300 IEEE JOURNAL ON SELECTED AREAS IN COMMUNICATIONS, VOL. 39, NO.

2, FEBRUARY 2021

Internet of Things for In-Home Health Monitoring

Systems: Current Advances, Challenges
and Future Directions
Nada Y. Philip , Senior Member, IEEE, Joel J. P. C. Rodrigues , Fellow, IEEE,
Honggang Wang , Senior Member, IEEE, Simon James Fong, and Jia Chen

Abstract— Internet of Things has been one of the catalysts I. I NTRODUCTION

in revolutionizing conventional healthcare services. With the
growing society, traditional healthcare systems reach their capac-
ity in providing sufficient and high-quality services. The world
is facing the aging population and the inherent need for
I N-HOME health monitoring allows patient care to continue
at home after a patient is discharged from the hospital.
It allows healthcare providers to reach patients outside of the
assisted-living environments for senior citizens. There is also four walls of the hospital, perform proper monitoring of patient
a commitment by national healthcare organizations to increase health conditions, continue to deliver quality care and identify
support for personalized, integrated care to prevent and manage
chronic conditions. Many applications related to In-Home Health at-risk populations. It also helps patients stay connected with
Monitoring have been introduced over the last few decades, their health providers, enable them to remain compliant with
thanks to the advances in mobile and Internet of Things treatment plans and improve their health conditions.
technologies and services. Such advances include improvements Internet of Things (IoT) based in-home health monitoring
in optimized network architecture, indoor networks coverage, applications are one of the key mobile health (mHealth) appli-
increased device reliability and performance, ultra-low device
cost, low device power consumption, and improved device and cations that provide proactive and preventive digital health
network security and privacy. Current studies of in-home health interventions [1], [2]. Digital health is “a broad umbrella
monitoring systems presented many benefits including improved term encompassing eHealth (which includes mHealth), as well
safety, quality of life and reduction in hospitalization and cost. as emerging areas, such as the use of advanced computing
However, many challenges of such a paradigm shift still exist, sciences in ‘big data’, genomics and artificial intelligence” [2].
that need to be addressed to support scale-up and wide uptake
of such systems, including technology acceptance and adoption Whereas mHealth can be defined as “mobile computing,
by patients, healthcare providers and policymakers. The aim medical sensor, and communications technologies for health
of this paper is three folds: First, review of key factors that care” [3].
drove the adoption and growth of the IoT-based in-home remote Over the years there has been a booming in the num-
monitoring; Second, present the latest advances of IoT based in- ber of mHealth applications in the market. According to
home remote monitoring system architecture and key building
blocks; Third, discuss future outlook and our recommendations Global Market Insights, mHealth Market size is set to exceed
of the in-home remote monitoring applications going forward. $289.4 billion by 2025 [5].
This prolific increase in mHealth applications and in-home
Index Terms— Internet of Things, IoT, Ambient assisted living,
eHealth, In-home, mHealth, remote monitoring, middleware, health monitoring is due to three main factors:
tutorial.
A. Current Healthcare Services Limitations and Health
Manuscript received December 1, 2020; accepted December 1, 2020. Date Policymakers’ Planning Directions
of current version January 15, 2021. This work was supported in part by
FCT/MCTES through national funds and when applicable co-funded EU funds Globally, the population aged 65 and over is growing faster
under the project UIDB/50008/2020, and in part by the Brazilian National
Council for Scientific and Technological Development (CNPq) under Grant
than all other age groups. According to an estimate by the
309335/2017-5. (Corresponding author: Nada Y. Philip.) World Health Organization (WHO), the number of individuals
Nada Y. Philip is with the Faculty of Science, Engineering and over 60 years will nearly double from 12% to 22% during the
Computing, Kingston University London, Surrey KT1 2EE, U.K.
(e-mail: [email protected]).
2015-2050 period. Approximately 80% of older adults have at
Joel J. P. C. Rodrigues is with the Federal University of Piauí (UFPI), least one chronic disease and 77% have at least two [4].
Teresina-PI 64049-550, Brazil, and also with the Instituto de Telecomuni- The incoming ‘Silver Tsunami’ will generate higher medical
cações, 6201-001 Covilhã, Portugal (e-mail: [email protected]).
Honggang Wang is with the University of Massachusetts Dartmouth, North
needs and caregiving, which will ultimately place more and
Dartmouth, MA 02747 USA (e-mail: [email protected]). more pressure on an already stressed healthcare system. There-
Simon James Fong is with the Faculty of Science and Technology, fore, finding novel ways and leveraging technology to manage
University of Macau, Macau SAR 999078, China, and also with the
ZIAT of Chinese Academy of Science, Zhuhai 13086558, China (e-mail:
the health of populations efficiently and cost effectively, will
[email protected]). be the key to sustainably provide the best quality of care.
Jia Chen is with IBM Watson Health, New York, NY USA (e-mail: Accordingly, treating individuals remotely with the support of
[email protected]).
Color versions of one or more figures in this article are available at
technology is on the agenda and plan of national and global
https://doi.org/10.1109/JSAC.2020.3042421. health policymakers. Recently the WHO organization created
Digital Object Identifier 10.1109/JSAC.2020.3042421 a framework for categorizing digital health interventions [2]:
0733-8716 © 2021 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See https://www.ieee.org/publications/rights/index.html for more information.

