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HOSPITAL TOPICS
The Impact of Healthcare 4.0 on the Healthcare Service Quality: A
Systematic Literature Review
Michael Sonya , Jiju Antonyb and Olivia McDermottc
aWITS Business School, University of Witwatersrand, Johannesburg, South Africa; bIndustrial and Systems Engineering, Khalifa
University, Abu Dhabi, UAE; cCollege of Engineering and Science, National University of Ireland, Gallway, Ireland
ABSTRACT
Healthcare 4.0 is inspired by Industry 4.0 and its application has resulted in a paradigmatic
shift in the field of healthcare. However, the impact of this digital revolution in the healthcare
system on healthcare service quality is not known. The purpose of this study is to examine
the impact of healthcare 4.0 on healthcare service quality. This study used the systematic
literature review methodology suggested by Transfield etal. to critically examine 67 articles.
The impact of healthcare 4.0 is analyzed in-depth in terms of the interpersonal, technical,
environmental, and administrative aspect of healthcare service quality. This study will be
useful to hospitals and other stakeholders to understand the impact of healthcare 4.0 on
the service quality of health systems. Besides, this study critically analyses the existing
literature and identifies research areas in this field and hence will be beneficial to researchers.
Though there are few literature reviews in healthcare 4.0, this is the first study to examine
the impact of Healthcare 4.0 on healthcare service quality.
1. Introduction
Healthcare 4.0 is a paradigmatic shift in the field
of healthcare systems. It is inspired by the fourth
industrial revolution known as Industry 4.0
(Jayaraman et al. 2020). The fourth industrial
revolution was inspired by internationalization,
growing competitiveness, technological develop-
ment in information and communications tech-
nology (ICT) and market development (Piccarozzi,
Aquilani, and Gatti 2018). Industry 4.0 led to
digital transformation of the organization. The
first industrial revolution was inspired by steam
power, the second industrial revolution was trans-
formed by electricity. The third industrial revo-
lution was inspired by advances in computing
technology in the year 1970s. The fourth indus-
trial revolution was inspired by advances in ICT
technologies which led to completely automated
and intelligent production process, capable for
autonomous communication and control within
various corporate layers in an organization
(Piccarozzi, Aquilani, and Gatti 2018; Aithal and
Sony 2020; Sony et al. 2021). Industry 4.0 is
driven by real-time data interchange and flexible
manufacturing due to vertical, horizontal and
end-to end integration (Sony 2018). The vertical
integration is integration of all functions with an
organization, the horizontal integration of all ele-
ments in a value chain and end-to end integra-
tion is digital integration of product in all the
phases of product life cycle. In a product centered
value creation process it is integration of
product-centered value creation process, wherein
a chain of activities is digitally integrated. E.g.,
customer needs analysis, product design and
development, production, services, maintenance
and recycling (Wang etal. 2016; Sony and Aithal
2020). Industry 4.0 is defined as “Industry 4.0
refers to the integration of Internet of Things (IoT)
technologies into industrial value creation enabling
manufacturers to harness entirely digitized, con-
nected, smart, and decentralized value chains able
to deliver greater flexibility and robustness to firm
competitiveness and enable them to build flexible
and adaptable business structures, [acquiring] the
permanent ability for internal evolutionary
© 2022 Taylor & Francis Group, LLC
CONTACT Michael Sony emailofsony@gmail.com WITS Business School, University of Witwatersrand, Johannesburg, South Africa.
https://doi.org/10.1080/00185868.2022.2048220
KEYWORDS
Healthcare 4.0;
Health 4.0;
healthcare service quality;
heath care quality;
review
2 M. SONY ETAL.
developments in order to cope with a changing
business environment as the result of a purposely
formulated strategy implemented over time”
(Prause and Atari 2017; Koether 2018; Piccarozzi,
Aquilani, and Gatti 2018). The term Industry 4.0
was introduced in 2011 in Germany as a strategic
German initiative to revolutionize the manufac-
turing Industry by using technology (Xu, Xu, and
Li 2018). During these periods of Industry 4.0,
healthcare systems also underwent a digital trans-
formation and was termed as Health care 4.0.
Healthcare 4.0 represents data-driven healthcare
systems using technologies such as smart health,
mHealth (mobile health), wireless health, eHealth,
online health, medical IT, telehealth/telemedicine,
digital medicine, health informatics, pervasive
health, and health information system (Herrmann
et al. 2018). Healthcare 4.0 has its uniqueness
and is characterized by the adoption of three
main paradigms Big data, IoT and Cloud com-
puting (Aceto, Persico, and Pescapé 2020). The
healthcare delivery process in healthcare 4.0
becomes a cyber-physical system that is equipped
with IoT, Radio Frequency Identification (RFID),
wearables, ambient sensors, all kinds of medical
devices, intelligent sensors, medical robots etc.
