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Citation: Sony, M.; Antony, J.;
Tortorella, G.L. Critical Success
Factors for Successful
Implementation of Healthcare 4.0: A
Literature Review and Future
Research Agenda. Int. J. Environ. Res.
Public Health 2023,20, 4669. https://
doi.org/10.3390/ijerph20054669
Academic Editor: Jimmy T. Efird
Received: 31 January 2023
Revised: 1 March 2023
Accepted: 2 March 2023
Published: 6 March 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Review
Critical Success Factors for Successful Implementation of
Healthcare 4.0: A Literature Review and Future
Research Agenda
Michael Sony 1, 2,* , Jiju Antony 3and Guilherme L. Tortorella 4,5,6
1WITS Business School, University of Witwatersrand, Johannesburg 2158, South Africa
2Oxford Brookes Business School, Oxford Brookes University, Oxford OX3 0BP, UK
3Department of Industrial and Systems Engineering, Khalifa University,
Abu Dhabi P.O. Box 127788, United Arab Emirates
4Mechanical Engineering Department, The University of Melbourne, Melbourne, VIC 3010, Australia
5IAE Business School, Universidad Austral, Buenos Aires B1630FHB, Argentina
6Production Engineering Department, Universidade Federal de Santa Catarina,
Florianopolis 88040-900, SC, Brazil
*Correspondence: emailofsony@gmail.com
Abstract:
The digitization of healthcare services is a major shift in the manner in which healthcare
services are offered and managed in the modern era. The COVID-19 pandemic has speeded up the
use of digital technologies in the healthcare sector. Healthcare 4.0 (H 4.0) is much more than the
adoption of digital tools, however; going beyond that, it is the digital transformation of healthcare.
The successful implementation of H 4.0 presents a challenge as social and technical factors must be
considered. This study, through a systematic literature review, expounds ten critical success factors for
the successful implementation of H 4.0. Bibliometric analysis of existing articles is also carried out to
understand the development of knowledge in this domain. H 4.0 is rapidly gaining prominence, and
a comprehensive review of critical success factors in this area has yet to be conducted. Conducting
such a review makes a valuable contribution to the body of knowledge in healthcare operations
management. Furthermore, this study will also help healthcare practitioners and policymakers to
develop strategies to manage the ten critical success factors while implementing H 4.0.
Keywords: healthcare 4.0; smart hospitals; digital transformation; health 4.0
1. Introduction
The healthcare industry is undergoing drastic changes due to an acceleration in costs
to the extent of $600 billion worldwide by 2027, making healthcare less affordable and
threatening the sustainability of industry margins [
1
]. However, there are opportunities
to the extent of $1 trillion to create value, thus improving healthcare by raising clinical
productivity, transforming the delivery of care, simplifying administrative procedures,
and applying Industry 4.0 technologies [
1
,
2
]. Accordingly, there is an urgent need to
digitize healthcare services so that the sustainable development goals of healthcare
can be met [
3
]. The fourth industrial revolution has drastically impacted healthcare
services, resulting in marked changes in the manner in which healthcare services are
delivered using technologies. To cite some examples of how the healthcare industry has
seen a significant transformation through the adoption of technologies, 3D printing has
emerged as a promising tool for offering new solutions to patients. Ref. [
4
] have reported
that 3D printing technologies have enabled the creation of prosthetics, surgical devices,
and customized replicas of bones, organs, and other anatomical structures. In a similar
vein, virtual reality technologies have been utilized in diagnoses and treatment, medical
training and education, teleconferencing, dentistry, psychiatry, surgery, and cognitive
rehabilitation [
5
]. Robotics has also played a crucial role in the healthcare industry,
Int. J. Environ. Res. Public Health 2023,20, 4669. https://doi.org/10.3390/ijerph20054669 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023,20, 4669 2 of 22
particularly in surgery and minimally invasive surgery [
6
,
7
]. Beyond that, robots are
used in fields such as assisting disabled individuals [
8
] and counselling, where the
human touch element is essential [
9
]. Additionally, technology has been integrated into
anatomical models, drug formulations, regenerative medicine, and engineered tissue
models to improve treatment success rates [
10
]. These technological advancements have
the potential to significantly transform the healthcare industry and improve patient
outcomes. Thus, the healthcare system is transforming into a smart, integrated system
with improved personalized care, high service quality, better customer experience, better
outcomes, and lower costs. As a result, there has been a paradigmatic shift in healthcare
systems: (1) toward health management instead of the treatment of disease, (2) where
clinical outcomes and quality are being given more importance, (3) moving toward
outpatient services (i.e., the retailization of health services), (4) with informed and
knowledgeable patients, and (5) emphasizing accountability and a values focus [
11
].
Furthermore, the COVID-19 pandemic has also accelerated the adoption of digital
technologies in hospitals to meet the needs of universal healthcare [12].
One of the definitions of healthcare 4.0 (H 4.0) is a continuous but disruptive process
of changing the entire healthcare value chain, including the production of drugs and
medical equipment, hospital care, nonhospital care, healthcare logistics, healthy living
environments, financial systems, and social systems. A vast number of cyber and physical
systems are closely combined through the Internet of Things, intelligent sensing, big data
analytics, AI, cloud computing, automatic control, autonomous execution, and robotics to
create digitized healthcare products, services, and enterprises [
13
]. The implementation of
H 4.0 may result in the achievement of the 8-Ps in healthcare: (1) preventive, (2) patient-
centered, (3) personalized, (4) precision, (5) participatory, (6) predictive, (7) pre-emptive,
and (8) pervasive healthcare [
14
]. Despite its immense potential, the literature on H 4.0 has
been scattered, lacking academic alignment and practical directions [15].
H 4.0 is not only a technical phenomenon but also a complex mixture of social (hu-
man) [
16
,
17
] and technical systems [
15
,
18
] intertwined in a goal-directed manner to meet
the objectives of healthcare systems [
19
]. The term healthcare 4.0 has appeared on blogs
and webpages for years; however, the first Scopus indexed research paper using the term
“healthcare 4.0” surfaced in 2018 [
14
,
20
]. While the term healthcare 4.0 is now commonly
used in academic and industry literature, its implementation has been limited [
13
,
15
,
18
].
Some of the reasons for limited implementation have been low acceptance of H 4.0 by
various stakeholders [
21
], high cost, data fragmentation, privacy and security concerns, lack
of a standardized framework [
17
,
20
,
22
], and a high failure rate of digital transformation
initiatives in healthcare [23,24].
