Considerations on Standardization in Smart Hospitals

Abstract

Smart hospitals involve the use of recent ICT (information and communications technology) technologies to improve healthcare access, efficiency, and effectiveness. Standardization in smart hospital technologies is crucial for interoperability, scalability, policy formulation, quality control, and maintenance. This study reviewed relevant international standards for smart hospitals and the organizations that develop them. Specific attention was paid to robotics in smart hospitals and the potential for standardization in this area. The study used online resources and existing standards to analyze technologies, standards, and practices in smart hospitals. Key technologies of smart hospitals were identified. Relevant standards from ISO (International Organization for Standardization) and IEC (International Electrotechnical Commission) were mapped to each core technology. Korea's leadership in smart hospital technology were highlighted. Approaches for standardizing smart hospitals were proposed. Finally, potential new international standard items for robotics in smart hospitals were identified and categorized by function: sampling, remote operation, delivery, disinfection, and movement tracking/contact tracing. Standardization in smart hospital technologies is crucial for ensuring interoperability, scalability, ethical use of artificial intelligence, and quality control. Implementing international standards in smart hospitals is expected to benefit individuals, healthcare institutions, nations, and industry by improving healthcare access, quality, and competitiveness.

INTRODUCTION

The concept for a smart hospital is not clearly established[1,2]; however, the term in general refers to hospitals that involve the use of recent information and communication technology (ICT) innovations to healthcare services. Spe-cifically, the smart hospital typically employs optimized and automated processes within an ICT environment, particularly leveraging robotics [3-5], ultra-connected net-works using 5G [6,7], cloud computing [8,9] and big data[10,11], artificial intelligence (AI) [12,13], and integrated healthcare Internet of things (IoT) [13-15]. This integra-tion facilitates various aspects of healthcare, including assessment, treatment, services, and integrated care. The innovation aims at improving healthcare access, efficiency, and effectiveness.
  To enhance the efficiency and quality of healthcare of smart hospitals and the delivery of associated healthcare services, standardization in smart hospital technologies is crucial: First, it ensures interoperability, allowing differ-ent systems and devices to communicate seamlessly. This interoperability is important for the integration of patient data across various platforms, ensuring that healthcare pro-viders have comprehensive and real-time access to patient information. Standardization also plays a key role in the scalability of smart hospital solutions. Standardized proto- cols and interfaces enable easier adoption of new technolo- gies across different hospitals and health systems, facilitat-ing the streamlined dissemination of innovative healthcare solutions. This scalability is particularly important for pub-lic health management, as it ensures that advancements in healthcare technology are not confined to elite institutions but are accessible across the healthcare spectrum, thereby democratizing advanced healthcare. From a policy perspec-tive, standardization is vital in formulating regulations that govern the use of smart hospital technologies. These regu-lations are necessary to protect patient privacy, ensure data security, and maintain ethical standards in the use of AI and other advanced technologies in healthcare. By estab-lishing clear standards, policymakers can provide a frame-work for responsible innovation, balancing the need for technological advancement with the imperative to protect patient rights and public health. Furthermore, standardiza- 
tion aids in quality control and maintenance of healthcare services. It establishes benchmarks for performance, safety, and reliability of smart hospital technologies used in hos-pitals. Adhering to these standards helps in minimizing er-rors and inconsistencies in patient care, thus enhancing the overall quality and safety of healthcare services.
  This study conducts a thorough review of the pertinent nternational standards applicable to smart hospitals and standards developing organizations (SDOs) that develop standards related to smart hospital technologies. This study places a special focus on the potential standardization items for robotics utilized in smart hospitals, underlining the sig-nificance of standardizing such technologies to uphold the highest levels of operational excellence and patient care.

