Computer-Supported Collaborative Work and Its Application to E-Health

Cosmin Porumb, Sanda Porumb, Bogdan Orza Communications Department

Technical University of Cluj-Napoca Cluj-Napoca, Romania

cosmin@hpm.ro , sanda@hpm.ro, orza@com.utcluj.ro

Dinu Budura Research and Development Department

Eta2U Timisoara, Romania abudura@eta2u.ro

Abstract— Most of the articles published in the last years present the asynchronous collaborative components integrated into the E-Health complex applications. They do not refer to the synchronous collaboration among the medical staff. A possible approach is because E-Health systems are patient-centered and the physicians, nurses and paramedics have to collaborate in a transparent manner not being focused on the synchronous collaborative tools. Our proposal is focused on advanced concepts for improving the telemedicine services and the real time collaboration among the medical staff. The article is based on a virtual collaboration prototype that supports both interpersonal and inter-process collaborative services and can be considered the core of a virtual healthcare community.

Keywords-computer-supported collaborative work; E-Health; ubiquitous computing; SOA; multi-tier architecture; virtual healthcare community.

I. INTRODUCTION Virtual collaboration and ubiquitous computing has

important roles in the modern healthcare system. They are relevant from two main points of view: the performance of the medical act and the cost of the healthcare services. The physician should be able to remotely monitor the patients based in the own environment or collaborate with an expert during the medical act. The paramedic is able to collaborate with the patient’s physician during the special cases in a ubiquitous medical environment. The assurance broker is able to analyze the reports and statistics related to the patient before enabling the payment for the provided healthcare services.

There are special cases when the virtual collaboration among the medical staff is important. The case of cardiovascular affections considered as a prime cause of mortality and morbidity in Romania is a first one. [4] The risk of cardiovascular morbidity and mortality remains high despite the attempts of correcting the cardiovascular risk factors. In the field of cardiovascular pathology the death risk by cardiovascular or vascular-cerebral accident persists even after the patients have left the hospital. By monitoring the health condition of the patients in the own environment and the analysis of evolution trends of the biophysical and biochemical parameters represents an essential prevention factor.

The treatments on different patients when nurses are not aware of treatment plans arranged by other nurses because information sharing did not exist in the hospital will be

another special case to be considered. The patients waste a lot of time, even take a day off work, but not receive treatment and this caused frustration and a loss of productivity. [6] Even asynchronous co-operation between the nurses can be a solution in such a case: information sharing and messaging capabilities can increase the performance of healthcare services.

The paramedic involved in the medical act has to know exactly all the information about the patient in order to compare the current values of medical parameters with the normal ones, prepare the treatment schema, if necessary, and share it with the patient’s physician before administrating it. Sometimes, the paramedic must take the decision in minutes or even less and the virtual collaboration with the patient’s physician can help a lot in the medical decision making process.

The physician in the Radiology department can store the medical information on Radiology Information System and patient’s physician can access it before defining the diagnosis and treatment schema. Once the information is stored on the RIS virtual library, both parties can initiate a virtual collaboration session that enables them to share the medical information and define the diagnosis and treatment schema together, if necessary.

Computer-supported collaborative work (CSCW) in telemedicine is based on models, processes and techniques that allow health professionals to efficiently access and pass on information to all associated parties of any healthcare situation. The intelligent agents, who can work on behalf of the medical staff, are made aware of the latest information and actions of other members in the team but they often need the expert validation. CSCW will also allow medical personnel such as experts, doctors, nurses and paramedics to work together and synchronously realize all activities from different remote locations. [5]

CSCW concept and its application in telemedicine have an important role in education and training process where health professionals are continuously involved. Even if talking about students, physicians, nurses, or technicians, with today’s unstoppable rise in technological progression, everybody is aware of benefits lifelong learning provides with. Professors and experienced specialists should be able to schedule training sessions, present special cases, from diagnosis to treatment schemas, and assist their students and young physicians to improve their skills during a real medical act.

2010 Third International Conference on Advances in Mesh Networks

978-0-7695-4092-4/10 $26.00 © 2010 IEEE

DOI 10.1109/MESH.2010.22

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The article is focused on advanced concepts for improving the telemedicine services by introducing the real time collaboration among the medical staff and consists of five parts and conclusions. The introduction highlights the importance of virtual collaboration in the medical act. A short but suggestive state of the art regarding the E-Health collaborative solutions is illustrated in the “Related Work” part. The third part, “Telemedicine Application Scenario”, describes some scenarios the authors have taken into account when designing the prototype. The system architecture and functional blocks are analyzed in the fourth part, “Generic Framework for CSCW”. The last part of the article, “Experimental Results”, illustrates the prototype in the real environment. The conclusions highlight the most important advantages and disadvantages of such a system.