Thus, we need to understand what key areas, activities, or factors must be effectively
executed for the successful implementation of H 4.0. The critical success factors (CSFs) are
typically the most important things that must go well for H 4.0 to be successful. They are
specific, measurable, and unique to the context under consideration, and identifying and
focusing on CSFs can help a healthcare organization to prioritize its efforts and resources,
make better decisions, and stay on track with implementing H 4.0. Thus, there is a need
for a study that critically investigates the CSFs for the successful implementation of H 4.0.
accordingly, the research questions this study investigates are:
RQ1:What are the critical success factors for the successful implementation of H 4.0?
RQ2:How should research on H 4.0 proceed given our findings?
To answer those questions, this study uses a systematic literature review to critically
analyze the previous literature, to identify the critical success factors for successfully
implementing H 4.0. The remaining part of the article first describes H 4.0, followed by
the methodology, descriptive analysis, and thematic analysis for unearthing the 10 critical
success factors, the scope for future research, and the conclusion.
Int. J. Environ. Res. Public Health 2023,20, 4669 3 of 22
2. Literature Review
Healthcare systems have undergone transitions over time [
21
]. Before the 20th cen-
tury, healthcare was largely a cottage industry, with patients receiving care at home from
family members, friends, or local healers. Healthcare 1.0 is devoted to patient–clinician
encounters [
18
]. Here, the patient visits the clinic and meets the physician and other health-
care practitioners, seeking solutions to their health problem. The physician and his team
through consultation, diagnosis, and testing provide treatment and subsequent follow-up.
Healthcare is mostly reactive, with doctors providing treatment after a patient becomes sick.
Healthcare 1.0 was prevalent for a long period [
25
]. The issues in this phase were a lack of
focus on preventative care and public health measures, limited medical knowledge and
technology, and one-on-one healthcare delivery, making it difficult to provide care to a large
population. In the early 20th century, hospitals became more institutionalized and began
using modern medical technologies such as X-rays, antibiotics, and surgical procedures.
Healthcare became more centralized and professionalized and hence Healthcare 2.0 was
an era of major development in health, life science and biotechnology, medical equipment,
and devices [
19
]. This was an era where imaging testing equipment, monitoring devices,
and surgical and life support systems were increasingly used in healthcare systems [
18
].
Hospitals became more prominent, and health insurance emerged. However, access to
healthcare was still limited based on socioeconomic situations, and the quality of care varied
widely. Furthermore, there was a lack of standardization in medical practices and limited
understanding of public health and disease prevention. With the advent of computers and
digital technology, healthcare became more data-driven and information-based and hence
Healthcare 3.0 was the era of implementation of information systems, electronic health,
and medical records to manage patient records across various units and departments of
healthcare systems and introduce telemedicine. Many manual processes within the health-
care systems were digitized [
26
]. However, there were still issues with data privacy and
security, and not all patients had access to these technologies, creating a healthcare divide
based on socioeconomic situations. In addition, there was a need for more standardization
and interoperability in health IT systems. H 4.0 is an era where healthcare delivery is
enabled by (1) medical cyber–physical systems (MCPS), (2) RFID, (3) IoT, (4) medical robots,
(5) wearable and ambient sensors, and (6) intelligent sensors, which are integrated with
cloud computing, artificial intelligence, big data analysis, and decision support techniques,
to achieve smart and interconnected healthcare delivery [
18
,
25
]. Here, all healthcare organi-
zations such as primary, secondary, and tertiary healthcare facilities, equipment and device
suppliers, patients, and communities are integrated into a digital ecosystem. In this era,
patient care is forecast to shift in terms of the use of AI techniques [
27
] and big data analyt-
ics [
28
] for proactive treatment, disease prediction and prevention, personalized medicine,
and enhanced patient-centered care [
25
,
29
]. H 4.0 will thus be an era of a pervasive, smart,
and interconnected healthcare community, as depicted in Figure 1.
The two fundamental elements of H 4.0 are (1) smartness and (2) interconnectedness.
2.1. Smartness
Smartness is the use of Industry 4.0 technologies such as artificial intelligence and
big data analytics to improve treatment, diagnosis, coordination, and communication
between healthcare service providers, patients, and other stakeholders, to achieve patient-
centered and individualized smart healthcare management [
15
]. This is achieved through
the use of I 4.0 technologies as follows: (1) stratification and classification for patients for
treatment, (2) prediction analysis for prediction of disease and development based on the
previous phase, (3) preventive and proactive care using outputs from the previous phase,
(4) monitoring, intervention, and optimal treatment to improve patient outcomes using I 4.0
technologies based on the previous phase, and (5) a closed loop [
25
,
30
]. All the elements
and connected in closed loops so that dynamic improvement of care takes place as depicted
in Figure 2.
Int. J. Environ. Res. Public Health 2023,20, 4669 4 of 22
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 4 of 23
Figure 1. Journey of healthcare from 1.0 to 4.0.
The two fundamental elements of H 4.0 are (1) smartness and (2) interconnectedness.
2.1. Smartness
Smartness is the use of Industry 4.0 technologies such as artificial intelligence and big
data analytics to improve treatment, diagnosis, coordination, and communication be-
tween healthcare service providers, patients, and other stakeholders, to achieve patient-
centered and individualized smart healthcare management [15]. This is achieved through
the use of I 4.0 technologies as follows: (1) stratification and classification for patients for
treatment, (2) prediction analysis for prediction of disease and development based on the
previous phase, (3) preventive and proactive care using outputs from the previous phase,
(4) monitoring, intervention, and optimal treatment to improve patient outcomes using I
4.0 technologies based on the previous phase, and (5) a closed loop [25,30]. All the ele-
ments and connected in closed loops so that dynamic improvement of care takes place as
depicted in Figure 2.
Figure 2. Smartness of H 4.0.
Figure 1. Journey of healthcare from 1.0 to 4.0.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 4 of 23
Figure 1. Journey of healthcare from 1.0 to 4.0.
The two fundamental elements of H 4.0 are (1) smartness and (2) interconnectedness.
2.1. Smartness
Smartness is the use of Industry 4.0 technologies such as artificial intelligence and big
data analytics to improve treatment, diagnosis, coordination, and communication be-
tween healthcare service providers, patients, and other stakeholders, to achieve patient-
centered and individualized smart healthcare management [15]. This is achieved through
the use of I 4.0 technologies as follows: (1) stratification and classification for patients for
treatment, (2) prediction analysis for prediction of disease and development based on the
previous phase, (3) preventive and proactive care using outputs from the previous phase,
(4) monitoring, intervention, and optimal treatment to improve patient outcomes using I
4.0 technologies based on the previous phase, and (5) a closed loop [25,30]. All the ele-
ments and connected in closed loops so that dynamic improvement of care takes place as
depicted in Figure 2.
Figure 2. Smartness of H 4.0.
Figure 2. Smartness of H 4.0.