METHODS

This study aimed to explore smart hospital technologies, and standardization organizations and technical com- mittees that are relevant to the smart hospital and its core technologies. Our methodology comprised a multi-faceted approach to identify, categorize, and analyze the relevant technologies, standards, and practices in smart hospitals with special focus on robotics in smart hospitals.
  We commenced by identifying a comprehensive list of technologies currently employed in smart hospitals. This process involved mostly a literature review of industry and technical reports [16,17] and investigation of global stan- dardization organizations (International Organization for Standardization [ISO], International Electrotechnical Com- mission [IEC], and Institute of Electrical and Electronics Engineers [IEEE]) and their committees relevant to smart hospital technologies. To search international standards, we used online standard search interface for ISO and IEC (Online Browsing Platform, https://www.iso.org/obp/ui) 
to search technical committees using keywords “smart hospital,” “digital hospital,” “artificial intelligence,” “cloud computing,” “big data,” “high-speed network,” “Internet of things,” “IoT,” “robotics,” “augmented reality,” “virtual reality,” and “mixed reality.” A group of five researchers were involved in reviewing the scopes, publications, and standards published to understand their roles and contri- butions to smart hospital standardization. Our study also included a thorough review of existing standards applicable to smart hospitals. The group assessed these standards for their scope, applicability, and relevance to the technologies identified. This review helped in understanding the cur- rent standardization landscape and identifying gaps where new standards may be necessary. Building on the insights gained, we identified standardization approaches suitable for smart hospitals (Figure 1) and established the prelimi-nary standard items for one of core technologies of smart hospitals—robotics, particularly the standard items devel- oped by the Pandemic Prevention Robotics Project Group.
  The Pandemic Prevention Robotics Project was conducted from July 2020 to June 2024 for 4 years. The Group used ICT-based robot technologies to develop pandemic response robots. The goal of the Group was to develop three types of robot ICT convergence life quarantine solutions: (1) for intensive healthcare sites, (2) for temporary healthcare facili- ties, and (3) for daily quarantine spaces to solve and improve problems with customized quarantine systems for each type.
  A survey was conducted in the nursing team of the nega- tive pressured isolation ward of a university hospital to identify their tasks which could be helped and replaced by robotic technologies as shown in Table 1. The survey identified the following areas in which robotics can replace tasks: aspiration care, medication administration, blood sampling, hygiene care, enteral nutrition, postmortem care, and medication replacement/exchange. The Group then developed the following robots and re-lated technologies:

1. Specimen extraction robot system

  This system is image-based automatic sampling planning technology and intelligent target (nasopharynx) contact recognition technology. The robot, designed for non-con-tact nasal specimen collection, ensures the safety of the test subjects by preventing excessive force during swab insertion and automates the sample collection process, thus enhanc-ing the sample handling capacity of healthcare institutions.

2. Delivery robot system

  This system is designed to deliver essentials like food, daily supplies, and medicines to patients, and collect trash or healthcare waste, transporting them to designated lo- cations. Main components of the system include a non- contact material transport and delivery robot platform, autonomous driving modules, and a modular manipulator for item delivery and collection.

3. Disinfection robot system

  This system is designed to work for multi-use facilities and living spaces and includes object identification and dis- infection control algorithms, and high-output, large-area ultraviolet-C–LEDs (light-emitting diodes) for disinfection.

4. Real-time monitoring and remote operation of treatment equipment

  This system aims to reduce the number of times health- care staff need to enter isolation wards, prevent cross- infection within the ward, and contribute to emergency response. It focuses on equipment such as ventilators, he- modialysis machines, and extracorporeal membrane oxy- genation devices.

5. Movement tracking

  The primary objective was to develop an accurate AI- based path tracking source technology using deep learn- ing methodologies. This was to trace the movements of confirmed cases and their close contacts quickly and ac- curately. The technology includes automatic path tracking technology using multi-view CCTVs (closed-circuit televi- sions) and sensors. While developing these robotics technologies, the Group realized that standardization of research artifacts was the critical element that would determine the applicability of the research and development (R&D) results. The robotics stan- dard items proposed in the paper are the end results of such consideration by the Pandemic Prevention Robotics Project.

RESULTS

1. Technologies for smart hospitals

  A smart hospital is the result of streamlined organiza- tion of various technological elements, and Figure 2 below shows the key technologies that form the technical back- bone of the smart hospital.

1) Internet of things

  IoT, or the Internet of things, is a network where various objects communicate and exchange information. Its core technologies include the internet, wireless communication, RFID (radio frequency identification), and sensor network technologies. When IoT is merged with cloud computing and AI, it leads to the development of innovative service models, broadening the range of connected devices. In the context of smart hospitals, IoT technology is important for improving clinical effectiveness, patient experience, and the efficiency of hospital operations.

