European Journal of Public Health, 2024, ckae191

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Public Health Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly
cited. For commercial re-use, please contact [email protected]
https://doi.org/10.1093/eurpub/ckae191
...............................................................................................................
Could digital twins be the next revolution
in healthcare?
Leonardo de Oliveira El-Warrak � and Claudio Miceli de Farias

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

COPPE—Graduate School and Research in Engineering, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil

�Corresponding author. COPPE—Graduate School and Research in Engineering, Federal University of Rio de Janeiro
(UFRJ), Horacio Macedo Avenue, 2030, Rio de Janeiro, RJ, 21941-972, Brazil. E-mail: [email protected].

Abstract
A Digital Twin (DT) can be understood as a representation of a real asset, a virtual replica of a physical object,
process, or even a system. They have been used in managing healthcare facilities, streamlining care processes,
personalizing treatments, and enhancing patient recovery. The potential impact of this tool on our society and its
well-being is quite significant. A quick review of the literature was carried out using the terms (‘Digital Twins’)
and (‘Digital Health’), and (Health Care) with a time interval of up to 5 years (2018–23). Using the PRISMA
Method, the search was conducted in six academic databases: IEEE Xplore, Dimensions, Scopus, Web of
Science, PubMed, and ACM. After applying the search strings and the exclusion criteria, a total of 13 publications
were identified and listed to constitute and support the discussion of this article. The selected studies were
categorized into 2 groups according to their application in healthcare: A group of clinical applications, subdi­
vided into topics on personalized care and reproduction of biological structures and another group of operation­
al applications, subdivided into topics such as optimization of operational processes, reproduction of physical
structures, and development of devices and drugs. The use of DT in healthcare presents important challenges
related to data integration, privacy, and interoperability. However, trends indicate exciting potential in person­
alizing treatment, prevention, remote monitoring, informed decision-making, and process management, which
can result in significant improvements in quality and efficiency in healthcare.
...............................................................................................................

Introduction Methods
he advent of the fourth industrial revolution, known as Industry The objective of this research was to analyse scientific publications
T4.0, resulted in a reinvention of the concept of simulation, giving with the purpose of investigating the use of DT in healthcare, trends,
rise to what is defined as digital twins (DT) [1–4]. The continuous and challenges in their use, providing insight into the possible paths
growth and evolution of technologies such as the Internet of Things, of healthcare. This research sought to answer two guiding questions:
artificial intelligence (AI), machine learning, and big data have ‘How are digital twins being used in the healthcare sector?’ and
enabled the collection, processing, and storage of large amounts of ‘What are the challenges and perspectives of using digital twins in
real-time data. These technologies are essential for the creation and the healthcare sector?’ PICO strategy (acronym for P: population/
operation of what we currently known as DTs. patients; I: intervention; C: control; O: outcome) is used to help to
Conceptually, a DT is defined as a real-time digital replica or define what the research question should in fact specify for this
virtual representation of an object, process, or system [1, 5]. Its paper (Fig. 1).
growing use across diverse sectors highlights its potential to revolu­ The Preferred Reporting Items for Systematic reviews and Meta-
tionize the way we create, manage, and operate even the most com­ Analyses (PRISMA) was a great help for authors to prepare trans­
plex systems. The health sector is recognized as a complex ecosystem parent accounts of their reviews, providing syntheses of the state of
that requires effective and efficient operations, optimizations, man­ knowledge in a field, from which future research priorities can be
agement, and control to offer reliable, economical, and quality identified. For this paper, a literature search was conducted in digital
health actions and services. Your main challenge is to provide the libraries of six academic databases: IEEE Xplore, Dimensions,
best possible healthcare services to patients using finite healthcare Scopus, Web of Science, PubMed, and ACM. The six databases
resources. The use of DT for predictive analysis, process improve­ were chosen with the aim of covering the Engineering and Health
ment, supply capacity planning, risk management, assertiveness in research areas. IEEE Xplore and ACM serve the purpose of contain­
diagnosis, and increased clinical safety, among others, will allow ing the Engineering/Technology area, whereas the PubMed database
managerial and clinical decisions to improve the quality of health is focused on the health area. Scopus, Web of Science and
care offered in the future [6–12]. Dimensions incorporate many fields of knowledge and were
This work aims to compile the state of the art in the use of DT in included to identify any other records relevant to this study that
healthcare, through a review of the scientific literature on the sub­ were not in the specific databases. We tried to restrict the search
ject, thus making it possible to evaluate the trends and challenges of by using specific keywords to find publications of interest.
this technology for the coming years in the healthcare sector. This The search strategy was based on three main terms: digital twins,
work expects to explore the various applications of DT in healthcare, digital health, and healthcare. Another filter applied in the search
their potential for further development, and the challenges they pre­ strategy was publications within a time range of up to 5 years (2018–
sent. By doing so, we hope to provide valuable insights for this 23). The resulting search query is shown below (Fig. 2):
growing technology and its potential to revolutionize the planning, At the end of applying the search strings, a total of 86 results were
production, and management of healthcare structures and processes. reported. After analysing possible duplicate references in the Zotero
2 of 7 El-Warrak and de Farias