2.2. Interconnectedness
This element depicts interconnection or integration across all aspects of the healthcare
system. The basic idea is to form an effective information network by integrating: (1) in-
teractions between caregivers, patients, and other team members responsible for patient
care using I 4.0 technologies for integration, (2) digital technologies for managing all com-
munications within the professional care team, (3) equipment and devices using sensors,
IoT, and different kinds of integration devices, (4) organizations and community and other
stakeholders, (5) insurance, billing, and costs as part of healthcare systems, and (6) care
Int. J. Environ. Res. Public Health 2023,20, 4669 5 of 22
transitions across time and space, i.e., over a patient’s lifetime or between inpatient spaces,
outpatient spaces, the home, and long-term care [25,31,32]. This is depicted in Figure 3.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 5 of 23
2.2. Interconnectedness
This element depicts interconnection or integration across all aspects of the healthcare
system. The basic idea is to form an effective information network by integrating: (1) inter-
actions between caregivers, patients, and other team members responsible for patient care
using I 4.0 technologies for integration, (2) digital technologies for managing all communi-
cations within the professional care team, (3) equipment and devices using sensors, IoT, and
different kinds of integration devices, (4) organizations and community and other stake-
holders, (5) insurance, billing, and costs as part of healthcare systems, and (6) care transitions
across time and space, i.e., over a patient’s lifetime or between inpatient spaces, outpatient
spaces, the home, and long-term care [25,31,32]. This is depicted in Figure 3.
Figure 3. Interconnectedness of H 4.0.
Thus, smartness and information integration are desired across every stage of the
patient journey, in every aspect of the healthcare system. A patient may stop at several
healthcare facilities along the way, such as a primary care clinic, specialists, a hospital, an
emergency room, a rehabilitation center, and long-term care, but the goal of H 4.0 is to
create technologies that facilitate smart communication and cooperation amongst the var-
ious parties engaged in the patient journey.
3. Research Method
A systematic literature review (SLR) was conducted in this study to bring transpar-
ency and replicability to the research, to build a firm foundation for future research on H
4.0 [33]. The existing studies were critically analyzed to find the critical success factors and
thus unearth areas for future research [34]. A successful SLR requires research questions
and a subsequent SLR process [35]. The study used the process put forward by Ref. [36]
to systematically carry out the literature review. The steps are detailed in Figure 4.
Figure 3. Interconnectedness of H 4.0.
Thus, smartness and information integration are desired across every stage of the
patient journey, in every aspect of the healthcare system. A patient may stop at several
healthcare facilities along the way, such as a primary care clinic, specialists, a hospital,
an emergency room, a rehabilitation center, and long-term care, but the goal of H 4.0 is
to create technologies that facilitate smart communication and cooperation amongst the
various parties engaged in the patient journey.
3. Research Method
A systematic literature review (SLR) was conducted in this study to bring transparency
and replicability to the research, to build a firm foundation for future research on H 4.0 [
33
].
The existing studies were critically analyzed to find the critical success factors and thus
unearth areas for future research [
34
]. A successful SLR requires research questions and
a subsequent SLR process [
35
]. The study used the process put forward by Ref. [
36
] to
systematically carry out the literature review. The steps are detailed in Figure 4.
3.1. Data Sources
To design a search string for H 4.0, a previous literature review was used as a refer-
ence [
15
,
17
,
37
]. A three-part search string was designed. Part 1 AND part 2 AND Part 3
were used in all combinations as a search string. To source only good quality research
papers, we used Web of Science, Scopus, Science Direct, Google Scholar, and PubMed as
the databases. We excluded conference proceedings and articles that were not in English.
The search string used is given in Appendix A.
Int. J. Environ. Res. Public Health 2023,20, 4669 6 of 22
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 6 of 23
Figure 4. Systematic review methodology.
3.1. Data Sources
To design a search string for H 4.0, a previous literature review was used as a refer-
ence [15,17,37]. A three-part search string was designed. Part 1 AND part 2 AND Part 3
were used in all combinations as a search string. To source only good quality research
papers, we used Web of Science, Scopus, Science Direct, Google Scholar, and PubMed as
the databases. We excluded conference proceedings and articles that were not in English.
The search string used is given in Appendix A.
3.2. Screening
In this phase, screening of the articles was conducted to eliminate systematic error or
bias. This was carried out through a protocol suggested by Popay et al. [38]. This protocol
is set out in Figure 5. The first step was an extensive search to find titles, abstracts, and
keywords that met the screening criteria.
Figure 4. Systematic review methodology.
3.2. Screening
In this phase, screening of the articles was conducted to eliminate systematic error or
bias. This was carried out through a protocol suggested by Popay et al. [
38
]. This protocol
is set out in Figure 5. The first step was an extensive search to find titles, abstracts, and
keywords that met the screening criteria.
To maintain the quality of articles, we used Cabells’ list. If the article was from a
predatory journal, it was eliminated [
39
]. After that, the titles of articles were examined,
which helped to remove duplicates. The abstract was also read to determine whether it
was suitable research. Furthermore, the reference list was combed to improve the search
criteria. A breakdown of the stage-wise number of articles is shown in Figure 4.
Int. J. Environ. Res. Public Health 2023,20, 4669 7 of 22
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 7 of 23
Figure 5. Literature review protocol.
To maintain the quality of articles, we used Cabells’ list. If the article was from a pred-
atory journal, it was eliminated [39]. After that, the titles of articles were examined, which
helped to remove duplicates. The abstract was also read to determine whether it was suita-
ble research. Furthermore, the reference list was combed to improve the search criteria. A
breakdown of the stage-wise number of articles is shown in Figure 4.
3.3. Data Analysis
The main goal of this research was to determine the critical success factors of H 4.0.
The final articles were read to identify directions, patterns, similarities, and differences
[40–43]. Eighty-nine articles were included in our review, considering the research ques-
tions. The lead researcher along with three assistants engaged in the coding process. Be-
forehand, we conducted pilot coding, wherein we jointly designed instructions and a cod-
ing scheme. Eight articles were extracted randomly from the sample. The lead researcher
Figure 5. Literature review protocol.
3.3. Data Analysis
The main goal of this research was to determine the critical success factors of H 4.0. The
final articles were read to identify directions, patterns, similarities, and differences [
40
–
43
].
Eighty-nine articles were included in our review, considering the research questions. The
lead researcher along with three assistants engaged in the coding process. Beforehand, we
conducted pilot coding, wherein we jointly designed instructions and a coding scheme.
Eight articles were extracted randomly from the sample. The lead researcher along with
a research assistant coded the articles for the themes of critical success factors for imple-
menting H 4.0. These codes were compared, then a coding scheme and instructions were
further developed. In the next phase, the remaining articles were coded, and themes were
compared. The simple percentage agreement was calculated as 83%. Wherever there was
disagreement, it was settled through discussion so that all viewpoints were captured.
