{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T23:15:23Z","timestamp":1781565323538,"version":"3.54.5"},"reference-count":152,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,9,15]],"date-time":"2025-09-15T00:00:00Z","timestamp":1757894400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Digit. Health"],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Digital twin (DT) technology holds significant promise for healthcare systems (HSs) due to real-time monitoring based on streaming operational data and <jats:italic>a priori<\/jats:italic> analysis capabilities without interrupting clinical workflows. However, the sociotechnical complexity of HSs presents challenges for effective DT implementation. A dichotomy also exists between the engineering and implementation science (IS) communities regarding DT implementation challenges. This study assesses the efficacy of the updated Consolidated Framework for Implementation Research (CFIR 2.0) in identifying DT implementation challenges, aiming to bridge the knowledge gap between IS and DT communities.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This study presents findings from a DT implementation case study in a family medicine clinic, an operational healthcare microsystem. It adopts CFIR 2.0 to guide semi-structured interviews with four key stakeholder groups (e.g., family medicine specialists, engineers, organizational psychologists, and implementation scientists). Participants (<jats:italic>N<\/jats:italic>\u2009=\u20098) were purposively sampled based on their roles in DT implementation. Thematic coding categorized interview data into seven themes: technological, data-related, financial and economic, regulatory and ethical, organizational, operational, and personnel. Thematic data were then cross-analyzed with challenges documented in DT literature to assess how effectively CFIR 2.0 identifies DT implementation challenges.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Challenges were grouped into three categories: (i) shared challenges captured by both IS and DT communities, (ii) CFIR 2.0-identified challenges overlooked in DT literature, and (iii) challenges documented in DT research but not captured through CFIR 2.0-guided interviews. While there was strong overlap between the communities, a formidable gap also remains. CFIR 2.0 effectively identified a diverse set of issues\u2014predominantly in organizational, financial, and operational themes\u2014including many overlooked by the DT community. However, it was less effective in capturing technological and data-related barriers critical to DT performance, such as modeling, real-time synchronization, and sensor reliability.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>CFIR 2.0 effectively identifies organizational and operational barriers to DT implementation in healthcare but falls short in addressing technological and data-related complexities. This study highlights the need for interdisciplinary collaboration for the successful transition of emerging DT technologies into practice to maximize their impact on HS efficiency and patient outcomes.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fdgth.2025.1611225","type":"journal-article","created":{"date-parts":[[2025,9,15]],"date-time":"2025-09-15T05:29:14Z","timestamp":1757914154000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":4,"title":["Evaluating CFIR 2.0 in identifying digital twin implementation challenges in healthcare: bridging the dichotomy between engineering and healthcare communities"],"prefix":"10.3389","volume":"7","author":[{"given":"Md Doulotuzzaman","family":"Xames","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taylan G.","family":"Topcu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah H.","family":"Parker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vivian","family":"Zagarese","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John W.","family":"Epling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,9,15]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1111\/wvn.12621","article-title":"Evidence-based practice improves patient outcomes and healthcare system return on investment: findings from a scoping review","volume":"20","author":"Connor","year":"2023","journal-title":"Worldviews Evid Based Nurs"},{"key":"B2","doi-asserted-by":"publisher","first-page":"e27571","DOI":"10.2196\/27571","article-title":"Hospital investment decisions in healthcare 4.0 technologies: scoping review and framework for exploring challenges, trends, and research directions","volume":"23","author":"Vassolo","year":"2021","journal-title":"J Med Internet Res"},{"key":"B3","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1016\/j.apergo.2006.04.011","article-title":"Human factors of complex sociotechnical systems","volume":"37","author":"Carayon","year":"2006","journal-title":"Appl Ergon"},{"key":"B4","doi-asserted-by":"publisher","first-page":"548","DOI":"10.1080\/00140139.2015.1015623","article-title":"Advancing a sociotechnical systems approach to workplace safety\u2014developing the conceptual framework","volume":"58","author":"Carayon","year":"2015","journal-title":"Ergonomics"},{"key":"B5","doi-asserted-by":"publisher","first-page":"041401","DOI":"10.1115\/1.4052701","article-title":"So you think your system is complex? Why and how existing complexity measures rarely agree","volume":"144","author":"Hennig","year":"2021","journal-title":"J Mech Des"},{"key":"B6","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1136\/bmj.323.7313.625","article-title":"The challenge of complexity in health care","volume":"323","author":"Plsek","year":"2001","journal-title":"Br Med