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

Figure 1. PICO strategy (Population, Intervention, Comparison, Outcome) criteria and definitions.

Figure 2. Search strings.

library, 28 duplicate results were excluded. At this point, a total of 58 download in the chosen databases. Furthermore, all articles that
publications were reached. This last material, then, went through a data did not explicitly mention the use of DT in health, as well as items
survey, collection, and analysis process, divided into three stages: selected in the search, which were books or book chapters, were also
excluded from the discussion.
• Pre-analysis evaluating title, abstract and keywords; The only inclusion criterion was confluent studies that dealt with
• Exploration of the selected material; topics related to DT, digital health, and health care.
• Treatment of results and interpretations. The main limitations of the method employed in this work are
related to the dependence on the quality of the included studies, the
The exclusion criteria included studies in languages other than reliance on the availability, and accessibility of published studies,
English and articles unavailable or only partially available for and the difficulty in addressing the heterogeneity among the studies.
 Could digital twins be the next revolution in healthcare? 3 of 7

This issue was mitigated by dividing the studies into themat­ data security, and listed them as the greatest obstacles at present
ic categories. for the large-scale implementation of this technology.
Following the pre-analysis stage, 31 results were excluded.
Subsequently, during the exploration of the remaining articles, an Discussion
additional 14 were excluded due to a lack of explicit focus on the
application of DT in healthcare. Figure 3 illustrates the en­ A DT can be understood as technology capable of mapping the real
tire process. world to the digital world through interaction between the two in
real time [13–16]. Healthcare is a field in which DT are being
Results explored and applied. To date, most studies [6, 8, 17–26] have
focused on virtualizing individual assets such as devices, structures,
The studies included for discussion can be categorized according to and patients, considering the point of view of a specific application,