2) Artificial intelligence

  AI-based healthcare services use AI’s core functions like learning and reasoning to diagnose and predict diseases, with healthcare organizations adopting these services for enhanced patient care. Advancements in AI, particularly in healthcare image analysis using deep learning and elec- tronic health record data, are improving the accuracy and timeliness of disease diagnosis and treatment. Moreover, the use of AI in smart hospitals automates administrative tasks, optimizing budgets and staffing efficiency, minimiz- ing equipment downtime, ensuring timely healthcare sup- ply procurement, and enhancing patient communication through virtual assistants.

3) Robotics

  Robots are increasingly central to healthcare services, aiding in surgery, rehabilitation, nursing, and logistics man- agement. Robotic systems enhance the precision in manag-ing and delivering medications, meals, and other necessi- ties. Additionally, robotic process automation, powered by AI, boosts administrative efficiency in hospitals, ensuring time and cost savings and reliable work processing.

4) High speed network

  Advanced communication networks such as 5G and Wi- Fi 6 are revolutionizing healthcare by enabling personal- ized smart healthcare solutions through the integration of wearable technology, machine learning, and big data. These high-speed networks facilitate cutting-edge healthcare services, including remote surgery with minimal latency, real-time vital sign monitoring, AI-based diagnostics, and virtual hospital visits, significantly improving healthcare access and quality.

5) Cloud and big data

  Cloud computing enhances healthcare services quality by offering flexible access to healthcare data and scalable stor- age, integrating vast health information systems for real- time data streaming, and improving interoperability among various healthcare systems and applications for efficient patient care. Concurrently, big data analytics are vital for predicting clinical outcomes and optimizing patient care, enabling early disease diagnosis and prevention, and im- proving healthcare supply chain management and service personalization, thereby driving innovative improvements in both healthcare service quality and operational efficiency.

6) Extended reality (VR/AR/MR)

  Augmented reality (AR), virtual reality (VR), and mixed reality (MR) are transformative technologies in smart hospi- tals, enhancing healthcare through surgical simulations, pa- tient education, disease diagnosis, and telehealth collabora- tion. These technologies (AR/VR/MR) are instrumental in improving healthcare training, aiding in preoperative plan- ning for complex surgeries, and enhancing patient care and rehabilitation through immersive experiences. Furthermore, MR facilitates remote expert consultation in surgeries, while AR improves patient engagement with their treatment.

2. Standard development organization for smart hospitals

  A smart hospital is an integrated model that merges sci- ence and technology. Central to this model is the develop- ment of advanced systems that exhibit functions typically realized in robotics and autonomous systems. Furthermore, this model integrates an array of specialized technologies such as signal processing technology, AI, and a wide range of application-specific technologies. The integration of these diverse technologies enables the creation and execu- tion of sophisticated, interconnected systems specifically designed for the healthcare sector.
  There exists a multitude of standards that may play a role in the operation and management of smart hospitals. How- ever, many of these guidelines and standards were not origi- nally developed with smart hospitals specifically in mind. They often have originated from broader domains such as information technology, data security, healthcare quality, and healthcare device regulations. This means that while they are applicable and crucial to the functioning of smart hospitals, they might not fully address the unique complexities and nu- ances specific to these technologically advanced healthcare facilities. This gap underscores the need for the development of tailored standards that can more effectively cater to the distinct requirements of smart hospitals, ensuring a higher level of precision and relevance in their application.

1) International Organization for Standardization

  ISO is a global body that develops and publishes a wide range of standards with its technical committees compris- ing domain experts who create standards in specific subject areas. The technical committee, ISO/technical committee 299 (robotics), has provided a robotics glossary, perfor- mance, and operation criteria for service robots, specialized standards for navigation and waist support robots, modu- larization requirements, as well as safety and application guidelines for the industry.

2) International Electrotechnical Commission

  ISO/IEC joint technical committee (JTC) 1, a collabo- ration between IEC and ISO for information technology standards, has a subcommittee, ISO/IEC JTC 1/SC 42 (ar- tificial intelligence). The latter published a standard, ISO/ IEC 23053 (framework for artificial intelligence systems using machine learning). And ISO/IEC JTC 1/SC 38 (cloud computing and distributed platforms) published a technical report, ISO/IEC technical report 23188 (cloud computing: edge computing landscape). Also, IEC/technical committee 129 (robotics for electricity generation, transmission, and distribution systems) addresses standardization of inspec- tion robots that be used in the air, underwater, sub-surface and in difficult terrains. IEC/technical committee 47 estab- lished key sensor standards.

