HEALTH THINGS A. REMOTE HEALTHCARE MONITORING
Internet of Health Things (IoHT) is basically an IoT-based Remote health monitoring technologies are normally adopted
solution that includes a network architecture that allows the by homecare, clinicians, and hospitals environments to
connection between a patient and healthcare facilities as, for remotely monitor the vital signs of an individual
example, IoT-based e-Health systems for communicating in real-time to patients, parents and physician
electrocardiography [11], heart rate [12], a possible abnormality, reducing the clinician time,
electroencephalogram [13], diabetes [14], and other different decreasing hospital costs, and improving quality of care.
kinds of monitoring of body (vital) signs based on Remote healthcare monitoring can be performed by
biomedical sensors. It includes pulse, oxygen in blood applications that acquire physiologic data from the patient to
(SPO2), airflow (breathing), body temperature, glucometer, be accessed remotely. Basically, these applications include a
galvanic skin response, blood pressure, patient position user interface (smartphones, tablets, and computers), a data
(accelerometer), and electromyography [15- 19]. collector (biosensors), and Internet connectivity. In this
The data input from patients can be collected through regard, it can be performed with the integration of IoT,
sensors and processed by applications developed for a user mobile computing and cloud storage, and a data
terminal, such as computers, smart phones, smart watches or, communication infrastructure as suggested by Machado et
even, a specific embedded device [20]. The user terminal is al., in [22]. This approach aims to capture, transmit, store,
connected to a gateway through short coverage and turn available the visualization of biomedical signals, in
communication protocols, such as, Bluetooth low energy real-time. In the same context, EcoHealth is a middleware
(BLE), Bluetooth, or 6LoWPAN (IPv6 over Low Power platform developed for IoT that connects patients, healthcare
Wireless Personal Area Networks) over the IEEE 802.15.4 providers, and devices [23]. It is a Web-based platform that
standard [21]. This gateway connects to a (clinical) server or allows data management and aims to simplify and
cloud services for data processing and storage. In the other standardize IoT applications development, addressing issues
hand, patients’ data can be stored in a health information like interoperability between different devices. Similar
system using electronic health records and, when the patient approach was developed by Serafim, in [24], an IoT-based

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network to monitor patients in rural and low population [33]. Sensors are directly connected to the users’ smartphone
density areas. Healthcare providers may analyze the data to receive the collected data. The data is processed and stored
from patients in remote locations and request emergency in the cloud to allow access and monitoring by the healthcare
assistance if necessary. Another solution, called U- providers.
Healthcare, is based on a mobile gateway for ubiquitous Qi et al., in [34], published a review on advanced Internet
healthcare systems that collects data, processes it and stores it of things enabled personalized healthcare systems (PHS)
in the cloud for remote access [25]. considering current works about IoT enabled PHS, and
An infrastructure composed by wireless body area enabling technologies, major IoT enabled applications and
network, personal server using intelligent personal digital successful case studies in healthcare, besides main challenges
assistant, and medical server tiers for remote healthcare and future perspectives about IoHT.
monitoring system is illustrated in Figure 2. Alshurafa et al., in [35], developed a prediction system
(Wanda - cardiovascular disease, CVD) to aid peoples in
reducing detected CVD risk factors, in which the individuals
received instructions by six months of technology support
and reinforcement. A prediction tool can aid clinicians and
scientists in identifying participants who may optimally
benefit from the remote health monitoring (RHM) system,
once that presented results satisfactory (F-score of 0.92),
identifying the behavior (using activity and blood pressure
signals, as well as questionnaires) during the first month of
intervention that help determine outcome success.
Abawajy et al., in [36], presented a patient health
monitoring (PPHM) system integrated cloud computing and
Internet of Things technologies, and applied in the real-time
monitoring of a patient suffering from congestive heart
FIGURE 2. Illustration of an architecture for remote healthcare failure using ECG, showing be a flexible, scalable, and
monitoring system. energy-efficient remote patient health monitoring system
very promising.
Some solutions are developed with low cost technology, Ara et al., in [37], proposed a secure privacy-preserving
such as the prototype proposed by Lima et al., in [26]. data aggregation approach based on bilinear ElGamal
Receiving pre-processed data, the supervisor system displays cryptosystem for RHM systems to improve data aggregation
it in a simple and cohesive way. The results show an efficiency and data privacy. Security analysis demonstrates
improvement of the individuals’ quality of life. An embedded that the proposed method preserves data confidentiality, data
system able to measure blood with low cost technology is authenticity, and data privacy and also is resists passive
described in [27]. Hosted by a device, a Webpage displays eavesdropping and replay attacks.
the stored data in a useful way. Healthcare providers may Nkenyereye and Jang [38] evaluated the performance of a
check the information simply by accessing the Internet. server-side JavaScript for healthcare hub server in RHM
More specific solutions are also being discussed. A remote System being 40 % faster than Apache Sling, presenting
body pressure monitoring system is proposed by Matar et al., high-performance, asynchronous, event-driven healthcare
in [28]. Applicable in sleep studies, anesthetic surgical hub server to handle an increasing number of concurrent
procedures, and other areas that wish to determinate body connections for RHM environment in remote places without
posture while lying down. A non-invasive glucose level local medical aid to local medical care.
sensing is proposed by Istepanian et al., in [29], sending Mamun et al., in [39], developed a cloud system for
patient data to healthcare professionals in real-time. Using a detecting and monitoring Parkinson patients that will enable
humidity sensor and a heart rate sensor, the prototype healthcare service in low resource setting.
proposed by Senthilkumar et al., in [30], monitors patients Ganapathy, Grewal and Castleman, in [40], evaluated a
with Sjögren syndrome. A system that monitors knee flexion remote self-monitoring of blood pressure to detect raised
on total knee arthroplasty patients is proposed by Msayib et blood pressure in pregnancy (50 women), in which 45 of
al., in [31]. The flexion angles data generated by exercise is them agreed that the remote monitoring adopted is easy to
sent for remote analysis, preventing the need of going to the use and 39 women prefer the proposed model of testing at
hospital several times a week. Also, an mHealth platform home.
capable for patients monitoring that seek cardiac
rehabilitation is discussed in Kitsiou et al., in [32]. Data B. HEALTHCARE SOLUTIONS USING SMARTPHONES
collected is sent to the cloud for remote access by healthcare Many IoHT solutions use smartphones. Moreover,
providers. A body sensors platform is discussed by Khan, in nowadays, healthcare or ambient assisted living solutions
cannot be proposed and designed without considering mobile