J"},{"key":"B7","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1177\/1524839903258020","article-title":"Setting objectives for community and systems change: an application of concept mapping for planning a statewide health improvement initiative","volume":"5","author":"Trochim","year":"2004","journal-title":"Health Promot Pract"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1145\/3427753","article-title":"Application of simulation in healthcare service operations: a review and research agenda","volume":"31","author":"Roy","year":"2020","journal-title":"ACM Trans Model Comput Simul (TOMACS)"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1431","DOI":"10.1057\/jors.2010.20","article-title":"Applications of simulation within the healthcare context","volume":"62","author":"Katsaliaki","year":"2011","journal-title":"J Oper Res Soc"},{"key":"B10","doi-asserted-by":"publisher","first-page":"e1511","DOI":"10.3109\/0142159X.2013.818632","article-title":"Simulation in healthcare education: a best evidence practical guide. AMEE guide No. 82","volume":"35","author":"Motola","year":"2013","journal-title":"Med Teach"},{"key":"B11","doi-asserted-by":"publisher","first-page":"301","DOI":"10.1016\/j.promfg.2015.07.155","article-title":"Simulation modelling in healthcare: challenges and trends","volume":"3","author":"Almagooshi","year":"2015","journal-title":"Procedia Manuf"},{"key":"B12","doi-asserted-by":"crossref","first-page":"386","DOI":"10.1201\/9781003425724-28","article-title":"Organizational barriers and enablers in reaching maturity in digital twin technology","volume-title":"Handbook of Digital Twins","author":"Aaltonen","year":"2024"},{"key":"B13","doi-asserted-by":"crossref","DOI":"10.1109\/CBI54897.2022.00009","article-title":"The sociotechnical digital twin: on the gap between social and technical feasibility","author":"Barn","year":""},{"key":"B14","doi-asserted-by":"crossref","DOI":"10.1109\/INDIN45523.2021.9557455","article-title":"The digital twin as an enabler of digital transformation: a sociotechnical perspective","author":"Rebentisch","year":""},{"key":"B15","volume-title":"Foundational Research Gaps and Future Directions for Digital Twins","year":"2023"},{"key":"B16","doi-asserted-by":"publisher","first-page":"4099","DOI":"10.1109\/ACCESS.2023.3349379","article-title":"A systematic literature review of digital twin research for healthcare systems: research trends, gaps, and realization challenges","volume":"12","author":"Xames","year":"2024","journal-title":"IEEE Access"},{"key":"B17","doi-asserted-by":"publisher","first-page":"e37641","DOI":"10.2196\/37641","article-title":"Digital twins for managing health care systems: rapid literature review","volume":"24","author":"Elkefi","year":"2022","journal-title":"J Med Internet Res"},{"key":"B18","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1007\/978-3-030-18732-3_1","article-title":"The convergence of digital twin, IoT, and machine learning: transforming data into action","volume-title":"Digital Twin Technologies and Smart Cities","author":"Kaur","year":"2020"},{"key":"B19","doi-asserted-by":"publisher","first-page":"32030","DOI":"10.1109\/ACCESS.2021.3060863","article-title":"The role of AI, machine learning, and big data in digital twinning: a systematic literature review, challenges, and opportunities","volume":"9","author":"Rathore","year":"2021","journal-title":"IEEE Access"},{"key":"B20","doi-asserted-by":"publisher","first-page":"83","DOI":"10.3390\/bdcc6030083","article-title":"Impactful digital twin in the healthcare revolution","volume":"6","author":"Hassani","year":"2022","journal-title":"Big Data Cogn Comput"},{"key":"B21","doi-asserted-by":"publisher","first-page":"20552076221149652","DOI":"10.1177\/20552076221149651","article-title":"Digital twin in healthcare: recent updates and challenges","volume":"9","author":"Sun","year":"2023","journal-title":"Digit Health"},{"key":"B22","doi-asserted-by":"publisher","first-page":"521","DOI":"10.1001\/jama.2021.25181","article-title":"The quintuple aim for health care improvement: a new imperative to advance health equity","volume":"327","author":"Nundy","year":"2022","journal-title":"JAMA"},{"key":"B23","doi-asserted-by":"publisher","first-page":"786441","DOI":"10.1155\/2022\/7786441","article-title":"Blockchain-based digital twins collaboration for smart pandemic alerting: decentralized COVID-19 pandemic alerting use case","volume":"2022","author":"Sahal","year":"2022","journal-title":"Comput Intell Neurosci"},{"key":"B24","first-page":"1","article-title":"Toward digital twins for human-in-the-loop systems: a framework for workload management and burnout prevention in healthcare systems","author":"Xames","year":"2023"},{"key":"B25","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1186\/s40504-021-00113-x","article-title":"The use of digital twins in healthcare: socio-ethical benefits and socio-ethical risks","volume":"17","author":"Popa","year":"2021","journal-title":"Life Sci Soc Policy"},{"key":"B26","doi-asserted-by":"crossref","first-page":"1145","DOI":"10.1061\/9780784483961.120","article-title":"Digital twin aided healthcare facility management: a case study of Shanghai Tongji Hospital","volume-title":"Construction Research Congress 2022","author":"Song","year":"2022"},{"key":"B27","doi-asserted-by":"publisher","first-page":"64390","DOI":"10.1109\/ACCESS.2025.3559502","article-title":"How can digital twins support the economic, environmental, and social sustainability of healthcare systems: a systematic review focused on the triple-bottom-line","volume":"13","author":"Xames","year":"2025","journal-title":"IEEE Access"},{"key":"B28","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science","volume":"4","author":"Damschroder","year":"2009","journal-title":"Implement