II. RELATED WORK Chan identified a growing abundance of consumer health

monitoring products in the IT market and the advantages of these devices that allow remote monitoring: patients have their health conditions monitored unobtrusively in their mobile environment. Most of them don’t support real time monitoring, neither collaboration among virtual teams that consist of physicians, paramedics, healthcare service providers, etc. Chan proposed a new paradigm to support the cooperation of healthcare professionals using multi-agent platforms. [5] Anya presented the inconveniences in the actual telemedicine systems, proposed an open and dynamic ubiquitous medical environment and defined new capabilities the complex E-Health systems should implement: patients’ information management and medical decision making. [6]

Kuroda illustrates how to design and implement a flexible prototype system that provides space and application sharing capabilities. Kuroda has been focused on composing virtual space, and proposed open 3D shared space construction scheme, which allows users to freely create, publish, and reuse spaced and applications required for various collaborative works. The proposal consists of subordinative shared space combination scheme and functional level application cooperation mechanism. In addition, the design and implementation of the prototype system has been explained and the feasibility of the proposed scheme through experiments is confirmed using the prototype system. [8]

Most of the articles published in the last years present the asynchronous collaborative components integrated into the E-Health complex applications. They don’t refer to the synchronous collaboration among the medical staff. A possible approach is because E-Health systems are patient-centered and the physicians, nurses and paramedics have to collaborate in a transparent manner not being focused on the synchronous collaborative tools. Our approach is focused on advanced concepts for improving the telemedicine services and the real time collaboration among the medical staff. The article is based on a virtual collaboration prototype that supports both interpersonal and inter-process collaborative services and can be considered the core of a virtual healthcare community.

III. TELEMEDICINE APPLICATION SCENARIO Recent advances in communications and distributed

information technologies have changed the way that business is conducted, even if talking about medicine. Enabled by technologies such as multi-agent platforms or multimodal interfaces, healthcare services have gone beyond the geographical and socio-cultural boundaries and became entities that not only compete in the global market, but also draw their resources from an international market. The trend of outsourcing seems to be replaced by strategic alliances, where healthcare service providers, physicians, paramedics and assurance brokers work together towards a common goal and share their responsibilities as well as their profits. The concept of a professional network has emerged as a means of dealing with this new type of alliance and now it can be integrated into a virtual healthcare environment. The approach consists of the individual entities such as physicians, paramedics, technicians, software agents or organizations that come together as a virtual team. The team members co-operate in order to achieve a set of goals, share their resources, knowledge, skills, equipments, costs, risks and profits.

The main idea of the virtual medical community, illustrated in Figure 1, is to unify the entire set of healthcare services into a complex but flexible environment, from assurance to surgery, cardiology, obstetrics or radiology, from planning and patient management or statistics to remote monitoring, treatment schemas, emergency or real time assistance to complex surgery cases. We considered the following types of actors in the system: physician, nurse, paramedic and patient, hospital manager and assurance broker when designing and implementing the prototype.

Figure 1. Medical professional community.

Each physician can share the knowledge and experience with other colleagues using the collaborative services. The physician in a small hospital or medical studio that investigates a patient can meet difficulties and he/she needs an expert’s opinion (the opinion of his/her professor in the university or even the opinion of his/her colleague from another department) before making the medical decision. The young physician on duty has to investigate an unusual case and he/she needs the opinion of his/her professor/head of department but a simple phone call is not enough for offering all the medical information related to the patient.

The basic approach can be observed if using collaborative

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capabilities in order to allow the medical staff to build a virtual medical community as a professional network where professionals with the same interests share ideas, concepts, methodologies and experiences, even cases in an interactive manner. The virtual community can be created among hospitals, private medical studios, individuals, and assurance companies based in different countries and provide services for patients from different countries.

The scenario is very simple and consists of the responses to: “How to integrate the advanced technology into the real medical environment?”, “How to integrate the well-known special equipments the medical staff already uses within the virtual organization?” and “How to demonstrate the efficiency of such a system?”.

Advance technology is already an important part of the medical life but it still raises problems for both patient and medical staff. If involving special IT equipments, the medical environment becomes much more complicated and the medical staff refuses to use them. Video communication functionalities improve the professional relationship among the medical staff and the virtual shared space component allows the physicians to share medical resources and increase the investigation efficiency.

