See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/354009690

Healthcare Robotics: Key Factors that Impact Robot Adoption in Healthcare

Conference Paper · August 2021

CITATION READS
1 1,432

2 authors:

Sujatha Alla Pilar Pazos

Old Dominion University Old Dominion University
10 PUBLICATIONS   44 CITATIONS    80 PUBLICATIONS   630 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Blockchain Technology View project

Collaborative learning View project

All content following this page was uploaded by Sujatha Alla on 19 August 2021.

The user has requested enhancement of the downloaded file.

Proceedings of the 2019 IISE Annual Conference
H.E. Romeijn, A Schaefer, R. Thomas, eds.

Healthcare Robotics: Key Factors that Impact Robot Adoption in

Healthcare
Sujatha Alla, Dr. Pilar Pazos
Engineering Management & Systems Engineering Department
Old Dominion University
Norfolk, VA 23529, USA

Abstract

In the current dynamic business environment, healthcare organizations are focused on improving patient satisfaction,
performance, and efficiency. The healthcare industry is considered a complex system that is highly reliant of new
technologies to support clinical as well as business processes. Robotics is one of such technologies that is considered to
have the potential to increase efficiency in a wide range of clinical services. Although the use of robotics in healthcare is
at the early stages of adoption, some studies have shown the capacity of this technology to improve precision, accessibility
through less invasive procedures, and reduction of human error during complex surgeries. Additionally, experts have
anticipated an increase in the use of robots for tasks that require physical strength, and also tasks that are repetitive, unsafe
or that might be contagious. Several studies reported cost savings as a result of using clinical robots. Although robotics
shows promise to reduce healthcare cost, the current hospital systems are still not using them in large scale. The
application of robotics in healthcare constitutes a problem of integration of new technology in an existing and highly
regulated complex system. This paper will present a classification of robots based on their role in a healthcare facility and
identify the key factors that affect the integration of robotics in healthcare by applying a prior technology integration
framework.

Keywords
Healthcare, Robotics, Technology integration, Key Drivers, Clinical robots, Robot adoption

1. Introduction
The use of robots in healthcare is a growing trend that seems to be gaining momentum in recent years [1, 5]. From the
first robotic surgical assistant more than a decade ago, to new research today, the use of robotics in healthcare is
advancing rapidly. In 2000, the da Vinci Surgical System was the first robotic device approved by the FDA to perform
surgical procedures. Since then, the system has conducted more than 20,000 surgeries [1]. Over the years, researchers
have introduced a number of innovative enhancements to medical robotics, designed to improve the quality of care,
assist with various therapies and deliver direct patient care. These robots also serve as a marketing tool to position
hospitals as early adopters of cutting-edge technology [2]. A robot has been defined as ‘a very powerful computer with
equally powerful software housed in a mobile body and able to act rationally on its perception of the world around it’
[3]. This paper introduces a classification of healthcare robots and identifies the factors affecting their integration in the
overall healthcare system. The factors identified in this study were informed through a literature review and structured
using IEEE standards for health informatics [4].

2. Literature Review
Shortage of clinical workforce, rising healthcare costs, and increase in number of vulnerable populations such as sick,
aged, and children with disabilities, that constantly require assistance have paved the way for robotic advancements in
the healthcare [5]. Clinical service robots are expected to play an increasing role in the tasks involving direct interactions
with patients. Their services range a plethora of tasks from dispensing drugs to treating quarantined patients, from
cleaning artery plaque in a human body to actively assisting patients with mental and/or physical disabilities, from
detecting a tumor in the radiology image to performing tele-operated surgeries, just to name a few. The types of robots
used in healthcare systems have been used to execute clinical caretaking tasks and to connect clinicians and patients in
ways that previously didn't exist, such as telemedicine robots [2]. These robots are more common in large, academic
medical centers, which are more likely to have the scale, budget and operational flexibility to invest in and implement
the technology [2].
1121
2.1 Classification of Robots in Healthcare
Robots can be classified into three categories, based on the spatial position with respect to the patient’s body. Those are
insertibles, wearables, and assistive systems. All these robots vary in the degree of their autonomy depending on the task
to be performed. Some robots are designed to have self-learning cognitive abilities to assist the behavioral therapy [7, 8].
● Insertibles (In the body)

o Microbots: Micro-size, untethered robots that can move through the body and can perform target therapy,
material removal, structural controlling, and sensing.
o Tethered robots: A small teleoperated robots or as a steerable needle that can perform surgical procedures
in areas inaccessible with traditional instruments. Especially, these are beneficial in the complex surgeries
where surgeons need to look at the enhanced visual of the area to perform precision surgery [6].