Sci"},{"key":"B29","doi-asserted-by":"publisher","first-page":"270","DOI":"10.1001\/jamasurg.2017.5565","article-title":"Barriers to and facilitators of implementing enhanced recovery pathways using an implementation framework: a systematic review","volume":"153","author":"Stone","year":"2018","journal-title":"JAMA Surg"},{"key":"B30","doi-asserted-by":"publisher","first-page":"e262","DOI":"10.2196\/jmir.5091","article-title":"Using the consolidated framework for implementation research to identify barriers and facilitators for the implementation of an internet-based patient-provider communication service in five settings: a qualitative study","volume":"17","author":"Varsi","year":"2015","journal-title":"J Med Internet Res"},{"key":"B31","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1108\/JHOM-12-2020-0512","article-title":"Barriers and facilitators in the implementation of an evidence-based health promotion intervention in a primary care setting: a qualitative study","volume":"35","author":"Rogers","year":"2021","journal-title":"J Health Organ Manag"},{"key":"B32","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13012-016-0437-z","article-title":"A systematic review of the use of the consolidated framework for implementation research","volume":"11","author":"Kirk","year":"2015","journal-title":"Implement Sci"},{"key":"B33","doi-asserted-by":"publisher","first-page":"31","DOI":"10.1186\/s13012-023-01286-z","article-title":"Ten years of implementation outcomes research: a scoping review","volume":"18","author":"Proctor","year":"2023","journal-title":"Implement Sci"},{"key":"B34","doi-asserted-by":"publisher","first-page":"e49868","DOI":"10.2196\/49868","article-title":"Barriers and facilitators to the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting: systematic review","volume":"26","author":"van Tilburg","year":"2024","journal-title":"J Med Internet Res"},{"key":"B35","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1186\/s13012-022-01245-0","article-title":"The updated consolidated framework for implementation research based on user feedback","volume":"17","author":"Damschroder","year":"2022","journal-title":"Implement Sci"},{"key":"B36","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1007\/978-3-319-38756-7_4","article-title":"Digital twin: mitigating unpredictable, undesirable emergent behavior in complex systems","volume-title":"Transdisciplinary Perspectives on Complex Systems: New Findings and Approaches","author":"Grieves","year":"2017"},{"key":"B37","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1016\/j.cirp.2018.04.055","article-title":"Digital twin driven prognostics and health management for complex equipment","volume":"67","author":"Tao","year":"2018","journal-title":"CIRP Annals"},{"key":"B38","doi-asserted-by":"publisher","first-page":"103277","DOI":"10.1016\/j.autcon.2020.103277","article-title":"Digital twin-enabled anomaly detection for built asset monitoring in operation and maintenance","volume":"118","author":"Lu","year":"2020","journal-title":"Autom Constr"},{"key":"B39","doi-asserted-by":"publisher","first-page":"107008","DOI":"10.1016\/j.infsof.2022.107008","article-title":"Predictive maintenance using digital twins: a systematic literature review","volume":"151","author":"van Dinter","year":"2022","journal-title":"Inf Softw Technol"},{"key":"B40","doi-asserted-by":"publisher","first-page":"354","DOI":"10.1007\/s00158-022-03425-4","article-title":"A comprehensive review of digital twin\u2014part 1: modeling and twinning enabling technologies","volume":"65","author":"Thelen","year":"2022","journal-title":"Struct Multidiscipl Optim"},{"key":"B41","doi-asserted-by":"publisher","first-page":"1253050","DOI":"10.3389\/fdgth.2023.1253050","article-title":"Digital twin for healthcare systems","volume":"5","author":"Vall\u00e9e","year":"2023","journal-title":"Front Digit Health"},{"key":"B42","doi-asserted-by":"publisher","first-page":"e50204","DOI":"10.2196\/50204","article-title":"Envisioning the future of personalized medicine: role and realities of digital twins","volume":"26","author":"Vall\u00e9e","year":"2024","journal-title":"J Med Internet Res"},{"key":"B43","doi-asserted-by":"publisher","first-page":"26637","DOI":"10.1109\/ACCESS.2020.2971576","article-title":"Human digital twin for fitness management","volume":"8","author":"Barricelli","year":"2020","journal-title":"IEEE Access"},{"key":"B44","doi-asserted-by":"publisher","first-page":"39444","DOI":"10.1109\/ACCESS.2021.3063786","article-title":"Guiding measurement protocols of connected medical devices using digital twins: a statistical methodology applied to detecting and monitoring lymphedema","volume":"9","author":"B\u00e9thencourt","year":"2021","journal-title":"IEEE Access"},{"key":"B45","doi-asserted-by":"publisher","first-page":"1104000","DOI":"10.3389\/fbioe.2023.1104000","article-title":"Co-simulation of human digital twins and wearable inertial sensors to analyse gait event estimation","volume":"11","author":"Uhlenberg","year":"2023","journal-title":"Front Bioeng Biotechnol"},{"key":"B46","first-page":"1","article-title":"Conceptual molecular communication solution for developing digital twin to enable precision medicine implementation","author":"Chude-Okonkwo","year":"2021"},{"key":"B47","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1007\/978-981-19-6649-1_7","article-title":"Cardiac digital twin modeling","volume-title":"Innovative Treatment Strategies for Clinical Electrophysiology","author":"Loewe","year":"2022"},{"key":"B48","doi-asserted-by":"publisher","first-page":"e70112","DOI":"10.1111\/cts.70112","article-title":"Augmented intelligence in precision medicine: transforming clinical decision-making