A survey on COVID-19 impact in the healthcare domain: worldwide market implementation, applications, security and privacy issues, challenges and future prospects

The Internet of Things (IoT) has made remarkable progress supporting many important applications and enhancing the quality of life [1]. IoT devices can collect and understand the surrounding environment. IoT is a very emerging paradigm in the history of the computing field, with an expected 60 billion gadgets at the end of 2022. On the one hand, IoT improves technologies with a very positive impact and enhances different real-time smart applications that improve the quality of the human lifestyle [2]. IoT plays a critical role in improving life by enabling smart things (smart applications), such as smart agriculture, housing, education, transportation, smart manufacturing, irrigation systems, and smart healthcare.

IoT has given people more independence and improved their ability to communicate with others [3]. Novel algorithms and protocols have enabled the IoT to play a key role in global connectivity. It connects many devices to the Internet, including wireless sensors, household appliances, and electrical equipment [4]. Agriculture [5], transportation [6‐8], urban [9], the household [10, 11], and healthcare [12‐16] are all examples of IoT applications. The Internet of Things is gaining popularity due to higher reliability, reduced costs, and the ability to predict occurrences better. Furthermore, the rapid IoT revolution has been supported by increased awareness of software applications, along with developments in computer and mobile technologies, the ubiquitous availability of wireless technology, and the growth of the digital economy [17]. Actuators, sensors, and other IoT equipment have been connected with other physical devices to control and transfer data using network technologies, such as Zigbee, Bluetooth, WI-FI (IEEE 802.11), and others.

The healthcare industry, in particular, has had rapid expansion in recent years, contributing significantly to employment and revenue [13]. A couple of years back, diseases and anomalies in the human body could only be identified by a medical examination in a hospital. The vast majority of patients were required to remain in the hospital during their treatment. This led to higher medical costs and a strain on rural and distant healthcare services. Due to technological advancements, many diseases may now be diagnosed and monitored using lightweight devices, such as smartwatches.

Furthermore, technological advancements have shifted the healthcare system from a hospital-oriented to a patient-oriented paradigm [18, 19]. Numerous clinical studies could be carried out at home without the support of a physician, such as blood glucose levels, monitoring blood pressure, and pO2 levels. Advanced telecommunications technology can also transmit clinical data from remote places to healthcare centers. The combination of these communication services and rapidly expanding technology (e.g., analysis of big data, machine learning, Internet of things (IoT), cloud and mobile computing, and wireless sensing ) has the potential to transform the industry [20]. The Internet of Medical Things (IoMT) improves electronic medical equipment’s accuracy, dependability, and productivity in the health sector [21‐24]. Researchers focus on developing a digital healthcare system by integrating current healthcare resources and services. As the IoT converges in many areas, we are focusing on the research contribution of IoT in the healthcare sector. This article explores how people have participated in the IoMT domain and its applications and future trends in medical services.

Pressure, temperature, electroencephalograph (EEG), electrocardiograph (ECG), and other physiological data are obtained from patients’ bodies using sensors that are implanted or wearable on the human body in healthcare [25, 26]. Humidity, temperature, date, and time are all examples of environmental data gathered. These data assist in developing accurate and appropriate conclusions regarding the health status of the patients. Data accessibility and storage are critical in the IoT ecosystem, because a massive volume of data is captured and collected from multiple resources (sensors, software, applications, e-mail, mobile phones, and others). The data collected by the aforementioned sensing devices are made accessible to doctors, caretakers, and other authorized people. The ability to exchange this data with IoMT practitioners through the cloud/server allows for quick patient diagnosis and, if needed, medical intervention. The majority of IoT systems include a user interface for medical professionals to use as a dashboard, allowing them to control, analyze, and evaluate data. Users, patients, and the communication module must collaborate for successful and secure transmission. The literature [27] has extensively investigated the evolution of the IoT system in medical monitoring, privacy, security, and control. These achievements demonstrate the significance of the Internet of Things in the healthcare sector and its promising future. However, ensuring the quality of service criteria, including sharing information privacy, affordability, dependability, security, and accessibility, is a potential concern while developing an IoMT device.