which are integrated into cloud computing, big
data analysis, artificial intelligence, and decision
support systems to achieve smart and intercon-
nected health delivery. Healthcare 4.0 connects
healthcare organizations and facilities along with
patient homes, and community are linked together
(Li and Carayon 2021). A point of distinction
between healthcare 4.0 and Industry 4.0 is people
engagement. In healthcare 4.0 patients and care-
givers are increasingly involved and share the
responsibility of monitoring the health, reporting
symptoms, participate in decisions involving deci-
sion making for planning their health. At present,
digital integration in healthcare organizations has
been restricted to specific sectors, or departments
or treatment or processes. The multi-disciplinary
nature of Healthcare 4.0 makes it difficult for the
stakeholders in this field to keep pace with tech-
nological progress (Aceto, Persico, and Pescapé
2020). Hence, most of the efforts of these initia-
tives have fallen short on results frustrating the
managers due to the high complexity of hospitals
or the healthcare system (Tortorella etal. 2021).
Therefore, there is a need for a study to under-
stand the impact of healthcare 4.0 implementa-
tion on healthcare service quality. This is
important because the quality of the healthcare
system determine how satisfied the patients with
the services offered. In a healthcare service qual-
ity, because of intangibility, heterogeneity and
simultaneity the patients evaluate healthcare ser-
vice quality based on interpersonal, technical,
environmental and administrative aspects of
healthcare service (Dagger, Sweeney, and Johnson
2007; Endeshaw 2020). Thus, we ask the research
question How does Healthcare 4.0 impact the
Healthcare Service Quality? The article is orga-
nized as follows; the background theory is elu-
cidated in section 2. The methodology is
explicated in section 3, followed by results and
discussions in section 4. The scope for future
research is delineated in section 5, followed by
the conclusion and limitation.
2. Background Theory
The review of literature is carried out first on
Healthcare Service Quality, subsequently on tran-
sition from Health care 1.0 to 4.0 and at last on
healthcare 4.0 and health service quality.
2.1. Health Service Quality
Healthcare service is an intangible product and
hence cannot be easily measured. Besides, the
characteristics such as intangibility, heterogeneity
and simultaneity, make the health care service
quality difficult to measure (Mosadeghrad 2013;
Endeshaw 2020). One of the most widely used
measures of healthcare service quality is mea-
sured is SERVQUAL. It has five dimensions such
as reliability, assurance, tangibles, empathy, and
responsiveness (Parasuraman, Zeithaml, and
Berry 1985, 1988). However, the drawback asso-
ciated with this model, is that it is developed for
a generic service setting, and it should be con-
textualized for the setting of use (Dagger, Sweeney,
and Johnson 2007; Um and Lau 2018). Though
there have been many studies to measure health
care service quality (Laroche etal. 2005; Dagger,
Sweeney, and Johnson 2007; Sabella, Kashou, and
Omran 2014; Russell, Johnson, and White 2015),
HOSPITAL TOPICS 3
one of the well-accepted model of health care
service quality is by Dagger, Sweeney, and
Johnson (2007). It has four dimensions interper-
sonal quality, technical quality, environmental
quality, and administrative quality. Interpersonal
service quality refers to the relationships devel-
oped and dyadic interaction between the service
provider and patient (Gr 1990; Brady and Cronin
2001). These mainly depend on the manner, com-
munication, and relationship (Dagger, Sweeney,
and Johnson 2007). The manner describes the
attitude and behavior of a service provider, the
communication elucidates the transfer of infor-
mation between a provider and customer, the
degree of interaction, the level of two-way com-
munication. The relationship refers to the close-
ness and strength of the relationship developed
between a provider and a customer (Dagger,
Sweeney, and Johnson 2007; Mosadeghrad 2013).
The technical quality involves two dimensions.
The first dimension is the outcome achieved and
the second is the technical competence of the
service provider. Technical competence depends
on the expertise, provider’s competence, knowl-
edge, qualifications, or skill. The service outcome
describes the outcome of the service process. In
other words, it is a result of his or her interac-
tions with a service firm over a single or multiple
service encounter (Dagger, Sweeney, and Johnson
2007; Duku et al. 2018; Abidova, da Silva, and
Moreira 2020). Environmental quality refers to a
complex mixture of environmental factors that
influences the patient’s perception. It consists of
two types the tangibles and intangibles (Dagger,
Sweeney, and Johnson 2007; Nimlyat and Kandar
2015). The tangible environment consists of the
design, function, or layout of the environment
and the signs, symbols, and artifacts found in
the environment (Dagger, Sweeney, and Johnson
2007; de Jager and Du Plooy 2011). The intan-
gible components comprise those components
that generally exist below consumers’ level of
awareness, thus affecting the pleasantness of the
surroundings. The administrative service quality
enables the production of core service. It adds,
value to the use of core healthcare service. The
three main themes under these dimensions are
timeliness, operation, and support. The timeliness
dimension is known as the factors involved in
arranging to receive medical services. To cite
some examples, it is appointment waiting lists,
waiting time, the ease of changing appointments,
and hours of operation (Dagger, Sweeney, and
Johnson 2007). The operation refers to the facil-
itation of core service production through the
general administration of the clinic and the coor-
dination, organization, and integration of medical
care. The support represents an augmented ser-
vice element that adds value to the core service,
e.g., adding a support program for patients.