with AI\/ML and\/or quantitative systems pharmacology models","volume":"17","author":"Venkatapurapu","year":"2024","journal-title":"Clin Transl Sci"},{"key":"B49","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1038\/s41746-024-01073-0","article-title":"Digital twins for health: a scoping review","volume":"7","author":"Katsoulakis","year":"2024","journal-title":"NPJ Digit Med"},{"key":"B50","first-page":"127","article-title":"Dementia sign detection system using digital twin","author":"Kobayashi","year":"2021"},{"key":"B51","doi-asserted-by":"publisher","first-page":"8519","DOI":"10.3390\/s22218519","article-title":"Evaluation of unobtrusive microwave sensors in healthcare 4.0-toward the creation of digital-twin model","volume":"22","author":"Khan","year":"2022","journal-title":"Sensors"},{"key":"B52","article-title":"A method for patient gait real-time monitoring based on powered exoskeleton and digital twin","author":"Wei","year":""},{"key":"B53","doi-asserted-by":"publisher","first-page":"530","DOI":"10.3390\/machines10070530","article-title":"Virtual and real bidirectional driving system for the synchronization of manipulations in robotic joint surgeries","volume":"10","author":"Qin","year":"2022","journal-title":"Machines"},{"key":"B54","doi-asserted-by":"publisher","first-page":"1077","DOI":"10.1007\/s11548-023-02863-9","article-title":"Twin-S: a digital twin for skull base surgery","volume":"18","author":"Shu","year":"2023","journal-title":"Int J Comput Assist Radiol Surg"},{"key":"B55","doi-asserted-by":"publisher","first-page":"1485","DOI":"10.3390\/diagnostics13081485","article-title":"Metaverse and medical diagnosis: a blockchain-based digital twinning approach based on MobileNetV2 algorithm for cervical vertebral maturation","volume":"13","author":"Moztarzadeh","year":"2023","journal-title":"Diagnostics"},{"key":"B56","doi-asserted-by":"publisher","first-page":"262","DOI":"10.20965\/ijat.2023.p0262","article-title":"Proposal of simulation-based surgical navigation and development of laparoscopic surgical simulator that reflects motion of surgical instruments in real-world","volume":"17","author":"Shibuya","year":"2023","journal-title":"Int J Autom Technol"},{"key":"B57","first-page":"1059","article-title":"Study of hospital emergency resource scheduling based on digital twin technology","author":"Hu","year":"2021"},{"key":"B58","first-page":"62","article-title":"Hospit\u2019win: a digital twin framework for patients\u2019 pathways real-time monitoring and hospital organizational resilience capacity enhancement","author":"Karakra","year":"2020"},{"key":"B59","first-page":"2495","article-title":"A modelling and simulation framework for in\u2121ligent control of emergency units in the case of Major crisis","author":"Augusto","year":"2018"},{"key":"B60","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1007\/978-3-031-24291-5_11","article-title":"Requirements for a digital twin for an emergency department","volume-title":"Service Oriented, Holonic and Multi-Agent Manufacturing Systems for Industry of the Future","author":"Bouleux","year":"2023"},{"key":"B61","first-page":"1","article-title":"Pervasive computing integrated discrete event simulation for a hospital digital twin","author":"Karakra","year":"2018"},{"key":"B62","doi-asserted-by":"publisher","first-page":"49088","DOI":"10.1109\/ACCESS.2019.2909828","article-title":"A novel cloud-based framework for the elderly healthcare services using digital twin","volume":"7","author":"Liu","year":"2019","journal-title":"IEEE Access"},{"key":"B63","doi-asserted-by":"publisher","first-page":"1082598","DOI":"10.3389\/fpsyt.2023.1082598","article-title":"Digital twins and the future of precision mental health","volume":"14","author":"Spitzer","year":"2023","journal-title":"Front Psychiatry"},{"key":"B64","doi-asserted-by":"publisher","first-page":"928387","DOI":"10.3389\/fsysb.2022.928387","article-title":"Drug development digital twins for drug discovery, testing and repurposing: a schema for requirements and development","volume":"2","author":"An","year":"2022","journal-title":"Front Syst Biol"},{"key":"B65","doi-asserted-by":"publisher","first-page":"26857","DOI":"10.1007\/s11042-021-11664-8","article-title":"COVID-19 outbreak and the role of digital twin","volume":"81","author":"Alrashed","year":"2022","journal-title":"Multimed Tools Appl"},{"key":"B66","doi-asserted-by":"publisher","first-page":"71","DOI":"10.1055\/s-0039-1677907","article-title":"Human factors and usability for health information technology: old and new challenges","volume":"28","author":"Carayon","year":"2019","journal-title":"Yearb Med Inform"},{"key":"B67","doi-asserted-by":"publisher","first-page":"743","DOI":"10.1001\/jama.2019.0161","article-title":"A decade of health information technology usability challenges and the path forward","volume":"321","author":"Ratwani","year":"2019","journal-title":"JAMA"},{"key":"B68","doi-asserted-by":"crossref","first-page":"69","DOI":"10.4324\/9781315385907-4","article-title":"Healthcare as a complex adaptive system","volume-title":"EHealth Research, Theory and Development","author":"Covvey","year":"2018"},{"key":"B69","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1007\/978-3-030-03874-8_3","article-title":"Making sense of implementation theories, models, and frameworks","volume":"30","author":"Nilsen","year":"2020","journal-title":"Implement Sci"},{"key":"B70","doi-asserted-by":"publisher","first-page":"1322","DOI":"10.2105\/AJPH.89.9.1322","article-title":"Evaluating the public health impact of health promotion interventions: the RE-AIM framework","volume":"89","author":"Glasgow","year":"1999","journal-title":"Am J Public