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PHILIP et al.: IOT FOR IN-HOME HEALTH MONITORING SYSTEMS 301

• Interventions for clients: clients are individuals who are Such applications will continue to rise due to the development
potential or current users of health services. of the recent communication protocol specifically designed for
• Interventions for healthcare providers: Healthcare IoT devices such as NB-IoT, LoraWan or Sigfox. In addition,
providers are members of the health workforce who the latest development in the IoT communication infrastructure
deliver health services. including 3GPP standard (5G IoT) is well positioned to pro-
• Interventions for a health system or resource managers: vide low-power, low-data-rate, and wide-area coverage cellular
managers are involved in the administration and planning connections to diverse types of IoT devices [8].
of public health systems. There has been an increase in the development of intelligent
• Interventions for data services: This includes functional- medical devices (e.g. blood pressure device, glucose meter,
ity to support steps related to data collection, management temperature sensors, weight scale, etc..) and wearable sensors
and processing. (to measure e.g. ECG, accelerometer, SPo2, Heart rate, etc..),
In most of the above intervention groupings, remote health with features focusing on low power, small size, portability and
monitoring applications are part of the end-to-end intervention easy to wear and use. Wearable sensors have gradually been
system. Remote health monitoring applications links the client developed in the form of accessories (e.g. bands, rings), smart
via sensors and home hub to the healthcare providers and clothing, body attachments and body insertions (e.g. insulin
resource managers via cloud data services. pumps, pacemakers). Alongside this development in wearable
To address limited health and social care resources, National sensors, there have been advancements in the design of smart
Health Services’ (NHS) policies and plans are set to change textiles, smart clothing, or e-textile, that consist of conductive
the services models to keep patients treatment at home and textile material that is attached to or woven together. The
community centers to reduce hospitalization, cost and provide tremendous advancements in low-profile and bioelectronics,
a better quality of life. As an example, NHS UK, sets out five nano technologies and materials have led to the development
changes to the NHS service model to address such needs [6]: of implantable sensors and biomedical devices for remote diag-
• Boost ‘out-of-hospital’ care: to dissolve the historic nosis and monitoring. Many challenges were resolved during
divide between primary and community health services. this development including the size of the sensors, battery
• NHS redesign: to reduce pressure on emergency services life and the development of stretchable and skin-attachable
at hospitals. electronic devices that can continuously and unobtrusively
• Empowering patients and personalized care: patients to monitor individuals’ activity and biomedical signals without
get more control over their health. any restriction to the individual’s daily activities. Wearable
• Digitally-enabled care: to be part of the primary and devices are equipped with wireless transceivers modalities,
outpatient care pathways across the NHS. e.g. Bluetooth, Zigbee, infrared, radio-frequency identification
• Integrated care systems: to focus on population health (RFID), WiFi and near-field communication (NFC) technolo-
and partnerships between local NHS organizations. gies. Such technologies allow the wearables to connect to other
The key enabler of these 5 major practical changes to smart devices (e.g. Smartphone) to enable remote diagnosis
the health service model is the remote health monitoring and monitoring for better quality care [9].
applications. The above mentioned ‘out of hospital’ care,
reducing emergency hospital services, personalized care, C. The Reported Evidence on the Benefits of mHealth
digitally enables care and integrated care systems models Applications in Terms of Quality of Care and
cannot happen without remote health monitoring types of Reduction of Cost
applications. In fact, the fast increasing focus towards pre- In-Home health monitoring applications have evolved over
cision medicine and personalized care is one of the factors the last few decades, addressing many healthcare conditions.
fueling the global mHealth market [5]. They aimed to provide more efficient and effective healthcare
services and contributed to a better quality of life and reduction
B. The Advances in the Underlying Enabling Technologies in in cost. There has been a sharp increase in the number of
Terms of Mobile phone capabilities, wireless communications, mHealth smartphone applications targeting various disease
sensors, wearables and IoT architectures and protocols. remote monitoring and self-management, helping patients bet-
The relatively low cost and proliferation of mHealth applica- ter manage their health conditions and enabling independent
tions, due to the massive penetration of smartphones, is making living. It aims to empower individuals through disease preven-
it a promising investment direction across the globe. In 2017, tion, health promotion and condition self-management [5].
it is estimated that 500 million smartphones new users from Based on [12] an estimated 7.1 million patients were
China and India were connected to the internet globally [5]. remotely connected to health monitoring devices in 2016,
Internet of Things (IoT) is an evolving IT revolution pro- which contributed to a saving of £1bn (over five years) for the
viding a paradigm shift in several areas including Healthcare. NHS by reducing bed blocking and unnecessary appointments.
The term “Internet-of-Things” can be defined as “ an umbrella In addition to the above mentioned benefits of remote health
keyword to cover various aspects related to the extension of the monitoring, it gives patients confidence that their conditions
Internet and the Web into the physical realm, by means of the (e.g. heart rate, blood pressure, SPo2 levels and sleep quality)
widespread deployment of spatially distributed devices with are monitored and alerts could be generated to inform their
embedded identification, sensing and/or actuation capabilities, healthcare professionals in real time [12]. In fact, one study
to enable a whole new class of applications and services" [7]. has shown that home monitoring of patients with congestive

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302 IEEE JOURNAL ON SELECTED AREAS IN COMMUNICATIONS, VOL. 39, NO. 2, FEBRUARY 2021

TABLE I
E XAMPLES OF M H EALTH AND A SSISTED L IVING
S ENSORS AND A PPLICATIONS

Fig. 1. IoT based in-home remote monitoring system architecture.