2.3. Transition of Health Care 1.0 to Health Care
4.0
There is strong resemblance between healthcare
and manufacturing systems (Zhong, Lee, and Li
2017), and this is due to contrast between part
flow and patient flow. In manufacturing systems,
the main objective is maintaining smooth part
flow, where as in healthcare system it is stream
lines patient flow (Zhong, Lee, and Li 2017). Like
manufacturing systems health care system has
also undergone evolution from health care 1.0 to
healthcare 4.0. Health care 1.0 represent a patient-
clinician encounter. The patient visits the clinic
and meets the doctor, who conducts diagnosis
with minimal use of technology, prescribes med-
ications, care plan for disease management, as
well as follow up plans. The follow up plans
include lab test, imaging test, referral to specialist
etc. (Li and Carayon 2021). Health care 2.0 was
due to the development in of technology in field
of health care. Technology has been used in
health care such as a) imaging test equipment
(CT Scan, MRI, ultra sound etc.), monitoring
devices (pulse oximeter, arterial lines, b)
Continuous glucose monitor etc.), and c) surgical
and life support equipment (surgical robots,
microscopes, chest tubes, ventilators etc.). These
technologies are used in health care 2.0 in diag-
nosis, treatment and monitoring (Subramoniam
and Sadi 2010; Li and Carayon 2021). Healthcare
3.0 is an era where there was development in the
field of information systems, electronic health
records (EHR), or electronic medical records
(EMR). These have been used for patient man-
agement across units or departments within
healthcare organizations. The manual processes
4 M. SONY ETAL.
within the healthcare systems have been digitized.
Besides, the value chains in healthcare systems
have been digitalized (e.g., Electronic after visit
summary). The records are well recorded, man-
aged and transmitted using the electronic medi-
ums. The advances in ICT have also resulted in
changes in health care service delivery in terms
of tele health, remote medical care, electronic
consultations etc. and are replacing face to face
consultations. Besides, the pandemic has accel-
erated this process. Thus, healthcare 3.0 has
changed the healthcare systems in a multidimen-
sional manner in various areas of patient man-
agement (Tiago etal. 2016; Li and Carayon 2021).
Health care 4.0 is use of Industry 4.0 technologies
in healthcare systems. The health care service
delivery process becomes cyber physical system
equipped, IoT enabled, RFID (Radio frequency
identification device) based, wearable sensors, use
of all kinds of intelligent medical devices and
medical robots etc. which are integrated with
artificial intelligence, cloud computing, intelligent
decision support systems, big data, machine
learning and interconnected health care delivery
systems. In such a system digital integration of
health care organizations, facilities, equipment &
devices, patients home and community are car-
ried out (Chanchaichujit et al. 2019; Tortorella
etal. 2020; Li and Carayon 2021). The diagram-
matic representation of all four phases of evolu-
tion of healthcare is depicted in Figure 1.
2.2. Health Care 4.0 and Health Care Service
Quality
There has been an increased usage of ICT in
healthcare to improve the efficiency, efficacy and
quality of healthcare systems (Aceto, Persico, and
Pescapé 2018). Healthcare 4.0 systems uses inter-
connected ICTs, electronics and microstructure
technology that enable more efficient therapeutic
structures and supporting processes (Sultan 2014;
Yang et al. 2015) known as Healthcare 4.0
(Tortorella et al. 2020). The increased usage of
ICT’s could be due to factors such as the avail-
ability of cheaper ICTS with the ability to diag-
nose and provide immediate results and solutions,
reduction in dimensions of ICT’s and higher
capacities to acquire and manage data (González
etal. 2016). Healthcare 4.0 reportedly is a trans-
formation in healthcare systems (Javaid and Khan
2021). The use of ICT is found in health treat-
ments and supporting processes of the hospital
(Tortorella et al. 2020). Some of the benefits of
the adoption of ICT in health care systems cost
reduction, wireless sensor networks for improved
Figure 1. Health care system evolution (Adapted from Li and Carayon 2021).
HOSPITAL TOPICS 5
transparency, electronic health record systems,
usage of mobile health applications, improve
diagnosis and patient care practices, support of
personalized medicine prospects, lower waiting/
lead times, foster collaborative healthcare,
improved support to training and education
(Tortorella etal. 2020). The ability of the health-
care system to deliver its promised results should
be assessed based on its impact on healthcare
service quality (Mosadeghrad 2013). Though
there are studies that specify the importance of
Healthcare 4.0 (Al-Jaroodi, Mohamed, and
Abukhousa 2020; Tortorella et al. 2020, 2021;
Aggarwal et al. 2021), there is no study yet on
how does healthcare 4.0 improve the healthcare
service quality. This study through a systematic
review of literature examines critically the impact
of healthcare 4.0 on the dimensions of the health-
care service quality.
