Posted on 11 Aug 2023 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.169178406.

62298915/v1 — This a preprint and has not been peer reviewed. Data may be preliminary.

A COMPREHENSIVE STUDY OF CLOUD, FOG, AND EDGE

COMPUTING TECHNOLOGIES FOR HEALTHCARE IoT
SYSTEMS
Mahmoud M. Hammad1 , Sajeda Banat1 , Qanita Bani Baker1 , Mohammed Al-refai1 , and
Baraa Abudhais1
1
Jordan University of Science and Technology Faculty of Computer and Information
Technology

August 11, 2023

Abstract
Cloud computing technology significantly emerged in various systems to enhance the platform and infrastructure of services.
Fog and Edge computing technologies transform computing power and processing close to the end-user and resolve many
data processing challenges. Healthcare IoT systems refer to using medical sensors and mobile computing to manage patients’
conditions and use cloud-based technologies to transfer collected patients’ data to the cloud computing storage. Many previous
research efforts focused on the use of edge, fog, and cloud computing technologies in the field of healthcare IoT systems.
However, no previous research study summarized the main research topics and trends in these research efforts. To that end, we
conducted a systematic and comprehensive empirical research study to understand the main research topics and the employed
computing technologies and trends in these research topics. This study investigated 100 research studies focusing on cloud-based
technologies in the filed of healthcare IoT systems published in highly reputable venues over the past decade. We created a
taxonomy of the main research topics of the investigated research manuscripts and reported the main focus of these research
efforts and the trends in this field. Our investigation concluded that the researchers mainly focused on the following five research
topics: big data, security, network latency, energy efficiency, and QoS. However, some research topics are well studied while
others are poorly investigated and need more attention. We found that the highest number of research papers focused on big
data, i.e., 63% of the studied papers, while the energy efficiency topic had the lowest number of papers, i.e., 17% of the papers.
Researchers and practitioners interested in the cloud-based healthcare IoT systems can use our findings to gear their work on
the areas that are poorly investigated to find better solutions.

1
Received 09 August, 2023; Revised 09 August, 2023; Accepted 09 August, 2023

DOI: xxx/xxxx

JOURNAL

A COMPREHENSIVE STUDY OF CLOUD, FOG, AND EDGE

COMPUTING TECHNOLOGIES FOR HEALTHCARE IoT
SYSTEMS
Mahmoud M. Hammad* | Sajeda Banat | Qanita Bani Baker | Mohammed Al-refai | Baraa Abudhais

1 Computer and Information Technology,

Jordan University of Science and Abstract
Technology, Irbid, Jordan
Cloud computing technology significantly emerged in various systems to enhance the
Correspondence platform and infrastructure of services. Fog and Edge computing technologies trans-
*Mahmoud M. Hammad, JUST University.
Email: [email protected]
form computing power and processing close to the end-user and resolve many data
processing challenges. Healthcare IoT systems refer to using medical sensors and
Present Address
Irbid, Jordan
mobile computing to manage patients’ conditions and use cloud-based technologies
to transfer collected patients’ data to the cloud computing storage. Many previous
research efforts focused on the use of edge, fog, and cloud computing technologies
in the field of healthcare IoT systems. However, no previous research study sum-
marized the main research topics and trends in these research efforts. To that end,
we conducted a systematic and comprehensive empirical research study to under-
stand the main research topics and the employed computing technologies and trends
in these research topics. This study investigated 100 research studies focusing on
cloud-based technologies in the filed of healthcare IoT systems published in highly
reputable venues over the past decade. We created a taxonomy of the main research
topics of the investigated research manuscripts and reported the main focus of these
research efforts and the trends in this field. Our investigation concluded that the
researchers mainly focused on the following five research topics: big data, security,
network latency, energy efficiency, and QoS. However, some research topics are well
studied while others are poorly investigated and need more attention. We found that
the highest number of research papers focused on big data, i.e., 63% of the studied
papers, while the energy efficiency topic had the lowest number of papers, i.e., 17%
of the papers. Researchers and practitioners interested in the cloud-based health-
care IoT systems can use our findings to gear their work on the areas that are poorly
investigated to find better solutions.

KEYWORDS:
Healthcare system; Internet of Things (IoT); Cloud computing; Fog computing; Edge computing.
2 Hammad M ET AL

1 INTRODUCTION

Internet of Things (IoT) is growing in many daily life sectors. According to newly published research by Statista 1 , the number
of IoT devices will grow up to 25.44 billion devices in 2030 compared to 2019. The number of currently active IoT devices is
7.74 billion devices. IoT is essentially defined as a network of connected smart devices everywhere that are expanded to apply a
large number of tasks such as healthcare monitoring, environmental sensing, industrial task processing, and various smart city
applications 2 . The most important core technology in IoT is Wireless Sensor Networks (WSNs) and the major technology used
in the healthcare IoT system is the Body Sensor Networks (BSNs). BSN is defined as a collection of sensors that are deployed
around and inside the patient body 3 .
Cloud computing aims to provide flexible resources and deployment facilities at a lower cost compared to on premises appli-
cations. In addition, cloud-based computing provides high availability features which means that the data can be accessed
anywhere, anytime by providing both applications and data storage services over the Internet 4 . Due to the ubiquitous of Infor-
mation and Communication Technology (ICT) in the healthcare field, healthcare resources are enhanced and utilized widely by
enhancing the quality of healthcare through instructing healthcare professionals and improving the safety of the patients by mon-
itoring the online treatment 5 . Healthcare IoT services are equally provided for all patients with a minimal cost compared with
traditional healthcare services 6 . Many available wearable IoT sensors can measure a particular patient’s physiological signs like
respiration rate (RR), heart rate (HR), and blood pressure (BP) with a single touch. In this sense, IoT facilitates mobile health,
and Ambient Assisted Living (AAL), which allows remote patient monitoring and follow-up the elderly people living alone at
home or in the hospital to take special treatment. Wearable IoT sensors and communication technologies are trying to improve
traditional interaction between healthcare providers and many patients in more effective healthcare services. Typical healthcare
IoT systems include data collection sensors, communication technologies, computing technologies, and advanced algorithms to
process and analyze data. Sensors are used to collect data from various patient devices. Advanced algorithms are applied to fil-
ter and process data and then analyze all filtered data through different application programs. Data is pre-processed partially at
Edge computing or Fog computing and then loaded to the center Cloud remote processing unit. After that, healthcare providers
retrieve collected data to diagnose, observe and treat patients efficiently, which allows patients to have access to many services
at the same time as depicted in Figure 1 .

FIGURE 1 Healthcare IoT System Architecture

IoT applications have been integrated with healthcare fields to supply more efficient medical treatment to patients. Cloud
computing technology in the healthcare IoT system brings many opportunities to healthcare providers and significantly enhances
healthcare services. Edge computing provides interoperability between various sensors by separating the edge devices from the
center of the network 7 . The sensors used in the healthcare IoT system produce a huge amount of data every second. Processing
of these data is practically impossible using traditional processing data techniques. Therefore, big data is a critical concept in
the healthcare IoT system which needs specific techniques for analyzing and processing.

0 Abbreviations: A COMPREHENSIVE STUDY OF CLOUD, FOG, AND EDGE COMPUTING TECHNOLOGIES FOR HEALTHCARE IoT SYSTEMS
Hammad M ET AL 3

In this study, we investigated large number of healthcare IoT system researches that are utilizing various computing tech-
nologies: Cloud, Fog, and Edge. To that end, we conducted a large-scale comprehensive study by analyzing the related research
papers based on exclusion and inclusion criteria. We present a detailed taxonomy of the main research topics of the healthcare
IoT systems. Moreover, we discuss the related concepts, services, and the main used applications.
The main contributions of this study are provided as follows:

• A comprehensive study of healthcare IoT systems with different computing technologies.