Int. J. Environ. Res. Public Health 2023,20, 4669 8 of 22
4. Results
The analysis was conducted in two dimensions: (1) descriptive and (2) thematic
analysis. The descriptive analyses were conducted to understand the evolution of the body
of knowledge. The thematic analyses were conducted to unearth the critical success factors
(CSFs) of H 4.0.
4.1. Descriptive Analysis
4.1.1. Timeline Distribution
A time trend analysis of the articles was performed to reveal their distribution over
time [44,45]. Figure 6depicts the timeline distribution of the articles.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 8 of 23
along with a research assistant coded the articles for the themes of critical success factors
for implementing H 4.0. These codes were compared, then a coding scheme and instruc-
tions were further developed. In the next phase, the remaining articles were coded, and
themes were compared. The simple percentage agreement was calculated as 83%. Wher-
ever there was disagreement, it was settled through discussion so that all viewpoints were
captured.
4. Results
The analysis was conducted in two dimensions: (1) descriptive and (2) thematic anal-
ysis. The descriptive analyses were conducted to understand the evolution of the body of
knowledge. The thematic analyses were conducted to unearth the critical success factors
(CSFs) of H 4.0
4.1. Descriptive Analysis
4.1.1. Timeline Distribution
A time trend analysis of the articles was performed to reveal their distribution over
time [44,45]. Figure 6 depicts the timeline distribution of the articles.
Figure 6. Time trend analysis.
Articles on H 4.0 appeared in the last five years. There has been an increasing trend,
suggesting that there has been increasing interest in the field of H 4.0.
4.1.2. Number of Authors
Figure 7 indicates the number of authors for the articles published, according to our
time trend analysis. Sixty-seven percent of the articles were authored by four or more au-
thors, suggesting that H 4.0 is an emerging subject, on which authors are collaborating to
develop the body of knowledge over time. This is understandable, as being an interdisci-
plinary subject, it requires the collaboration of authors from various disciplines to develop
the body of knowledge.
2
13
19 18
36
1
0
5
10
15
20
25
30
35
40
2018 2019 2020 2021 2022 2023
Figure 6. Time trend analysis.
Articles on H 4.0 appeared in the last five years. There has been an increasing trend,
suggesting that there has been increasing interest in the field of H 4.0.
4.1.2. Number of Authors
Figure 7indicates the number of authors for the articles published, according to our
time trend analysis. Sixty-seven percent of the articles were authored by four or more
authors, suggesting that H 4.0 is an emerging subject, on which authors are collaborating
to develop the body of knowledge over time. This is understandable, as being an interdisci-
plinary subject, it requires the collaboration of authors from various disciplines to develop
the body of knowledge.
4.1.3. Productive and Influential Authors
The top ten most productive authors in this field are listed in Table 1. The productive
authors were classified based on the number of publications.
Flavio S. Fogliatto from Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil was the most productive author with 12 publications. He was followed by 11
publications from Neeraj Kumar of the University of Petroleum and Energy Studies, India,
Sudeep Tanwar from Nirma University, India, and Guilherme Luz Tortorella from the
University of Melbourne, Australia.
Int. J. Environ. Res. Public Health 2023,20, 4669 9 of 22
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 9 of 23
Figure 7. Number of authors.
4.1.3. Productive and Influential Authors
The top ten most productive authors in this field are listed in Table 1. The productive
authors were classified based on the number of publications.
Table 1. Productive authors.
Sr No
Author
Articles
Total Citations
1
Fogliatto F.S.
12
157
2
Kumar N.
11
1038
3
Tanwar S.
11
1361
4
Tortorella G.L.
11
156
5
Tyagi S.
7
979
6
Pang Z.
5
127
7
Vassolo R.
5
100
8
Yang G.
5
127
9
Narayanamurthy G.
4
51
10
Saurin T.A.
4
53
11
Tonetto L.M.
4
53
Flavio S. Fogliatto from Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil was the most productive author with 12 publications. He was followed by 11 pub-
lications from Neeraj Kumar of the University of Petroleum and Energy Studies, India,
Sudeep Tanwar from Nirma University, India, and Guilherme Luz Tortorella from the
University of Melbourne, Australia.
4.1.4. Influential Authors
To determine the most influential authors, we calculated the CPP (citations per pub-
lication), as are shown in Table 2.
Table 2. Influential authors.
ID
Author
Documents
Total Citations
CPP
1
Parekh K.
1
339
339
2
Mistry I.
1
273
273
3
Evans R.
2
363
181.5
4
Tyagi S.
7
979
139.86
5
Kumari A.
2
271
135.5
6
Tanwar S.
11
1361
123.73
1
3
2 2 3
1 1
6
45
11
9
13 12
25
0
5
10
15
20
25
30
2018 2019 2020 2021 2022 2023
1
2
3
4
Figure 7. Number of authors.
Table 1. Productive authors.
Sr No Author Articles Total Citations
1 Fogliatto F.S. 12 157
2 Kumar N. 11 1038
3 Tanwar S. 11 1361
4 Tortorella G.L. 11 156
5 Tyagi S. 7 979
6 Pang Z. 5 127
7 Vassolo R. 5 100
8 Yang G. 5 127
9Narayanamurthy
G. 4 51
10 Saurin T.A. 4 53
11 Tonetto L.M. 4 53
4.1.4. Influential Authors
To determine the most influential authors, we calculated the CPP (citations per publi-
cation), as are shown in Table 2.
Table 2. Influential authors.
ID Author Documents Total Citations CPP
1 Parekh K. 1 339 339
2 Mistry I. 1 273 273
3 Evans R. 2 363 181.5
4 Tyagi S. 7 979 139.86
5 Kumari A. 2 271 135.5
6 Tanwar S. 11 1361 123.73
7 Kumar N. 11 1038 94.36
8 Liu M. 1 90 90
9 Memmi G. 1 90 90
10 Qiu H. 1 90 90
CPP = citations per publication
In terms of the most influential authors, Parekh K. and Mistry I., though they had only
one publication each, had better citations than the other authors. However, in terms of
Int. J. Environ. Res. Public Health 2023,20, 4669 10 of 22
total citations, Tanwar S. and Kumar N. had higher numbers of citations, with 11 docu-
ments each.
4.1.5. Top Source Journal
The top ten journals to have published articles on H 4.0 are depicted in Table 3.
Table 3. Top ten journals.
ID Source Documents
1IEEE J. Biomed. Health
Inform. 5
2IEEE Trans. Ind. Inform. 5
3IEEE Access 4
4Comput. Electr. Eng. 3
5IEEE Internet Things J. 3
6Int. J. Prod. Res. 3
7Technol. Forecast. Soc.
Change 3
8IEEE Netw. 2
9IEEE Trans. Eng. Manag. 2
10 IEEE Trans. Netw. Sci. Eng. 2
The IEEE Journal of Biomedical and Health Informatics and IEEE Transaction on
Industrial Informatics top the list.