● Wearables (On the Body)

These robots are used to support bodily functions and are used permanently or semi-permanently on the body.
o Robotic Prostheses and Exoskeletons: Support people with amputations who use wearable robot
prostheses or to handle physical objects. Robots can be even used for powered-knee and ankle prostheses to
do everything from running to dancing in incapable patients. MANUS robot arm, Bestic arm, Handy 1 robot
are some of the examples [7].

● Assistive Systems (Outside the Body)

o Mobile manipulators: Physicians can safely teleoperate mobile robots to treat patients with highly
infectious diseases as Ebola virus or can guide robots to treat patients in rural or remote locations where
human doctors are not available. The Da Vinci surgical system is an example of both proximate and remote
robots which is known for its flexibility and controllability [4].
o Patient Simulators: Clinicians/healthcare students train on high fidelity robotic patient simulators, which
can simulate physiological cues, and sense and respond to learners.
o Mental & Behavioral healthcare: Support people with cognitive impairments by responding to their
emotions, support wellness as a weight loss coach, or provide companionship. Patients can hold, hug, pat,
or talk to the companion robot, Paro as they would do with a pet [8].
o Physical Support Task: Support people with motor impairments, physical disorders, and movement
constraints due to brain injuries. Robotic wheelchairs, robotic walkers, etc. provide external manipulation
capabilities and prevent accidents. A typical example is Pearl, developed as part of the Nursebot project at
Carnegie Mellon University to assist elderly people [9].
o Service robots: deliver meals, medication and laundry in hospitals [3].

All these robots typically use sensor data to make decisions. They can vary in their degree of autonomy, from fully
autonomous to fully teleoperated, though most modern systems have shared autonomy. While fully autonomous systems
are independent of human intervention, shared autonomous systems operate under the guidance of other systems or users.
More broadly, robotic technology includes affiliated systems, such as related sensors, algorithms for processing data, and
so on. Robots can help caregivers and the clinical workforce, who are overloaded with work and experience high rates
injury during clinical procedures. Currently, shared autonomous systems are the most commonly used systems to
compliment or support a healthcare professional while fully autonomous systems are a long way off from being integrated
into healthcare systems.
Today, scientists, governments, and all business sectors envision robotics as a major component of technological,
economic, and social development in the 21st century [10]. However, the paradigm shift towards robot integration and
human-robot collaboration in healthcare has many unresolved questions and research directions relevant to ontological
research and standardization. Industrial robots were standardized soon after they entered the field by standards such as
ANSI (American National Standards Institute) R15.06–1999. The safety measures in those standards include keeping
robotic devices away from the human workers to prevent accidents. Although surgical robots were introduced more than
a decade ago, there is no single accepted standard yet [11]. The tasks of clinical robots would require them to work closely
with humans, hence it is prudent to apply safe design concepts and absolutely necessary to satisfy general medical device
standards such as IEC (International Electrotechnical commission) 60601 and IEC 62304[9]. IEEE-RAS (Robotics and
Autonomous Systems) formed a working group entitled Ontologies for Robotics and Automation (ORA) to develop
standard ontology and associated methodology for knowledge representation, however it does not specifically concern
clinical robots. Our literature review revealed that the standards developed by ISO are the most relevant to regulating
healthcare robots.
2.2 ISO Standards for Healthcare Robots

1122
ISO defined specific requirements and guidelines for inherently safe design, protective measures, and information for
use of personal care robots.
Personal care robots: ISO 13482:2014 presents significant hazards and describes how to deal with them for each
personal care robot type. The following are the guidelines that are defined to regulate the clinical robots:
● describes hazards associated with the use of these robots, and provides requirements to eliminate, or
reduce, the risks associated with these hazards to an acceptable level
● limitations of human-robot physical contact applications.
● covers robotic devices used in personal care applications, which are treated as personal care robots.
● is limited to earthbound robots and their speed should not exceed 20 km/hr [12]
.

3. Methodology
While the use of robots as part of the clinical workspace appears promising, it is important to understand the challenges
and implications of robot adoption. This process involves the integration of an evolving and developing technology
into a complex system such as a healthcare organization. Given that health care providers are very complex and
vulnerable systems, the integration of robots should be evaluated from both human and robot intelligence perspective.
Although robots are already being used in healthcare selectively, broader integration will require careful consideration
of the key drivers of broader adoption [13].