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health support, in [41]. In this work, applications that support Lorenzi et al., in [48], proposed a m-health wearable
diagnosis, clinical communication, providing drug references wireless sensing system for monitoring human motion
or medical education are defined as healthcare solutions disorders as, for example, freezing of gait (FoG) in
using smartphones. It aims to create a connection between Parkinsonian, and timely provide rhythmic auditory
sensors, smartphones, and the healthcare team. Since security stimulations to release the gait block, assisting the individual
is one of the main issues on IoHT, a project concerning during the daily activity. Ren et al., in [49], also proposed a
healthcare data access is proposed by Murakami et al., in user verification system leveraging unique gait patterns
[42], and aims to test mobile devices used to access data. In derived from acceleration readings (embedded within
Figure 3 is illustrated the mobile devices and apps for smartphones) to detect possible user spoofing in m-
smartphone healthcare. healthcare systems. Silsupadol, Teja and Lugade, in [50],
assessed in 34 healthy adults the performance of a
smartphone-based accelerometer in quantifying
spatiotemporal gait parameters when attached to the body or
in a bag, belt, hand, and pocket. Pepa, Verdini and Spalazzi,
in [51], used a smartphone app to acquire, process, and store
inertial sensor data and rotation matrices about device
position for gait parameters estimation during daily living.
Osmani et al., in [52], carried out a study with patients
diagnosed with bipolar disorder to detect episodes and
identify behavior changes using smartphones.
Alshurafa et al., in [53], developed a novel approach to
improve smartphone battery consumption and examine the
effects of smartphone battery lifetime on compliance for
RHM system. The same authors developed the WANDA
method, which remotely evaluate the risk of cardiovascular
disease using wearable smartphone for cardiac abnormality
FIGURE 3. Smartphone for healthcare system to store and process
electrophysiological data. recognition.
Seeger, Laerhoven and Buchmann, in [54], validated a
A simple and effective solution is proposed by Costa et al., middleware targeted for medical applications on smartphone-
in [43], to work as a medical check reminder. It automatically like platforms that relies on an event-based design to enable
sends a text message to the patient's phone one day before the flexible coupling with changing sets of wireless sensor units,
scheduled appointment with the physician. HealtheBrain is a while posing only a minor overhead on the resources and
more specific application, proposed by Shellington et al., in battery capacity of the interconnected device.
[44]. It focuses on allowing the square-stepping exercise to Poon and Friesen, in [55], proposed an automatic detection
be done by elderly people in their place of living without system of chronic wounds (color and size features) for
cognitive loss. healthcare environment using image analysis and processing
Crema et al., in [45], proposed a local biosensor and machine learning techniques embedded in a mobile app
virtualization based on a simplifying the wearables as, for (m-health system). Wang et al., in [56], considered the same
example, relying only on simple analog front ends and approach developing a novel wound image analysis system
communication interfaces, and exploiting the computational implemented solely on the Android smartphone.
capability of the smartphone, not only for implementing Velikova et al., in [57], developed the StripTest reader, a
gateway features but also for processing raw biosignals as smartphone interpreter of biochemical tests based on paper-
well, increasing the potentiality of mhealth applications. The based strip colour using image processing techniques, using
virtual sensor was evaluated in electrocardiogram signals camera phone for acquisition, processing the images within
analyzing the hearth and respiratory rates. the phone and comparing them with gold standard.
Aranki et al., in [46], developed a smartphone-based Higgins, in [58], carried out a study on benefits of using
system for real-time tele-monitoring of vital signs and medical app evaluating smartphone applications for patients'
general cardiovascular symptoms thought physical activity in health and fitness, discussing limitations of apps and future
patients with heart disease, being the main challenge to apply trends.
in diabetes and hypertension and other chronic disease. Matarazzo et al., in [59], discussed the confluence of
Barret and Topol, in [47], investigated the possibilities in emerging technologies, which can provide regular
which smartphones and the Internet of medical things can infrastructure data streams, within structural health
improve medicine, believing that smartphones has a monitoring procedures for the immediate goal of system
direct influence on individual's everyday life, which can identification and towards automated maintenance of bridges
bring great contributions to the healthcare field. from vibration data.