A wide range of IoT-based applications is developed using IoMT services and technologies. The taxonomy of the IoMT field is depicted in Fig. 1. The physical layer, also defined as the perception layer, involves gathering and transmitting body temperature, heart rate, and other bodily data using physical devices and sensors and then delivering that data to the network layer. It comprises a set of syntactic and semantic rules that determine the operational activity block of a computer network while transmitting data. Numerous protocols [28] have been deployed to ensure efficient data transfer for the IoT infrastructure. According to a recent study, [29], over 90% of all IoT device traffic is unencrypted, exposing 57% of these devices to data breaches.

The COVID-19 virus has exploded unexpectedly, putting the entire healthcare system on high alert. The Internet of Medical Things (IoMT) and COVID-19 have encouraged scientists to establish a new “smart” healthcare system based on early identification, control of spread, education, and medication, making life in the new norm simpler. The motivation of this survey is to determine the role of IoMT applications in improving healthcare systems as well as technology advancements in IoMT devices, as well as to evaluate the current state of research on the efficacy of IoMT economic advantages to patients and healthcare systems worldwide, as well as to provide a brief overview of technologies that strengthen IoMT and the security and threat challenges that come with developing a smart healthcare system.

In recent years, several significant works have been produced. Researchers from multiple angles have already evaluated this extensive literature to determine the current status of smart healthcare evolution. Thus, a systematic and comprehensive review of related papers published on the subject was conducted. As a result, it is difficult to compare our work to prior surveys. Table 1 presents a fair and comprehensive comparison of prior studies with the proposed study.

This study aims to provide an in-depth assessment and analysis of technology innovations in the smart healthcare system. As the concept of “smart healthcare” evolves with the advancement of associated technologies, there is a need to compile the work from these diverse aspects and provide a comprehensive repository. The significant contributions of this paper are summarized as follows:The following is the structure of this paper: “Research methodology” covers the research methodology. “Worldwide IoMT implementation and supportive market” provides an overview of global IoMT implementation and a supportive market. “Applications on internet of medical things” discusses IoMT applications. “IoMT architecture system” addresses IoMT devices and technologies. “IoMT security and privacy” addresses IoMT security and privacy. “IoMT research open concerns and future directions” provides the open issues and future directions. Finally, “Conclusions” concludes the paper. Table 2 shows the lists of acronyms.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic literature methodology is selected to find publications and target specific data for this research, as illustrated in Fig. 2, [36]. In October 2019, as part of a research strategy, a search of the Scopus database was conducted using the website’s search tool. Furthermore, a new search in the same database will be performed in June 2020 to include papers published in 2020. The database’s selection is based on its effectiveness. This database is valuable and important in academics, because it contains a variety of publications and archives. IEEE, ACM, and Elsevier are some of the most well-known publishers, aside from being frequently referred to in similar bibliographic reviews [37].In addition, a new search in the same database was constructed in February 2020. The technique for finding study subjects in this database is to look for phrases related to the usage of technology in the field of healthcare, such as “Internet of Medical Things,” “medical devices,” “communication technology,” “smart health care” and other terms associated with “IoT” and “synonym terms. The papers’ publication dates were not criteria for eliminating them. The study is restricted to open-access publications, such as journal and conference articles. This survey article involves creating a search methodology and data source selection and using a collection of keywords. The following keyword combinations have been used as search instructions for the database:

The three parts of the PRISMA review process are identification, scanning, and eligibility testing. In the identification stage, documents are found using a Google Scholar search; 612 papers were found due to this step. Duplicate and non-conforming papers were removed during the scanning process, and 504 were chosen. The papers unrelated to healthcare were then filtered out during the eligibility testing stage. In the last step, 401 papers were selected for this research.