heart failure leads to lower hospitalization rates and improved

mortality [13]. A meta-analysis study on the effectiveness of
mHealth interventions for patients with diabetes reported that
over a period of a year on average, mHealth interventions
improve glycemic control (HbA1c) compared to conventional
care by as much as 0.8% for patients with type 2 diabetes and
0.3% for patients with type 1 diabetes [11].
In this paper, we first set the stage by presenting the
main components of IoT based In-home health monitoring
system along with some examples. Inspired by the main
technology building blocks of IoT based in-home health mon-
itoring systems, section II provides an extensive discussion
on the technology advances used in such systems. Section III
identifies the main challenges and future directions in devel-
oping successful IoT in-home health monitoring systems that
could scale up and lead to successful deployment in national
healthcare services. Section IV concludes the paper with a
summary.
II. C URRENT A DVANCES IN I OT T ECHNOLOGIES
AND S ERVICES FOR I N -H OME H EALTH
M ONITORING A PPLICATIONS
IoT technology is one of the main enablers of in-home
health monitoring system architecture. Fig. 1 represents a
typical example of the main building blocks of IoT in-home
health monitoring systems. Fig.1 demonstrates the functional
modules of such systems and their interaction. The cloud hub
of the system consists of several modules (storage server,
feature extraction module and decision support system). The
patient hub handles the interaction with the patient, wearable
sensors and devices and the transfer of the patient’s vital
signs and the receiver of the treatment plan. Healthcare
professional hub applications interact with the medical staff
and facilitate patients’ treatment. In IoT based in-home health
monitoring systems, the communication between the cloud
hub and other user applications related to the patient’s and
healthcare professional hub is via interoperable and secure
Cloud Communications API (e.g. based on RESTful web
services).
There has been a tremendous increase of such applica- [14], [38], [53]–[62]. Table I presents a summary of several
tions for chronic disease self-management (e.g. Diabetes and of such applications. It includes a brief description of the
Cancer), medication adherence (Smart pills), assistive living systems, their advantages and lists the sensors used in the
(Parkinson and mild cognitive conditions) and many more remote monitoring.

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PHILIP et al.: IOT FOR IN-HOME HEALTH MONITORING SYSTEMS 303

Fig. 2. Key technologies for IoT based In-home health monitoring systems. Fig. 3. IoT protocols in terms of range and data rate.

The architecture of IoT based in-home health monitoring that allows communications between sensor(s) and personal
systems typically includes five main key IoT technologies computer devices, e.g. smartphone using short-range commu-
as shown in Fig. 2. Inspired by these five technologies, nications that include e.g. Bluetooth, BLE, WIFI and Zigbee.
the following sub-sections presents the current advances in It depends on the required bandwidth. For instance, for sensor
IoT technologies and services for in-home health monitoring signals with a low bandwidth of 0.5 Hz, such as SPo2 signal,
applications. BLE is sufficient to be used to transmit the data [15]. While
A. mHealth and Assistive Sensors 25 lead ECG signals bandwidth can reach 500Hz would need
WiFi communications modalities as the required bandwidth
These represent invasive and non-invasive sensors used to is high [15]. Fig. 3 presents some of the IoT communications
monitor biomedical signals and living environment changes. protocols in terms of data rate and range [16]. Recent protocols
Biomedical signals depend on the individual’s lifestyle, mental are specifically designed for IoT devices such as NB-IoT,
and medical conditions (e.g. diabetes, COPD, Cancer and LoraWan or Sigfox. They are designed to use low-power wide-
mental disorder). Such medical conditions need the manage- area networks (LPWAN) that enable the connection of a large
ment and control of some parameters, e.g. Glucose level, number of devices at a low bit rate, low energy consumption
blood pressure, temperature, ECG and weight. And hence and low cost. In particular, the IEEE 802.15.6, is a wireless
the need for sensors devices to measure these conditions. body area network (WBAN) standard developed for enhanced
For the living environment, it depends on the assistive living health monitoring, which supports data rates up to 10Mbps,
technologies that individuals need, e.g. personal alarms, sensor 1-2 meters range, low power, and high reliability [17]. The
mats, camera, etc. To enable communications of the measured latest development in the IoT communication infrastructure
signal with the surrounding world, these sensors are attached includes the latest 3GPP standard development of (5G IoT)
to wireless communications modalities including, RFID, NFC, to provide low-power, low-data-rate, and wide-area coverage
Bluetooth and BLE, WiFi and Zigbee. cellular connections to diverse types of IoT devices [8]. This
Table 1 represents a list of sensors and devices related to includes two connection types; direct 3GPP connection via
some chronic disease management, adherence and assisted narrowband IoT (NB-IoT) and indirect non-3GPP connection.
living applications. Most of these sensors and devices are For NB-IoT, it requires merely 180 kHz as the minimum
manufactured with data communications standards to allow bandwidth for both uplink and downlink. To support non-
interoperability and communications with applications. Exam- 3GPP 5G IoT connections, a heterogeneous link combining a
ples of such standards are the ISO/IEEE 11073 Personal low-power wide-area network (LPWAN) and cellular networks
Health Data (PHD) and oneM2M. They both are designed via relay user equipment (UE) appears to be a promising
to allow message communications with devices using appli- option [8].
cation layer protocols including Hyper TextTransfer Protocol
(HTTP), Constrained Application Protocol (CoAP), and Mes- C. Middleware Layer
sage Queuing Telemetry Transport (MQTT). It is a service-oriented software layer that allows the
communications with heterogeneous devices like sensors and
B. Short-Range Communications Networks actuators from one end and the cloud services at the other end.
Short-range communications networks are represented in The central role of the middleware layer is to create an abstrac-
this discussion as Wireless sensor networks (WSN) and Per- tion of underlying sensors. The middleware layer acts as a
sonal Area Networks (PAN): WSN, is a network composed mediator between the cloud and sensor devices by collecting
of a set of sensors to monitor different health conditions the sensed data and uploading them to the cloud platform. The
and/or assistive living parameters. Usually, this is referred to middleware layer is usually developed in a unified way that
as Wireless Body Area Network (WBAN) in the case of wear- allows communications with any type of sensor and runs any
able required to be worn by individuals. PAN, is a network applications with minimum configurations [19]. A middleware