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Firth et al., in [60], published a review of all randomized interconnectivity, microcontrollers, communication channels,
clinical trials reporting the effects of psychological and several applications.
interventions delivered via smartphone on symptoms of Regarding patient’s location and mobility, a fall detection
anxiety (sub-clinical or diagnosed anxiety disorders), system for elderly patients is shown in several contributions,
observing, among others, a significantly greater reduction in such as in Lopes et al., in [68], Horta et al., in [69], and Mano
total anxiety scores. et al., in [70]. It monitors and detects activities such as
Chao, Meenan and Ferris, in [61], proposed and evaluated walking, running, sitting or standing up, lying down, and
the used of smartphones applied for skin monitoring and falling. Artificial intelligence integrated to IoT architecture is
automatic melanoma detection, showing that an early used to categorize each activity, in [72], as well as for
intervention, through a pre-diagnosis at home, can intrusion detection in computer networks, in [73,74]. Similar
successfully treat this disease. approach is described in Mainetti et al., in [71], a real-time
Brayboy et al., in [62], developed a free smartphone, location monitoring system for elderly people.
named Girl Talk, containing comprehensive sexual health Keeping in mind that drug compliance in AAL is one of
information, and determine the application’s desirability and the most important issues, new devices can be regarding
appeal among teenage girls. patient safety to support diabetes therapy management, for
example. This solution controls patient’s personal data and
C. AMBIENT ASSISTED LIVING connects it to the healthcare professional.
Ambient assisted living (AAL) is an IoT-based service that Bleda et al., in [75], explained the smart sensory furniture
supports care of elderly or incapacitated patients. These sensory layer (ambient assisted living system that allows
solutions wish extend the independent life of the individuals inferring a potential dangerous action of an elderly person
in their homes by providing more safety, in [63]. Connecting living alone at home) distributed signal processing technique
users to smart objects, such as blood pressure sensors and in a network of sensing objects massively distributed,
motion sensors, it is a common use of this service. AAL not physically coupled, wirelessly networked, and energy
only provides a safer environment but also increases limited.
autonomy and stimulates the user to have a more active life, Liu, Shoji and Shinkuma, in [76], proposed a logical
in [64]. In Figure 4 is presented an ambient assisted correlation-based sleep scheduling mechanism (LCSSM) to
living system overall physical architecture. implement energy-efficient wireless sensor networks in
ambient-assisted homes (AAH). LCSSM analyzes sensory
data generated by different human behaviors to detect the
logical correlations between sensor nodes in an AAH.
Rafferty et al., in [77], introduced a new method to
implementing assistive smart homes based on an intention
recognition mechanism incorporated into an intelligent agent
architecture. The method was performed across three
scenarios: (i) considered a web interface, focusing on testing
the intention recognition mechanism, (ii) and (iii) involved
retrofitting a home with sensors and providing assistance
with physical activities.
Schwiegelshohn et al., in [78], evaluated the robots in
assisted living environments with different solutions for
combining robotics and home automation/smart home for use
in ambient assisted living.
Zdravevski et al., in [79], proposed a generic feature
FIGURE 4. Illustration of an ambient assisted living system. engineering approach for selecting robust features from a
variety of sensors, which can be used for generating reliable
An IoT based architecture for AAL is proposed by Valera, classification models, reducing reduce the cost of AAL
Zamora and Skarmeta, in [65]. It is developed to solve systems by facilitating execution of algorithms on devices
problems, such as mobility and security in medical with limited resources and by using as few sensors.
environments. M-hub is another IoT software architecture, Yuan, Tie and Song, in [80], modeled and analyzed a
which uses cloud for AAL, in [66]. It is a middleware used in multi-tier AAL applications, and aims to optimize resource
mobile devices that automatically finds and connects smart provisioning while meeting requests' response time
objects. In this regard, H3IoT is an architectural framework constraint, demonstrating achieve dynamic resource
for monitoring health of elderly people, in [67]. It is provisioning while meeting the performance constraint.
composed by five IoT based layers that include sensors Yao et al., in [81], analyzed several real-world
experiments conducted for AAL-related behaviors with