3. Methods
The systematic literature review was conducted
to study the impact of healthcare 4.0 on health-
care service quality. It was used to identify, select
and critically appraise research to answer the
research question (Dewey and Drahota 2016).
The systematic literature review should be carried
out transparently, therefore, a systematic meth-
odology suggested by Tranfield, Denyer, and
Smart (2003) was used. Figures 2 and 3 depicts
the research protocol which was used to carry
out this study. The literature search process was
designed to answer the research question, using
base level studies. A method suggested by Booth,
Sutton, and Papaioannou (2016) was used to
identify the literature. It consists of using a com-
bination of query strings for the titles, abstract,
keywords studies. The search strings for this
Figure 2. Systematic review methodology.
6 M. SONY ETAL.
study were divided into three parts. Part 1 was
used for healthcare 4.0, part 2 was used for
healthcare service quality and part 3 was used
for key characteristics of the healthcare service
quality which was adapted from (Dagger, Sweeney,
and Johnson (2007). The keywords used in the
study are given in Appendix A. The database
used in this study is depicted in Figure 3.
Healthcare 4.0 is an emerging research area hence
we have included conference proceedings and
other peer-reviewed articles.
3.1. Screening Criteria
The screening of articles was carried out in this
phase using a methodology suggested by Popay
et al. (2006). This protocol was used to obtain
the final selection of articles are depicted in
Figure 3. If the articles are from predatory jour-
nals it was discarded. The predatory journals were
identified from Cabbells list (Das and Chatterjee
2018) of predatory journals. Subsequently, the
titles and abstracts were analyzed in greater detail.
It further helped to eliminate the duplicate and
Figure 3: Literature review protocol.
HOSPITAL TOPICS 7
irrelevant articles. The reference list of each article
was used to improve the search criteria. The total
number of articles and their breakdown is depicted
in Figure 2.
3.2. Data Analysis
The main goal of this study was to discover the
impact of healthcare 4.0 on Healthcare service
quality. The articles were identified, and it was
decided to identify the patterns, directions, sim-
ilarities, and differences. Sixty-seven articles were
extracted after review considering the research
objective of the study. These articles were ana-
lyzed and presented in the next section.
4. Results and Discussion
The articles were thematically analyzed and cat-
egorized based on the dimensions of healthcare
service quality such as the impact on interper-
sonal, technical, environmental, and administra-
tive quality.
4.1. Healthcare 4.0 Impact on Interpersonal
Quality
In the era where Internet technologies are used
by the patients, resulting in more patient knowl-
edge, the service provider-patient relationship
assumes paramount importance (Singh and Dey
2021). Healthcare 4.0 thus has an immense
potential to impact the dyadic relationship
between the service provider and patient in the
healthcare setting by using ICT. Communication
in the doctor-patient relationship has improved
a lot by the use of ICT in the healthcare domain
(Haluza and Jungwirth 2014). The ICT enabled
online health communities provided by Healthcare
4.0 service providers results in a sustained, long
time relationship with the patient (Wu 2018), as
it promotes patient satisfaction with the service
provider. The use of technologies such as data
mining helps in the effective design, development,
operation and maintenance of online health com-
munities for effective communication (Durairaj
and Ranjani 2013; Anand, Pal, and Dubey 2016).
Patient drug information is an important aspect
of the quality of care. In the websites of drug
manufacturers, this information should be at an
easy readability level so that patient is well
informed of the drug which is being consumed
(Robert Sabaté and Diego 2021). Healthcare 4.0,
by using the integrated system of a drug database
and online chatbots (“A chatbot or chatterbot is
a software application that is used to conduct an
on-line chat conversation via text or text-to-speech,
instead of providing direct contact with a live
human agent”) (Bates 2019; Mierzwa etal. 2019).
It can help the patient through personalized com-
munication related to the drug being consumed,
its positive and negative aspects. This transpar-
ency in communication will result in a better
service provider-patient relationship. The use of
humanoids (“A humanoid is a non-human entity
with human form or characteristics”) in commu-
nication can improve the service provider–patient
relationship in terms of mirroring one’s voice
when speaking to a patient. It will help in better
driving in a point about treatment compliance
or when being counseled for various aspects of
the disease. One such real-life application is
Pepper organizes sing-songs, makes gin and ton-
ics and can mirror your tone of voice when
speaking to you (Schüssler et al. 2020; Howick,
Morley, and Floridi 2021). These studies suggest
that artificial caregivers can complement human
caregivers, which in turn will free up the time
of doctors which in other words can be thought
of as "AI will allow doctors to be more human"
(Academy of Medical Royal College 2019).