A. Physician’s point of view The physicians use the interactive environment as a

simple tool not a sophisticated one. When diagnosing a patient and meeting a strange case, he/she accesses the system and searches for an expert in area. The own virtual assistant queries the contact list or deals with the intelligent blocks in order to find the available expert as soon as possible. When finding the available expert, the physician’s virtual assistant initiates the collaborative session that allows remote diagnosis and monitoring. During the collaborative session, the physician will be able to share digital resources such as special equipments (e.g. echograph, laparoscope, ECG/EKG device, etc.), medical sheet and any other information about the patient.

B. Expert’s point of view The expert can be located in the same hospital the

physician performs his/her activity, in another hospital, in a private studio, academic environment, at home, or different country. The expert is notified by the own virtual assistant about a physician/paramedic in the professional community requires remote assistance. The notification can be via email or SMS if the specialist is off-line or internal messaging if he/she is on-line. The expert accesses the system using the PC, notebook, tablet PC or mobile device and he/she can also invite another expert to assist them, if necessary. When assisting the physician/paramedic, the expert can ask for other details about the patient’s health conditions or health history such as the video sequence captured from the special equipments, medical sheet, description of other health issues, etc. If this additional information is not enough for the diagnosis a remote real time monitoring can be realized. That way the expert remotely investigates the case by controlling the medical equipments, talking to the patient, and sharing the medical sheet and health history with the patient’s

physician. In the same manner, the expert can assist the paramedics during the emergency case.

C. Paramedic’s point of view The paramedic’s virtual assistant retrieves the

information about the patient(s) in an emergency and helps the paramedic to contact the patient physician and share basic information with him/her. The virtual assistant deals with the intelligent components in order to query the database and find the patient’s physician, medical sheet and health history and presents them in a compact format to the paramedic. That way, the paramedic will be able to administrate a first treatment schema until arriving to the hospital where the physician continues the investigation. If the patient is already remotely monitored, the virtual assistant notifies the paramedics about the patient’s health history and medical sheet by retrieving the information using a Bluetooth connection to the remote monitoring devices.

D. Nurse’s point of view Nurses can easily improve their activities by using

advanced technologies. The nurse’s virtual assistant needs to know exactly where the physician is and does, what treatment schema each patient has, and where to find the patient’s medical sheet and health history and how to share this information among the medical staff. The nurse should be able to insert new patients in the system, allocate treatment schema to each one, or setup remote monitoring devices for patients. The virtual assistant will notify the nurse about the health conditions of each patient being remotely monitored and elaborate statistics and reports to be forwarded to the physician when necessary.

IV. GENERIC FRAMEWORK FOR CSCW

A. Prototype architecture The proposal highlights the importance of the

collaborative technologies in E-Health platforms: virtual assistance, human-computer interaction, video telephony, video conferencing, online focus group, virtual shared space, media streaming or video capture/recording functionalities.

Figure 2. Prototype architecture.

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The prototype is based on a hybrid architecture, illustrated in Figure 2, that extends the multi-tier enterprise architecture and complies with the advantages of SOA (Service Oriented Architecture). It consists of the following blocks: JBoss application server, Tomcat web server, MySQL database server, OSFlash Red5 media server, OpenOffice 2.0, GostScript, MEncoder libraries and it provides integration functionalities and allows the developers to externalize the media services (Influxis, e.g.) or storage capabilities (virtual library). These functional blocks communicate each other based on the “software as a service” SOA (Service Oriented Architecture) paradigm. Tomcat web server hosts the web components that implement the front controller mechanism and JBoss hosts the business logic components. MySQL database server stores the information regarding the patients, resources, physician, paramedics, healthcare service providers, assurance brokers, and virtual community. OSFlash Red5 media server provides with video telephony/conferencing capabilities, media streaming and video capture functionalities and supports the remote shared objects. The OpenOffice 2.0 and GostScript libraries are involved in the system architecture in order to implement the resource conversion to .pdf and slideshow formats. That part of the conversion block manages .doc, .xls, .ppt, .html, .rtf formats (medical sheets, health history, educational content, etc.). The MEncoder component is used for converting the multimedia sequences to .flv format (such as video sequences captured from the special equipments, or recorded using professional devinces). It supports .avi, .mpg, .mpeg, .mov, .wmv, .au, .mp3, .wma, .gpp, .mp4 formats. That way the service handler component can manage the digital content in a unified manner (slideshow, .swf and .flv). The Business intelligence block consists of a set of intelligent agents able to learn actors’ behavior and elaborate statistics, analytics reports and scenarios based on the activity tracking. They are running within the JADE multi-agent platform. The client block is created using the Adobe Flex technology and allows the end-user to access the system via web or own mobile devices (smart phones, PDAs, Pocket PCs, tablet PCs).