• A taxonomy of the main research topics that are addressed in healthcare IoT systems when the cloud, fog, and edge
computing technologies are employed with these systems.

• Providing statistical results of the collected data for each addressed research topic.

The rest of the paper is organized as follows: Section 2 presents a background of the related technologies. Section 3 presents
the related work. Section 4 demonstrates the methodology we followed in this research. Section 5 provides the main results and
findings. Sections 6, 7, 8, 9, and 10 present each research topic in more details. Section ?? discusses the results. Finally, the
paper concluded in Section 11.

2 BACKGROUND

This section presents a concise background of healthcare IoT systems, Cloud computing, Edge computing, and Fog computing
technologies.

2.1 IoT
Internet of Things (IoT) is considered a new technology that intends to combine various embedded technologies with physical
objects that communicate with each other and interact with the external environment. IoT is incorporated with additional tech-
nologies such as Cloud computing, Edge computing, Fog computing, communication technologies, Internet protocols, smart
sensors, RFID, and various big data analytics technologies 8 .
IoT uses many features of these technologies, and as a consequence, IoT inherited open issues and challenges from all these tech-
nologies 9 . Actually there are a lot of challenges in the promising technologies (e.g., big data, wearable devices, Fog, Edge, and
cloud computing) that are used in healthcare IoT systems. Many of the appeared challenges are related to security, data manage-
ment, and data exchange between devices. Therefore, new concepts and solutions have emerged in the cloud computing, Edge
computing, and Fog computing technologies to solve such challenges, and to facilitate the integration of these technologies with
the different IoT systems.

2.2 Healthcare IoT

In recent years, the propagation of IoT smart devices lead to a rise in demand for the remote healthcare system. The succes-
sive demand to deliver high quality healthcare services and to enhance the management of health information opened a lot of
research fields in the domain of Healthcare IoT 10 .
In the healthcare industry, ICT (Information and Communication Technology) enhanced the equal provision of healthcare ser-
vices for elderly people and patients on a large scale. Sensors and various communication technologies, combined with IoT,
are used to enhance healthcare services by improving the communication between patients and healthcare providers 11 . On the
other hand, many research studies focused on the combination of wearable IoT sensors and smart mobile devices in different
routine activities, healthcare monitoring, healthcare diagnosing, tracking, and locating healthcare-associated things 12 . IoT tech-
nology moves the healthcare system from a centralized manner to a decentralized one to improve patient treatment. Today, home
becomes the main healthcare services center for most elderly people and patients, which reduces medical costs and healthcare
response time 13 .
Healthcare IoT system indicates the use of medical sensors, mobile computing, and cloud computing technologies to really
manage patients’ conditions and use communication technologies to transfer collected patient data to the cloud computing stor-
age 14 . Therefore, healthcare providers retrieved collected data to diagnose, observe, and treat patients efficiently on the time.
4 Hammad M ET AL

The cloud received structured and filtered data and makes important operations on it. It performs various data analytics methods,
ontology, semantics, and machine learning to improve data handling and convert it into useful knowledge 15 . Different services
provided by the cloud can be reached by different stakeholders like physicians, patients, blood banks, hospitals, insurers, IoT
service providers, cloud service providers, healthcare providers, etc.

2.3 Cloud Computing

Cloud computing, defined in 16 is an evolving model that provides required computing resources including services such as net-
works, data storage, and elastic applications to consumers with minimal management effort. In general, cloud computing aims
to provide flexible resources and deployment facilities with a low cost compared with real building computing infrastructure
on the companies. Also, cloud computing supports the high availability feature by providing both applications and data stor-
age services over the Internet, which means that users can access data from anywhere at anytime. 17 . In addition, main cloud
computing providers help IoT companies pay for the only specific resources used with no additional cost for a software license,
maintenance contract, installing upgrades, and control of resources 18 .
Cloud computing has a lot of resources in terms of extensive processing as those needed in deep learning and big data storage.
The main disadvantages of cloud computing are the high distance between healthcare IoT nodes and cloud computing storage.
This leads to more latency of highly sensitive services and makes personal patients’ data vulnerable to many attacks by unau-
thorized entities 19 . Also, all the collected data from the wearable IoT sensors may not necessarily be transferred to cloud storage
across the Internet.

2.4 Fog Computing

The concept of fog computing refers to expanding the cloud computing model to the edge of the network. Recently, fog computing
has been introduced to allow new types of services in Information technology as local storage, local computation, and control
for IoT devices in minimal time when compared to cloud computing 20 . The healthcare system is one of the most domains
that realize this concept by developing a middle layer of smart gateways in the network between IoT sensors and the cloud.
Fog computing provides many advantages for healthcare IoT applications which include improving privacy, reducing latency ,
enhancing reliability, and supporting geographic diversity 11 .
In Fog architectures, gateway nodes make data processing locally along with a transmission of data to the cloud servers. Various
analytical processes like data processing methods, data cleaning, feature extraction, and real-time analysis are transferred to
the fog computing layer 21 . Furthermore, fog computing allows management of the resources at the local layer, but most of the
management techniques are limited to low computation costs methods as rule-based algorithms 22 . Although Fog computing-
based systems provide a lot of advantages for healthcare IoT systems as shown in Table 1 , Fog computing nodes have bounded
functionality due to the restricted computational capacity in the edge devices.

2.5 Edge Computing

Edge computing technologies have been applied since 2002 23 . Healthcare IoT devices collect data and act as an edge node to
provide an entry point to the active network. The edge computing module moves the control of the services in the network from
central nodes or cloud computing nodes to the sensors themselves which are defined as edge nodes. Edge computing differs
from fog computing through the location of where the extra computing power is found 24 .
In edge computing, the processing control and communication abilities are in the IoT devices themselves directly. The edge node
can be a detector, an embedded system, a sensor, or a smart object 23 . But the processing control in fog computing is applied
in the local area network, where collected data are analyzed and processed in the node, router, hub, or gateway and sent to the
suitable devices.
The edge computing devices and fog computing nodes can perform many defined processes, including sending data during
milliseconds and reducing the amount of data for permanent cloud storage or temporary storage in the edge device or fog hub as
shown in Table 1 . Many healthcare actuators must respond quickly to IoT sensor data in seconds and cannot be late for minutes
to send data to the cloud to be analyzed and then transfer the results back to the patient sensors.
Hammad M ET AL 5

TABLE 1 Summary of advantages and disadvantages of computing technologies with healthcare IoT system

Edge Fog Comput- Cloud Com-

Computing ing puting
Advantages Making More stor- Unlimited
critical deci- age space computing
sions in-situ, and com- power and
reducing net- putational huge storage
work traffic, power com- space
minimizing pared to edge
operating computing
cost, and
improv-
ing system
performance
Disadvantages Limited Limited Slow
storage storage and response
and limited limited com- time and
computing puting power require high
power com- compared bandwidth
pared to Fog to Cloud
computing Computing

3 RELATED WORK

In this section, we provide some of the previous surveys that have focused on studying healthcare IoT systems. Previous studies
have concentrated on specific aspects of healthcare IoT systems. But most of these studies have not discussed the healthcare
IoT systems from the computing technologies prescriptive (Cloud, Fog, and Edge), and to find the gaps and main challenges in
those systems with a comprehensive study of different aspects.