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304 IEEE JOURNAL ON SELECTED AREAS IN COMMUNICATIONS, VOL. 39, NO. 2, FEBRUARY 2021

layer provides interoperability among interconnected devices

and offers an abstraction layer to facilitate the development of
applications [20]. In other words, middleware is a software
abstraction between the application layer and the system
infrastructure. Middleware platforms enable physical mashups
by creating and offering value-added services to applications
based on the combination of available system resources [20].
The key requirements for a middleware layer are:
• It should support interoperability to support multiple
heterogeneous devices.
• It should provide a high-level API to access the services
that abstract the underlying devices.
Existing literature contains a plethora of research efforts
offering middleware solutions for IoT applications with varied
scopes [19]. The main goal of most of the existing middleware Fig. 4. Middleware software architecture design.
systems and research projects was to build a unified adapta-
tion layer framework to support the important needs of the
respective domains. Some of these efforts focus on providing description of sensors and utilizes IETF CoAP (Constrained
integration to existing middleware. For example, Mosden [21] Application Protocol) for machine to machine (M2M) commu-
is a middleware application to collect sensor data from external nications. A comprehensive review of middleware platforms
and mobile phone’s internal sensors and uploads it to the GSN can be found in [19], [50], [51], [65].
(Global Sensor Network) middleware. Driven by the Web-of-Things (WoT) vision the design for
UBIWARE [22], proposes an agent-based middleware to a typical patient hub platform architecture can be divided into
classify and register different devices as resources and then three layers, as shown in Fig. 4: application layer, middleware
link them as components of business processes. It is built on layer and sensors layer [18]. The application layer uses the
top of the Java Agent Development Framework JADE. It rep- middleware layer to gather the data from the sensor layer
resents each resource as a software agent (a Java component) and send to the cloud. The middleware layer proposed in this
that monitors the resource and supports the interoperation with architecture is based on RESTful web services that enable the
other system elements. Each agent has a behavioural model to WoT paradigm at the cloud to cope with the interoperability
define the agent’s role, which is represented in a UBIWARE challenge by offering a standard interface. This paradigm treats
specific rule-based semantic language called Semantic Agent all the available services as resources and provides Uniform
Programming Language (SAPL). UBIWARE middleware is Resource Identifiers (URIs) to interact with those resources
focused more on systems that can support multiple agents to using HTTPs, which allow the usage of widely adopted and
control resources. tested standards. Based on the discussion above, the following
HYDRA [23], which evolved into Linksmart, is a service- are the main design goals of any middleware layer for IoT
oriented paradigm-based middleware. It is resource-aware, based in-home health remote monitoring applications:
so it only hosts its Network Manager component on more • Heterogeneity: The design should be extensible to support
powerful devices which are called Hydra-enabled devices. The heterogeneous wireless protocols, sensor devices and
restricted less powerful devices are connected to the Hydra net- BAN.
work by a proxy that provides web service interfaces to access • Mobility: The patient-hub application of in-home health
a device. Each Hydra-enabled device enables communication remote monitoring system must run unobtrusively to
among devices and may host a proxy to act as a gateway. monitor different health-related attributes while support-
Many EU projects including, REACTION [24], inCASA [25], ing the patient’s mobility at home (e.g. engaging in some
ebbits [26], MASSIF [27], SEEMPubS [28], SEAM4US [29], simple home activities like gardening).
have employed HYDRA middleware. However, the interoper- • Interoperability: It must be fully interoperable with the
ability of HYDRA is limited to Health Device Profile (HDP) cloud, and must synchronize the recorded medical data
devices [30]. Furthermore, HYDRA doesn’t follow REST to the cloud.
design principles. • Adaptability: The architecture should be modular and
MyHealthAssistant [49] is an Event-driven smartphone extensible to handle different sensor configuration
based Middleware architecture. It is efficiently designed to changes.
consume low energy and resources while collecting and • User Experience: Reliability and timeliness are the most
merging data from BAN sensors and other assistive sensor important performance requirements of the patient-hub
networks. side of in-home health remote monitoring applications.
OpenIoT middleware [31], an EU FP7 project, is focused This in addition to measures to meet high accessibility
on enabling IoT application development based on the utility and usability requirements of the patient-hub.
cloud computing delivery model. It follows REST design • Security: As typical requirements in any e-health plat-
principles and offers resources as RESTful web services. form, considerable security and privacy are required to
It also uses W3C Semantic Sensor Networks (SSN) for the support confidentiality, integrity and availability.