Health"},{"key":"B71","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1748-5908-3-1","article-title":"Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges","volume":"3","author":"Kitson","year":"2008","journal-title":"Implement Sci"},{"key":"B72","doi-asserted-by":"publisher","first-page":"e8775","DOI":"10.2196\/jmir.8775","article-title":"Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies","volume":"19","author":"Greenhalgh","year":"2017","journal-title":"J Med Internet Res"},{"key":"B73","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13012-020-01003-0","article-title":"The use of the PARIHS framework in implementation research and practice\u2014a citation analysis of the literature","volume":"15","author":"Bergstr\u00f6m","year":"2020","journal-title":"Implement Sci"},{"key":"B74","first-page":"e0000418","article-title":"The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: a scoping review","author":"Shin","year":"2025"},{"key":"B75","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s41256-019-0115-1","article-title":"A synthesis of implementation science frameworks and application to global health gaps","volume":"4","author":"Villalobos Dintrans","year":"2019","journal-title":"Global Health Res Policy"},{"key":"B76","doi-asserted-by":"publisher","first-page":"1450","DOI":"10.1186\/s12913-022-08871-w","article-title":"A scoping review of applications of the consolidated framework for implementation research (CFIR) to telehealth service implementation initiatives","volume":"22","author":"Rangachari","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"B77","doi-asserted-by":"publisher","first-page":"e084398","DOI":"10.1136\/bmjopen-2024-084398","article-title":"Barriers and facilitators to implementing imaging-based diagnostic artificial intelligence-assisted decision-making software in hospitals in China: a qualitative study using the updated consolidated framework for implementation research","volume":"14","author":"Liao","year":"2024","journal-title":"BMJ Open"},{"key":"B78","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1186\/s43058-024-00654-0","article-title":"Facilitators and barriers to implementing patient-reported outcomes in clinical oncology practice: a systematic review based on the consolidated framework for implementation research","volume":"5","author":"Lyu","year":"2024","journal-title":"Implement Sci Commun"},{"key":"B79","doi-asserted-by":"publisher","first-page":"390","DOI":"10.1186\/s12913-024-10847-x","article-title":"Using the consolidated framework for implementation research to integrate innovation recipients\u2019 perspectives into the implementation of a digital version of the spinal cord injury health maintenance tool: a qualitative analysis","volume":"24","author":"Bourke","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"B80","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13012-017-0628-2","article-title":"Assessing citation networks for dissemination and implementation research frameworks","volume":"12","author":"Skolarus","year":"2017","journal-title":"Implement Sci"},{"key":"B81","volume-title":"Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being","year":"2019"},{"key":"B82","doi-asserted-by":"publisher","first-page":"6333","DOI":"10.3390\/s23146333","article-title":"Using the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework to identify barriers and facilitators for the implementation of digital twins in cardiovascular medicine","volume":"23","author":"Winter","year":"2023","journal-title":"Sensors"},{"key":"B83","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1111\/j.1468-0009.2005.00409.x","article-title":"Contribution of primary care to health systems and health","volume":"83","author":"Starfield","year":"2005","journal-title":"Milbank Q"},{"key":"B84","doi-asserted-by":"publisher","first-page":"1001","DOI":"10.1016\/j.chest.2019.04.103","article-title":"Battling intensivist burnout: a role for workload management","volume":"156","author":"Lilly","year":"2019","journal-title":"Chest"},{"key":"B85","doi-asserted-by":"publisher","first-page":"e4805","DOI":"10.7759\/cureus.4805","article-title":"A review on strategies to manage physician burnout","volume":"11","author":"Patel","year":"2019","journal-title":"Cureus"},{"key":"B86","volume-title":"Quality by Design: A Clinical Microsystems Approach","author":"Nelson","year":"2011"},{"key":"B87","doi-asserted-by":"publisher","first-page":"432892","DOI":"10.6064\/2012\/432892","article-title":"The impact of primary care: a focused review","volume":"2012","author":"Shi","year":"2012","journal-title":"Scientifica (Cairo)"},{"key":"B88","volume-title":"State of the Primary Care Workforce 2023","year":"2023"},{"key":"B89","article-title":"Medscape physician burnout & depression report 2022: stress, anxiety, and anger","author":"Kane","year":"2022","journal-title":"Medscape"},{"key":"B90","doi-asserted-by":"publisher","first-page":"1477","DOI":"10.1002\/iis2.13218","article-title":"A rapid review of how model-based systems engineering is used in healthcare systems","volume":"34","author":"Xames","year":"2024","journal-title":"INCOSE International Symposium"},{"key":"B91","volume-title":"Systems Engineering and Analysis. Vol. 4","author":"Blanchard","year":"1990"},{"key":"B92","doi-asserted-by":"publisher","first-page":"114523","DOI":"10.1016\/j.socscimed.2021.114523","article-title":"Sample sizes for saturation in qualitative research: a systematic review of empirical tests","volume":"292","author":"Hennink","year":"2022","journal-title":"Soc Sci Med"},{"key":"B93","doi-asserted-by":"publisher","first-page":"7940","DOI":"10.3390\/app13137940","article-title":"Digital twins: the new frontier for personalized