Empathy, compassion and trust are fundamental
elements of a healthcare system and the use of
artificial intelligence, therefore, do the menial
tasks of service providers and free up their time
to be more human (Kerasidou 2020). Recent
studies have shown that humans are being able
to distinguish between empathetic robot and
non-empathetic robot (Suzuki et al. 2015;
Chita-Tegmark, Ackerman, and Scheutz 2019).
Thus, the development in Healthcare 4.0 will
make the service providers more empathetic
using artificial intelligence. The field of affective
computing is being used in healthcare systems
(Tripathi et al. 2021). The compassionate health-
care robots have depicted compassionate com-
munication with older adults. In a study, it was
found that these compassionate robots can be
8 M. SONY ETAL.
used to deal with patients with dementia (Tanioka
et al. 2021). The use of intelligent devices such
as smartphone, wearable sensors, intelligent vehi-
cles, automatically detecting and analyzing human
emotions via internet results in a new paradigm
called as Internet of Emotional People (IoEP)
(Han etal. 2021). The use of IoEP in healthcare
4.0 will enable the healthcare assistant to be more
friendly and empathetic, which will lead to a
better patient experience. Secondly, it will be a
boon to patients suffering from mental health
issues as the artificial service provider will be
able to judge the emotional state of the patients
and offer services based on it (Han etal. 2021).
Ethorobotics is defined as “the science of apply-
ing social behavioral rules for the design of social
robots interacting with living beings (animals or
humans)” (Miklósi etal. 2017). The field of etho-
robotics lays the foundation of human-robot rela-
tionship (Miklósi et al. 2017). The social robots
in healthcare 4.0 have been used in patients for
providing social supports, education, motivation
and encouragement (Tapus, Maja, and Scassellatti
2007; Dawe etal. 2019; Casas etal. 2020). Humor
has been used by healthcare service providers to
relax the patients. It has been found to relax both
the service provider and patients and found to
increase staff coping, emotional resilience, and
perceptions of the work environment (Åstedt‐
Kurki and Isola 2001; Dean and Major 2008).
The studies on robots verbal humor has suggested
jokes were rated as funnier by participants when
told by an android-type robot rather than when
delivered in text form (Sjöbergh and Araki 2008).
A social robot is defined as “a physically embod-
ied, autonomous agent that communicates and
interacts with humans on an emotional level. It
follows social behavior pattern and have various
“states of mind,” and adapt to what they learn
through their interactions (Campa 2016)”. Social
Robots in healthcare 4.0 setting could be designed
to be humorous which may result in relaxing the
patient in a service environment (Lappalainen
2019). The relationship between patient and arti-
ficial intelligent robot in a healthcare setting, due
to repeated interactions can be developed
(Liberman-Pincu, Van Grondelle, and Oron-Gilad
2021), therefore healthcare 4.0 service providers
should be mindful of this relationship when
designing the system. Thus, it can be concluded
that healthcare 4.0 implementation will positively
impact the interpersonal aspect of healthcare ser-
vice quality.
4.2. Healthcare 4.0 Impact on Technical Quality
Healthcare 4.0 may impact both the outcome
achieved and the technical competence of the
service provider. The knowledge, competence and
skill of the healthcare service provider are
enhanced by the use of ICT. The healthcare pro-
fessionals who are proficient in healthcare and
ICT will be able to create a health ecosystem that
would contribute significantly to Healthcare 4.0
(Siribaddana etal. 2019). The professional devel-
opment of healthcare professionals is improved
based on the incorporation of ICT (Fagerström
etal. 2017). In a study, it was found that health-
care professionals who possessed ICT technology
had the greater nursing ability (Fujino and
Kawamoto 2013). Therefore, ICT skills will boost
the professional knowledge of healthcare profes-
sionals. The competence of healthcare profession-
als is increased manifold times due to the
implementation of Healthcare 4.0. To cite an
instance, the diagnosis of heart disease is found
to be a serious concern in the health care setting.
However, the use of a real-time monitoring sys-
tem for early prediction of heart disease using
the Internet of Things along with intelligent algo-
rithms has improved the accuracy of detection
(Basheer, Alluhaidan, and Bivi 2021). Community
health can also be managed effectively using
healthcare 4.0. To cite an instance Intelligent
healthcare system using Naive Bayesian Network
(NBN) can be designed for detecting even viral
diseases such as Dengue and it further uses Social
Network Analysis at the cloud subsystem, to pro-
vide Global Positioning Systems (GPS)-based
global risk assessment of the dengue virus infec-
tion on Google Maps and which will enable to
control dengue virus infection outbreak (Sood,
Sood, and Mahajan 2021). Artificial intelligence
is becoming a doctor’s assistant. It can tirelessly
collect and collate a large amount of data on
diagnostics and treatment and provide the doctor
with the same on-demand, at anytime and any-
where (Wehde 2019). Healthcare 4.0 helps
HOSPITAL TOPICS 9
healthcare professionals with a large amount of
data about the patients, which can help in effec-
tively managing health conditions. To cite an
instance an IoT based early detection and pre-
diction of urine-based diabetes system is designed
which helps in early detection of diabetes. It was
found to be highly useful for monitoring and
prediction (Bhatia et al. 2020). Healthcare 4.0
also interconnects wearable sensors, smart sensors
and social networking data of patients which can
be used by healthcare providers to predict, diag-
nose and monitor health conditions (Ali et al.