4.1.6. Countries
The top ten most productive countries in H 4.0 research are listed in Table 4. India tops
the list with 34 documents, followed by Brazil and Australia. We infer that since India and
Brazil are developing countries, researchers there have realized the importance of H 4.0 for
their country’s development, leading to research articles from these countries.
Table 4. Top ten countries.
ID Country Documents Citations
1 India 34 1670
2 Brazil 19 246
3 Australia 16 124
4 China 12 202
5 United Kingdom 12 536
6 United States 11 315
7 Argentina 10 117
8 Sweden 7 162
9 Canada 5 139
10 Chile 5 100
4.1.7. Keyword Analysis
Vosviewer was used to identify the top key words used by the authors, as depicted
in Figure 8. H 4.0 is surrounded by technologies such as the Internet of Things, medical
computing, electronic health records, artificial intelligence, Industry 4.0, digital storage,
healthcare, and so on. Furthermore, it is applied in both diagnosis and patient treatment to
improve healthcare service delivery and performance.
Int. J. Environ. Res. Public Health 2023,20, 4669 11 of 22
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 11 of 23
4.1.7. Keyword Analysis
Vosviewer was used to identify the top key words used by the authors, as depicted
in Figure 8. H 4.0 is surrounded by technologies such as the Internet of Things, medical
computing, electronic health records, artificial intelligence, Industry 4.0, digital storage,
healthcare, and so on. Furthermore, it is applied in both diagnosis and patient treatment
to improve healthcare service delivery and performance.
Figure 8. Keyword analysis.
4.1.8. Type of Study
The articles were classified into empirical and conceptual studies, as shown in Figure
9. The conceptual articles were articles that introduced concepts and ideas without testing
them. The empirical studies were those that involved the use of empirical data.
Figure 9. Type of study.
2
5
32
15
8
16 16
21
1
0
5
10
15
20
25
2018 2019 2020 2021 2022 2023
Conceptual
Empirical
Figure 8. Keyword analysis.
4.1.8. Type of Study
The articles were classified into empirical and conceptual studies, as shown in Figure 9.
The conceptual articles were articles that introduced concepts and ideas without testing
them. The empirical studies were those that involved the use of empirical data.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 11 of 23
4.1.7. Keyword Analysis
Vosviewer was used to identify the top key words used by the authors, as depicted
in Figure 8. H 4.0 is surrounded by technologies such as the Internet of Things, medical
computing, electronic health records, artificial intelligence, Industry 4.0, digital storage,
healthcare, and so on. Furthermore, it is applied in both diagnosis and patient treatment
to improve healthcare service delivery and performance.
Figure 8. Keyword analysis.
4.1.8. Type of Study
The articles were classified into empirical and conceptual studies, as shown in Figure
9. The conceptual articles were articles that introduced concepts and ideas without testing
them. The empirical studies were those that involved the use of empirical data.
Figure 9. Type of study.
2
5
32
15
8
16 16
21
1
0
5
10
15
20
25
2018 2019 2020 2021 2022 2023
Conceptual
Empirical
Figure 9. Type of study.
The timeline distribution of articles suggests that though research started with concep-
tual articles, empirical articles have dominated the research domain. The empirical studies
Int. J. Environ. Res. Public Health 2023,20, 4669 12 of 22
have revolved around the implementation of a particular technology, e.g., an IoT-fog-based
H 4.0 system using blockchain technology.
4.2. Thematic Analysis of Articles
The thematic analysis of articles highlighted 10 critical success factors for the successful
implementation of H 4.0.
4.2.1. Digital Integration and Interconnectedness of the Healthcare Ecosystem
H 4.0 works in an integrated and interconnected ecosystem [
46
] where platforms used
by the government, private hospitals, other health agencies, insurance firms, pharmacies,
and other stakeholder are digitally connected. Data sharing among these entities should be
encouraged but consider the privacy rights of the patients [
47
]. Healthcare data must be
protected by high security and privacy [
48
] and hence security standards such as HIPAA,
COBIT, and DISHA have been developed. There is a need for all stakeholders to use such
standards in a uniform manner, or else there will be an issue concerning the interoperability
of the systems [
49
]. Thus, for the successful implementation of H 4.0, the platforms of
all stakeholders should be able to communicate with one another [
50
]. Another factor
to consider is the technology infrastructure, which will enable connectivity among the
stakeholders [
51
]. This will be a country-specific issue as some countries have better
technology infrastructures than others. In addition, the level of digital connectivity will
vary considerably between developed and developing countries. Regardless, however,
for the success of H 4.0, a highly integrated and interconnected healthcare ecosystem
is required.
4.2.2. Human-Centric Automation of Healthcare Providers
Healthcare providers are labor-intensive and high in touch dimensions [
17
]. However,
healthcare providers are using technology to upgrade their operations and automate
workflows. This has resulted in the automation of various processes of healthcare providers,
thus improving the productivity, efficiency, and efficacy of patient care [
52
]. Various
functions in a hospital such as finance, medical, legal, administration, and compliance
departments are automated to various degrees. Automation is also extended to inpatient
and outpatient management, laboratories, pharmacies, radiology, blood banks, biometric
systems, alert systems, feedback, HVAC, lighting, and so on [
52
,
53
]. There are various
interfaces in a healthcare ecosystem. To name just one, patient–system interfaces could be
automated by incorporating voice, gesture, and easy-to-operate touchscreen systems [
54
].
In addition, intelligent sensing and monitoring systems for patients will help in offering
personalized care, made possible thanks to the high degree of automation of various
patient activities [
55
,
56
]. Further monitoring of multiple advanced patient parameters will
help in understanding the real-time status of patients and will help in the management
of disease [
57
,
58
]. The success of H 4.0 implementation will depend on the degree of
human-centric automation of healthcare providers [14].
4.2.3. Improve Patient-Centricity and the Patient Experience
Patient centricity is defined as a dynamic process where the patient controls the
flow of information to and from them through a variety of channels, enabling them to
make decisions in line with their preferences, values, and beliefs [
59
]. This fundamentally
transformative concept affects how healthcare decisions are made and who has the authority
to make them [
52
,
59
]. Patients’ voices were suppressed for too long, but now patient-
centricity gives not only a voice to patients but also emphasizes consideration of their
values, thoughts, preferences, strengths, and shortcomings while making a healthcare
decision [
17
,
60
]. In such ways, patient-centricity improves the patient experience. Modern
technologies have also been used in hospitals to improve the patient experience [
61
]. Before
the treatment phase, hospitals are using technologies such as wearable monitoring devices
to render real-time personalized care [
62
]. During treatment, the digital identity of the
Int. J. Environ. Res. Public Health 2023,20, 4669 13 of 22
patient is used, and medical records are generated and added to their data file, which can
be assessed from anywhere. In addition, chatbots [
63
,
64
] and humanoids [
65
,
66
] are giving
real-time help to patients throughout their treatment, in addition to the personalized care
of physicians and support staff. They further help in patient education. After the treatment,
wearable sensors offer real-time data about the patient [
67
] and help in extending care to
patients’ homes and offices. Abnormal parameters are flagged, and the patient and their
physician collaborate on the patient’s management [
68
]. In addition, technology will also
help with setting reminders for follow-up and so on. The success of H 4.0 will be based on
how digital technologies are used to improve patient-centricity and the patient experience.