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PHILIP et al.: IOT FOR IN-HOME HEALTH MONITORING SYSTEMS 305

TABLE II These modules handle the medical data provided by the end
I OT C LOUD C OMPUTING I NDUSTRIAL P LATFORMS users. Typically, the cloud computing services are designed
with three main objectives: flexibility, scalability and inter-
operability [14]. Interoperability is facilitated through the
adoption of electronic health record handling standards e.g.
HL7 FHIR to a seamless integration between systems. Scal-
ability and flexibility are facilitated by the fact that new
resources can easily be added to the model without chang-
ing the cloud communication API endpoints. The storage
server saves the patient data, bio-signals and bio-parameters
transferred from the patient hub and medically relevant data
resulted from the patient’s evaluation by medical staff. The
feature extraction module retrieves from the storage the raw
signals originating from the patient hub (e.g. ECG). The
module extracts several higher-level features to be used in
the decision process. The decision support system (DSS) is
designed based on semantic web technologies (e.g. RDF,
OWL) and dynamic rules to enhance the inference process.
Some typical functions provided by the decision support
procedure include raising alarm, sending alerts, is to produce
alarms, warnings and notifications about the status of patients’
health based on the patients’ extracted features.

E. IoT Applications
IoT applications constitute the interface between the user
and the devices. They enable device to device, humans to
device, and human to human interactions.. They should be
D. Cloud Computing able to present data intuitively, identify problems and suggest
solutions. Many research studies systematically reviewed the
Cloud computing is another sub-system of in-home health features of such applications for IoT based in-home health
remote monitoring system. It is an internet-based computing remote monitoring for chronic disease self-management. For
platform that is utilized to provide; data storage to store the example, the authors of [52] systematically reviewed the litera-
collected data from the different IoT devices and sensors, ture and identified the features for mobile diabetes applications
servers to process and analyse the collected data, and intel- while the authors of [33] systematically reviewed the literature
ligent systems that used the analysed data to produce alarms identified the features of COPD self-management applications.
and knowledge to support the decision of e.g. healthcare Both studies were based on identifying the main features of
professional for patient treatment. Recently the concept of IoT user applications. The following are examples of such
fog computing was introduced to provide a mix of local features for chronic disease self-management applications:
and cloud-computing services that act as a highly virtualized • Measurement: This is device to device interaction; it
platform that provides computing, storage, and networking allows communication between the application running
services between end devices and traditional cloud computing on a smartphone and the sensors. In case of diabetes,
data centers [63]. Many IoT cloud computing platforms were measurements of blood glucose level.
introduced that can be used as Infrastructure as a Service • Questionnaires: This is a device to human interaction; it
(IaaS), Platform as a service (PaaS) or Software as a Service allows the collection of subjective status (e.g. mood) of
(SaaS), Table II presents the most common IoT platforms the patients via dialogue or validated questionnaires.
and their key characteristics. The table lists these platforms • Educational: This is a device to human interaction; to
along with their characteristics: connectivity, security, data provide personalized education based on patients’ needs
format support, programming language support and analytics (e.g. nutrition information education).
capabilities [32]. When selecting a cloud computing platform • History: This is a device to human interaction; to provide
other factors are important to be considered like pricing model, details about the collected data over a period of time.
availability, deployment type and hardware required. • Diary and reminder: This is a device to human interac-
Fig. 1 gives an example of cloud computing services tion; to remind patients about the treatment plan schedule.
required for an IoT based in-home remote management. These • Communications: This is human to human electronic
services can be hosted on one of the platforms in Table II communications. E.g. via motivational messaging
platforms, e.g. Amazon Web Services. These cloud services between Healthcare professional and patients.
consist of three main parts, the storage server, the feature • Medication: this is device to human interaction; it pro-
extraction module and the decision support system (DSS). vides e.g. the list of medications, frequency and dosage.

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306 IEEE JOURNAL ON SELECTED AREAS IN COMMUNICATIONS, VOL. 39, NO. 2, FEBRUARY 2021