This paper reviewed the literature and governing standards of technology integration relevant to the implementation
of robots in healthcare. The goal of the search was to identify the most important technical, social, and organizational
factors that have been identified as having an impact on robot adoption in healthcare. The search was conducted using
the databases Springer, IEEEXplore, Elsevier, and Medline. The search included factors associated with technology
acceptance in healthcare because this field has investigated the factors influencing new technology adoption from the
end user perspective, which is critical to achieve integration in a healthcare organization [14]. This is a key aspect of
robot integration that has not been addressed by the standards. We believe that acceptance factors can help determine
key factors that impact robot technology adoption from the perspective of the end user, including the patient and the
healthcare provider.
3.1 Key Factors that Affect the Robot Adoption in Healthcare
The literature review revealed a broad range of factors that have been associated with broad adoption of robots in
healthcare. The identified factors can be classified into three major categories organizational, technological, and human
factors.
Table 1: Factors associated to broad adoption of robots in healthcare
Context Factors Factors established by IEEE
standards
Technological Design and Technical Issues, System Reliability, Safety and Reliability, Clinical
System Compatibility Effectiveness, Capability and
Functionality

Human Trust, Perceived Usefulness, Ease of Use, Usability and Acceptability, Security
Confidentiality/Privacy Concerns, Attitude, and Trust, Ethical Issues
Confidence
Organizational Legal, Security, Cost, Interoperability, Recruitment Cost effectiveness
and Training (man power), Appropriateness or
Relevance for Processes

IEEE established eHealth standards collection (IEEE 11073-20702™), which is a portfolio of standards related to
medical device communications, security, wireless networking, measurement, and electrical systems standards [4].
The aim of these collection of standards is to promote the interoperability, increase the cost savings/efficiency, and
support successful implementation of these new technologies. The IEEE standards outlines a number of factors that
are considered critical to achieve successful technology integration

1123
 At the organizational level, these standards identified the following factors:
● Cost effectiveness: It is natural that robots cost dramatically high because of their high-end technology. In
addition to that installation and maintenance costs, infrastructure remodeling costs, user training costs would
be the inevitable expenses that would make the budget much more than the cost of robot itself. In this context,
it is critical to assess the realistic requirement of integrating robots in general healthcare setting. If not the
case of EHRs (Electronic Health Records) repeat. Since the integration of EHR system was so poorly designed
instead of saving clinicians time and ended up adding more non-value-added work there by increasing costs
[12]. It is important to assess the goals of stakeholders to understand what kind of robot is required in a
particular hospital if at all one is required.

At the technical level, the following factors have been identified as critical:
● Safety and Reliability: There will be situations where people must be in the workspace of robot. This becomes
extremely vulnerable when a patient is under anesthetized and would be under control of a surgical robot. If a
functional glitch were to occur in a robot while serving vulnerable patients it is very scary to imagine the
implications. There has not been a lot of research on safe cognitive human-robot interaction [9].
Robot manufacturers should set definitive criteria on robots’ functions, capabilities, and constraints so that
stakeholders would not function it beyond its intended use. Also, extensive testing should be done on applying
various stress and strain levels and under various physical environment conditions to fully understand the
limitations of the system.
● Clinical Effectiveness: Clinical effectiveness can be measured when the system in question performs as
expected and does not result in non-added value and provides overall improved patient experience. However,
Hospital administrators and healthcare professionals should take care in analyzing the clinical requirements vs.
added value. They should check whether the robot has undergone regulatory approval before considering it no
matter how advanced the technology it carries or how non-risky it appears.
● Capability & Functionality: As the clinical robots are still in evolving stage it is hard to foresee the challenges
in their functioning capabilities. To avoid unwanted consequences, it is important to test their capabilities in
multi-institutional care settings. The adaptability feature has to be studied carefully as every patient is different
the clinical tasks associated with these patients often require to be altered to cater to the patient-specific needs.
Evaluation metrics and performance reviews should be done to reevaluate the capabilities frequently.
At the human level, the following factors were identified:
● Usability & Acceptability: As in any new technology introduction, if the robotics technology is too complex
for an average user to understand then the usage of robot will soon become reduced irrespective of its capability.
Along with the ease of use the non-intimidating appearance would quickly gain the acceptance of users. The
operating instructions should be fool-proof and easy to understand for a non-technical user. Hence, the robots
have to be tested with all its direct users to avoid any waste of resource and time. The design of the robots play
an important role in the usability and acceptability factor. For instance, if the robot prosthesis intended for a
user with disability requires deep cognitive ability to operate, the user may not be comfortable in using it at all.
● Security & Trust: According to a study [15], Trust is generally considered to be an important antecedent of
the acceptance and consequent use of any technology in healthcare. Naturally, while coming to trusting robots
in this security sensitive field the impact of trust factor greatly multiplies. The trust factor would be attained
over a certain time of use during which the robot must be fail-safe or fault-tolerant. If robot design allows it to
have a fail-safe system, it can fail as long as the failure causes the system to render itself into a safe state. But,
if robots were to given partial control or at least semi-autonomous it is important to develop more fault-tolerant
systems as it can become hard to control them manually. This would be especially problematic with social
assistive systems where robots are employed as caregivers for physically/mentally disabled people. Also,
sometimes it would be hard to detect certain failures until a threshold point is reached. If one failure sets of
another failure causing a chain reaction that go unnoticed the damages done might be serious. Hence, in order
to attain the trust factor, the security of the system must be robust. Various risk assessment methods must be
applied before deploying them in real-time environment.
● Ethical Issues: This is another aspect that should be purely viewed in a human angle rather than in a technical
or a business perspective. There are many arguments that human touch and human care plays an important role
in speed recovery of patients. Some people argue that having robot companions and mechanical caretakers may