4.2.4. Use Big Data and Analytics
The medical IoT is being increasingly used in H 4.0, with data from devices stored
considering the privacy and security of patients [
69
,
70
] Another factor to consider is the use
of a medical cyber–physical system (MCPS), which combines embedded software control
devices, complex physiological dynamics of patients, and networking capabilities in the
modern medical field [
22
]. This results in medical cyber–physical data which are generated,
digitally stored electronically, and accessed remotely by medical staff or patients [
71
]. The
data can be used through analytics to improve every aspect of hospital operations and
patient care [
72
]. Data analytics used in patient care are primarily in these dimensions:
(1) prediction of disease progression, (2) early disease detection, (3) personalization of
healthcare, (4) personalized management of disease, (5) drug discovery, and (6) managing
patient data. They can also be used in healthcare operations for (1) automation of various
administrative processes, (2) managing patient flows, (3) insurance, (4) accurate costing,
(5) capacity management, and (6) scheduling [
18
,
50
,
53
,
54
]. The hospital typically uses four
types of data analytics: descriptive, prescriptive, predictive, and discovery analytics, in
both patient care and managing hospital operations. Some of the healthcare data analytics
technologies are: (1) AI tools, (2) cloud computing platforms, (3) blockchain networks,
(4) health information exchanges, and (5) machine learning models [
73
–
79
]. Thus, the
successful implementation of H 4.0 warrants the use of big data analytics in both patient
care and hospital operations management.
4.2.5. Managing Digital Healthcare Supply Chains
Digital healthcare supply chains refer to the use of digital technologies and data
analytics to manage and optimize the flow of healthcare products and services [
8
,
22
]. These
technologies can help to improve the efficiency, transparency, and reliability of supply chain
processes, while also reducing costs and enhancing patient outcomes. While implementing
H 4.0, healthcare organizations need to invest in the necessary technology infrastructure,
data analytics capabilities, and talent, to manage the supply chains. Another facet to
consider is digitally managing the intersection of healthcare and supply chain principles
to create service designs in healthcare that are affordable, accessible, meet the healthcare
needs of patients, and are patient-centric [
80
,
81
]. One emerging concept is retail medical
clinics (RMCs). RMCs are located inside retail shops and provide an array of healthcare
services at a very low cost compared to hospitals, doctors, or emergency rooms but at
the same quality. This concept improves patients’ access and awareness and healthcare’s
affordability. RMC brings the following advantages: (1) provides bundles of healthcare
services in one set, (2) resolves healthcare supply and demand issues, (3) frees hospitals
up for major procedures while RMC takes care of basic needs, and (4) places the retail,
efficiency, and cost-effectiveness of services under one umbrella [
82
]. Furthermore, the
integration of RMCs, hospitals, and other healthcare stakeholders will help to create a
healthcare ecosystem that is responsive, effective, affordable, and offers patient-centric
healthcare. Thus, for the success of H 4.0, there should be a proliferation of RMCs in both
urban and rural areas under the umbrella of major retail giants offering a bundle of services
and digitally integrated ecosystems.
Int. J. Environ. Res. Public Health 2023,20, 4669 14 of 22
4.2.6. Strategies for Promoting H 4.0
Healthcare innovation is fundamentally driven by rising healthcare costs, technological
breakthroughs in the field of science, medicine, and rapid digitization of healthcare [
50
,
55
].
For this innovation to be acceptable at the grassroots level, the stakeholders should formulate
strategies to implement H 4.0 [
15
,
18
]. These strategies should target building a technical
infrastructure to promote H 4.0. In addition, strategies should also consider means to improve
the highly skilled manpower in these smart healthcare systems [
53
]. Plus, further strategies
should be formulated to support the promotion of integration among all stakeholders in
healthcare. In these ways, successful implementation of H 4.0 can be made possible with the
formulation of strategies for promoting H 4.0.
4.2.7. Promote a Culture for H 4.0
The organizational culture in a healthcare setting reflects the shared ways of thinking,
behaving, and feeling [
36
]. There are three levels of organizational culture in healthcare.
The first is the visible manifestation. This comprises visible aspects of culture as follows:
(a) distribution of services and roles in organizations, (b) the physical facilities’ layouts,
(c) the established pathways of care, (d) demarcation between staff groups in activities
performed, (e) staffing practices, reporting arrangements, and dress codes, (f) reward
systems, and (g) the local rituals and ceremonies that support approved practices [
83
]. The
second level constitutes shared ways of thinking, which include the values and beliefs used
to justify and sustain the visible manifestations. The third level then constitutes deeper
shared assumptions, which are unconscious and unexamined underpinnings of day-to-day
practice [
84
]. Healthcare organizations are varied in terms of specialty, with groups based
on occupation and hierarchies in terms of professions and service lines. Some beliefs may be
shared and common and others may be dominant in certain groups. The implementation of
H 4.0 involves not only the implementation of technical aspects of ICT integration but also
dealing with social (human) elements in the implementation of concepts such as patient-
centricity and improvements to the human experience [
83
]. For H 4.0 to be successful,
the values and belief about improving patient-centricity and the patient experience using
digital technologies should be shared among all stakeholders in healthcare. There is a need
to change the thinking from traditional service-provider-oriented thinking to patient-centric
thinking. This hinges on the promotion of a H 4.0 culture.
4.2.8. Healthcare Leadership
Health leadership is defined as “the ability to identify priorities, provide strategic
direction to multiple actors within the health system, and create commitment across the
health sector to address those priorities for improved health services” [
85
]. H 4.0 imple-
mentation builds on two components: (a) smartness and (b) integration within healthcare
systems. This requires new ways of carrying out healthcare activities as it enables real-time
customization of care to patients and professionals [
54
]. The complexity of healthcare
systems is in their public and private health providers, primary healthcare systems, acute,
chronic, and aged care provisions, retail clinics, and so on [
86
]. Thus, there is a need for a
leader who will strategically provide insights to these multiple stakeholders and motivate
them to undertake the path of H 4.0 implementation, providing direction for all actors
within the healthcare system.