III. C HALLENGES , R ECOMMENDATIONS AND F UTURE one of these models. It identifies QoS metrics as functional
D IRECTIONS OF I OT BASED I N -H OME H EALTH stability, performance, compatibility/interoperability, usabil-
M ONITORING S YSTEMS ity, reliability, security, maintainability/modularity/scalability
As the IoT technologies are becoming affordable and and portability. The work in [39] mapped these metrics to
increasingly accepted by patients and healthcare workers, IoT systems and identified reliability, performance, functional
innovative applications are blooming and continue to be fueled stability, security, compatibility/Interoperability and maintain-
by venture capitals and research funds from both private ability/scalability as QoS metrics in IoT architectures.
sectors and government. The prospect of IoT for eHealth is Based on this QoS list, this paper considers the following
promising, new functions are being added into products and recommendation and future directions that need addressing in
services with technological advances in sensor abilities in the future development of IoT based in-home health remote
hardware, ubiquitous communication, and analytics supports monitoring:
of cloud/fog/big data computing. eHealth is listed as a pri- A. Performance, Functional Stability and Reliability
ority in the European Digital Agenda in Horizon 2020 [34].
These QoS indicators are end-to-end based, applicable to
A saving of almost 100 billion Euro is possible in healthcare
all the sub-components of the IoT architecture starting from
expenses with the aid of eHealth and mHealth. It is expected
the individual’s home to the healthcare cloud services. For
that the market value of all the wearable devices that measure
the cloud services, it is to ensure that the cloud infrastructure
fitness and wellness worldwide will be over $12 billion USD
can serve the maximum expected number of clients without
by 2022 [35]. Recently a buffet of eHealth applications tapping
dropping requests, and also to identify potential performance
on the power of IoT has emerged, ranging from ambient
bottlenecks on the server-side. This will involve monitoring
assisted living for illness prevention to paramedic emergency
of the memory consumption to detect any problems with
services for rescue.
undesired memory leakage and badly designed caching of
A fully integrated in-home health monitoring system, with
data. For the individual’s home end this involves the per-
optimized workflows at the hospitals, is arriving soon in the
formance, functional stability and reliability of the WBAN
future. Since chronic disease treatment and rehabilitation is
and WPAN networking concerning wireless interference from
not a once-off event, a full array of IoT sensors should be in
the coexistence of different short communications modali-
place to facilitate bodily and environmental monitoring as a
ties (e.g. WiFi, ZigBee or BLE that employ the 2.4 GHz
holistic approach. IoT plays an important role in enabling data
ISM band). In particular, WiFi uses the highest transmission
links from multiple places for virtual consultation in future
power compared to other technologies, operating at the same
TeleHealth. Based on this, a doctor and patients’ consultation
frequency band, resulting in a higher interference. Besides,
can be equipped with not just lab results, but also with the
the use of large packet sizes in WiFi technology affects the
history of data remotely measured while patients at home
surrounding wireless devices’ available bandwidth. Wireless
using some wearables and in-home remote patient monitoring
interference can cause intermittent connectivity or unexpected
applications. Using the available data and aided by decision-
disconnections, delays in connection and data transfer, slow
support systems that also have access to big data for other
network speeds, and poor signal strength. Many research
individuals, the doctor can make a better diagnosis and provide
efforts were conducted to study the cause and effect of the
personalized treatment. Such a disruptive technology could
coexistence issues in WBAN (IEEE 802.15.6), WiFi, BLE
have a transformative impact on global healthcare systems
and IEEE 802.15.4 [64]. Energy Consumption Management
and drastically reduce healthcare costs and improve speed and
is another performance metric that can lead to degradation in
accuracy for diagnoses [36].
performance/reliability and functional stability. For example,
The realization of this ambitious scenario and in general
at the individual home end continuous monitoring scenarios
IoT based remote monitoring in the healthcare sector that
mean wearables need to be active for a long amount of time
requires data sharing and transfer between embedded devices
and these can be hours to days, it depends on the clinical
is complex and gives rise to several challenges and open issues
scenario. This means draining the battery that will need re-
that need to be addressed in the future development of such
charging and hence disconnection for the continuous moni-
systems.
toring process. A low battery charge causes symptoms similar
IoT based in-home health remote monitoring is a network
to that caused by wireless interference. Performance/reliability
of systems, devices and sensors which are connected and
and functional stability are vital QoS indicators. Systems with
share data. It is a platform which allows to manage the data
low performance/reliability and functional stability lead to low
and controls the devices remotely based on requirements.
adoptions and acceptance by end-users of such systems [38].
These requirements for IoT systems are measured by the
Developers, testers, evaluators and device manufacturers need
quality of services (QoS) provision by these systems and
to address and solve such indicators. This could eventually
the satisfaction of the end-users’ requirements. This paper
lead to higher adoption of such systems and a scale-up of
addresses the IoT challenges and open issues by mapping
such services in the healthcare sector that as reported in the
them to the IoT QoS and end-users’ requirements. There
literature can lead to a better quality of life and low cost.
is a range of quality factors that can be used to quantify
QoS and many different Quality Models have been pro- B. Security, Privacy. Ethics and Law
posed to identify the QoS metrics in distributed systems. Addressing security and privacy issues in IoT systems
The ISO/IEC 25010 [37] quality model ISO/IEC (2010) is design and development is vital to develop trust in using IoT

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PHILIP et al.: IOT FOR IN-HOME HEALTH MONITORING SYSTEMS 307