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

the application of DT in the health sector into 2 groups: the clinical such as body parts, organs, or body systems aimed at personalizing
applications group, with 7 records, and the operational applications care. Another potential for its use lies in virtualizing contexts and
group, with 6 records. situations that involve several interrelated strategic assets of a
When carrying out the content analysis of the articles, we can also healthcare organization, such as a hospital [27–29].
verify a subdivision within the groups. In the clinical applications According to the World Health Organization (WHO), digital
group, we have five articles that are focused on the theme of person­ health encompasses the field of knowledge and practice related to
alized care/precision medicine, signalling the development of digital the development and use of digital technologies to support health
technologies based on real-time patient data for the management of [30–32]. The ability to collect, analyse and share data effectively
specific diseases or conditions, one article addressing the reproduc­ is enabling unprecedented personalization in healthcare,
tion of biological structures creating avatars of organs or even the improving the assertiveness of treatments, reducing costs, and
human body and another that focuses on ethics issues related to putting patients in control of their own health. However, for this
using DTs in healthcare. In the operational applications group, we to become a reality, it is necessary to combine efforts in initia­
have a subgroup, with 5 articles, that discuss the application of DT tives that boost the analytical intelligence of healthcare organi­
supporting the optimization of operational processes by using real- zations to enable the integration, mining, and interoperability of
time data integration, advanced analytics, and virtual simulations to data [7, 23, 25, 32–34]. Although digital health has extraordinary
improve patient care and another subgroup with one article that potential, it faces significant challenges and risks. Despite ena­
relies on the construction of virtual structures such as hospitals. bling increased access to healthcare, it can also be perceived as a
The full spectrum of the articles is detailed below (Fig. 4). ‘form of barrier’, where people who benefit most often face more
In summary, in the sample of selected articles, the main benefits difficulties in access due to a lack of resources or digital skills
of using DT technology for healthcare predominantly included [35–38].
increased personalization of care, improved quality of care with Established as a global priority in 2005 by the WHO [39], the
the increasingly consistent use of precision medicine and gains in digital transition has significantly impacted the health sector by
the operational efficiency of health facilities, equipment and services. creating the conditions for redefining the care model to make it
However, some of the included studies also highlighted key chal­ more integrated, participatory, and personalized. Currently, the de­
lenges related to DTs in healthcare, such as interoperability, the livery of healthcare services continues to occur in a fragmented and
processing of large volumes of data, patient confidentiality and timely manner for most patients. It becomes extremely difficult for

Figure 3. PRISMA flow diagram.

4 of 7 El-Warrak and de Farias

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

Figure 4. Findings.

healthcare professionals and patients to monitor all important DT offer remarkable potential to significantly improve healthcare
events, correlations and exposures that negatively affect the provi­ delivery [10]. Considering the results found in the selected literature,
sion of healthcare, both in terms of cost and quality. In this context, 4 main axes of the application of DT in healthcare are presented:
 Could digital twins be the next revolution in healthcare? 5 of 7

Axis 1: use of digital twins for virtual representation strategies based on the progression of a patient’s disease, resulting in
of biological structures more personalized and less invasive interventions. Furthermore,
continuous monitoring of tumours in DT enables a more agile re­
The use of DT in the virtual representation of biological structures
sponse to changes in the clinical picture, providing better results for
has enabled a new approach in medical education and clinical prac­
patients. At the work of Wickramasinghe et al. [21], DTs can sup­
tice. The evolution of imaging technologies, such as magnetic res­
port personalized treatment for uterine cancer. Similarly, in wom­
onance imaging and computed tomography, has allowed the
en’s health, DT are used to monitor gynaecological conditions such
creation of extremely precise 3D models of organs and tissues.
as endometriosis and fibroids and to manage pregnancy more ef­
These models provide an interactive representation that not only
fectively. The ability to simulate scenarios and monitor the progress
increases the understanding of anatomy but also improves know­
of pregnancy in a virtual environment offers patients more person­
ledge retention for medical students. The ability to ‘navigate’ organs