In 25 to guarantee the high level of healthcare IoT system performance, they analyzed the main challenges that need to provide
an efficient and secure healthcare monitoring system. In 26,27 , different IoT security and privacy features from the healthcare
aspects were surveyed that include threat types, attack classifications, and security requirements, and reviewed the last technical
trends in IoT healthcare solutions. Further, to minimize security risks, they proposed a smart, collaborative security model and
presented IoT policies and controls for healthcare services that benefit various stakeholders’ technologies in different countries.
Farahani et al. 6 provided a thorough study of several case examples of applications and services that are used with fog comput-
ing. Also, they discussed the applicability of IoT in medicine and healthcare by displaying a comprehensive architecture of the
eHealth IoT system.
Ida et al. 28 , provided an overview of the IoT security vulnerabilities and the main security and privacy challenges in the cloud
for the eHealth context from the network and the hardware prescriptive. Also, they presented various solutions for the IoT
and Cloud security, especially to preserve the health information, while Ghosal et al. 29 , studied various machine learning
approaches that are used to solved various security attacks. Scarpato et al. 30 and Darwish et al. 31 , presented different solutions
used to improve the role of the healthcare system from a security and communication prescriptive.
Qi et al. 32 , presented a set of problems related to IoT healthcare systems that include high dimensionality of produced data,
heterogeneity of connected IoT wearable devices that produced a huge amount of data, and how to make processing of these
data. AbdElnapi et al. 33 , focused on the latest IoT technologies for healthcare as important medical sensors, cloud computing,
and various communication technologies when dealing with the big data generated from different medical IoT sensors.
Aazam et al. 34 , reviewed the main elements and architecture of fog in the healthcare cloud-IoT environment also provided how
fog can be used to solve latency problems, especially in an emergency. Mahmoud et al. 35 , they talked about efficient solutions
for obtaining energy efficiency in data transmission and processing required in the healthcare solution. Dhanvijay et al. 36 ,
6 Hammad M ET AL

reviewed the most recent network architecture topology and applications in the healthcare IoT-based solutions also focused on
the Wireless Body Area Network (WBN) technology, especially for elderly people.
Most previous studies have not discussed the effect of cloud, fog, and edge computing in healthcare IoT systems with a compre-
hensive review of aspects related to each type of computing technology. Therefore, this study addresses detailed taxonomy and
insights for many challenges and issues facing healthcare IoT systems for the realization of an efficient healthcare IoT system.

4 METHODOLOGY

This section shows the methodology applied in this study. We choose the most relevant research that covered topics related
to the Internet of Things (IoT), healthcare, and computing technologies that include Cloud, Fog, and Edge computing. Many
studies regarding IoT technologies and architectures have been carried out in various subject areas such as medicine, computer
science, and healthcare. In our study, published research papers have been studied using the Scopus database, to create a
complete list of research papers on IoT in the healthcare field with the Cloud, Fog, and Edge computing technologies.

The selected papers were searched using the online database service Scopus1 . The main benefits of using Scopus as opposed
to other similar resources are ease of use. Scopus is used as a high-quality bibliometric and a curated data source for academic
research in quantitative science study 37 . Also, Scopus database gives access to STM journal articles, and the references involved
in those articles. It brings together better quality, advanced analytics, and superior technology in one solution. Make the research
workflow more effective and efficient by providing the save list techniques to save the search result after each search query 38 .
We extracted research from the Scopus database using the following search keywords in different query structures: Healthcare,
e-Health, Smart Health, IoT, Cloud, Fog, and Edge. In our study, we found the related research papers by analyzing each paper’s
abstract, introduction, and conclusion. Then, we selected the papers that would be more relevant to our study. More specifically,
we searched for papers and selected the relevant ones according to the three main phases, i.e., Exploration phase, Investigation
phase, and Analysis phase, which are described in Figure 2 .

4.1 Exploration phase:

In the exploration phase, data are collected using the Scopus database, this phase contains a set of steps to find the necessary
research articles as follows:

1. Using the Scopus site to find out research about smart healthcare IoT systems and cloud computing technologies using
the article title, abstract, and keywords in the search field.

2. Searching using 3 specified query structures as follow:

• IoT and Cloud and (Healthcare OR smart Health OR e-Health), with the result of 968 papers.
• IoT and Edge and (Healthcare OR smart Health OR e-Health), with the result of 620 papers.
• IoT and Fog and (Healthcare OR smart Health OR e-Health), with the result of 516 papers.

We found that the number of extracted papers was relatively large, with 2104. Manually, we removed duplicate papers
on the title of each paper. After identifying and removing duplicate papers, 850 papers remained among which the
inclusion/exclusion criteria were applied.

3. Include papers based on specific criteria as follows:

(a) Publication year of research between 2011 and 2019 as shown in the Figure 3 .
(b) Papers that have Q1 or Q2 Journal rank or conference papers with a high citation number.
(c) Papers that have an experimental or case study in the healthcare IoT system field.

1 https://www.scopus.com
Hammad M ET AL 7

FIGURE 2 Flowchart diagram of the systematic research steps

FIGURE 3 Number of annual publications on healthcare IoT systems

From ScimagoJR site 39 we got rank for all paper then sort them descending and take the highest Q1, Q2 and conference paper.
At the same time, we check each paper if have experimental or case study in the healthcare IoT systems, by reading abstract,
introduction and conclusion of each paper.
After applying these steps and inclusion criteria, we ended up with 100 papers used in our research. We found that the highest
number of research has Q1 rate with 51 paper out of 100, Q2 with 31 paper, and conference paper with 18 paper, as shown in
the Figure 4 .
8 Hammad M ET AL

FIGURE 4 Number of paper classifications (Q1, Q2, Conference)

4.2 Investigation Phase:

In this phase, we classify articles using two criteria, type of solved issues and type of computing technology in the healthcare
IoT system.

4.2.1 Main Research Topics Classification

This study considers different healthcare IoT research areas with the different computing technologies Cloud, Fog, and Edge.
First, we define the main research topics that are considered in each paper. Then, we discuss how to solve each topic that
affects healthcare IoT systems when combined with Cloud, Fog, or Edge computing technologies. Finally, we discuss the related
concepts, services, and applications.

4.2.2 Computing Technologies Classifications

There are different technologies in the computing environment for healthcare IoT system, including Cloud computing, Fog com-
puting, and Edge computing 11 . In Cloud computing, patients and doctors can connect directly to the cloud using the Internet.
Transmission of a huge amount of data in a short time is not efficient in a typical cloud computing architecture. To overcome
these problems new computing paradigms such as Fog computing, and Edge computing have been applied which process the
data in the local gateways or connected devices 4 .
Fog computing nodes process the request from IoT devices using local resources or transmit it to the cloud server’s resources.
Therefore, fog computing can manage delay-sensitive computation, and decrease power consumption while reducing traffic con-
gestion 40 . Generally, the main characteristics of fog computing with healthcare IoT systems are low latency, location awareness,
real-time processing, wireless and mobile access, scalability, and geographical distribution support 41 . To improve the accuracy
of diagnosis and analysis of diseases in healthcare IoT systems, many researchers applied Fog computing architecture.
Also, Edge computing provides storage, computation, and networking services to IoT users. Healthcare IoT devices collect data
and act as an edge node to provide an entry point to the active network 38 . In healthcare IoT systems, edge computing guaran-
tees the efficiency of provided services. The data processing of the patient needs an efficient platform that ensures less delay in
response time.