3) Institute of Electrical and Electronics Engineers

  IEEE is engaged in standardization efforts in robotics, covering areas like robot navigation and ethical aspects of autonomous robots.
  The IEEE Robotics and Automation Society’s Stand- ing Committee for Standards Activities collaborates with various stakeholders spanning researchers, industry, and other SDOs to identify standardization needs in robotics. Key standards include the IEEE Standard Ontologies for Robotics and Automation (IEEE 1872-2015) that cover essential terms, definitions, attributes, relationships, and others, facilitating task-based reasoning and communica- tion. The IEEE Standard for Autonomous Robotics (AuR) Ontology (IEEE 1872.2-2021) extends IEEE 1872-2015 for AuRs by defining additional ontologies. The IEEE Standard for Robot Map Data Representation for Navigation (IEEE 1873-2015) includes models and formats for two-dimen- sional metric and topological maps. The IEEE Ontological Standard for Ethically Driven Robotics and Automation Systems (IEEE 7007-2021) sets out ontologies at various abstraction levels, providing the necessary definitions and concepts for ethically driven robots and automation sys- tems. New standardization areas in human-robot interac- tions are also being explored in interaction terminology, interaction design, and measurement of robot agility.
  The Engineering Medicine and Biology Society Stan- dards Committee focuses on healthcare robots, setting a standard for classification, terminologies, and definitions for healthcare robots.

3. Technical committees of ISO and IEC for smart hospitals

  Table 2 presents representative technical committees and sub-committees of ISO and IEC that are engaged in stan- dardization efforts pertinent to foundational technologies of smart hospitals. Table 3 shows samples of relevant standards from ISO and IEC for each core technology in smart hospitals.

4. Smart hospitals and technologies in Korea

  Korea is a leader in smart hospital technology, which is a result of a concerted effort by the government and major corporations. The government plan to establish 18 smart hospitals by 2025 [18]. Korea Health Industry Development Institute (KHIDI) fosters smart hospital for the realization of future smart healthcare. KHIDI also provides a smart health- care service model and organic connection & proliferation among healthcare institutions. Supporting this transforma- tion, major hospitals in Korea have shown significant digital maturity. Large enterprises, such as Samsung and Hyundai, funded hospitals and are increasingly investing in the health- care and digital technology sectors. This shift has brought the value of Korea’s digital health market to significant heights, with a recorded value of £4.4 billion as of the end of 2020 [19]. A study revealed that close to 90.5% of hospitals in Korea have implemented electronic medical records (EMR) systems, with 42 tertiary hospitals maintaining a 100% EMR implementa- tion rate since 2015 [20]. These developments collectively un- derline Korea’s status as a global frontrunner in smart hospital technology, setting a benchmark for healthcare innovation worldwide. Notably, Newsweek announced the world’s best smart hospitals 2024 for hospitals leading the way in electronic functionalities, telemedicine, digital imaging, AI, and robotics[21]. Most of the selected Korean hospitals (14 in total) have stood out in AI and digital imaging. These hospitals signifi- cantly enhance patient care and healthcare staff efficiency through AI-based real-time biometric monitoring, EMR data integration, and preemptive alert systems, addressing man-power shortages and reducing potential healthcare errors.
  The successful domestic implementation of smart hospi-tal technologies establishes a strong foundation for global expansion, offering a competitive edge in international markets due to the demonstrated efficiency and opera- tional improvements, with leading innovations in medicine delivery/dispensing robots, smart infection control, AI- based fall and pressure sore management, smart outpatient services, and intelligent workflow management (logistics automation and delivery robots), and healthcare informa- tion systems. Table 4 shows examples of international ven- tures of Korean smart hospitals.