medicine?","volume":"13","author":"Cellina","year":"2023","journal-title":"Appl Sci"},{"key":"B94","doi-asserted-by":"publisher","first-page":"69841","DOI":"10.1109\/ACCESS.2023.3292119","article-title":"Leveraging digital twins for healthcare systems engineering","volume":"11","author":"Mohamed","year":"2023","journal-title":"Ieee Access"},{"key":"B95","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1109\/MCE.2022.3208986","article-title":"Digital twins for healthcare 4.0\u2014recent advances, architecture, and open challenges","volume":"12","author":"Alazab","year":"2022","journal-title":"IEEE Consum Electroni Mag"},{"key":"B96","doi-asserted-by":"publisher","first-page":"16749","DOI":"10.1109\/JIOT.2021.3051158","article-title":"Digital twin for intelligent context-aware IoT healthcare systems","volume":"8","author":"Elayan","year":"2021","journal-title":"IEEE Internet Things J"},{"key":"B97","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/B978-0-32-399163-6.00009-3","article-title":"Challenges of digital twin in healthcare","volume-title":"Digital Twin for Healthcare","author":"Dahir","year":"2023"},{"key":"B98","doi-asserted-by":"publisher","first-page":"1178912","DOI":"10.3389\/fmed.2023.1178912","article-title":"The potential of the medical digital twin in diabetes management: a review","volume":"10","author":"Chu","year":"2023","journal-title":"Front Med (Lausanne)"},{"key":"B99","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-030-18732-3_6","article-title":"Health care in the cyberspace: medical cyber-physical system and digital twin challenges","volume-title":"Digital Twin Technologies and Smart Cities","author":"Jimenez","year":""},{"key":"B100","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1016\/j.promfg.2020.02.084","article-title":"Digital twin models in industrial operations: a systematic literature review","volume":"42","author":"Melesse","year":"2020","journal-title":"Procedia Manuf"},{"key":"B101","doi-asserted-by":"crossref","DOI":"10.1109\/ICISS59129.2023.10291219","article-title":"A systematic literature review of recent trends and challenges in digital twin implementation","author":"Arin","year":""},{"key":"B102","doi-asserted-by":"publisher","first-page":"103558","DOI":"10.1016\/j.compind.2021.103558","article-title":"Implementation of digital twins in the process industry: a systematic literature review of enablers and barriers","volume":"134","author":"Perno","year":"2022","journal-title":"Comput Ind"},{"key":"B103","doi-asserted-by":"publisher","first-page":"563","DOI":"10.3390\/biomedinformatics3030039","article-title":"A comprehensive survey of digital twins in healthcare in the era of metaverse","volume":"3","author":"Turab","year":"2023","journal-title":"BioMedInformatics"},{"key":"B104","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1016\/j.bmt.2023.02.001","article-title":"Exploring the revolution in healthcare systems through the applications of digital twin technology","volume":"4","author":"Haleem","year":"2023","journal-title":"Biomed Technol"},{"key":"B105","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1016\/B978-0-443-21598-8.00011-7","article-title":"Digital twins in healthcare and biomedicine","volume-title":"Artificial Intelligence, Big Data, Blockchain and 5G for the Digital Transformation of the Healthcare Industry","author":"Subasi","year":"2024"},{"key":"B106","doi-asserted-by":"publisher","first-page":"167653","DOI":"10.1109\/ACCESS.2019.2953499","article-title":"A survey on digital twin: definitions, characteristics, applications, and design implications","volume":"7","author":"Barricelli","year":"2019","journal-title":"IEEE Access"},{"key":"B107","doi-asserted-by":"publisher","first-page":"6155","DOI":"10.1007\/s00405-024-08662-5","article-title":"Challenges and directions for digital twin implementation in otorhinolaryngology","volume":"281","author":"Vall\u00e9e","year":"2024","journal-title":"Eur Arch Otorhinolaryngol"},{"key":"B108","doi-asserted-by":"publisher","first-page":"4556","DOI":"10.1093\/eurheartj\/ehaa159","article-title":"The \u201cDigital Twin\u201d to enable the vision of precision cardiology","volume":"41","author":"Corral-Acero","year":"2020","journal-title":"Eur Heart J"},{"key":"B109","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1038\/s41746-022-00640-7","article-title":"The health digital twin to tackle cardiovascular disease\u2014a review of an emerging interdisciplinary field","volume":"5","author":"Coorey","year":"2022","journal-title":"NPJ Digit Med"},{"key":"B110","doi-asserted-by":"crossref","DOI":"10.1109\/ICE.2019.8792622","article-title":"Digital twins in eHealth\u2013: prospects and challenges focussing on information management","author":"Lutze","year":""},{"key":"B111","doi-asserted-by":"publisher","first-page":"1522","DOI":"10.3390\/jpm13101522","article-title":"Digital twins in healthcare: methodological challenges and opportunities","volume":"13","author":"Meijer","year":"2023","journal-title":"J Pers Med"},{"key":"B112","doi-asserted-by":"publisher","first-page":"907066","DOI":"10.3389\/fmed.2022.907066","article-title":"The digital twin in medicine: a key to the future of healthcare?","volume":"9","author":"Sun","year":"2022","journal-title":"Front Med (Lausanne)"},{"key":"B113","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/B978-0-32-399163-6.00008-1","article-title":"Digital twin for healthcare immersive services: fundamentals, architectures, and open issues","volume-title":"Digital Twin for Healthcare","author":"Aloqaily","year":"2023"},{"key":"B114","doi-asserted-by":"publisher","first-page":"e19390","DOI":"10.1016\/j.heliyon.2023.e19390","article-title":"Literature review of digital twin in