4.2.9. Healthcare Employees’ Skills
Healthcare employees are key to the successful implementation of H 4.0. The im-
plementation of H 4.0 changes the traditional ways of working with healthcare service
providers [
50
]. It involves delivering care anytime and anywhere through the aid of digiti-
zation [
69
]. The use of technology in healthcare will further extend care beyond the walls
of healthcare service providers, and hence, healthcare employees, in addition to traditional
skills of healthcare, also need digital skills [
20
,
70
]. Another point to consider is how core
technical healthcare skills will transform with the use of technology. To provide an example,
Int. J. Environ. Res. Public Health 2023,20, 4669 15 of 22
in addition to diagnostic tests, the physician may also rely on big-data-based analytics
for confirming and contrasting the diagnostic findings. Such developments warrant the
acquisition of new skillsets for healthcare workers from physicians to administrative staff.
Furthermore, on-demand healthcare, teleconcilium, telemonitoring, teleconsultation, re-
mote access to equipment, tele appointments, and so on also require new skills of healthcare
workers [
50
,
53
,
87
]. Thus, for the success of H 4.0, there is a need for constant deskilling,
reskilling, and upskilling for all categories of healthcare workers. However, there is a
global shortage of healthcare workers, and some such as specialists and nurses are in huge
shortage, leaving them with little time for training in new technologies.
4.2.10. Adoption of New Business Models
Platform-based business models bring ecosystem participants in a digital network to-
gether to co-create goods and services [
19
,
87
]. These models are making inroads into healthcare
providers. Traditionally, mergers and acquisitions were used by healthcare service providers
for increasing market share or mitigating threats [
88
]. The advances in technology in health-
care have resulted in using platform-based business models to achieve newer revenue avenues.
H 4.0 provides numerous opportunities, and the need for building localized ecosystems may
be harnessed by healthcare service providers. However, there will be challenges in terms of
convincing stakeholders, and the cost of the technology will be very high. H 4.0 provides
numerous opportunities to use new business models such as the platform-based model. It will
provide benefits in terms of (1) use of underutilized assets, (2) giving non-strategic assets to
ecosystems, (3) modularizing different facets of healthcare services, (4) improving the patient
experience, and (5) improving the customer experience, thereby bringing in more customers
to the platform, which further improves the value [
50
,
53
,
56
]. Thus, for the successful imple-
mentation of H 4.0, improved business models may be unearthed that introduce new ways of
making money using digital technologies.
5. Discussion
This study identifies ten factors that influence the successful implementation of H 4.0,
and examines their impact on the implementation process in two ways. First, it considers
the individual impact of each factor on the successful implementation of H 4.0. Second, it ex-
plores the interdependence between these factors and how they can collectively contribute
to the successful implementation of H 4.0. This section is divided into two subsections to
address both aspects.
5.1. Individual Impact of CSFs on Successful Implementaiton of H 4.0
This study delineates ten CSFs, which are essential for the successful implementation
of H 4.0. The first CSF is digital integration and interconnectedness of the healthcare
ecosystem; the key factor here will be to convince the various stakeholders in the healthcare
system, including patients, healthcare providers, insurers or payers, and regulatory bodies,
as regards the use of H 4.0 technologies to create a more efficient, effective, and patient-
centered healthcare system [
47
,
71
]. The second CSF is the human-centric automation
of healthcare; the key factor here will be the decision as regards which aspects of the
healthcare system should have H 4.0 technologies applied while still maintaining the
critical role of human decision-making and judgement. The third CSF is that healthcare 4.0
must improve and prioritize the patient experience and ensure that patients are at the center
of all healthcare decisions [
52
–
54
]. The key factor here is that healthcare systems must adopt
patient-centric H 4.0 technologies that enable patients to be active participants in their
healthcare. The fourth CSF is the use of big data and analytics; the key factor for its success
will be how healthcare service providers analyze the large volumes of healthcare data to
identify patterns and trends that can be used to improve patient outcomes and experiences
and optimize healthcare delivery. The fifth CSF is the use of digital healthcare supply
chains; the key factor for success here will be leveraging retail supply chain technologies to
improve the efficiency of healthcare delivery, reduce waste, and improve the availability of
Int. J. Environ. Res. Public Health 2023,20, 4669 16 of 22
healthcare products and services. The sixth CSF unearthed in the study is the importance
of strategy in the implementation of H 4.0; the key factor for its success will be a well-
defined strategy that can help healthcare organizations to maximize the benefits of H 4.0
technologies while minimizing the risks and challenges associated with adoption. By
aligning technology investments with organizational goals and objectives, improving
collaboration and communication, and ensuring that data are collected and analyzed in a
meaningful and actionable way, healthcare organizations can position themselves for the
successful implementation of H 4.0. The seventh CSF unearthed in the study is to have a
culture to implement H 4.0; the key factor here will be to have a supportive organizational
culture that can facilitate the adoption of new technologies, promote collaboration and
communication between different stakeholders, and ensure that H 4.0 initiatives are ethical
and comply with data privacy. The eighth CSF is to have leaders who can foster a culture
of innovation and continuous improvement, address resistance to change, align initiatives
with organizational goals, and manage complex and rapidly changing environments,
which are essential for the success of H 4.0. The ninth CSF is the importance of employee
skills, which are essential for the successful implementation of healthcare 4.0. Healthcare
organizations need to invest in employee training and development to ensure that their
employees possess the necessary technical and soft skills to effectively utilize and maintain
these H 4.0 technologies [
20
,
70
]. The last CSF is the importance of the adoption of new
business models. Healthcare organizations need to develop innovative and adaptable
business models that leverage new technologies and data to improve patient outcomes,
reduce costs, and navigate the complex regulatory and legal requirements of healthcare
4.0. By developing new models for financing and reimbursement, promoting collaboration
and partnerships, and adapting to changing patient needs and regulatory requirements,
healthcare organizations can ensure that healthcare 4.0 is implemented effectively. For
successful implementation, all ten CSFs will have interdependence, with impacts on one
another. For instance, having a good leader who supports H 4.0 will help in promoting a
culture for H 4.0 and devising a strategy for the implementation of H 4.0.
5.2. Interdependnace of CSFs for Sucessful Implemenation of H 4.0
Digital integration and interconnections are critical in today’s healthcare industry [
47
,
71
].
The ten CSFs are interdependent, requiring consideration of their effects on each other for the
successful implementation of H 4.0. With the successful implementation of H 4.0, healthcare
providers can connect with patients and other providers more easily and efficiently, resulting
in the generation of big data [
15
,
18
]. Big data analytics can be used to provide coordinated
and integrated care to patients, resulting in an improved patient experience. The use of an
appropriate strategy, along with human-centered automation, improves the efficiency of care
delivery and creates a patient-centric experience. The patient-centric experience is another
factor that is dependent on digital integration and interconnection and human-centered
automation. When patients have access to personalized digital tools and technologies, they can
participate more actively in their own care. This participation leads to better health outcomes
as patients become more engaged and motivated to take care of their health. Moreover, big
data and analytics can further help healthcare providers better understand patient needs
and preferences, which allows them to peronalize care to meet individual patient needs.