based systems in the healthcare domain. Security mechanisms C. Interoperability

must be embedded (privacy by design [40]) at every layer
and every component of IoT architecture to prevent security IoT interoperability can be defined as “the ability of two sys-
threats and attacks and preserve privacy. There are many tems to communicate and share services with each other” [45].
commercial and personal devices being created without due IoT interoperability can be classified as device interoper-
diligence to ensure these security and privacy aspects [41]. ability, networking interoperability, syntactic interoperability,
Developers need to ensure that the “things” that make up the semantic interoperability, and platform interoperability [46].
IoT and the systems to which they connect to are secure; Interoperability plays a major role in IoT development and
that the sensors, devices, gateways, IoT services can be particularly in the healthcare domain. IoT based in-home
trusted by the users and their identity, safety and privacy health remote monitoring incorporates heterogeneous IoT sen-
protected and maintained. In many in-home health IoT based sors, devices, applications and services, which involves high
remote monitoring applications, the developers rely on the amounts of data exchange in heterogeneous formats. Hence,
embedded security mechanisms’ (e.g. encryption) in the man- interoperability should be considered by IoT developers and
ufactured hardware and software components of the sensors medical device manufacturers when developing IoT based
and the transceivers of the wireless communications. Mostly, remote monitoring systems. Many medical devices e.g. Glu-
the developers of the data acquisition applications of such cose meter, blood pressure devices are based on the ISO/IEEE
sensors and devices base their design of such applications 11073 Personal Health Data (PHD) interoperability standards
on the principles of privacy by design and employ all the in their data communication that direct the developers of
possible security mechanisms in terms of authorization and IoT application at the data acquisition side to use the same.
authentications, anonymization and encryption both when data However, other IoT devices are developed based on oneM2M
stored and mobile. Many such applications usually are con- communication protocol. Hence it is necessary to have some
nected to existing healthcare information services that have mechanisms that make PHD and oneM2M being able to talk
their own security mechanisms and privacy policies applied, to each other within the same IoT system [47].
but may not be up-to-date with the latest security standards and Although many IoT standards and platforms have been
mechanisms. developed and helped in advancing IoT interoperability issues,
Privacy protection solutions need to help users decide who there are still some open research challenges to be solved [45]:
should legitimately access and alter information. Users of • To focus on cross-layer cross-platform interoperability
IoT must have confidence that their data collection, storage than just the sensor/device and network layer interop-
and usage is being done in a manner that benefits them and erability using semantic web technologies and internet-
does no harm to their privacy. In general several guidelines working APIs.
and regulations already addressed privacy in developing IoT • The interoperability should be made possible irrespective
applications, such as the Health Insurance Portability and of the underlying technologies (e.g. non IoT devices).
Accountability Act (HIPAA) [42], and the EU General Data • Interoperability testing needs to be automated instead of
Protection Regulation (GDPR) [40]. However, there is a need the current complex process of interoperability testing
to consider the secondary use of the collected data using in- that includes all the stakeholders of technology providers,
home IoT remote monitoring. The patients involved in using developers and end-users that may affect proper interop-
such systems may consent for their data to be used for the erability testing and in many cases may affect security
primary purpose of the in-home health remote monitoring and mechanisms testing.
not the future/secondary use, e.g. building algorithms using • Adopting public RESTAPI to access the resources rather
the collected data (Big data analytics) [44]. than custom RESTAPI which makes mashing up of data
With the development of IoT, several use cases are sup- across platform difficult. Most IoT platforms provide
ported but it has also caused an increase to critical ethical public RESTAPI, but still, some IoT platforms use custom
and legal violations [48]. IoT based applications require an RESTAPI.
appreciation of both the ethico-legal milieu and the socio- • Development of unified IoT gateway platform to consider
political landscape. The requirements of the social license for many standardized communications protocols where the
research are: Reciprocity, non-exploitation and Service of the device manufacturers may select the appropriate protocols
public good [43]. For these criteria to be satisfied, there is (e.g. CoAP for constrained devices). Or they maybe
a need in including the public in the dialogues that concern free interoperability gateway solutions for facilitating the
their collected data. Research that improves NHS care needs to device to device (D2D) communication.
satisfy the requirements of non-exploitation and service of the Interoperability challenges get more difficult to handle with
public good. However, misuse of data being collected via (e.g. the increased complexity of interconnected IoT systems in
such IoT applications), without consultation, infringes these terms of technologies, integrated services, information and
requirements [44]. It has been noticed that one of the issues Open access, human factors and cross-border governance
in the low adoption of IoT applications among end-users is frameworks [66]. ISO/IEC 21823-1:2019(E) [67] is one of the
the lack of trust in IoT devices concerning data protection, current Interoperability for IoT systems framework standards
privacy and safety. Therefore, this issue must be consid- to address these difficulties and provides a common under-
ered to improve trust among people using IoT devices and standing of interoperability in general IoT systems and the
systems. various elements within them.

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308 IEEE JOURNAL ON SELECTED AREAS IN COMMUNICATIONS, VOL. 39, NO. 2, FEBRUARY 2021

D. Scalability In addition, another important challenge is the gap between

Scalability is another important aspect of IoT future direc- the IoT technology community and the medical community.
tion in in-home health remote monitoring. It means the The technology of IoT based healthcare monitoring is being
possibilities of adding new, services, sensors, devices, and progressed quickly today. However, it is not widely used
applications without affecting the overall performance of the in the medical community such as hospitals; the medical
system. Scalability means developing IoT platforms that sup- communities still hesitate to adopt the remote monitoring
port a large number of sensors, devices, serves with different technology due to some reasons. For example, how will an
storage, processing, communications and bandwidth require- insurance company pay the remote diagnosis charge (e.g., in
ments [68], [69]. Both the middleware layer and cloud services USA)? We want to note that IoT based remote monitoring is
are great examples of scalability. They provide sufficient not the replacement of traditional face to face diagnosis, and is
support to scale up the IoT system when adding new sensors, more like an assistive technology that can enhance the current
devices and service requirements. This direction has led to a medical approaches.
new research paradigm in developing a unified IoT framework As the evolution of society, diseases and technologies con-
that satisfies global requirements. tinues, new mHealth scenarios and applications will appear
and become a reality, these identified open issues will be
IV. C ONCLUSION ongoing. The research communities need to continue reporting
IoT technologies have matured since its conception a decade on the benefits, challenges and lessons learned of IoT in-home
ago, with increasingly successful implementations at smart city health monitoring systems deployment so that new system
and smart home projects around the world. eHealth, however, development can learn from.
has its root from the era of modern digitization movements This paper presents the needs, the technologies advances,
since decades ago, from revamping electronic health records to the challenges, recommendations and future directions of IoT
telemedicine provision. By tapping on the ubiquitous comput- based in-home health monitoring systems.
ing power and sensing ability, IoT fueled eHealth applications
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[63] F. Bonomi, R. Milito, J. Zhu, and S. Addepalli, “Fog computing and its Honggang Wang (Senior Member, IEEE) research
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[67] Interoperability for IoT Systems—Part 1: Framework, docu- supported by NSF (6 grants), DoT, NIH, UMass President Office, and UMass
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iso.org/standard/71885.html Sponsored Research Recognition Award in 2015. His research is reported
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10.1016/j.future.2018.11.018.