Following the search, Fig. 3 depicts the number of publications produced by each search technique (item). The search technique is developed depending on the content of the primary study areas. Figure 4 illustrates a restricted search of publications published between 2017 and 2020. For relevant papers, IEEE Xplore, Google Scholar, ReseachGate, ScienceDirect, the ACM Digital Library, MDPI, and other engineering and health journals were searched. In the first search, 612 papers were found. The phrase “Internet of Medical Things” received the most publications. After eliminating identical and irrelevant entries, the search is narrowed to 401 papers.

UnivDatos Market Insights recently added a comprehensive analysis of the internet medical products market to its vast database [38]. The market research on the IoMT is prepared by compiling information on industry factors, such as market drivers, constraints, and opportunities. This novel study combines several investigations to acquire broader market knowledge of internet-connected medical devices. The market research on the IoMT provides a comprehensive analysis of recent industry breakthroughs and market trends propelling market expansion. In addition, this statistical market research resource investigates and predicts the global and regional markets for internet-connected medical devices. Between 2021 and 2027, the international market for the IoMT is expected to develop at a compound annual growth rate (CAGR) of 18.5%, reaching US $284.5 billion, as shown in Fig. 5.

The IoMT uses communication networks to connect medical equipment and applications to a health information technology infrastructure. The IoMT comprises smart wearable, portable smart screens, and other smart health status monitoring equipment. According to a survey [13], over 27% of healthcare enterprises plan to integrate IoT by 2021, while over 60% have already done so. Some of the advantages of IoMT encompass better disease management, better patient outcomes, better therapy and prevention, and better management of health care data and drugs. Furthermore, due to the growth in integrated medical equipment and technological advancements, the industry is experiencing an increase. According to research, by 2021, there will be over 50,000 healthcare innovations accessible. Furthermore, it is predicted that the IoMT would save the healthcare industry $300 billion per year by improving drug adherence and remote patient monitoring.

A wide range of IoT-based applications is built using IoMT services and technologies [50]. Many suggestions have been made for the progress of humanity by researchers in various fields. To put it another way, concepts are more focused on the developer, whereas applications are more focused on the user. Fast improvements in IoT technology have made portable gadgets, wearable sensors, and medical equipment more affordable and user-friendly. These technologies might gather clinical information, make disease predictions, track patients’ health, and send out notifications in a medical emergency. Some of the most recently available commercial devices and applications are discussed in the following section. Various IoMT-based applications, including single and multiple condition applications, as shown in Fig. 10, have also been addressed.

Depending on the complexity of healthcare systems, it is critical to handle dozens of medical devices connected to the Internet in a heterogeneous manner to maintain the greatest standard of dependability. As a result, an adaptable, layered architecture is required. The IoMT five-layer model describes a tiered architecture, where each layer performs a distinct function [89]. The five layers are perception, communication network, platform (processing), application, and business layers, as illustrated in Fig. 11. The device layer, also known as the perception layer, comprises hardware, including sensors, actuators, and controllers. Connectivity to other smart IoMT devices, network devices, and servers is the responsibility of the communication network layer. Its characteristics are also leveraged in the processing and transmission of sensor data. Sensor data is transmitted from the perception layer to the platform (processing) layer via networks (for example, Bluetooth, RFID, WiFi, 3G, LAN, and NFC). The IoT platform layer, also known as the processing (middleware) layer, stores, analyses, and processes massive volumes of data received from the communication layer and provides service support, interpretations, cloud computing, and middleware technology. It can handle and facilitate many services to the lower layers, such as notifications, data retrieval, big data processing, cloud computing, and analytics for IoMT applications through cloud platform services, such as Microsoft Azure, Amazon Web Services, and Google Cloud, and others. The application layer is in charge of providing the user with application-specific services [90, 91]. This layer contains a variety of devices, including monitoring devices, location devices, tracking systems, telemedicine, medical e-records, health fitness systems, remote diagnostic systems, and so on. The business layer is in charge of the overall IoMT system, including applications, security, business and profit models, and users’ privacy. Each feature has its own set of security and privacy problems. As a result, security and privacy problems are classified into the following categories based on their frequency in each layer.