healthcare","volume":"9","author":"Machado","year":"2023","journal-title":"Heliyon"},{"key":"B115","doi-asserted-by":"publisher","first-page":"129079","DOI":"10.1109\/ACCESS.2022.3227644","article-title":"Toward IoRT collaborative digital twin technology enabled future surgical sector: technical innovations, opportunities and challenges","volume":"10","author":"Das","year":"2022","journal-title":"IEEE Access"},{"key":"B116","doi-asserted-by":"publisher","first-page":"e39698","DOI":"10.2196\/39698","article-title":"Technical, ethical, legal, and societal challenges with digital twin systems for the management of chronic diseases in children and young people","volume":"24","author":"Drummond","year":"2022","journal-title":"J Med Internet Res"},{"key":"B117","doi-asserted-by":"publisher","first-page":"394","DOI":"10.1136\/medethics-2020-106134","article-title":"Represent me: please! towards an ethics of digital twins in medicine","volume":"47","author":"Braun","year":"2021","journal-title":"J Med Ethics"},{"key":"B118","doi-asserted-by":"publisher","first-page":"31","DOI":"10.3389\/fgene.2018.00031","article-title":"Digital twins in health care: ethical implications of an emerging engineering paradigm","volume":"9","author":"Bruynseels","year":"2018","journal-title":"Front Genet"},{"key":"B119","doi-asserted-by":"publisher","first-page":"e33081","DOI":"10.2196\/33081","article-title":"Ethical issues of digital twins for personalized health care service: preliminary mapping study","volume":"24","author":"Huang","year":"2022","journal-title":"J Med Internet Res"},{"key":"B120","doi-asserted-by":"publisher","first-page":"583","DOI":"10.1017\/jme.2022.97","article-title":"The use and ethics of digital twins in medicine","volume":"50","author":"Iqbal","year":"2022","journal-title":"J Law Med Ethics"},{"key":"B121","doi-asserted-by":"publisher","first-page":"745","DOI":"10.3390\/jpm11080745","article-title":"Digital twins: from personalised medicine to precision public health","volume":"11","author":"Kamel Boulos","year":"2021","journal-title":"J Pers Med"},{"key":"B122","doi-asserted-by":"crossref","DOI":"10.1115\/DETC2022-88786","article-title":"Challenges in implementing digital twins\u2013a survey","author":"Trauer","year":""},{"key":"B123","doi-asserted-by":"publisher","first-page":"113524","DOI":"10.1016\/j.dss.2021.113524","article-title":"Digital twin: generalization, characterization and implementation","volume":"145","author":"VanDerHorn","year":"2021","journal-title":"Decis Support Syst"},{"key":"B124","doi-asserted-by":"publisher","first-page":"108952","DOI":"10.1109\/ACCESS.2020.2998358","article-title":"Digital twin: enabling technologies, challenges and open research","volume":"8","author":"Fuller","year":"2020","journal-title":"IEEE Access"},{"key":"B125","doi-asserted-by":"publisher","first-page":"7610","DOI":"10.1080\/00207543.2021.2014591","article-title":"The emergence of cognitive digital twin: vision, challenges and opportunities","volume":"60","author":"Zheng","year":"2022","journal-title":"Int J Product Res"},{"key":"B126","doi-asserted-by":"publisher","first-page":"107424","DOI":"10.1016\/j.infsof.2024.107424","article-title":"Stakeholders collaborations, challenges and emerging concepts in digital twin ecosystems","volume":"169","author":"Tripathi","year":"2024","journal-title":"Inf Softw Technol"},{"key":"B127","doi-asserted-by":"publisher","first-page":"1","DOI":"10.36948\/ijfmr.2024.v06i02.14597","article-title":"Demystifying explainable AI: understanding, transparency, and trust","volume":"6","author":"Jangoan","year":"2024","journal-title":"Int J Multidiscip Res"},{"key":"B128","doi-asserted-by":"publisher","first-page":"e005569","DOI":"10.1136\/bmjopen-2014-005569","article-title":"Physician user satisfaction with an electronic medical records system in primary healthcare centres in Al Ain: a qualitative study","volume":"4","author":"Al Alawi","year":"2014","journal-title":"BMJ Open"},{"key":"B129","doi-asserted-by":"publisher","first-page":"779","DOI":"10.1016\/j.ijmedinf.2014.06.011","article-title":"Electronic health records implementation: an evaluation of information system impact and contingency factors","volume":"83","author":"Nguyen","year":"2014","journal-title":"Int J Med Inf"},{"key":"B130","article-title":"Why aren\u2019t they happy? An analysis of end-user satisfaction with electronic health records","author":"Unni","year":""},{"key":"B131","doi-asserted-by":"publisher","first-page":"370","DOI":"10.1002\/sys.21481","article-title":"Elemental patterns of verification strategies","volume":"22","author":"Salado","year":"2019","journal-title":"Syst Eng"},{"key":"B132","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s40436-021-00375-w","article-title":"State-of-the-art survey on digital twin implementations","volume":"10","author":"Liu","year":"2022","journal-title":"Adv Manuf"},{"key":"B133","doi-asserted-by":"crossref","DOI":"10.1201\/9781003425724-61","article-title":"Digital twins for proactive and personalized healthcare\u2013challenges and opportunities","author":"Venkatapurapu","year":""},{"key":"B134","doi-asserted-by":"publisher","first-page":"325","DOI":"10.3233\/IKS-2001-00045","article-title":"On the systems engineering and management of systems of systems and federations of systems","volume":"2","author":"Sage","year":"2001","journal-title":"Inform Knowl Syst Manag"},{"key":"B135","doi-asserted-by":"crossref","DOI":"10.1002\/9781119516699","volume-title":"Systems Engineering Principles and Practice","author":"Kossiakoff","year":"2020"},{"key":"B136","volume-title":"Digital Twin Market Report\u2014Global Industry Growth and Demand Forecast to 2030","year":"2022"},{"key":"B137","doi-asserted-by":"publisher","first-page":"7194","DOI":"10.3390\/s23167194","article-title":"Unleashing