5. Standardization approaches for smart hospitals

  Innovation serves as the primary driver of growth and prosperity of an economy and standards ensure perfor-mance and safety of products and services [22] and define communication interfaces, safety features, and evaluation metrics [23].
  One daunting task facing decision makers in industry and policy is to employ standardization judiciously and ef- fectively to bolster innovation, considering the longstand- ing perception that standards and innovation are inherently 
contradictory.
  While standards may occasionally impede innovation by solidifying inefficient technologies, thus increasing resis- tance to change, they typically foster innovation by encap- sulating technological expertise, establishing a foundation for the development of new technologies [24]. Figure 1 shows basic approaches to be taken when de- veloping standards for smart hospitals. (1) Standardization 
efforts should take holistic approaches rather than one that focuses on individual technical components necessary for operation of smart hospitals. (2) Standardization should start from the existing R&D outcome, such as the Smart Hospital Pilot Project and Pandemic Prevention Robotics Project, and progressively build other standards on them. (3) Standardization efforts should be directed towards those areas in which Korea has technical excellence such as AI and robotics. (4) Standardization efforts should con-sider global certification. (5) Standardization efforts should focus primarily on the best models proven domestically and internationally. (6) Standardization should be multi- SDOs such as ISO and IEC.

6. Potential standard items in robotics

  The Pandemic Prevention Robotics Project conducted research on the development of a “Pandemic Response Ro- bot & ICT Integrated Prevention Control System” utilizing ICT foundations and robotic technologies. The Project developed three types of robots integrated with ICT: (1) intensive for healthcare care settings, (2) for living treatment facilities, and (3) for everyday pandemic prevention spaces. The primary areas of development in- clude (1) specimen collection robots, (2) delivery robots, (3) disinfection robots, (4) remote operation systems, and (5) movement tracking technology development. The Project has identified the following potential international stan- dard items for robotics in smart hospitals.

1) Sampling robots

  The 15 new international standardization items for 
sampling robots encompass a comprehensive framework designed for optimizing robotic functionality in the smart hospital, as shown in Table 5.

2) Remote operation

  A sample of new international standardization items for tele-ICU in Table 6 emphasizes the development and evalu- ation of kiosk-based remote monitoring solutions in inten- sive care environments.

3) Delivery robots

  The six new standardization items in Table 7 for deliv- ery robots include a range of guidelines and requirements aimed at enhancing their functionality and safety, particu- larly in contexts where infection prevention is crucial.

4) Disinfection robots

  The nine new standardization items in Table 8 for dis- infection robots provide a comprehensive framework for their design, functionality, safety, and effectiveness.

5) Movement tracking/contact tracing

  The six new standardization items in Table 9 for move- ment tracking or contact tracing focus on tracking/tracing and identification technologies, especially in high-risk and multi-purpose facilities.

CONCLUSION

  The development of smart hospitals aligned with interna- tional standards and obtaining international accreditation is anticipated to have a profound and multifaceted impact on individuals, healthcare institutions, nations, and indus- try. Over the long term, the streamlined functioning of the healthcare delivery system will contribute to improved population health and bolster the healthcare industry’s global competitiveness.
  AI will boost treatment efficacy and safety through intel- ligent diagnostic systems. Remote collaboration systems in smart hospitals and operating rooms will raise healthcare service standards. Smart hospitals will empower patients to manage their health and access personalized services anytime, anywhere. This will aid in early disease detection, enhance health management, and secure personal health data, leading to more precise treatments. International ac- creditation of smart hospitals boosts service quality and global competitiveness. This certification increases the credibility of healthcare institutions and attracts interna- tional patients, improving national healthcare quality and global reputation. International standardization in smart hospital technologies drives innovation and increases ex- ports of competitive technologies. This provides domestic smart hospitals and technologies global competitiveness, stimulates job creation, and fosters industrial growth, ben- efiting the nation overall. In conclusion, the establishment of internationally standardized smart hospitals is expected to generate a multidimensional positive impact, paving the way for the evolution of a sustainable healthcare system both domestically and internationally.

Conflicts of Interest

  No potential conflict of interest relevant to this article was reported.

ORCID

Sun-Ju Ahn: https://orcid.org/0000-0002-8325-2312 
Sungin Lee: https://orcid.org/0000-0002-4260-2160 
Chi Hye Park: https://orcid.org/0009-0004-7237-9547 
Da Yeon Kwon: https://orcid.org/0009-0009-0965-8718 
Sooyeon Jeon: https://orcid.org/0000-0003-4585-2111 
Han Byeol Lee: https://orcid.org/0009-0005-0485-6724 
Sang Rok Oh: https://orcid.org/0000-0002-1102-031X