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various users, showing that the Big Bang–Big Crunch internet, of the data from different sensors placed in a house
interval type-2 fuzzy-logic-based systems (BB-BC IT2FLSs) of a person having dementia.
outperform the type-1 fuzzy logic system counterparts, as Dobbins, Rawassizadeh and Momeni, in [91], collected
well as other conventional nonfuzzy techniques, and the information from tri-axial accelerometers and a heart-rate
performance improves when the number of subjects monitor to distinguish different physical activity using
increases. supervised machine learning algorithms.
Erden et al., in [82], published a survey on signal analysis
and processing techniques employed with different types of D. WEARABLE DEVICES
sensors, such as pyro-electric infrared, and vibration sensors, Wearables are smart devices that can be attached, for
accelerometers, cameras, depth sensors, and microphones, example, to the body, such as watches, shoes, or body
analyzing the increase of diseases and healthcare costs, sensors, as showed in Figure 5. Those devices should be able
shortage of caregivers, and a rise in the number of to connect to physiological transducers to display patient’s
individuals unable to live independently. signals, such as body temperature, heart rate, blood pressure,
Hossain et al., in [83], highlighted the AAL and others, in [92].
communication from several message change perspectives
and developed a general tool of alert/response with
dependable RESTful communication throughout the message
trail within a local and cloud-based environment, offering a
lightweight option to address the variability of message
change in AAL.
Parada et al., in [84], considered the RFID intelligent
system to identify user-object interactions using machine
learning techniques to enable an AAL system in a retail store
with accuracy rate of 86 %.
Machado et al., in [85], analyzed a method to allow AAL
systems to identify and predict situations that may endanger
users in their living environment, proposing a
complementary and alternative to acquire comprehension of
a former person's behavioral providing this knowledge when
cognitive impairments will occur, improving to traditional
expert systems applied to AAL.
Zschippig and Kluss, in [86], suggested to extend the
concepts of AAL, active ageing and ageing in place to the
garden. They evaluated the motivations and possible benefits
of gardening, especially in regard to managing health and
FIGURE 5. Different types of wearable technology.
well-being dynamically adapting AAL garden.
Wickramasinghe, Torres and Ranasinghe, in [87], used
heuristic and machine learning techniques to recognize ‘long- A common use of wearable devices is the use for
lie’ situations, reducing the influence of outliers in the RFID monitoring user’s physical activity, such as the system
information from location of a fall on the smart carpet with proposed by Portocarrero et al., in [93]. Devices that can be
F-score of 0.93. worn are also used to take care of elderly people. In this
Garcés et al., in [88], provided a survey on quality models context, a system developed for vital signs monitoring on
(QM) and quality attributes (QA) that are important for the elderly people in rest homes is described in Rios and Bezerra,
AAL field, investigating how QM and QA are defined, in [94]. Sensors located on the patient clothes collect data
evaluated, and adopted in the studies, making available an used to monitor their health parameters. Also, a ubiquitous
analysis of the maturity of the works selected. system for monitoring elderly patients with Alzhheimer’s is
Roy, Abidi and Abidi, in [89], proposed an activity patter described in Raad et al., in [95]. When needed, the patient
recognition method via possibilistic network-based classifiers presses a button and sends important data, such as oxygen
with uncertain observations, achieving with accuracy 79 % of saturation, blood pressure, and heart rate to the healthcare
a proposed activity. professional for analysis.
Demir et al., in [90], proposed an integrated system design More specific wearable devices are also found in the
that allows collection, recording and transmission through literature, such as the system proposed by Chen et al., in [96].
Internet of Things approach, where information from smart It enables real-time data access in the cloud and monitors
things around us can be evaluated and transmitted over the blood pressure, temperature, electrocardiogram (ECG), and
oxygen saturation. Regarding another very specific use, UCC