4.3 Analysis Phase:

In this phase, we read the full text of the selected papers to extract the critical data. To gather the data, we designed an extraction
form in Microsoft Excel. Then, we collected the data from 100 selected papers manually.
For each paper, the following data were collected: type of computing technology (Cloud, Fog, Edge), main issues that con-
sidered in each article, how to solve these issues, type of network protocols, type of communication technologies, type of
disease, system place, data collected technologies, data storage techniques, authors country, funding country/university agency,
publication year, citation number, cloud provider type, and the main participated stakeholders in the system.
Hammad M ET AL 9

In this phase, we try to interpret the collected data, including the type of computing technologies and the main issues in health-
care IoT systems. In each studied issue, we used different graphs and views to present the number of studies that were solved by
different types of computing technologies (Cloud, Fog, and Edge). The findings can show differences in the data which should
be considered. Also, the following section shows the main findings and results.

5 RESULTS AND FINDINGS

This section describes the results and findings of our comprehensive study of cloud, fog, and edge computing technologies
within the domain of healthcare IoT systems.

5.1 Computing Technology

Among the selected papers, we found that 60% of them used cloud computing technology to address healthcare IoT systems’
challenges, 24% used Fog computing, and 16% used Edge computing. Also, we found an increasing number of studies for
healthcare IoT systems using Fog computing technology from 2017 to 2019 compared to previous years. Figure 5 shows the
number of healthcare IoT system trend studies between 2011 and 2019. From 2011 to 2014, there were stability and weaknesses
in healthcare IoT research that depend on cloud computing technology. But we observed a significant increase in the number of
studies from 2016 to 2019.

FIGURE 5 Number of annual publication trends of healthcare IoT systems using different computing technologies

5.2 Main Research Topics

We found that the most investigated and studies research topics in the cloud computing-based healthcare IoT systems are big
data, security, energy efficiency, latency, and other QoS aspects. Depending on our study, Figure 6 shows these main research
topics.
Also, Figure 7 shows for each research topic the number of papers that address it. For example, We found that the highest
number of research papers focused on big data, i.e., 63 out of 100 research papers, while the energy efficiency topic had the
lowest number of papers, i.e., 17 papers.
10 Hammad M ET AL

FIGURE 6 Main research topics in healthcare IoT system

FIGURE 7 Number of papers that address each research topic

6 BIG DATA RESEARCH AREA

Recently, huge data was collected from sensors and wearable IoT devices in the healthcare IoT systems. This data is varied and
often unstructured, and requires huge resources for processing, which raised a concern in the computing resources and time
needed to analyze the collected data 42 . Therefore, healthcare providers had to employ new technologies like cloud computing
and fog computing to deal with such varied and big data streams. A set of choices are used to overcome some of the big data
issues by reducing the processing cost and supporting early diagnosis of illnesses 12,43 . In order to get helpful information from
big data streams, an essential step is required to reduce data complexity, and this step includes data cleaning such discarding
unnecessary and redundant parts of the data.
Hammad M ET AL 11

In the following subsections, we present how cloud computing, edge computing, and fog computing technologies addressed
the ability to process huge and complex healthcare data flows. Figure 8 shows the number of papers that addressed the big data
aspect using cloud, fog, and edge computing technologies. For example, 55.56% of studied papers used the cloud computing
technology to solve big data issues, 28.57% used Fog computing, and 15.78% used Edge computing.

FIGURE 8 Number of papers that addressed the big data topic using cloud, fog, and edge computing technologies

6.1 Big data processing in Cloud computing

One of the main advantages of cloud computing is saving a huge amount of data and various resources in a huge data center on
the Internet. Moreover, current cloud computing architectures provide effective execution enhancement by combining different
environments to execute the applications at different levels. Also, cloud computing offers pay-as-you-go to services that include
virtualization, networking, big data analytics, and data-parallel processing on customized servers 44,45 .
Moreover, advanced healthcare providers are improving their infrastructure to deal with a huge amount of data produced by
WBAN IoT sensors by using multi-cloud data computing to ensure the highest level of cost-efficiency, data availability, and
reliability 46 . The multi-cloud computing architecture enables the deployment of the tasks to the proper environment (public,
private or hybrid cloud), which speeds up the processing steps. The authors of 47,48 used Microsoft Azure and Google as multi-
cloud computing with OpenIoT structure. Furthermore, the survey conducted in 49 found that 86% of respondents are dealing
with current cloud computing as multi-cloud.

6.2 Big data processing in Fog computing

Cloud computing sources were extended to the edge network, known as the Fog computing layer. Both Cloud and Fog layers
provide data processing, storage, and application features to the users.Data processing on the fog computing layer performs an
essential role in healthcare monitoring systems. This layer is necessary especially for medical scenarios that involve emergency
cases, which require taking critical decisions and sending notifications to the specialists with the least possible time. In 21,4,50 ,
12 Hammad M ET AL

they used fog computing, which is placed in the patient’s home, to decrease the processing time, increase efficiency, reduce the
amount of data required to send to the cloud, and avoid more latency.
In 51,52 , they used fog computing to improve the healthcare system and enhanced the fog computing layer with distributed data
storage and data mining techniques.

6.3 Big data processing in Edge computing

Big data processing using edge computing power and storage near the healthcare IoT devices allows data cleaning and analysis
in low response time before sending data to the centralized cloud system, which improves data transmission efficiency. In 52 ,
they deployed edge servers at the already known places of a city to collect the Chikungunya virus data from users and make the
processing of the data, then transmitting it to the Cloud. In 53,54 , they found that the use of edge computing to process data has a
better effect on disease detection when compared to cloud computing, and found that edge computing helped in sending earlier
notification announcements to the medical service provider compared to cloud computing.

7 SECURITY RESEARCH AREA

Combining IoT devices in the healthcare field with Cloud, Fog, and/or Edge computing technologies led to a lot of security
issues that need to be resolved 55,56 . These issues can happen at different phases, such as the security of the collected data
from healthcare IoT devices, either during sending data to (cloud, Fog, and Edge) to make processing, or while saving data in
computing storage 57,58 . This section concentrates on the security issue related to the data flow of healthcare IoT systems with
the different computing technologies (Cloud, Fog, and Edge).

7.1 Security in Healthcare IoT Systems Using Different Computing Technologies

Collecting patient-sensitive data is the main subject of evaluating security protocols and algorithms. There are different
paradigms about the computing environment for healthcare, including Cloud computing, Fog computing, and Edge computing.
Many solutions include secure algorithms, computing technologies, and Internet protocols to protect collected patients’ sensi-
tive and health information. Figure 9 provides the number of studies that consider security issues by computing technologies.
According to Figure 9 , the most percentage including 59.4% of studies used cloud computing technology architecture to solve
security issues, 31.3% used Fog computing architecture, and 9.3 % used Edge computing architecture.
Depending on Figure 9 , cloud computing is the most used layer to solve security issues in healthcare IoT systems. However,
as will be described in the following sub-sections, the fog computing layer plays an essential role in the confidentiality and the
security of healthcare IoT systems.