A recent study [29] claims that more than 90% of all IoT device traffic is unencrypted, which means that 57% of IoT devices are susceptible to attacks that reveal sensitive data. Cyber-attacks are not only disruptive to the system; they may even endanger people’s lives. Any Cyber-attack has the potential to be devastating, putting patients’ lives at stake [120]. The rapid expansion and adoption of IoMT, particularly during pandemics, may raise ethical security issues, making it more challenging to secure the privacy of crucial and sensitive medical data. Several attacks, threats, and hazards can have an impact on various levels of the IoMT architecture [120].

As a result, the IoMT industry must follow rigorous security and privacy restrictions. It was also noted that the IoMT has security and privacy issues, as illustrated in Fig. 17, that must be addressed. For effective intrusion detection and prevention, methods such as cryptographic or non-cryptographic algorithms are recommended. Various malware attacks targeting IoMT systems have been discovered to compromise data security, integrity, authenticity, and data availability. Key management, intrusion detection, authentication, and access control have all been prioritized in the current security approach [121].

The mechanisms of grouping complex systems that synchronize and work collaboratively and simultaneously to seem like a centralized platform to the end-user are known as “systems of systems.” Internal systems combine their resources and competencies to provide further services as a unified system. One example of a system of systems is smart healthcare. Since the recent pandemic, COVID-19, is considered, this emphasizes a tremendous area of research, as no such preemptive strategy had been discovered at the start [144]. The integration of IoMT could lead to an extensive range and complexity of cutting-edge technology-based healthcare facilities and medical procedures that were initially assumed unattainable before the nano-tech generation. Designing, developing, and operating such nano-sized devices effectively is a concern that requires great consideration to enable humans to live healthier lives in the long run. Therefore, developers must be familiar with smart healthcare systems’ significance and real-world implementation to respond to the demands and cope with smart healthcare. A comprehensive range of research gaps and constraints must be addressed for such a broad range of diverse research and development in smart healthcare systems. Smart healthcare architectures and frameworks are being developed by researchers to deploy, coordinate, and develop smart IoMT applications. Moreover, with the emergence of various technological advancements, such as cloud computing, the IoMT security and privacy community has yet to extensively explore a variety of promising future research fields. Some research directions for strengthening the healthcare systems are listed below.

This survey paper provides an in-depth, comprehensive, and systematic review of IoMT in technical development, worldwide IoMT adoption, supportable market devices, applications, communication protocols, research gaps, and the most fundamental IoMT security and privacy challenges. First, an overview of the IoT and global IoMT underlying technologies, market trends, methodologies, and IoMT applications in many fields has been presented. Then, minor and significant similarities in related work reviews that have been done over the last few years and the contribution of each endeavor have been addressed. Furthermore, the relevance of security in the context of IoMT and how it differs from other systems due to the heterogeneity of its various applications has been emphasized. Furthermore, the most appropriate application fields and several valuable research benefits have been identified. This research paper gives complete knowledge to researchers and professionals in the field, assisting them in understanding the immense potential of IoT in the medical domain and identifying major IoMT applications and challenges.

During the COVID-19 pandemic, most IoMT systems were utilized primarily for tracking and identifying infected people as a form of digital monitoring, raising specific concerns about IoMT devices, applications, and communication protocols. However, many citizens around the world accept this as a necessary measure. Other IoMT applications have included infection detection, surveillance, and testing to reduce the infection risk or speed up diagnostic tests. IoMT systems are subject to the same security constraints as IoT systems, but the concern is higher, because IoMT devices affect people’s lives. As a result, this paper has thoroughly covered current achievements in IoMT security, including experiments using the latest technologies, such as blockchain to reduce security risks to individuals and systems. According to a discussion on the future direction of IoMT in the final section of this paper, hybrid technologies will be devised in the coming years, combining knowledge from the fields of big data analytics, data mining, artificial intelligence, and IoMT advances have made automation, modeling, and forecasting systems more effective and precise.