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is a ubiquitous health monitoring system for cardiac current industry practices of security as an afterthought or an
arrhythmias detection, in [97]. Data is captured using add-on affect the resulting device and the potential
wearable ECG sensors and it is sent to cardiologists for consequences to the user's security and privacy.
analysis. More generic systems are also found, in which Lomotey and Sriramoju, in [106], seeked out to streamline
sensors capture data to be stored and accessed in the cloud, in the process by proposing a wearable IoT data streaming
real-time. infrastructure that offers traceability of data routes from the
Thapliyal, Khalus and Labrado, in [98], published a survey originating source to the health information system. To
on Internet of Things and medical devices as alternative overcome the complexities of mapping and matching device
technologies to recognize stress and manage using cloud- data to users, they used an enhanced Petri Nets, tracking and
based services, smartphone apps and wearable smart health the possible detection of medical data compromises.
devices to aggregate and compute large data sets that track Sood and Mahajan, in [107], proposed a method to detect
stress behavior over long periods of time. and monitor the outbreak of chikungunya virus based on IoT
Spanò, Pascoli, and Iannaccone, in [99] proposed an and fog concepts in RHM system. To diagnose infected users
electrocardiogram remote monitoring system dedicated to and generate emergency alerts from fog layer the Fuzzy-C
long-term residential health monitoring integrated with means algorithm is considered.
Internet of Things. Cui et al., in [108], applied a connective and semantic
Liu and Sun, in [100], published a survey on available similarity clustering algorithm and a hierarchical
attack approaches on intelligent wearables, as well as the combinatorial test model based on finite state machine to
corresponding countermeasures, from the perspectives of solve the problem of smart wearable systems due numerous
data integrity, authenticity, and privacy, once that the states usually lead to various unanticipated problems. The
intelligent wearables are vulnerable to various cyber-attacks, FSM model of user manipulations is usually used to model
bringing up unprecedented security challenges in terms of the system design specification of a smart phone for black-
privacy leakage, financial loss, and even malicious invasion box testing
of other connected IoT components and applications.
Huang et al., in [101] evaluated the wearable devices III. IoHT INDUSTRY STATUS
embedded into individual to realize their displacement vector The growing of IoHT is experiencing a great debate and
in mobile environments, thus estimating their own locations exploration. New start-ups, companies, and multinationals
with main aim of walking prediction mechanism to increase corporations are taking a step towards that might be a giant
localisation accuracy, demonstrating that the used approach market and empowering products and advances. Table I
achieves lower localisation error in various moving speeds. presents a compilation of these solutions for better
Guía et al., in [102], investigated the benefits of using understanding the IoHT solutions available now. For each
wearable and Internet-of-Things technologies in streamlining identified solution, it is considered the provided service, the
the creation of such realistic task-based language learning company and the available product as well as a brief
scenarios, showing that the use of these approaches will description of its characteristics.
prove beneficial by freeing the instructors of having to keep
records of the tasks performed by each student during the IV. DISCUSSION
class session. Previous sections presented relevant works proposed by the
Cirani and Picone, in [103], analyzed the characteristics of industry and the related literature for IoHT. However, it is
wearable applications for IoT scenarios and describe the necessary to make sure that IoHT is not only a promise but
interaction patterns that should occur between wearable or also a real solution. This section identifies the best works
mobile devices and smart objects, as well as presented an searched among research publications performed by the
implementation of a wearable-based Web of Things authors. A technological analysis is performed to consider
application used to evaluate the described interaction patterns the industry needs.
in a smart environment, deployed within their department's The criteria used to select the considered best research
IoT testbed. contributions/publications are the following: security
Pasluosta et al., in [104] carried out a detailed review and mechanisms, supported communication technologies, and
discuss the existing wearable devices and the Internet-of- hardware/OS (operating system) platform. Table II presents
Things infrastructure used to Parkinson disease, prioritizing the best qualified works following those criteria. Moreover,
how this technological tool may lead to a shift in paradigm in their importance is discussed. For each one, it is mentioned
terms of diagnostics and treatment. the reference where it is published, its used mechanisms,
Arias et al., in [105], analyzed the question of the communication technologies, and hardware platform and/or
possibility and effects of combination between Internet of used operating system. Works that did not mention any
Things and wearable devices on traditional design practices security and privacy mechanism were excluded from this
and their implications for security (Google Nest Thermostat) analysis since it is considered a major issue on e-Health
and privacy (Nike+ Fuelband) fields, approaching how systems.