2021). Electronic health records, medical health
records, personal health records are digitized and
can be used by the doctors at anytime and any-
where resulting in better decision-making ability
to save the lives of patients even in most complex
circumstances (Garets and Davis 2006; Al-Jaroodi,
Mohamed, and Abukhousa 2020). A large amount
of biological data are generated in terms of
genomics, microbiomics, proteomics, metabolo-
mics, epigenomics, transcriptomics at a very rapid
pace and that too at low cost (Chen and Snyder
2013) and this can be used in near future for
personalized medicines. The use of robots has
increased the competence of health service pro-
viders. It has been used very widely in surgeries.
Robotic surgery are surgical procedures which
are done using robotic systems (Barbash and
Glied 2010). To cite an instance robot-assisted
surgery is being conducted even during pandemic
times (Sharma and Bhardwaj 2021). Studies have
suggested that robotic-assisted surgery might have
various advantages such as early recovery after
surgery, shorter hospital stay, and reduced loss
of blood and fluids as well as smaller incisions
(Van den Eynde et al. 2020). Robotic-assisted
surgeries are also used in spine surgeries espe-
cially for pedicle screw placement (McKenzie
et al. 2021). In another study, it was suggested
that robotic-assisted surgery is in the initial stages
for critical surgeries such as head and neck sur-
geries and needs further studies for its evaluation
(Boehm et al. 2021). Digital twin is defined as
“is a virtual representation of an object or system
that spans its lifecycle, is updated from real-time
data, and uses simulation, machine learning and
reasoning to help decision-making” (Madni,
Madni, and Lucero 2019; Kuo etal. 2021). Digital
twins act as a digital replica for the physical
object or process they represent. It provides
real-time monitoring and evaluation without
being in close proximity. It is used in personal-
ized medicine as a dynamic digital replica of
patients which are created with historical infor-
mation and can be useful for realizing more
effective care interventions, helping physicians
and other intersecting care technologies in under-
standing the medical state of the patient
(Björnsson et al. 2019; Croatti etal. 2020). This
digital replica of patients can help the doctors to
be more competent in dealing with the patients,
as it will help in simulating various scenarios
and find the optimal course of action which will
improve the clinical outcome. In broad manner
healthcare 4.0 will impact the technical quality
by improving the skill and outcomes of healthcare
service in terms of improved success in rehabil-
itation, monitoring physiological and pathological
symptoms, self-management wellness monitoring
and prevention, medication intake monitoring
and smart intake, personalized healthcare,
cloud-based health information systems, telemed-
icine telepathology and disease monitoring,
assisted living, robotic-assisted surgeries, and per-
sonalized management of patients (Thuemmler
2017; Al-Jaroodi, Mohamed, and Abukhousa
2020; Croatti et al. 2020). Therefore, healthcare
4.0 implementation will positively impact the
technical aspect of healthcare service quality.
4.3. Healthcare 4.0 Impact on Environmental
Quality
Healthcare 4.0 can impact the environmental
quality in terms of tangibles and intangibles in
a smart hospital. The patient perception of envi-
ronmental quality gets shaped due to the smart
devices which are integrated within the smart
hospital. In terms of ward care in a smart hos-
pital, the ward care is highly automated through
a microcontroller that collects various sensor
information in the ward. It transmits this data
using wireless technology to the central station
where algorithms would be analyzing the data
for any patterns or trends which will help the
healthcare providers to intervene and manage
the clinical outcome (Rahman etal. 2019; Ravali
10 M. SONY ETAL.
and Priya 2021). The wearable IoT’s such as
which can deliver personalized, immediate, and
goal-oriented feedback based on specific track-
ing of health data obtained via various embed-
ded sensors are used prolifically in healthcare
4.0. It will be capable of extracting data in terms
of accelerometer (“a device that measures the
vibration, or acceleration of motion of a struc-
ture”), gyroscope (“device used for measuring
or maintaining orientation and angular veloc-
ity”), temperature sensor, moisture, location,
heart rate sensor, and blood pressure monitor.
These IoTs will be linked to healthcare 4.0 cen-
tral stations in hospitals where the patient is
under treatment, and the algorithms monitor
and offer personalized solutions to patients
(Jayaraman etal. 2020). Another application that
is becoming popular in healthcare 4.0 is fabric
and flexible sensors. These are low-cost patches
that are worn for days at a time and discarded,
e.g., Sano Intelligence’s continuous blood chem-
istry monitoring patches (Swan 2012) or
Australian Center for NanoMedicine (ACN) has
developed a new wearable sensor that informs
exposure to ultraviolet rays so that patients
reduce the exposure (Gerg 2018). The ambient
IoTs are making inroads in most hospitals.