Nada Y. Philip (Senior Member, IEEE) received

the Ph.D. in mHealth, with the thesis title ’Med-
ical Quality of Service for Optimized Ultrasound
Streaming in Wireless Robotic Tele-ultrasonography
System,’ from Kingston University, U.K., in 2008.
She is currently an Associate Professor in the field of
mobile health (mHealth) with Kingston University
Simon James Fong is currently an Associate Pro-
London. She is the Founder of the research group
fessor with the Computer and Information Science
Digital Media for Health in 2012. Her research
Department, University of Macau, also an Adjunct
interests are mainly in the advancement of data and
Professor with the Faculty of Informatics, Durban
multimedia communication, networking and infor-
University of Technology, South Africa, ZIAT of
mation technology for healthcare applications. She is the PI and Co-PI of
Chinese Academy of Science, and the Department
many national and international mHealth projects in the areas of personalized
of Computer Science, Xi’an Polytechnic University,
health for Diabetes, Cancer and COPD conditions, 5G health, wearables and
Xi’an, China. He is the co-founder of the Data Ana-
cloud computing, IoT, AI and Big data analytics for health, social robotics
lytics and Collaborative Computing Research Group,
for health, end to end QoS, and QoE in medical video streaming. She is the
University of Macau. Prior to his academic career, he
author and coauthor of more than 80 journals, peer-reviewed conferences, and
took up various managerial and technical posts, such
book chapters. She is a member of the editorials and the review panels for
as Systems Engineer, IT Consultant, and e-Commerce Director in Australia
many journals, including the IEEE-IoT, JSAC, and WCMC. She is the Editor
and Asia. He has published over 450 international conference and peer-
of the IEEE e-health TC newsletter. She is a reviewer on both the MRC and
reviewed journal papers, mostly in the areas of data mining, big data analytics,
the NIHR research bodies. She is a fellow of the Higher Education Academy,
meta-heuristics optimization algorithms, and their applications. He serves on
and a Senior Member of the IEEE Communication Society and the IEEE
the editorial boards of the Journal of Network and Computer Applications
Engineering in Medicine and Biology Society (EMBS).
(Elsevier), IEEE IT Professional Magazine, and various special issues of
SCIE-indexed journals. He is also an active researcher with leading positions
Joel J. P. C. Rodrigues (Fellow, IEEE) is currently
such as the Vice-Chair of the IEEE Vice-Director of International Consortium
a Professor with the Federal University of Piauí,
for Optimization and Modelling in Science and Industry (iCOMSI).
Brazil, a Senior Researcher at the Instituto de Tele-
comunicações, Portugal, and a Collaborator of the
Post-Graduation Program on Teleinformatics Engi-
neering at the Federal University of Ceará (UFC),
Brazil. He is the Leader of the Next Generation Net-
works and Applications (NetGNA) Research Group
(CNPq), an IEEE Distinguished Lecturer, a Member
Representative of the IEEE Communications Society
on the IEEE Biometrics Council, and the President
of the Scientific Council at ParkUrbis–Covilhã Science and Technology Park. Jia Chen received the Ph.D. degree in physics from Yale University. She is
He was the Director for Conference Development-IEEE ComSoc Board of an Offering Leader of Blockchain solutions for Healthcare and Life Sciences
Governors (2018–2019), the Technical Activities Committee Chair of the at IBM’s Innovation and Solution Incubation Team. She serves on the IBM
IEEE ComSoc Latin America Region Board (2018–2019), the Past-Chair of Academy of Technology Leadership Team. She previously led technical
the IEEE ComSoc Technical Committee on eHealth, the Past-chair of the strategy at IBM Watson Health Innovation, with a focus on data and AI.
IEEE ComSoc Technical Committee on Communications Software, and a Prior to that, she was the Global Leader of the Watson Experience Centers at
Steering Committee Member of the IEEE Life Sciences Technical Community IBM, responsible for Watson AI client experiences across all Watson Group.
and Publications Co-Chair (2014–2017). He is the Editor-in-Chief of the She held leadership positions for innovation and client engagement at IBM
International Journal on E-Health and Medical Communications and an Corporate Headquarters as well as emerging markets. She was formerly the
editorial board member of several high-reputed journals. He has been the Director of Health Solutions for Smarter Cities at IBM, and the Director of
General Chair and TPC Chair of many international conferences, including Technical Sales and Innovation for IBM’s Growth Market Units. She led the
the IEEE ICC, IEEE GLOBECOM, IEEE HEALTHCOM, and the IEEE identification, structuring, and execution of first of a kind technology and
LatinCom. He has authored or coauthored over 900 papers in refereed business initiatives that provide innovative and sustainable differentiation for
international journals and conferences, three books, two patents, and one ITU- IBM’s clients. She was named as one of the top 35 technology innovators
T Recommendation. He had been awarded several Outstanding Leadership under the age of 35 worldwide by MIT’s Technology Review in 2005, the Best
and Outstanding Service Awards by the IEEE Communications Society and Researcher of the Year by Small Times Magazine in 2006, and one of the top
several best papers awards. He is a member of the Internet Society and a 26 Tech Women Innovators at IBM in 2015. She serves on the Yale Graduate
Senior Member of the ACM. School Alumni Association Board.

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