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Access

Security and privacy mechanisms are important to be conventional wired security schemes less suitable.
considered in IoHT applications since they are working with Accordingly, it is hard to locate a complete security
critical personal data. It is almost impossible that a convention that can treat both wired and wireless channel
contribution may result in a real product if security and qualities similarly, in [20].
privacy issues are not considered. An important aspect to consider on IoT is the scalability of
the solution since the quantity of IoHT devices will expand
TABLE I continuously. More devices are getting associated with the
MORE RELEVANT KNOWN IOHT SOLUTIONS FROM INDUSTRY
worldwide data arrange. In this manner, planning a
Service Company Product Brief description
profoundly adaptable security plot without bargaining
BeClose BeClose Remote Monitoring System offers a
Ambient
Assisted Living
Remote sense of comfort and independence to both the security prerequisites turns it a testing assignment. Another
Technologies
assisted living
Inc.
Monitoring
System
caregiver and the individual that needs their
support.
important aspect to be evaluated in the considered related
Fade: Fall Fade is an application for Android mobile literature is the hardware platform. As shown in Table II, the
Ambient
assisted living
Fade Detector
(App)
devices capable of detecting and sending an
alarm message when a person suffers a fall.
research works used hardware prototyping platforms, such as
Healthcare Arduino and Raspberry Pi, indicating that the selected works
Solutions Mcare is a bracelet that informs parents
Using
Mcare Mcare (App)
whenever the child moves away.
are in early stage of development.
Smartphones
Healthcare TABLE II
Solutions iOximeter
Using
Safe Heart
(App)
An oximeter for smartphones. TECHNOLOGY USED IN THE SELECTED RESEARCH PUBLICATIONS
Smartphones
Security Heterogeneous Technologies Hardware Platform
Healthcare Reference
Mechanisms and Communication and/or OS
Solutions Medisafe Medisafe is a product that acts as a medication
Medisafe
Using (App) reminder.
Smartphones
Healthcare Cryptographic
OnTrack OnTrack allows quickly and easily keep Al-Taee et al. [121] Bluetooth, 3G/LTE and Wi-Fi Java
Solutions Algorithm
OnTrack Diabetes tracking of everything needed to manage
Using
(App) diabetes.
Smartphones
Gomes et al. [66] SDDL DDS, MR-UDP, S2PA Android
Remote Continuously monitors heart and respiratory Symmetric-key
EarlySense SkyeModule M2 and
Healthcare EarlySense rate, fall prevention, early detection of patient Jara et al. [122] encryption AES- NFC, 6LoWPAN, RFID
All-in-One Jennic JN5139
Monitoring deterioration and pressure ulcer prevention. CBC
Remote Machado et al. [22] ECDH, SSL Bluetooth, WiFi Android and Arduino
Simple device used to monitor people
Healthcare NovaSom AccuSom
sleeping.
Monitoring Maia et al. [23] JAAS RestFul APIs Arduino
Remote Enterprise Service
Hi Mainetti et al. [71] BLE, GPS and GPRS Raspberry Pi
Healthcare Tele-ECG System of records of electrocardiogram. Bus (ESB)
Technologies
Monitoring
Proteus Digital Health consists of ingestible
Mano et al. [70] SSL SFTP Android, Raspberry Pi
sensors, a small portable sensor patch, an
application on a mobile device and a provider.
Remote
Proteus Digital Proteus In this case, the pill dissolves in the stomach Matar et al. [28] SSL Bluetooth and Wi-fi Computer
Healthcare
Health Inc. Discover and produces a small signal that is picked up
Monitoring
by a sensor used in the body, which again Murakami et al. [42] SSL GSM, GPRS, CDMA and WiFi Computer
relays the data (patient health information) to
a smartphone application. Bluetooth, ZigBee, XBEE and
Ray [67] BT SSP MicaZ and Libelium
2G/3G/4G
Body sensor so flexible and soft used to
BioStampR
Wearable MC10 collect data from the patient to help in
C
researches.
A. INDUSTRY STATUS DISCUSSION
The Apple Watch Series is a wearable that
Wearable Apple
Apple allows the developers community to build an An important goal of this survey is the analyzes of the IoHT
Watch infinite number of new applications for
Healthcare. real status: who is using it? is it necessity? where is it used?
“Enterprise” provides customized, secure IoT is it good in terms of usability? and, finally, what is the best
solutions and engineering services for
Wearable Bittium Enterprise
industrial, healthcare, and wearable sports solution in each category? This sub-section discusses these
device manufacturers.
topics and elects the best solution on each category based on
Device capable of tracking your complete
Wearable Qardio QardioCore heart health on your smartphone and share those criteria.
data with your doctor.
The products presented for remote healthcare monitoring
Smart Sock 2 uses pulse oximetry to track
Wearable Owlet
Smart Sock
2
your infant’s heart rate and oxygen levels are used by patients who need to be continuously monitored,
while they sleep.
but not necessarily inside a hospital. They can be at home
Wearable
Monica
Healthcare
Monica
AN24
Solution for home clinical management and
remote monitoring.
using a device for monitoring their condition and send the
data to be analyzed by a health professional remotely. Being
able to be at somewhere else other than the hospital increases
IoHT devices are associated both to near field and patient’s comfort, reduce costs and hospital infection. As
worldwide communications systems through an extensive proposed in Pourhomayoun et al., in [111], remote healthcare
plethora of MAC layer network technologies, such as Zigbee, monitoring frameworks may be an effective way to reduce
Z-Wave, LoRa, SigFox, Ingenu, Bluetooth, Bluetooth Low hospital readmission rates. Among the solutions selected by
Energy, WiFi, GSM, WiMax, and 3G/4G described in [109, the authors for remote healthcare monitoring, EarlySense is
110]. Wireless channel attributes of these systems make