Digital healthcare supply chains are also essential in ensuring that patients have access to the
healthcare, medications and other supplies they need. When the supply chain is optimized
using H 4.0 technologies, patients can receive their medications and supplies quickly and
efficiently, which leads to better health outcomes and an improved patient experience. All of
these factors are interconnected and interdependent. A well-defined strategy is necessary to
ensure that all of these elements are working together to achieve the overall goal of improving
patient outcomes. An innovative and adaptable business model is also crucial as it allows
healthcare providers to adjust to changes in the industry and meet the evolving needs of
patients. It further helps in sustaining the performance of H 4.0. Leadership that fosters
innovation and continuous improvement is essential in driving change and ensuring that
Int. J. Environ. Res. Public Health 2023,20, 4669 17 of 22
all the stakeholders are using H 4.0 technologies constantly to improve the patient-centricity
and experience. Finally, employee skills development is critical in ensuring that healthcare
providers have the knowledge and tools they need to deliver high-quality care using H 4.0
technologies. When employees are well-trained and equipped with the latest technologies
and tools, they are better able to meet the needs of patients and provide them with a patient-
centric experience. Last but not least, implementing digital integration, driving forward
human-centered automation, devising strategies for H 4.0 promotion, and using big data
analytics require an organizational culture where the shared values and beliefs of all healthcare
stakeholders are centered on improving patient-centricity and the patient experience using
digital technologies. Thus, the successful implementation of H 4.0 rests on the important
foundation of promoting a culture of H 4.0.
6. Scope for Future Research
•
This study finds ten critical success factors for the successful implementation of H 4.0.
None of the studies in the literature explicitly addressed all the factors for the successful
implementation of H 4.0, indicating the need for studies that explicitly outline the
factors that could impact the implementation of H 4.0.
•
Another interesting area of future research could be qualitatively exploring the success
factors in various healthcare subsectors. Studies may examine whether these factors
may differ, for example, in biotechnology, pharmaceuticals, equipment, facilities,
distribution, and managed healthcare.
•
The healthcare system and ICT technologies vary across countries [
89
,
90
]; hence, there
is a need for studies to explore whether these critical success factors vary between
developing and developed countries.
•
Studies should also quantitively rank the critical success factors so that the importance
of these factors can be examined in various settings such as between developed and
developing countries. In addition, understanding the relevance of these factors will
help in developing a framework for the successful implementation of H 4.0.
•
Future studies should also be targeted on how to develop digital integration and
the interconnectedness of the healthcare ecosystem. Studies have examined these in
parts [
19
,
47
]; however, comprehensive insights as regards developing a framework for
integration and interconnectedness are lacking.
•
Human-centric automation design is gaining importance in healthcare systems. Health-
care systems are sociotechnical systems, and hence, to be successful, there is a need
for a high level of compatibility between social and technical systems. Future studies
should explore the relationship between human-centric automation and the success of
H 4.0 implementation.
•
H 4.0 success depends on its ability to improve the patient experience and patient-
centricity [
53
,
76
]. Future studies should examine how H 4.0 technologies impact the
various dimensions of the patient experience. There is also a need for longitudinal
studies to understand the time-oriented changes patients experience with the use of
digital technologies.
7. Conclusions
H 4.0 is an emerging area of research. Although there has been interest in academia in
H 4.0, none of the previous studies examined the critical success factors for implementing
H 4.0. This study through a systematic review explicates ten critical success factors for the
successful implementation of H 4.0. Our findings contribute to the theory of healthcare
operations management. First, the study thematically analyzes the literature to explore ten
critical success factors for H 4.0 implementation. Second, this study, through bibliometric
analyses, describes the development of the body of knowledge on H 4.0 implementation.
Third, future research directions are proposed that will support the development of the
field of healthcare operations management.
Int. J. Environ. Res. Public Health 2023,20, 4669 18 of 22
The study finds that the successful implementation of H 4.0 requires the adoption of a
patient-centric approach and the alignment of technology investments with organizational
goals and objectives. Furthermore, the study highlights the importance of a supportive
organizational culture, effective leadership, and employee skills in the successful imple-
mentation of H 4.0. The study also emphasizes the need for healthcare organizations to
develop innovative and adaptable business models that leverage new technologies and
data to improve patient outcomes, reduce costs, and navigate the complex regulatory and
legal requirements of healthcare 4.0.
In terms of implications for practice, this study will help healthcare service providers,
policymakers and other stakeholders to be sensitive to the critical success factors for H 4.0
implementation. Furthermore, this study will also help healthcare service providers to
assess the current state of H 4.0 implementation and how actions can be taken in each of
the critical dimensions to successfully implement H 4.0. The study’s scope was limited
by the databases it utilized, and its analysis was limited to English-language articles.
Additionally, only peer-reviewed research papers were included, which may have excluded
other relevant sources of information. As a result, future research should expand its scope
to include a wider range of documents.
Author Contributions:
Conceptualization, M.S., J.A. and G.L.T.; methodology, M.S., J.A. and
G.L.T.; software, M.S.; validation, M.S., J.A. and G.L.T.; formal analysis, M.S., J.A. and G.L.T.;
investigation, M.S., J.A. and G.L.T.; resources, M.S., J.A. and G.L.T.; data curation, M.S., J.A. and
G.L.T.; writing—original draft preparation, M.S., J.A. and G.L.T.; writing—review and editing,
M.S., J.A. and G.L.T. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix A. Search Keyword String
Table A1. Search strings used for this study.
Part 1 Part 2 Part 3
Industry 4.0 Advantages Health system
Or Or Or
Industrie 4.0 Benefits Hospitals
Or Or Or
The fourth industrial revolution
Pros Health centre
Or Or Or
The 4th industrial revolution Strength Health
Or Or Or
Healthcare 4.0 Strengths Primary care
Or Or Or
Heath 4.0 Positives Secondary care
Or Or Or
Medical 4.0 Gains Tertiary care
Or Or Or
Cyber physical system Pluses Nursing home
Or Or Or
Int. J. Environ. Res. Public Health 2023,20, 4669 19 of 22
Table A1. Cont.
Part 1 Part 2 Part 3
Medical Cyber physical system Highlights Clinic
Or Or Or
CPS Positive effects Hospice
Or Or
MCPS Implementation
Or Or
Internet of things Successful implementation
Or Or
Big data Success factors
Or
Digitization
Or
Digitization
Or
Digitilisation
Or
Digitisation
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