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

alized and safer care. This also makes it possible to identify compli­
and systems in a virtual environment has a lasting impact on the
cations early, which is essential to ensure maternal and foetal health.
training of future doctors, providing an immersive learning experi­
In the area of geriatric care, DT enable the creation of care plans
ence that can be difficult to achieve with traditional methods.
adapted to the complex needs of older adults. With the aging of the
The creation of a fully developed DT of a human is still a goal for
population, this personalization becomes crucial for guaranteeing the
the future. However, several companies and research institutes are
quality of life of elderly people. Digital twins can model a patient’s
exploring the development of digital replicas of body parts or
health conditions, considering comorbidities and risk factors associated
physiological systems for specific purposes. For example, in the field
with advanced age. This results in more comprehensive and effective
of orthopaedics, these DT can be used to create virtual models of a
patient’s musculoskeletal system, including skin, bones, joints, and care that improves seniors’ quality of life and reduces unplanned hos­
muscles. These DT can be employed to simulate surgical procedures, pital admissions. Rivera et al. [6] explained that the use of DTs to
test various implants prior to surgery, and predict how a patient will support precision medicine techniques in the context of continuous
respond to treatment. monitoring and personalized data-driven medical treatments could fa­
Building a DT for this purpose demands access to extensive cilitate the management of chronical conditions. Digital twins can also
healthcare data repositories, which include genetic information, improve the management of trauma and fractures, especially in the
medical records, imaging, histopathology, and other pertinent sour­ elderly population as explained by Ricci et al. [33] as well as in mental
ces. These data must be of high quality, accurate, and comprehen­ health, when used in association with virtual coaching solutions accord­
sive. For Viceconti et al. [25], the discussion on the creation of the ing to Gabrielli et al. [20].
Virtual Human needs technical, political, and social considerations, A crucial point in the use of DT in personal care concerns the
such as the challenge of providing fair and transparent use of data. ethical and moral risks associated with use without any type of re­
Perhaps the greatest change is in the path that health treatments will flection. This has been well explored by Huang et al. [37].
follow, moving from being organized by a standard to being based on
the genetic, phenotypic, structural, physical, and psychosocial charac­ Axis 3: use of digital twins to depict healthcare
teristics of the individual, being referred to as precision medicine or structures and improve operational efficiency
even broader as personalized care. Essentially, patients are treated as Operational efficiency in healthcare is a constant concern, and DT
individuals and not according to some norm or standard of care (pro­ play a crucial role in optimizing healthcare systems. One of the main
viding the right treatment, at the right time to the right person). benefits is the improvement in resource allocation in hospitals and
other healthcare units. DT allow a detailed analysis of the use of
Axis 2: use of digital twins to improve healthcare beds, personnel, and equipment, enabling more efficient and effect­
processes (personalized care) ive planning. This not only reduces patient waiting times but also
Digital twins are software-based replicas that simulate the dynamic improves assertiveness in the provision of care, resulting in a more
functions and potential failures of engineered products and successful patient journey and a more positive experience for every­
processes. In healthcare, patient-specific DT integrate established one involved in the care process. This topic was addressed both in
knowledge of human physiology and immunology with real-time, the works of Michelfeit [19] and Cheng et al. [29].
patient-specific clinical data. This integration enables predictive Taking a hospital as an example, by using historical and real-time
computer simulations across various types of diseases and condi­ data from operations, as well as information from the surrounding
tions. These medical DT could prove invaluable in healthcare man­ environment, such as cases of notifiable diseases and traffic acci­
agement, leveraging mechanistic insights, observational data, dents, the DT allows the hospital unit manager to make informed
medical histories, and the capabilities of AI to optimize treatment decisions, identify a lack of beds, optimize team schedules, and
strategies and improve patient outcomes. manage room occupancy more effectively. This approach not only
In the context of personal DT, prevention emerges as a pivotal increases resource efficiency but also improves hospital and staff
focus, accompanied by the empowerment of patients. Central to this performance while reducing costs. In the works of Sun et al. [8],
approach is ensuring that patients comprehend their health status Vall�ee [23], Chaudhari et al. [26], and Rajanikanth et al. [28], DT
and take responsibility for it. Currently, the strategy involves com­ were seen as a potentially important technology in improving the
paring patients with a comprehensive database to identify similar­ patient’s journey by seeking to streamline operational and care proc­
ities and differences. However, the aim is to advance beyond this by esses. By building a DT of the patient’s journey, the healthcare unit
gathering historical health data from earlier stages when the patient can predict patient activity and plan operational capacity according
was healthy. These data can then be utilized to assess current health to demand, resulting in significant improvement in services deliv­
status, estimate risks, and devise a tailored prevention plan. This ered to the patient, in addition to increased safety, increased volume
approach empowers patients to adjust their behaviours proactively and a better patient experience.
and detect potential diseases early, leveraging straightforward infor­ Modelling and forecasting the demand for healthcare services are
mation that can be extracted without direct patient involvement, also areas where DT offer great potential. By analysing real-time
according to the work of Schwartz et al. [4]. data and simulating scenarios, healthcare systems can make more
The application of DT to improve healthcare processes is driving informed decisions about resource distribution and staffing, ensur­
significant advances in several areas. In oncology, e.g. DT play a ing that care is available where and when it is needed. These capa­
fundamental role in modelling tumours and simulating treatments. bilities are critical for improving operational efficiency and ensuring
This approach allows physicians and oncologists to adjust treatment that the healthcare system is prepared for future challenges.
6 of 7 El-Warrak and de Farias