These IoT’s measure motion, door, pressure,
video, object contact, and sound sensors are
widely used in several Healthcare 4.0 applica-
tions. It is used in patient monitoring in chronic
conditions, fall monitoring, detecting abnormal
behaviors in patients, elderly care (Memon etal.
2014; Al-Jaroodi, Mohamed, and Abukhousa
2020; Jayaraman et al. 2020). The virtual assis-
tants and chatbots in hospitals for managing
various patients’ needs in a healthcare setting.
Intelligent conversational agents and virtual
assistants are used to complement healthcare
service capacity. The most used ones in hospitals
are chatbots and voice assistants to increase the
health service capacity to screen symptoms,
deliver healthcare information, and reduce expo-
sure (Sezgin etal. 2020). To achieve a safe, reli-
able, stable and efficient circulation of hospital
material, an RFID tag is attached to each patient
and his materials such as medicines, disposables
etc. These are stored in a database and can be
easily retrieved anywhere and anytime (Tian
etal. 2019). The patient experience in healthcare
4.0 is improved greatly in terms of intelligent
physical examination systems, online appoint-
ments, integrated patient-physician interactions
(Tian etal. 2019). Healthcare 4.0 thus has smart
hospitals which use IoT in providing healthcare
service in terms of smart monitoring
(Naranjo-Hernández et al. 2012; Hassanalieragh
et al. 2015), having an IoT based architecture
for the health sector (Pang 2013), healthcare
frameworks (Hossain and Muhammad 2016),
smart healthcare service management (Patsakis
etal. 2014; Catarinucci etal. 2015), quick access
to personal health, equipment localization, IoT
based care for hospitalized patients and con-
trolled drug consumption (Uslu, Okay, and
Dursun 2020). Therefore, in healthcare 4.0 sys-
tems the tangibles such as intelligent hospital
building, interconnected medical equipment and
devices, robot-assisted surgeries and medical
care, electronic medical health records, intelli-
gent monitoring of patient flow, digital manage-
ment of caregivers, virtual assistants and chatbots
which are integrated at the cyber level in terms
of an electronic physician, environment control,
remote monitoring, abnormal recognition, dis-
ease prediction and real-time simulation (Cui
et al. 2020), plays a major role in healthcare
service delivery. Therefore, healthcare 4.0 imple-
mentation will positively impact the environ-
mental aspect of healthcare service quality.
4.4. Healthcare 4.0 Impact on Administrative
Quality
Healthcare 4.0 impact the support system which
enables the production of core service. The sup-
port system such as administrative management
of hospitals. The medical records in healthcare
4.0 are digitized, error-free and accessible to
healthcare professional anytime, anywhere (Wehde
2019). The patient privacy of data is protected
using modern technologies such as blockchain
technology (Tanwar, Parekh, and Evans 2020).
Technologies such as a digital twin are used for
the strategic planning of hospitals. A digital twin
of a hospital is created which replicates the oper-
ational strategies or medical process. This enables
to determine what is the optimal course of action
HOSPITAL TOPICS 11
and also its impact on various systems can be
studied (Croatti etal. 2020). From patient admis-
sion to discharge and beyond the ICT are used
to manage the patient information (Øvrelid,
Sanner, and Siebenherz 2017). A good patient
flow is important for the wellbeing of the patient
and also optimum use of scarce hospital resources
(Bygstad et al. 2019). The patient flow is man-
aged at each service points, with paperless tech-
nologies which are a result of direct integration
of medical CPS (Shishvan, Zois, and Soyata 2020)
with information subsystems of hospital admin-
istration. In hospital operations, there is a need
to deal with complex inpatient care workflows,
enhance patient diagnosis, treatment, care, safety
and satisfaction (Frisch 2019). The design of
intelligent hospitals has focused on the integra-
tion of diverse technologies, to provide a seamless
exchange of information within the various func-
tional department of the hospital. RFID has been
used in various operations and processes
(Asamoah et al. 2018). The main application of
RFID in hospitals revolves around institutional
visualization and tracking and localized choke
point solution including validations and process
verification (Asamoah etal. 2018). This helps in
optimizing the patient flow and thereby helping
the optimal use of hospital resources. Even in
intensive care units (ICU), integration of RFID
technology computerizes and tracks admissions,
care plans, vital monitoring, the prescription and
medication administration process for patients in
this service (Martinez Perez, Dafonte, and Gómez
2018). ICT enabled managing of health system
provides support for doctor, patient, management,
and other stakeholders. There various modules
such as administration, patient, billing module
offers integrated support solutions in hospital
electronic management (Yalawar et al. 2019).
Online support groups will be available with the
implementation of healthcare 4.0, using smart
virtual physicians (Goetz etal. 2020) and chatbots
(Bates 2019). This will help in answering basic
frequently asked questions of the patients and
the queries which need human intervention can
be answered by the physicians in the due course.