7.1.1 Security issue for healthcare IoT system in Cloud computing

In healthcare IoT systems, the cloud architecture can enhance healthcare services and improve the frequent updating of the
healthcare system 3,59,60 . However, security is one of the main issues when integrating cloud computing with the healthcare IoT
system because of the high level of data interoperability, integration, and sharing of these data between healthcare providers
and organizations 61 . Distinguishing between the actual user and the attacker at the cloud level is a complex process. There are
many security threats in the cloud as Denial of Services attack (DOS/DDoS), Man-in-the-Middle attack, and Sleep Deprivation
attack 6,8,4 . To mitigate these threats, cloud computing technologies process and save collected data in distributed cloud servers
privately 58,19 , and only allows authorized users to securely use patient data by authenticating themselves using robust authenti-
cation algorithms. However, most commonly used security techniques in practice are overlooked at the cloud level because of
the trade-off between the efficiency, speed up of the system, and security problems in healthcare IoT systems 62 .
Hammad M ET AL 13

FIGURE 9 Number of studies consider security issues by computing technologies

7.1.2 Security issue for healthcare IoT system in Fog computing

Compared to the cloud layer, fog nodes use more powerful encryption schemes, access control policies, isolation measures, and
integrity checks to preserve the security of patient-sensitive data 8 . The fog computing paradigm is qualified to overcome the
security issues that typical cloud computing architecture is exposed to 50 . Providing fog computing as a middle layer and acting
on the edge-side improves data security, consistency, accuracy, minimizes the latency rate, and improves service quality. Because
fog nodes spread near the end-users and some places with relatively weak monitoring, it is more vulnerable to malicious attacks.
Furthermore, Man-in-the-middle attacks can stop sending patient data from the healthcare IoT devices to the healthcare provider,
which leads to life loss in some cases 7,63,64 . As a solution to these issues, the multi-layer communication approach was used,
which helped in solving many security and privacy issues, including authentication and authorization, identity management,
data sharing policy, quality of services, etc.

7.1.3 Security issue for healthcare IoT system in Edge computing

The edge computing layer is very close to the end-users, and therefore, it introduces a platform at the application layer for
protecting the data collected by various IoT sensors 65 . For example, in 7,66 , they proposed techniques for encrypting the patients’
data at the application layer before sending the data to the cloud servers. Furthermore, To ensure availability while receiving
denial of services (DoS) attacks, the edge architecture uses backup systems and redundancy techniques.

8 LATENCY RESEARCH AREA

The latency issues vary depending on the nature of healthcare IoT applications. It differs with the type of application and the
healthcare IoT systems field. Some applications have more constraints than others. Some healthcare IoT applications are autho-
rized to have some delays while others are not. For instance, sending blood pressure can allow delays up to 2 to 4 seconds 67 .
While ICU applications, ambulance applications, and emergency applications allow less delay. Surgery applications need to
send multimedia data as interactive video and audio to remotely and the allowed latency for these applications must not beat
more than 300ms 68 .

If cloud computing is used, normally raw data is sent from IoT nodes to the cloud to be processed and stored. While transferring
the data, unpredictable network circumstances may cause delayed responses. The case is even more dangerous when in the case
of transferring streaming-based data as EEG or ECG signals. To overcome this possible delay for critical data, the analysis of
such data is done in the distributed edge gateway and (i.e., the local network level) using time-sensitive procedures 69 . Then, the
analyzed data is transferred to the cloud server for further processing and permanent storage.
14 Hammad M ET AL

8.1 Latency Issue in Healthcare IoT Systems Using Different Computing Technologies
Healthcare IoT sensors produce a huge amount of data. Processing and analyzing these data need more time, leading to delays
in the provided services to the patient, especially in the cloud environment. Recently, traditional services of cloud environments
have been unable to obtain the latency requirements of healthcare IoT systems. To solve this problem, in 9 , they used near edge
devices to process and store data locally, to overcome latency problems and provide better QoS. In 70 , to execute healthcare
monitoring applications using BAN, they used cloudlet computing as a solution to solve high latency problems, especially in
critical tasks. They used WiFi direct communication between concentrator and cloudlet to reduce data transmission latency, or
LTE to transfer data from the concentrator to the cloud without using cloudlet technology. In 43,71 , to minimize the time of data
processing and the number of communications, they used a local cloud or cloudlet with the MapReduce technique which leads
to reduce the overall processing delay.
In 6,21,50,72,73,74,75 , wearable IoT sensors can produce a huge amount of raw data within a short time. But it is not necessary and
not feasible to transfer these data from many patients to the cloud. Therefore, fog computing is reasonable to filter, process, and
compress the data before moving it to the cloud, which is crucial for better visualization, low latency, and context awareness
in emergency and ICU rooms. Consequently, the latency can be reduced because of the shorter physical distance. In 76 , when
applied fog computing concept, they decreased 90% of exchange data from patients to the cloud and reduced up to 20% of the
processing time. As provided in Figure 10 , we found that most researchers used the Fog computing paradigm to solve latency
issues.

FIGURE 10 Number of studies that consider High Latency issues using different computing technologies

In conclusion, based on our findings, to reduce the latency in the cloud environment between healthcare IoT sensors and
patients, the fog computing techniques are integrated with the cloud environment. Fog computing is designed to be close to IoT
sensors, which provide quicker responses to patients in emergency cases compared to cloud computing.

9 ENERGY EFFICIENCY RESEARCH AREA

Energy efficiency is one of the most important aspects in the field of healthcare IoT systems due to its impacts on the environment,
operating expenses, and service quality. Healthcare wearable sensors generate a high amount of data that needs high energy and
lead to a short lifetime of the battery. In terms of resource consumption due to data processing, the most resource consumption
techniques are the speech and image processing techniques 67 . Depending on our study, to obtain energy efficiency in healthcare
IoT systems, researchers used different optimization algorithms, different computing techniques as Edge or Fog computing,
different types of communication technologies, and appropriate hardware according to the type of system. To decrease the usage
of energy, optimization algorithms were also applied. An efficient energy architecture for healthcare IoT systems is proposed
Hammad M ET AL 15

in 77 . This approach uses sleep mode method to reduce the energy consumption depending on turning IoT sensors to sleep mode
in three cases: the battery level is low when the area size covering override the rank of battery level, the situation of battery
level, and the demand of collecting data from patients in a specific interval of time. Therefore, Cloud resources allocated to the
system are saved when IoT sensors changed to sleep mode. In 48,78 , they used Raspberry Pi because it has features of having less
power consumption of nearly one-tenth when compare with other hardware.

9.1 Energy Efficiency in Healthcare IoT Systems Using Different Computing Technologies
Data transmission and computational tasks are the most energy consuming processes in healthcare IoT system. According
to Figure 11 , the most significant percentage comprising 47.1% of the reviewed studies used cloud computing technology
architecture to address the energy efficiency field, 35.3% used Fog computing architecture, and 17.6% used Edge computing
architecture. In general, the work to reduce energy consumption in IoT healthcare systems focused on eliminating unnecessary
communications. For example, using fog computing in the intelligent gateway with efficient scheduling tasks can reduce energy
consumption in healthcare IoT sensors. Also, in the data centers, determining the appropriate place to process collected data in
the Cloud or Fog depends on the type and amount of collected data. Also, most healthcare IoT systems focus on privacy and
security protocols that consume less energy in the IoT devices, and therefore, lightweight protocols are used.

FIGURE 11 Number of studies that address the high energy efficiency topic

10 QUALITY OF SERVICES RESEARCH AREA

In IoT healthcare systems, providing quality of Service (QoS) requirements is one of the critical aspects. Quality of Service
(QoS) controls the network’s capabilities and resources to afford a reliable backbone to healthcare IoT services. For example,
QoS controls latency, delay variations, packet loss, and bandwidth and communication protocols. IoT healthcare systems that
are based on cloud, edge, and fog computing technologies have multiple QoS aspects to be controlled, such as performance,
reliability, scalability, and availability. The following subsections discuss those aspects.