Axis 4: use of digital twins for the development of decision-making, and process management, which can result in sig­
medicines and health devices nificant improvements in quality and efficiency in healthcare. This
work could, in some way, contribute to expanding discussions on
In relation to drug development, DT enable detailed simulation of
the topic, opening space for new reflections.
molecules, pharmacological interactions, and virtual clinical trials.
It is worth noting that, despite the sector’s rising costs, increased
Throughout the drug development process, extensive amounts of
demand for services and the already established role of primary
data are generated and managed, which DTs’ harness to create
models. Consequently, DTs can expedite clinical trials in drug re­ health care (PHC) in improving the health levels of a population,
search, enabling faster trials with reduced patient enrolment. there were no studies in the selected literature, on the specific use of
The increasing use of personal health monitoring devices, such as DT. As it is the main axis of changes in health systems to improve
mobile apps and integrated sensors, enables active surveillance of health levels, PHC can receive due attention from the scientific

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

the user’s key health parameters, such as electrocardiogram (ECG), community and the industrial complex as a promising field for
blood pressure, heart rate, and glucose level, minimizing potential the use of twin digital technology in healthcare and in the operation
inaccuracies in data recording. Such devices can collect and transmit of its units.
information anonymously to the cloud, where it can be compared More in-depth future studies should be carried out to explore the
with disease symptom histories or even alert competent healthcare possible consolidation of the use of DTs in health, especially in
professionals when necessary. processes linked to health care and PHC, or even clarify which
As previously stated, DTs offer two key benefits: real-time health initiatives should be implemented or even strengthened to sustain
information and predictions, and interactive capabilities that allow the progress achieved thus far.
communication between DTs, decision-makers, and, depending on
the model, the individuals themselves. To address the ethical con­
cerns surrounding DTs, it is important to clarify the conditions and Author contributions
requirements for using them to simulate a person’s health. At first, Leonardo El-Warrak conceptualized the paper. Leonardo El-Warrak
each DT must correspond to a real person and be assigned a unique
acquired the data. Leonardo El-Warrak conducted the data analysis.
identifier. This identifier will allow logging into one’s virtual repre­
Leonardo El-Warrak produced the figure and tables. Leonardo El-
sentation, setting health parameters to monitor, and controlling who
Warrak led the authorship of each draft and the final version of the
can view this information. Ensuring the DT is accurately created,
manuscript. Leonardo El-Warrak and Claudio M. de Farias reviewed
and the data validated is crucial, with an authorized institution
overseeing this process. To protect privacy, technologies like pass­ and revised each draft of the manuscript and provided intellectual
words, biometrics, and blockchain encryption should be used to content. All authors read and approved the final manuscript.
prevent data tampering. Continuous data exchange between sensors, Leonardo El-Warrak acts as guarantor for this article.
wearables, and the DT is required to ensure the DT accurately Conflict of interest: The authors declare no competing interests.
reflects changes in the person’s health status. Future solutions, like
blockchain technologies, might be necessary to maintain accuracy
and reliability even if data flow is disrupted. It is important to spe­ Funding
cify the scope and purpose of the DTs, including the types of data
they will handle, such as text (diagnosis records), numbers (weight, The authors have no funding to disclose.
blood pressure), or images (ECGs), and how this data will be proc­
essed. Clearly defining the interfaces for data input and transfer is