VOLUME XX, 2018 9

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Access

the one that offers the most complete solution, in [112]. It cardiovascular diseases. An important data is that, only in
monitors heart and respiratory rate, has a fall prevention 2016, 6 million devices were sold.
system, detects early patient deterioration, and prevents Healthcare solutions using smartphones has become
pressure ulcer. The aspects taken into consideration were increasingly common these days. These solutions range from
security and how much the solutions explored the a simple application to remind the patient to take a medicine
possibilities within IoHT. Additionally, EarlySense publishes or an oximeter. According to Saúde Business, in [123], it is
their studies on the company’s Website; great results are estimated that there are more than a hundred million mHealth
shown. However, the solution is not available worldwide and Apps around the world. The number of people with diabetes
only has offices in USA and Israel. has risen from 108 million (in 1980) to 422 million in 2014.
Fall is one of the main causes of fatal injury in elderly According to the World Health Organization, this scenario is
people, turning these patients lives more dependent of care, likely to increase considerably. It requires some care to avoid
in [113]. The Fade App aims to solve the elderly falls unpleasant aspects caused by diabetes. One very good
problem, in [114]. For being simple, easy to use, and solution related to diabetes is On Track Diabetes, in [124].
addressing such an important issue in ambient assisted living OnTrack Diabetes is an App for people with type-2 diabetes.
environments, Fade is very effective in this topic. In 2010, in It helps users better manage their conditions by performing
USA, a study proved that 21.649 deaths were caused by fall blood glucose, blood pressure, exercise, food, medication,
and 5.402 of them are associated with people with more than pulse and weight checks.
65 years old, in [113]. The increasing number of elderly
population gives importance to the existence of Apps, such V. CONCLUSION AND FUTURE WORKS
as Fade and many other solutions for AAL environments. Internet of Things is bringing innovations to many
According to the Global Health Observatory, in [115], segmentations of the industry. One of the fastest industries to
healthy life expectancy at birth was 63.1 years in 2015; more embrace this opportunity is healthcare, turning available a
than available mobile Apps it is necessary to give assistance new market based on IoHT. That fact led the authors to
to this growing population. There are some devices develop a comprehensive survey to analyze the state of the
specifically built for the AAL market. BeClose monitoring art on the topic. To accomplish this goal, the most recent
system is an example of a solution that combines several IoHT publications and products were identified, described,
sensors with artificial intelligence approaches providing more and analyzed. It is possible to conclude that there are many
freedom to elderly people, in [116]. services and applications for IoHT, these solutions attend the
When it comes to wearable devices, many possibilities society needs, but are growing isolated. The discussion on
emerge. In USA, 15% of the healthcare consumers use this paper may help developers and entrepreneurs to build
wearable devices, such as, smart watches and fitness devices. solutions that embrace all the society. Additionally, this
It is predicted that 110 million of wearable devices will be paper can be considered as a source of information for
sold by 2018, in [117]. The goal is always to make the user healthcare providers, specialists, and the general population
as much comfortable as possible to provide quality interested in IoHT.
healthcare. Therefore, the main aspects taken into Nevertheless, this review does not provide a deep
consideration to analyze the previously presented wearable understanding about some fundamental topics, including
solutions were patient’s comfort, data security, and usability. topologies, architectures, and platforms for IoHT; security
Although MC10 offers a state-of-the-art body sensor capable requirements, challenges, and proposed models. There are
of gathering complex physiological data, in [118], Bittium’s other technologies which are not explored in this review and
smart watch takes the leading position in the context of this could be explored further, such as big data, augmented
paper, offering a solution that covers more users, in [119]. reality, and cognitive systems. Finally, policies and
The smart watch is capable to measure vital signs, regulations are very important in the healthcare sector and
monitoring patient location, detecting body positioning and should be considered in future researches.
medicine dosage, and timing management. As security is
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Access

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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/ACCESS.2017.2789329, IEEE
Access

the Internet-of-things”. IEEE Jordan Conference on Applied MURILO HENRIQUE SABINO has a 5-
Electrical Engineering and Computing Technologies, 2015. year bachelor degree in Biomedical
[122] A.J. Jara, M.A. Zamora and A.F.G. Skarmeta, “An Internet of Engineering from the National Institute of
Things-based personal device for Diabetes therapy management in Telecommunications (Inatel), Brazil, 2017.
Ambient Assisted Living”. Personal and Ubiquituos Computing, vol. He worked as a trainee at NCC
15, pp. 431-440, 2011. Certificações do Brasil Ltda, Bureau
[123] Saúde Business, “O que é Mobile Health”. Veritas group for one year. After, he got
http://saudebusiness.com/noticias/o-que-e-mobile-health- the position of Certification Engineer and
infografico/, 2017. Leader Auditor (ISO 9001/13485) in the
[124] OnTrack, “OnTrack Diabetes App”. Retrieved from same company. His fields of interest
https://www.ontrack.org.au/diabetes/, 2017. include new IEC standards, ISO 13485, Inmetro Ordinance No. 54, as well
as ambient assisted living and IoT for helthcare.