10.1 Performance
Performance is a very important aspect to be addressed in healthcare IoT systems because they include a wide variety of het-
erogeneous tools that collect huge amount of medical and health data for acute and chronic cases, and such data need to be
processed quickly using high performance computing technologies. Therefore, healthcare IoT systems must contain improved
16 Hammad M ET AL

methods to ensure high-performance results. Scalability and interoperability perform the main role in the performance of IoT
healthcare systems. Furthermore, IoT big data should be processed in a distributed and parallel way to enhance the performance
of data analysis.
Many techniques were introduced in different domains to obtain high-performance healthcare IoT systems 4,7,10,19,79 . For
example, correct interaction and connection between different IoT healthcare devices guarantee that both the tools and patient
personal information are under suitable care. Furthermore, a low-power WBAN device gives reliable and efficient infrastructure
to all embedded, non-embedded, and wearable sensor devices for the patient body. In 7,80,23,73,81 , the tasks between fog computing
nodes and cloud computing system must be coordinated, so high computational tasks are performed permanently in the cloud
computing resources, but other analytical tasks are performed in the fog nodes to reduce the load and enhance the performance
of different healthcare activities.

10.2 Availability
IoT availability is defined as the reachability of IoT services when the network link or device failures occur. A minor interruption
of critical healthcare services, especially for older people or in an emergency, may disrupt that service’s provisioning and lead to
patient death. The availability of IoT healthcare services in a cloud-based computing network is the first major demand. Cloud
computing platforms include data storage and computing resources that are distributed on large networks. These networks must
be consistent in healthcare IoT performance and availability services.
Healthcare IoT systems require interoperability, and therefore, these systems must use protocols, as 6LoWPAN, and IPv6 which
are significant for healthcare systems where availability always must be provided. In 66 , they proposed a service placement
algorithm to increase the service availability and the quality of service (QoS) satisfaction rate by mapping applications to the
nearest fog devices and then pass the services of the applications to other fog devices depend on the available fog nodes.

10.3 Scalability
Healthcare IoT systems must be developed to help a large number of patients. Also, doctors and other healthcare specialists
must use the devices and troubleshoot any problem remotely. This requires transacting with a huge amount of connections from
the wearable IoT sensors and devices to the healthcare servers. Scalability is defined as the ability of the healthcare IoT system
to keep meeting system requirements in case of an increase in demand for its services. In 6 , they used a clustering approach to
improve scalability with more efficient communication among sensors, and to increase the duration of the network connections
by decreasing the number of directors between the IoT nodes and their corresponding coordinators.
In 82 , they used a load balancing algorithm with cloud computing to improve the scalability of the IoT network. This algorithm
enhances energy consumption and processing abilities and reduces the time consumption of the data processing.

10.4 Reliability
Reliability of healthcare IoT systems has absolute importance. Any problem in such a system availability often has direct con-
sequences on patients and end users, so the system must operate without any failure. The unpredictable reliability could drive
many problems in obtaining reliable health monitoring and transferring important signals from patients to healthcare services.
Recently, many researchers addresses the reliability aspect using fog computing techniques. This gateway can offer a lot of fea-
tures such as local data processing, local storage, secure data mining, etc. 50,83,84,64 . The reasons for using fog computing and
local data processing are: (1) for long-range remote monitoring of patients suffering from chronic diseases, Internet disconnec-
tion may happen frequently. Therefore, local data processing and local data storage improve system consistency and reliability 8 ,
and (2) fog computing allows preserving the system’s operation locally in the local storage of the fog layer.

11 CONCLUSION AND FUTURE WORK

Healthcare IoT systems use medical sensors, mobile computing, and cloud computing technologies to manage patients’ con-
ditions and use communication technologies to transfer collected patient data to cloud computing storage. With the rapid
Hammad M ET AL 17

increase of using IoT devices in the healthcare field, combining IoT with different Cloud, Fog, and Edge computing technolo-
gies improved healthcare IoT systems. Cloud computing technology significantly emerged in various healthcare IoT systems
to enhance the platform and infrastructure of services. However, healthcare IoT sensors produce a huge amount of data, so
processing and analyzing this data need more time, especially in the cloud computing environment. Fog and Edge computing
technologies transform computing power and processing to the end-user and resolve many data processing challenges including
latency and performance.

In this study, we conducted a survey to identify the main research topics that have been addressed in the domain of healthcare
IoT systems when used with cloud, fog, and edge computing technologies. We applied a large-scale comprehensive study by
analyzing the related research papers based on the exclusion and inclusion criteria that are described previously in the paper.
Our investigation found that healthcare IoT systems address mainly five research topics, namely: big data, security, latency,
energy efficiency, and QoS. We found that the highest number of research papers focused on big data, i.e., 63% of the studied
research papers, while the energy efficiency topic had the lowest number of papers, i.e., 17% of the papers. Most of the papers
that focused on the big data topic used the cloud computing technology to solve big data processing issues, i.e., 55.5% of
the research papers that address big data used cloud computing. Likewise, 59.4% of the security-related papers addressed the
security aspect in the cloud layer. Most of the papers that address the latency topic used the edge and fog layers, i.e., 68% of
the latency-related papers, to reduce latency in healthcare IoT systems. Most of the papers that address energy efficiency used
cloud computing, i.e., 47% of the papers, and fog computing, i.e., 35% of the papers, to improve energy efficiency. Overall, we
found that the Fog computing layer has a better performance, less latency, and better security protocols compared to the cloud
layer. The edge and fog layers also enhance the cloud layer by applying early data cleaning and processing tasks to the received
raw data before the data is finally transmitted to the cloud layer for further processing and storage.

Finally, considering future research, we plan to investigate, deeply and in details, the state-of-the-art technologies that are
applied in the identified five reserach topics, which are: big data, security, latency, energy efficiency, and QoS. Furthermore,
we will investigate the gaps and open research problems in these topics. As an another future work direction, we plan to how
healthcare IoT systems emerged and changed before and after the Covid-19 pandemic period and study the pandemic impact on
the different computing technologies, i.e., cloud, fog, and edge computing, that are employed with these healthcare IoT systems.

11.1 Acknowledgements
An Acknowledgements section is started with \ack or \acks for Acknowledgement or Acknowledgements, respectively. It must
be placed just before the References.
18 Hammad M ET AL

11.2 Bibliography
References

1. Holst A. IOT connected devices worldwide 2019-2030. 2021.

2. Rahmani AM, Gia TN, Negash B, et al. Exploiting smart e-Health gateways at the edge of healthcare Internet-of-Things: A
fog computing approach. Future Generation Computer Systems 2018; 78: 641–658.

3. Hossain MS, Muhammad G. Cloud-assisted industrial internet of things (iiot)–enabled framework for health monitoring.
Computer Networks 2016; 101: 192–202.

4. Manogaran G, Varatharajan R, Lopez D, Kumar PM, Sundarasekar R, Thota C. A new architecture of Internet of Things
and big data ecosystem for secured smart healthcare monitoring and alerting system. Future Generation Computer Systems
2018; 82: 375–387.

5. Fanjiang G, Grossman JH, Compton WD, Reid PP, others . Building a better delivery system: a new engineering/health
care partnership. 2005.

6. Farahani B, Firouzi F, Chang V, Badaroglu M, Constant N, Mankodiya K. Towards fog-driven IoT eHealth: Promises and
challenges of IoT in medicine and healthcare. Future Generation Computer Systems 2018; 78: 659–676.

7. Pace P, Aloi G, Gravina R, Caliciuri G, Fortino G, Liotta A. An edge-based architecture to support efficient applications
for healthcare industry 4.0. IEEE Transactions on Industrial Informatics 2018; 15(1): 481–489.

8. Moosavi SR, Gia TN, Nigussie E, et al. End-to-end security scheme for mobility enabled healthcare Internet of Things.
Future Generation Computer Systems 2016; 64: 108–124.

9. Suciu G, Suciu V, Martian A, et al. Big data, internet of things and cloud convergence–an architecture for secure e-health
applications. Journal of medical systems 2015; 39(11): 1–8.