crucial. Additionally, it must be determined what kind of feedback
Data availability
the DT should provide. This feedback could be directed to the per­ The data analysed during this study are available from the corre­
son being simulated, their doctor, or a designated decision-maker. sponding author upon reasonable request.
The feedback, which might include predictions, suggestions, alerts,
or treatment plans, should help the person and their healthcare
providers make informed decisions about their health, such as Ethical approval and consent to participate
improving lifestyle habits or seeking further treatment. Privacy
and security must be prioritized, especially in decision-making proc­ International ethical legislation was respected. There was no need
esses, to balance detailed health information with privacy concerns. for approval by a research ethics committee because the study was
Many of these technical requirements remain unresolved, especially carried out using data from Scientific Databases, which is publicly
concerning the processing and modelling of large datasets. accessible, unrestricted and does not identify people in any way.
Finally, DT have the potential to offer significant societal benefits,
such as enhancing precision in public health interventions.
However, their application in personalized medicine may not be
equally accessible to all individuals or communities, which could Key points
exacerbate existing disparities. Additionally, identifying patterns
within a population of DTs might lead to problematic segmentation • DT appears as one of most discussed technology applications
and discrimination. Therefore, it is essential to establish governance within the Digital Health trend.
mechanisms that protect individual rights, ensure the privacy and • The use of digital twins in primary health care is still poorly
security of personal biological data, and promote transparency and explored but has great potential for improving the
fairness in both the use of data and the distribution of its benefits at population’s health indicators, especially across
both individual and societal levels. developing countries.
• The combination of healthcare and digital twins opens the
Conclusions door to a revolution in healthcare delivery. With the potential
to improve diagnoses, treatments, care coordination and
The use of DT mainly in process optimization and healthcare lines remote monitoring, this correlation promises to offer
presents important challenges related to data integration, privacy, significant benefits for patients, professionals, and the entire
and interoperability. However, trends indicate great potential in healthcare system.
personalizing treatment, prevention, remote monitoring, informed
 Could digital twins be the next revolution in healthcare? 7 of 7

References ities-offered-by-digital-twins-in-medicaltechnology-05899262.pdf (23 April 2023,

date last accessed).
[1]0 Barricelli BR, Casiraghi E, Fogli D. A survey on digital twin: definitions, charac­
[20] Gabrielli S, Piras EM, Mayora Ibarra O. Digital twins in the future design of digital
teristics, applications, and design implications. IEEE Access 2019;7:167653–71.
therapeutics. In: Adjunct Proceedings of the 2023 ACM International Joint
https://doi.org/10.1109/ACCESS.2019.2953499
Conference on Pervasive and Ubiquitous Computing & the 2023 ACM
[2]0 Pires F, Cachada A, Barbosa J et al. Digital twin in industry 4.0: technologies,
International Symposium on Wearable Computing, Atlanta, Georgia, USA, 2023.
applications and challenges. In: Proceedings of the 2019 IEEE 17th International
Conference on Industrial Informatics (INDIN). Helsinki, Finland: IEEE, 2019, [21] Wickramasinghe N, Jayaraman PP, Forkan ARM et al. A vision for leveraging the
721–26. https://doi.org/10.1109/INDIN41052.2019.8972134 concept of digital twins to support the provision of personalized cancer care. IEEE
Internet Comput 2022;26:17–24. https://doi.org/10.1109/MIC.2021.3065381
[3]0 Tsaramirsis G, Kantaros A, Al-Darraji I et al. A modern approach towards an
industry 4.0 model: from driving technologies to management. J Sensors 2022; [22] The Health Foundation. Person-centered care made simple: what everyone should