JOEL J. P. C. RODRIGUES [S’01, M’06, RAFAEL MACIEL PRINCE has a 5-year

SM’06] is a professor and senior researcher at bachelor degree in Biomedical Engineering
the National Institute of Telecommunications from the National Institute of
(Inatel), Brazil and senior researcher at the Telecommunications (Inatel), Brazil, 2017. He
Instituto de Telecomunicações, Portugal. He has has experience as an electronics technician with
been professor at the University of Beira an emphasis on medical equipment at Audiosonic
Interior (UBI), Portugal and visiting professor at Equipamentos company. He is an expert of the
the University of Fortaleza (UNIFOR), Brazil. IEC 60601 standards series for medical products
Prof. Rodrigues is the leader of the Internet of development and safety. Quality Lead Auditor of
Things research group (CNPq), Member of the standard ISO 9001 with experience in quality
IEEE ComSoc Board of Governors as Director management system implementation integrated
for Conference Development, IEEE ComSoc Distinguished Lecturer, the with the standard ISO/IEC 13485 for medical
President of the scientific council at ParkUrbis – Covilhã Science and devices. He works at NCC Certificações do Brasil, a Bureau Veritas
Technology Park, the Past-Chair of the IEEE ComSoc Technical Company, as a medical product certification engineer. His fields of interest
Committee on eHealth, the Past-chair of the IEEE ComSoc Technical include quality management system, new iec standards, as well as remote
Committee on Communications Software, Steering Committee member of healthcare monitoring and IoT for healthcare.
the IEEE Life Sciences Technical Community and Publications co-Chair,
and Member Representative of the IEEE Communications Society on the JALAL F. AL-MUHTADI, PhD, is the
IEEE Biometrics Council. He is the editor-in-chief of Three International Director of the Center of Excellence in
Journals and editorial board member of several high-reputed journals. He Information Assurance (CoEIA) at King Saud
has been general chair and TPC Chair of many international conferences, University. He is also an Assistant Professor at
including IEEE ICC, GLOBECOM, and HEALTHCOM. He is a member the department of Computer Science at King
of many international TPCs and participated in several international Saud University. Areas of expertise include
conferences organization. He has authored or coauthored over 550 papers cybersecurity, information assurance, privacy,
in refereed international journals and conferences, 3 books, and 2 patents. and Internet of Things. He received his PhD and
He had been awarded several Outstanding Leadership and Outstanding MS degrees in Computer Science from the
Service Awards by IEEE Communications Society and several best papers University of Illinois at Urbana-Champaign,
awards. Prof. Rodrigues is a licensed professional engineer (as senior USA. He has over 50 scientific publications in the areas of cybersecurity
member), member of the Internet Society, and a senior member ACM and and the Internet of Things.
IEEE.
VICTOR HUGO C. DE ALBUQUERQUE
[M’17] has a PhD in Mechanical Engineering with
DANTE BORGES DE REZENDE emphasis on Materials from the Federal
SEGUNDO has a 5-year bachelor degree in University of Paraíba (UFPB, 2010), an MSc in
Biomedical Engineering from the National Teleinformatics Engineering from the Federal
Institute of Telecommunications (Inatel), University of Ceará (UFC, 2007), and he
Brazil, 2017. He has experience as a Clinical graduated in Mechatronics Technology at the
Engineering Intern at Antônio Moreira da Federal Center of Technological Education of
Costa Hospital. His fields of interest include Ceará (CEFETCE, 2006). He is currently
patient data security and availability, remote Assistant VI Professor of the Graduate Program in
healthcare, as well as ambient assisted living Applied Informatics, and coordinator of the
and IoT for healthcare. Laboratory of Bioinformatics at the University of Fortaleza (UNIFOR). He
has experience in Computer Systems, mainly in the research fields of:
Applied Computing, Intelligent Systems, Visualization and Interaction,
HERES ARANTES JUNQUEIRA has a 5- with specific interest in Pattern Recognition, Artificial Intelligence, Image
year bachelor degree in Biomedical Processing and Analysis, as well as Automation with respect to biological
Engineering from the National Institute of signal/image processing, image segmentation, biomedical circuits and
Telecommunications (Inatel), Brazil, 2017. human/brain-machine interaction, including Augmented and Virtual
He received scholarship to study abroad Reality Simulation Modeling for animals and humans. Prof. Victor is the
sponsored by CAPES and CNPq at Temple leader of Computational Methods in Bioinformatics Research Group. He is
University and Illinois Institute of editorial board member of the IEEE Access, Computational Intelligence
Technology in 2014-2015. He was Assistant and Neuroscience, Journal of Nanomedicine and Nanotechnology
at Inatel and worked in the projected Research, and Journal of Mechatronics Engineering, and he has been Lead
“Wheelchair Controlled by Voice” sponsored Guest Editor of several high-reputed journals, and TPC member of many
by FAPEMIG. He has experience in Embedded Systems Programing, international conferences. He has authored or coauthored over 160 papers
Embedded Linux, Front-End Programing, Artificial Intelligence, in refereed international journals, conferences, 4 book chapters, and 4
Biosignals Processing. He works at Ciena Communications, Brazil. patents.

VOLUME XX, 2018 9

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