1124
 defeat whole purpose of “nursing back to health” concept. Social influence and ethical concerns also are
considered to be the key drivers for robot adoption [16].

4. Discussion
Robot adoption in healthcare constitutes a challenging technological transition that is posed to face numerous barriers
to technology integration. Healthcare robots are semi-autonomous systems that require close collaboration and
interaction with humans and clinical personnel. This characteristic of mimicking some aspects of human intelligence
may pose a risk to humans and threaten to disrupt the already complex healthcare system. As a result, integration of
robots is expected to face an intense level of scrutiny on the technical, societal, and organizational implications before
the adoption can take place. The key factors affecting robotic integration identified in this research were informed by
governing standards of technology integration in healthcare as well as literature relevant to technology acceptance and
technology integration models in healthcare. Healthcare robots is a system that combines mechanical devices, advanced
software coding, and embedded human intelligence. Robots are expected to impact a wide spectrum of entities and
personnel across the healthcare domain either directly or indirectly. Also, since robotics technology largely depends on
extremely dynamic fields like nanoelectronics and machine learning the evolution of these systems is highly
unpredictable. It has been frequently reported that 40 percent of the previous technology developments had been
unsuccessful or partially successful due to the lack of understanding of sociotechnical aspects of IT [17]. Given the level
of complexity that healthcare robotics carries, its impending challenges are much more unpredictable. These challenges,
if not addressed diligently, would diminish the potential benefits of clinical robotic applications.

In spite of advancements in technology and increasing interest in adapting robotics in healthcare, there are several factors
that may delay its adoption. Several reasons including need for state-of-art technology, need for new infrastructure for
the robots to be installed, training/knowledge to operate, concerns with human acceptance, lack of trust in new
technology, high installation and maintenance costs, need to hire personnel to maintain the hardware and software related
to robot mechanisms. In healthcare, most problems are open-ended and there is no one-size-fits-all solution. Every
person, task, and care setting are different, and require robots to be able to robustly learn and adapt spontaneously.

Another impending reason for introducing robotics in healthcare is costs and cost effectiveness. Technological
innovation in health care is an important driver of cost growth. Implementing this expensive technology may not be
affordable to the public hospitals or hospitals in rural areas. This inequality in treatment methods may create a bias in
the way health services are provided and how health insurance is calculated for an individual patient.

Large hospital systems often embrace new modes of technology to support patient treatment and improve effectiveness.
However, new technologies can lead to increases in costs, either because they are simply more expensive than previous
treatments or because their introduction requires an expansion of the existing infrastructure. The paucity of meaningful
data on cost-benefit calculation of robot adaptation still remains as a potential barrier. Without proper alignment between
the costs and benefits associated to robot adoption, we can expect it to proceed at an exceedingly slow pace.