the power of IoT: a comprehensive review of IoT applications and future prospects in healthcare, agriculture, smart homes, smart cities, and industry 4.0","volume":"23","author":"Chataut","year":"2023","journal-title":"Sensors"},{"key":"B138","doi-asserted-by":"publisher","first-page":"546","DOI":"10.1109\/JSYST.2020.3023041","article-title":"Industry 4.0 implementation challenges and opportunities: a managerial perspective","volume":"15","author":"Bajic","year":"2020","journal-title":"IEEE Syst J"},{"key":"B139","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1186\/s13012-021-01111-5","article-title":"Rapid versus traditional qualitative analysis using the consolidated framework for implementation research (CFIR)","volume":"16","author":"Nevedal","year":"2021","journal-title":"Implement Sci"},{"key":"B140","doi-asserted-by":"publisher","first-page":"262","DOI":"10.1109\/MNET.118.2200071","article-title":"Human digital twin for personalized healthcare: vision, architecture and future directions","volume":"37","author":"Okegbile","year":"2023","journal-title":"IEEE Netw"},{"key":"B141","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12913-018-3163-1","article-title":"Applying the consolidated framework for implementation research to identify barriers affecting implementation of an online frailty tool into primary health care: a qualitative study","volume":"18","author":"Warner","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"B142","doi-asserted-by":"publisher","first-page":"e10201","DOI":"10.1002\/lrh2.10201","article-title":"CFIR simplified: pragmatic application of and adaptations to the consolidated framework for implementation research (CFIR) for evaluation of a patient-centered care transformation within a learning health system","volume":"4","author":"Safaeinili","year":"2020","journal-title":"Learn Health Syst"},{"key":"B143","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13643-018-0734-5","article-title":"Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review","volume":"7","author":"Li","year":"2018","journal-title":"Syst Rev"},{"key":"B144","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13012-016-0534-z","article-title":"Combined use of the consolidated framework for implementation research (CFIR) and the theoretical domains framework (TDF): a systematic review","volume":"12","author":"Birken","year":"2017","journal-title":"Implement Sci"},{"key":"B145","article-title":"Bridging informatics and implementation science: evaluating a framework to assess electronic health record implementations in community settings","author":"Richardson","year":""},{"key":"B146","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1007\/s10916-024-02104-9","article-title":"Identifying facilitators and barriers to implementation of AI-assisted clinical decision support in an electronic health record system","volume":"48","author":"Finkelstein","year":"2024","journal-title":"J Med Syst"},{"key":"B147","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1186\/s12911-021-01745-x","article-title":"Assessing the implementation of a clinical decision support tool in primary care for diabetes prevention: a qualitative interview study using the consolidated framework for implementation science","volume":"22","author":"Pratt","year":"2022","journal-title":"BMC Med Inform Decis Mak"},{"key":"B148","doi-asserted-by":"publisher","first-page":"e37338","DOI":"10.2196\/37338","article-title":"Using an integrated framework to investigate the facilitators and barriers of health information technology implementation in noncommunicable disease management: systematic review","volume":"24","author":"Sung","year":"2022","journal-title":"J Med Internet Res"},{"key":"B149","doi-asserted-by":"publisher","first-page":"e44732","DOI":"10.2196\/44732","article-title":"Physician-and patient-elicited barriers and facilitators to implementation of a machine learning\u2013based screening tool for peripheral arterial disease: preimplementation study with physician and patient stakeholders","volume":"7","author":"Ho","year":"2023","journal-title":"JMIR Cardio"},{"key":"B150","doi-asserted-by":"publisher","first-page":"455","DOI":"10.2147\/JHL.S487589","article-title":"Organizational factors driving the realization of digital health transformation benefits from health service managers: a qualitative study","volume":"16","author":"Brommeyer","year":"2024","journal-title":"J Healthc Leadersh"},{"key":"B151","doi-asserted-by":"publisher","first-page":"59","DOI":"10.3389\/fpubh.2020.00059","article-title":"Planning for implementation success using RE-AIM and CFIR frameworks: a qualitative study","volume":"8","author":"King","year":"2020","journal-title":"Front Public Health"},{"key":"B152","doi-asserted-by":"publisher","first-page":"e22866","DOI":"10.2196\/22866","article-title":"Creation of an evidence-based implementation framework for digital health technology in the intensive care unit: qualitative study","volume":"6","author":"Mosch","year":"2022","journal-title":"JMIR formative Research"}],"container-title":["Frontiers in Digital Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fdgth.2025.1611225\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,15]],"date-time":"2025-09-15T05:29:19Z","timestamp":1757914159000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fdgth.2025.1611225\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,15]]},"references-count":152,"alternative-id":["10.3389\/fdgth.2025.1611225"],"URL":"https:\/\/doi.org\/10.3389\/fdgth.2025.1611225","relation":{},"ISSN":["2673-253X"],"issn-type":[{"value":"2673-253X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,15]]},"article-number":"1611225"}}