Downloaded from https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckae191/7909469 by guest on 10 January 2025

2022:1. https://doi.org/10.1155/2022/5023011 know about person-centered care. Quick guide. London: The Health Foundation;
2016. https://www.health.org.uk/publications/person-centred-care-made-simple.
[4]0 Schwartz SM, Wildenhaus K, Bucher A et al. Digital twins and the emerging
(20 September 2023, date last accessed).
science of self: implications for digital health experience design and “Small” data.
Front Comput Sci 2020;2:31. https://doi.org/10.3389/fcomp.2020.00031 [23] Vall�ee A. Digital twin for healthcare systems. Front Digit Health 2023;5:1253050.
https://doi.org/10.3389/fdgth.2023.1253050
[5]0 Mussomeli A, Meeker B, Shepley S et al. Expecting digital twins. Deloitte insights.
Cited 6 October 2023. https://www2.deloitte.com/us/en/insights.html (2 May [24] Venkatesh KP, Raza MM, Kvedar JC. Health digital twins as tools for precision
2023, date last accessed). medicine: considerations for computation, implementation, and regulation. NPJ
Digit Med 2022;5:150. https://doi.org/10.1038/s41746-022-00694-7
[6]0 Rivera LF, Jim�enez M, Angara P et al. Towards continuous monitoring in per­
sonalized healthcare through digital twins. In: Proceedings of the 29th Annual [25] Viceconti M, De Vos M, Mellone S et al. Position paper from the digital twins in
International Conference on Computer Science and Software Engineering, Toronto, healthcare to the virtual human twin: a moon-shot project for digitalhealth re­
Ontario, Canada, 2019. search. IEEE J Biomed Health Inf 2023. https://doi.org/10.1109/JBHI.2023.3323688

[7]0 Scharff S. From digital twin to improved patient experience. Siemens [26] Chaudhari P, Gangane C, Lahe A. Digital twin in industry 4.0: a real-time virtual
Healthineers. Cited 16 October 2023. https://www.siemens-healthineers.com/per replica of objects improves digital health monitoring system. In: Proceedings of the
spectives (10 September 2010, date last accessed). International Conference on Information Systems and Management Science. Cham:
Springer International Publishing, 2021.
[8]0 Sun T, He X, Li Z. Digital twin in healthcare: recent updates and challenges. Digit
Health 2023;9:20552076221149651. https://doi.org/10.1177/20552076221149651 [27] Karakra A, Fontanili F, Lamine E et al. Pervasive computing integrated discrete
event simulation for a hospital digital twin. In: 2018 IEEE/ACS 15th International
[9]0 Fuller A, Fan Z, Day C et al. Digital twin: enabling technologies, challenges and
Conference on Computer Systems and Applications (AICCSA). IEEE, 2018, 1–6.
open research. IEEE Access 2020;8:108952–71. https://doi.org/10.1109/ACCESS.
2020.2998358 [28] Aluvalu R, Mudrakola S, V UM et al. The novel emergency hospital services for
patients using digital twins. Microprocessors Microsyst 2023;98:104794.
[10] Armentano R, Bhadoria RS, Chatterjee P, Deka GC. The Internet of Things:
Foundation for Smart Cities, EHealth, and Ubiquitous Computing. Boca Raton, [29] Cheng W, Lian W, Tian J. Building the hospital intelligent twins for all-scenario
Florida, USA: Chapman and Hall/CRC, 2017. intelligence health care. Digit Health 2022;8:20552076221107894.

[11] Gunal MM. Simulation for Industry 4.0. 2019. https://doi.org/10.1007/978-3-030- [30] World Health Organization. Global Strategy on Digital Health 2020-2025. Geneva:
04137-3 (24 May 2023, date last accessed). World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.