10. Muhammed T, Mehmood R, Albeshri A, Katib I. UbeHealth: a personalized ubiquitous cloud and edge-enabled networked
healthcare system for smart cities. IEEE Access 2018; 6: 32258–32285.

11. Maksimović M, Vujović V. Internet of things based e-health systems: ideas, expectations and concerns. In: Springer. 2017
(pp. 241–280).

12. Yang G, Jiang M, Ouyang W, et al. IoT-based remote pain monitoring system: From device to cloud platform. IEEE journal
of biomedical and health informatics 2017; 22(6): 1711–1719.

13. Demir E, Köseoğlu E, Sokullu R, Şeker B. Smart home assistant for ambient assisted living of elderly people with dementia.
Procedia computer science 2017; 113: 609–614.

14. Wang T, Bhuiyan MZA, Wang G, Rahman MA, Wu J, Cao J. Big data reduction for a smart city’s critical infrastructural
health monitoring. IEEE Communications Magazine 2018; 56(3): 128–133.

15. Kumar PM, Gandhi UD. A novel three-tier Internet of Things architecture with machine learning algorithm for early
detection of heart diseases. Computers & Electrical Engineering 2018; 65: 222–235.

16. Stergiou C, Psannis KE, Kim BG, Gupta B. Secure integration of IoT and cloud computing. Future Generation Computer
Systems 2018; 78: 964–975.

17. Bonomi F, Milito R, Natarajan P, Zhu J. Fog computing: A platform for internet of things and analytics. In: Springer. 2014
(pp. 169–186).

18. Atlam HF, Alenezi A, Alharthi A, Walters RJ, Wills GB. Integration of cloud computing with internet of things: challenges
and open issues. In: IEEE. ; 2017: 670–675.

19. Zhang XM, Zhang N. An open, secure and flexible platform based on internet of things and cloud computing for ambient
aiding living and telemedicine. In: IEEE. ; 2011: 1–4.
Hammad M ET AL 19

20. Rahmani AM, Liljeberg P, Preden JS, Jantsch A. Fog computing in the internet of things: Intelligence at the edge. Springer
. 2017.

21. Gia TN, Jiang M, Rahmani AM, Westerlund T, Liljeberg P, Tenhunen H. Fog computing in healthcare internet of things:
A case study on ecg feature extraction. In: IEEE. ; 2015: 356–363.

22. Dubey H, Yang J, Constant N, Amiri AM, Yang Q, Makodiya K. Fog data: Enhancing telehealth big data through fog
computing. In: 2015 (pp. 1–6).

23. Oueida S, Kotb Y, Aloqaily M, Jararweh Y, Baker T. An edge computing based smart healthcare framework for resource
management. Sensors 2018; 18(12): 4307.

24. Pathinarupothi RK, Durga P, Rangan ES. Iot-based smart edge for global health: Remote monitoring with severity detection
and alerts transmission. IEEE Internet of Things Journal 2018; 6(2): 2449–2462.

25. Sawand A, Djahel S, Zhang Z, Naït-Abdesselam F. Toward energy-efficient and trustworthy eHealth monitoring system.
China Communications 2015; 12(1): 46–65.

26. Islam SR, Kwak D, Kabir MH, Hossain M, Kwak KS. The internet of things for health care: a comprehensive survey. IEEE
access 2015; 3: 678–708.

27. Alasmari S, Anwar M. Security & privacy challenges in IoT-based health cloud. In: IEEE. ; 2016: 198–201.

28. Ida IB, Jemai A, Loukil A. A survey on security of IoT in the context of eHealth and clouds. In: IEEE. ; 2016: 25–30.

29. Ghosal P, Das D, Das I. Extensive survey on cloud-based IoT-healthcare and security using machine learning. In: IEEE. ;
2018: 1–5.

30. Scarpato N, Pieroni A, Di Nunzio L, Fallucchi F. E-health-IoT universe: A review. management 2017; 21(44): 46.

31. Darwish A, Hassanien AE, Elhoseny M, Sangaiah AK, Muhammad K. The impact of the hybrid platform of internet of things
and cloud computing on healthcare systems: opportunities, challenges, and open problems. Journal of Ambient Intelligence
and Humanized Computing 2019; 10(10): 4151–4166.

32. Qi J, Yang P, Min G, Amft O, Dong F, Xu L. Advanced internet of things for personalised healthcare systems: A survey.
Pervasive and Mobile Computing 2017; 41: 132–149.

33. AbdElnapi NMM, Omran NF, Ali AA, Omara FA. A survey of internet of things technologies and projects for healthcare
services. In: IEEE. ; 2018: 48–55.

34. Aazam M, Zeadally S, Harras KA. Health fog for smart healthcare. IEEE Consumer Electronics Magazine 2020; 9(2):
96–102.

35. Mahmoud MM, Rodrigues JJ, Saleem K. Cloud of Things for Healthcare: A Survey from Energy Efficiency Perspective.
In: IEEE. ; 2019: 1–7.

36. Dhanvijay MM, Patil SC. Internet of Things: A survey of enabling technologies in healthcare and its applications. Computer
Networks 2019; 153: 113–131.

37. Martn A, Thelwall M, Orduna-Malea E, López-Cózar ED. Google Scholar, Microsoft Academic, Scopus, Dimensions,
Web of Science, and OpenCitations’ COCI: a multidisciplinary comparison of coverage via citations. Scientometrics 2021;
126(1): 871–906.

38. Singh D, Tripathi G, Alberti AM, Jara A. Semantic edge computing and IoT architecture for military health services in
battlefield. In: IEEE. ; 2017: 185–190.

39. Lab S. ScimagoJR, SJR : Scientific Journal Rankings. 2022.

40. Monteiro K, Rocha E, Silva E, Santos GL, Santos W, Endo PT. Developing an e-health system based on IoT, fog and cloud
computing. In: IEEE. ; 2018: 17–18.
20 Hammad M ET AL

41. Bhatia M, Sood SK. Exploring temporal analytics in fog-cloud architecture for smart office healthcare. Mobile Networks
and Applications 2019; 24(4): 1392–1410.

42. Kumar PM, Lokesh S, Varatharajan R, Babu GC, Parthasarathy P. Cloud and IoT based disease prediction and diagnosis
system for healthcare using Fuzzy neural classifier. Future Generation Computer Systems 2018; 86: 527–534.

43. Quwaider M, Jararweh Y. A cloud supported model for efficient community health awareness. Pervasive and Mobile
Computing 2016; 28: 35–50.

44. Amin SU, Hossain MS, Muhammad G, Alhussein M, Rahman MA. Cognitive smart healthcare for pathology detection and
monitoring. IEEE Access 2019; 7: 10745–10753.

45. Xie R, Khalil I, Badsha S, Atiquzzaman M. Fast and peer-to-peer vital signal learning system for cloud-based healthcare.
Future Generation Computer Systems 2018; 88: 220–233.

46. Quintero D, Lee FN. IBM Reference Architecture for High Performance Data and AI in Healthcare and Life Sciences. 2019.

47. Ullah F, Habib MA, Farhan M, Khalid S, Durrani MY, Jabbar S. Semantic interoperability for big-data in heterogeneous
IoT infrastructure for healthcare. Sustainable cities and society 2017; 34: 90–96.

48. Jusak J, Pratikno H, Putra VH. Internet of Medical Things for cardiac monitoring: Paving the way to 5G mobile networks.
In: IEEE. ; 2016: 75–79.

49. Akulov D. The benefits of using a multi-cloud strategy for IoT platforms. 2019.

50. Ahmad M, Amin MB, Hussain S, Kang BH, Cheong T, Lee S. Health fog: a novel framework for health and wellness
applications. The Journal of Supercomputing 2016; 72(10): 3677–3695.