Thus, the implementation of healthcare 4.0 will
positively impact the administrative aspect of
healthcare service quality.
5. Future Research Direction
Patient interpersonal needs may differ in a
healthcare setting (Verlinde et al. 2012). It
would vary depending upon the demographics,
psychographics, types of illness, social status
(Ong et al. 1995). Therefore, future research
should analyze the impact of healthcare 4.0
technologies in meeting the different types of
interpersonal needs of patients. Healthcare 4.0
implementation and its impact on the inter-
personal aspect of healthcare service quality
needs to be empirically validated in non-weird
(Laajaj etal. 2019) samples. The studies devoted
to understanding the acceptance of healthcare
4.0 technologies as a means of interpersonal
communication, in a healthcare setting by cer-
tain vulnerable groups such as uneducated,
elderly or poor socio-economic backgrounds in
a healthcare setting will help to understand the
implication of healthcare 4.0 in these popula-
tions. Qualitative studies on the use of virtual
assistants by the healthcare providers and
patients and the satisfaction derived from a
longitudinal perspective will help to understand
the time-oriented acceptance of modern tech-
nologies. The impact of healthcare 4.0 on the
clinical outcome of different type of illness may
vary. Therefore, there is a need for a study that
classifies illness into typologies and its impact
on clinical outcomes using healthcare 4.0. The
service providers perception toward using
healthcare 4.0 as a virtual assistant will also
help us to understand the acceptability of these
technologies in a different socio-economic and
cultural setting. The patient’s perceptions on
AI-enabled systems in conducting critical and
non-critical medical procedures should also be
studied to understand the satisfaction levels of
patients with the modern technologies in dif-
ferent socio-economic, cultural, demographic
settings. The impact of smart hospitals and
their impact on the environmental aspect of
healthcare service quality should be empirically
examined. The studies may investigate the
aspects such as smart building, layout, smart
diagnostics, smart artifacts, virtual assistants,
chatbots and their impact on the perception of
patients in all four dimensions should also be
explored. The use of healthcare 4.0 technologies
12 M. SONY ETAL.
in planning, organizing, staffing, directing, and
coordinating hospital management should be
studied in both developing and developed
countries, as the efficacy may differ in both
setting. Such studies will help to unearth the
factors which may impact healthcare 4.0 imple-
mentation and hospital management. The
healthcare service quality model should be
applied in hospitals where healthcare 4.0 is
implemented in varying degrees such as early
adopters and late adopters to understand its
impact on healthcare service quality. Also, lon-
gitudinal studies will help to unearth how
healthcare service quality after implementing
healthcare 4.0 varies in patients over time.
6. Conclusion
Healthcare 4.0 is a paradigmatic shift in the field
of healthcare due to the integration of physical
systems of healthcare with cyber systems to cre-
ate a digital health ecosystem that will benefit
the stakeholder. This study will provide a refer-
ence to healthcare service providers as to how
the implementation of healthcare 4.0 will impact
healthcare service quality. We have discussed in
detail the implementation of healthcare 4.0 can
positively impact interpersonal, technical, envi-
ronmental, and administrative aspects of health-
care service quality. From the specific analysis
of literature, we have depicted how the health
sector will benefit from the implementation of
healthcare 4.0. From an academic perspective,
the extant literature of healthcare 4.0 is analyzed
in detail to depict the impact on each of health-
care service quality dimensions. This will help
the future researchers as a guide and means of
carrying out future research. Hospitals can use
this study to understand the impact healthcare
4.0 can have on healthcare service quality. This
study can be a starting point for hospitals to
understand the importance of healthcare 4.0 and
devise strategies for its implementation. The lim-
itation of this study that it represents a theoret-
ical analysis of literature. In addition, only
English language literature was considered. It is
also limited by the databases considered in
this study.
Funding
e author(s) reported there is no funding associated with
the work featured in this article.
ORCID
Michael Sony http://orcid.org/0000-0002-8003-5216
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HOSPITAL TOPICS 17
Appendix A. Search keywords
Part 1 Part 2 Part 3
Healthcare 4.0
Or
Health 4.0
Or Industry 4.0 in H4.0 or Internet of things in
healthcare
Or Big data in Healthcare
Or Cloud Computing in Healthcare
Or Smart Health
Or E health
Service Quality
Or
Health service quality
Or
Health quality
Or
Healthcare service quality
Or Healthcare Quality
Or Healthcare quality improvement
Or Healthcare quality initiatives
Or Healthcare quality assurance
Or Hospital service quality
Or Patient healthcare service quality
Interpersonal quality
Or
Technical quality
Or
Environmental quality
Or
Administrative quality
Or
Interaction
Or
Relationship
Or
Outcome
Or
Expertise
Or
Atmosphere
Or
Tangibles
Or
Timeliness
Or
Operation
Or
Support