The process of acquiring and implementing one of these systems in a healthcare facility requires thorough review of
cost-benefit analysis, clinical outcomes impact, regulatory approvals and requirements, staffing personnel, physician
and staff training, infrastructure and maintenance needs, and technical requirements. Technologists, researchers,
providers, and end users must closely collaborate to ensure successful implementation.

5.Conclusion
This research was aimed at shedding light into the factors that influence the adoption of robotic technology in healthcare.
Healthcare needs should be realized and assessed based on the factors that were identified. The effective design of
human-robot clinical settings will require partnerships between experts in robotics and automation, human-computer
interaction, cognitive sciences, as well as clinicians, caregivers, and psychologists. A limitation of this study is that
factors influencing robot technology adoption are expected to change over time since the functionalities and capabilities
of clinical robots are expected to continuously evolve. In this changing environment, standards and legal implications
established by regulatory bodies will also need to evolve.

References
[1] Bozovic, V. (2008). Medical robotics.

1125
[2] Lee, J. (2013). Robots get to work. Modern Healthcare.
[3] Ichbiah, D. (2005). Robots: From science fiction to technological revolution. New York: Harry N. Abrams.
[4] IEEE. (2017). IEEE eHealth Standards Collection (Standard No. IEEE 11073-20702™). Retrieved from
https://innovate.ieee.org/ieee-ehealth-standards-collection/
[5] Olaronke, I., Oluwaseun, O., & Rhoda, I. (2017). State of the art: a study of human-robot interaction in
healthcare. International Journal of Information Engineering and Electronic Business, 9(3), 43.
[6] Qureshi, M. O., & Syed, R. S. (2014). The impact of robotics on employment and motivation of employees
in the service sector, with special reference to health care. Safety and health at work, 5(4), 198-202.
[7] Diehl, J. J., Crowell, C. R., Villano, M., Wier, K., Tang, K., & Riek, L. D. (2014). Clinical applications of
robots in autism spectrum disorder diagnosis and treatment. In Comprehensive guide to autism (pp. 411-422).
Springer, New York, NY.
[8] Luxton, D. D. (Ed.). (2015). Artificial intelligence in behavioral and mental health care. Academic Press.
[9] Pollack, M. E., Brown, L., Colbry, D., Orosz, C., Peintner, B., Ramakrishnan, S., ... & Thrun, S. (2002, August).
Pearl: A mobile robotic assistant for the elderly. In AAAI workshop on automation as eldercare (Vol. 2002, pp.
85-91).
[10] Haidegger, T., Barreto, M., Gonçalves, P., Habib, M. K., Ragavan, S. K. V., Li, H., ... & Prestes, E. (2013).
Applied ontologies and standards for service robots. Robotics and Autonomous Systems, 61(11), 1215-1223.
[11] Kazanzides, P. (2009, September). Safety design for medical robots. In Engineering in Medicine and Biology
Society, 2009. EMBC 2009. Annual International Conference of the IEEE (pp. 7208-7211). IEEE.
[12] International Organization for Standardization. (2014). Robots and robotic devices -- Safety requirements for
personal care robots (Standard No. ISO 13482:2014). Retrieved from https://www.iso.org/standard/53820.html
[13] Okamura, A. M., Mataric, M. J., & Christensen, H. I. (2010). Medical and health-care robotics. IEEE Robotics
& Automation Magazine, 17(3), 26-37.
[14] Bröhl, C., Nelles, J., Brandl, C., Mertens, A., & Schlick, C. M. (2016, July). TAM reloaded: a technology
acceptance model for human-robot cooperation in production systems. In International Conference on Human-
Computer Interaction (pp. 97-103). Springer, Cham.
[15] Abbas, R. M., Carroll, N., & Richardson, I. (2018, June). In Technology We Trust: Extending TAM from a
Healthcare Technology Perspective. In 2018 IEEE International Conference on Healthcare Informatics (ICHI)
(pp. 348-349). IEEE.
[16] Riek, L. D. (2017). Healthcare robotics. Communications of the ACM, 60(11), 68-78.
[17] Alaiad, A., & Zhou, L. (2014). The determinants of home healthcare robots adoption: An empirical
investigation. International journal of medical informatics, 83(11), 825-840.
[18] Burke, J. L., Murphy, R. R., Rogers, E., Lumelsky, V. J., & Scholtz, J. (2004). Final report for the
DARPA/NSF interdisciplinary study on human-robot interaction. IEEE Transactions on Systems, Man, and
Cybernetics, Part C (Applications and Reviews), 34(2), 103-112.

1126
 Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

View publication stats