[12] Guo J, Lv Z. Application of Digital Twins in multiple fields. Multimed Tools Appl [31] Ministry of Health. Digital Health Strategy for Brazil 2020-2028. Bras�ılia, Brazil:
2022;81:26941–67. https://doi.org/10.1007/s11042-022-12536-5 Ministry of Health; 2020. http://bvsms.saude.gov.br/bvs/publicacoes/estrategia_
saude_digital_Brasil.pdf
[13] Kritzinger W, Karner M, Traar G et al. Digital twin in manufacturing: a cat­
egorical literature review and classification. IFAC-PapersOnLine 2018;51:1016–22. [32] El-Warrak L, Nunes M, Luna G et al. Towards the future of public health:
https://doi.org/10.1016/j.ifacol.2018.08.474 roadmapping trends and scenarios in the post-COVID healthcare era. Healthcare
(Basel) 2023;11:3118. https://doi.org/10.3390/healthcare11243118
[14] Ahram T, Karwowski W, Falc~ao C. Applications of systems engineering for testing
and evaluation: a human systems integration perspective. In: Boehm-Davis DA, [33] Ricci A, Croatti A, Montagna S. Pervasive and connected digital twins—a vision
Durso F, Lee JD (eds), APA Handbook of Human Systems Integration. for digital health. IEEE Internet Comput 2022;26:26–32. https://doi.org/10.1109/
Washington, DC: American Psychological Association, 2015, 101–11. MIC.2021.3052039

[15] Grieves M. Digital twin: manufacturing excellence through virtual factory repli­ [34] Majumder S, Deen MJ. Smartphone sensors for health monitoring and diagnosis.
cation. NASA White Paper. 2014. https://www.researchgate.net/publication/ Sensors (Basel) 2019;19:2164. https://doi.org/10.3390/s19092164
275211047_Digital_Twin_Manufacturing_Excellence_through_Virtual_Factory_ [35] Barros M, Lima P, Oliveira D et al. Digital inclusion and education: equity and
Replication (25 May 2023, date last accessed). access. Int J Sci Stud 2023;1:124–49. https://doi.org/10.61571/riecv1i2.120
[16] Semeraro C, Lezoche M, Panetto H et al. Digital twin paradigm: a systematic [36] Garcia LP, Duarte E. Infodemic: excess quantity to the detriment of quality of
literature review. Comput Ind 2021;130:103469. https://doi.org/10.1016/j.com information about COVID-19. Epidemiol Serv Sa� ude 2020;29:e2020186. https://
pind.2021.103469 doi.org/10.1590/s1679-49472020000400019
[17] Bj€ornsson B, Borrebaeck C, Elander N et al. Digital twins to personalize medicine. [37] Huang PH, Kim KH, Schermer M. Ethical issues of digital twins for personalized
Genome Med 2019;12:4. https://doi.org/10.1186/s13073-019-0701-3 health care service: preliminary mapping study. J Med Internet Res 2022;
[18] Safa E, Asan O. Digital twins for managing health care systems: rapid literature 24:e33081.
review. J Med Internet Res 2022;24:e37641. [38] Millstone E, Zwanenberg PV. A crisis of trust: for science, scientists or for insti­
[19] Michelfeit F. Exploring the possibilities offered by digital twins in medical tech­ tutions? Nat Med 2000;6:1307–8. https://doi.org/10.1038/81462
nology. Siemens Healthcare GmbH; 2018. https://static.healthcare.siemens.com/ [39] WHO—World Health Organization. Health systems: improvement performance.
siemens_hwem-hwem_ssxa_websites-context-root/wcm/idc/groups/public/ WHR 2000. Geneva: WHO, 2000. https://cdn.who.int/media/docs/default-source/
@global/@press/documents/download/mda4/nzm4/~edisp/exploring-the-possibil health-financing/whr-2000.pdf?sfvrsn=95d8b803_1&download=true

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Public Health Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which
permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.
[email protected]
European Journal of Public Health, 2024, 00, 1–7
https://doi.org/10.1093/eurpub/ckae191
Original Manuscript