51. Ray PP, Thapa N, Dash D. Implementation and performance analysis of interoperable and heterogeneous IoT-edge gateway
for pervasive wellness care. IEEE Transactions on Consumer Electronics 2019; 65(4): 464–473.

52. Rani S, Ahmed SH, Shah SC. Smart health: A novel paradigm to control the chickungunya virus. IEEE Internet of Things
Journal 2018; 6(2): 1306–1311.

53. Azimi I, Takalo-Mattila J, Anzanpour A, Rahmani AM, Soininen JP, Liljeberg P. Empowering healthcare iot systems with
hierarchical edge-based deep learning. In: ; 2018: 63–68.

54. Geman O, Chiuchisan I, Ungurean I, Hagan M, Arif M. Ubiquitous healthcare system based on the sensors network and
android internet of things gateway. In: IEEE. ; 2018: 1390–1395.

55. Sarkar S, Chatterjee S, Misra S, Kudupudi R. Privacy-aware blind cloud framework for advanced healthcare. IEEE
Communications Letters 2017; 21(11): 2492–2495.

56. Manikandan R, Patan R, Gandomi AH, Sivanesan P, Kalyanaraman H. Hash polynomial two factor decision tree using IoT
for smart health care scheduling. Expert Systems with Applications 2020; 141: 112924.

57. Yang Y, Zheng X, Guo W, Liu X, Chang V. Privacy-preserving fusion of IoT and big data for e-health. Future Generation
Computer Systems 2018; 86: 1437–1455.

58. Yeh LY, Chiang PY, Tsai YL, Huang JL. Cloud-based fine-grained health information access control framework for
lightweightiot devices with dynamic auditing andattribute revocation. IEEE transactions on cloud computing 2015; 6(2):
532–544.

59. Muhammad G, Rahman SMM, Alelaiwi A, Alamri A. Smart health solution integrating IoT and cloud: A case study of
voice pathology monitoring. IEEE Communications Magazine 2017; 55(1): 69–73.

60. Benadda B, Beldjilali B, Mankouri A, Taleb O. Secure IoT solution for wearable health care applications, case study Electric
Imp development platform. International Journal of Communication Systems 2018; 31(5): e3499.
Hammad M ET AL 21

61. Sharma A, Choudhury T, Kumar P. Health monitoring & management using IoT devices in a Cloud Based Framework. In:
IEEE. ; 2018: 219–224.

62. Doukas C, Maglogiannis I. Bringing IoT and cloud computing towards pervasive healthcare. In: IEEE. ; 2012: 922–926.

63. Hu JX, Chen CL, Fan CL, Wang Kh. An intelligent and secure health monitoring scheme using IoT sensor based on cloud
computing. Journal of Sensors 2017; 2017.

64. Jia X, He D, Kumar N, Choo KKR. Authenticated key agreement scheme for fog-driven IoT healthcare system. Wireless
Networks 2019; 25(8): 4737–4750.

65. Gia TN, Dhaou IB, Ali M, et al. Energy efficient fog-assisted IoT system for monitoring diabetic patients with cardiovascular
disease. Future Generation Computer Systems 2019; 93: 198–211.

66. Devarajan M, Ravi L. Intelligent cyber-physical system for an efficient detection of Parkinson disease using fog computing.
Multimedia Tools and Applications 2019; 78(23): 32695–32719.

67. La QD, Ngo MV, Dinh TQ, Quek TQ, Shin H. Enabling intelligence in fog computing to achieve energy and latency
reduction. Digital Communications and Networks 2019; 5(1): 3–9.

68. Feng S, Liang Z, Zhao D. Providing telemedicine services in an infrastructure-based cognitive radio network. IEEE Wireless
Communications 2010; 17(1): 96–103.

69. Wac K, Bargh MS, Bert-jan F, Bults RG, Pawar P, Peddemors A. Power-and delay-awareness of health telemonitoring
services: the mobihealth system case study. IEEE journal on selected areas in communications 2009; 27(4): 525–536.

70. Hassanalieragh M, Page A, Soyata T, et al. Health monitoring and management using Internet-of-Things (IoT) sensing with
cloud-based processing: Opportunities and challenges. In: IEEE. ; 2015: 285–292.

71. Mahmoud MM, Rodrigues JJ, Saleem K, Al-Muhtadi J, Kumar N, Korotaev V. Towards energy-aware fog-enabled cloud
of things for healthcare. Computers & Electrical Engineering 2018; 67: 58–69.

72. Verma P, Sood SK. Fog assisted-IoT enabled patient health monitoring in smart homes. IEEE Internet of Things Journal
2018; 5(3): 1789–1796.

73. Bibani O, Mouradian C, Yangui S, et al. A demo of IoT healthcare application provisioning in hybrid cloud/fog environment.
In: IEEE. ; 2016: 472–475.

74. Fernández-Caramés TM, Froiz-Míguez I, Blanco-Novoa O, Fraga-Lamas P. Enabling the internet of mobile crowdsourc-
ing health things: A mobile fog computing, blockchain and IoT based continuous glucose monitoring system for diabetes
mellitus research and care. Sensors 2019; 19(15): 3319.

75. Ozdemir AT, Tunc C, Hariri S. Autonomic fall detection system. In: IEEE. ; 2017: 166–170.

76. Vilela PH, Rodrigues JJ, Solic P, Saleem K, Furtado V. Performance evaluation of a Fog-assisted IoT solution for e-Health
applications. Future Generation Computer Systems 2019; 97: 379–386.

77. Mahmoud MM, Rodrigues JJ, Ahmed SH, et al. Enabling technologies on cloud of things for smart healthcare. IEEE Access
2018; 6: 31950–31967.

78. Yacchirema D, Sarabia-Jacome D, Palau CE, Esteve M. System for monitoring and supporting the treatment of sleep apnea
using IoT and big data. Pervasive and Mobile Computing 2018; 50: 25–40.

79. Mohammed J, Lung CH, Ocneanu A, Thakral A, Jones C, Adler A. Internet of Things: Remote patient monitoring using
web services and cloud computing. In: IEEE. ; 2014: 256–263.

80. Sood SK, Mahajan I. Wearable IoT sensor based healthcare system for identifying and controlling chikungunya virus.
Computers in Industry 2017; 91: 33–44.
22 Hammad M ET AL

81. Singh H, Mallaiah R, Yadav G, Verma N, Sawhney A, Brahmachari SK. iCHRCloud: web & mobile based child health
imprints for smart healthcare. Journal of medical systems 2018; 42(1): 1–12.

82. Gomes BdTP, Muniz LCM, Silva d. S. eFJ, Ríos LET, Endler M. A comprehensive and scalable middleware for ambient
assisted living based on cloud computing and internet of things. Concurrency and Computation: Practice and Experience
2017; 29(11): e4043.

83. Azimi I, Anzanpour A, Rahmani AM, et al. HiCH: Hierarchical fog-assisted computing architecture for healthcare IoT.
ACM Transactions on Embedded Computing Systems (TECS) 2017; 16(5s): 1–20.

84. Rawashdeh M, Zamil MGA, Hossain MS, Samarah S, Amin SU, Muhammad G. Reliable service delivery in Tele-health
care systems. Journal of Network and Computer Applications 2018; 115: 86–93.

How to cite this article: Hammad M., Banat S., Bani Baker Q., Al-refai M., and Abudehais B. (2023), A COMPREHENSIVE
STUDY OF CLOUD, FOG, AND EDGE COMPUTING TECHNOLOGIES FOR HEALTHCARE IoT SYSTEMS, Software -
Practice and Experience, 2023;00:1–6.