The hybrid architecture guarantees several advantages such as cost effectiveness, flexibility, scalability, and platform independence. Since each layer in the stack is based on an open source solution, the entire stack can be implemented for the cost of development plus the cost of hardware. No piece of the stack requires software licenses. The system is arguably easier to maintain and expand, and quicker to adjust to business requirements. If mobility is required, the end-user accesses the services using the mobile device (smart phones, Pocket PC, PDA, mini laptops, tablet PCs) without any other deployment actions, just using a dedicated client application.

The presented architecture is horizontally scalable, meaning it grows as you add hardware to it. No single piece of the architecture is a bottleneck because each piece of the stack grows on its own, and is loosely coupled to the other pieces in the stack. In that case, the system specifications highlight the importance of the multimedia capabilities such

as: video communication, media recording/streaming, virtual shared space, knowledge and desktop sharing. The system architect easily introduced an open source media server (OSFlash Red5) in the hybrid architecture in order to support the needed functionalities.

Service Oriented Architecture (SOA) is an enterprise-scale IT architecture for linking resources on demand. In a Service Oriented Architecture, resources are made available to participants in a value net and a sequence of business, typically spanning multiple applications within an enterprise or across multiple enterprises. SOA’s virtue of loosely-coupling is an effect of the application of late binding, standalone and message based. SOA offers mechanisms of flexibility and interoperability that allow different technologies to be dynamically integrated, independently of the system’s platform in use. The system architect extended the framework architecture by adding new independent functional blocks that co-operate each other, share resources, and inter-change messages, based on the service interoperability provided by SOA.

B. CSCW Framework components The CSCW framework provides with synchronous and

asynchronous collaborative work capabilities and contains a set of components dedicated to the cooperation activities. Figure 3 illustrates the functional diagram and the collaborative modules: user management block, virtual library, search engine, statistics module, electronic agenda, project management module, virtual shared space, multimedia messaging, forum, videoconferencing tool, and online focus group.

Figure 3. CSCW framework components.

In order to simplify the development process, the framework components will be divided in 4 main categories: generic components, interpersonal collaborative components, interactive components, and inter-process collaborative components. The generic components implement the main functionalities such as database management, user management, statistics and electronic schedule. Interpersonal collaborative components allow the end-users to actively participate to the collaborative process using the communication tools: multimedia messaging, form, virtual shared space, videoconference, video telephony, online focus group, etc. The interactive components allow the end-users to interact with the system using the natural language. The search engine, virtual library and project management tools are considered as

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interactive components. Inter-process collaborative components are intelligent components such as business intelligence and virtual assistant that permit the developer to automate the collaborative process in a transparent manner.

V. EXPERIMENTAL RESULTS We implemented the prototype in several hospitals and

medical studios in Cluj-Napoca and our region and the end-users considered it as really useful not just for decision making in emergency cases but also for collaboration among departments in the same hospital/studio or in different institutions. The career development is also a scenario where to apply such a solution. [4]

The simplest scenario we can meet is when a physician faces out a problem when investigating a patient. He/she launches the application and integrates the special equipment in the system. In order to have a complete health history, the physician can record the investigation and save the discussion with the patient and health monitoring with special equipments in a compact format. The rich client block (intelligent user interface) dynamically sets up the transmission/recording parameters according to the bandwidth between the client and server machines and starts capturing until the end of monitoring. At the end of the investigation, the physician is able to review the multimedia sequence, annotate the important zones using the annotation tools and save the multimedia file onto the server.

The physician’s virtual assistant will be able to browse the sections of the virtual library and compare current health conditions with the patient’s medical sheet and health history and present them to the physician in an interactive manner. It is also responsible for retrieving information about the remotely monitored patients and notifies the physician about their health conditions.

Figure 4. Liver echography

In Figure 4 the physician is involved in a liver echography but is not sure about the diagnosis. In that case the best solution is to contact one expert in area and the physician’s virtual assistant deals with the system in order to contact an available expert. The expert is notified in the system and also via email or SMS about the problems and he/she must confirm the presence as soon as possible. If the expert is not available from different reasons, another expert will be

contacted. The one-on-one collaboration among the medical staff is realized using the video telephone approach. The component provides with good video quality and flexible frame rate that depends on the allocated bandwidth. Instant messaging capabilities among the attendees are optional but the most important component is the built-in shared space that allows digital resource sharing and recording features. By using the shared space component, the physician and expert share the medical information related to the patient (recorded medical information, or live examination using special medical devices). The sessions can be recorded and played back as Video-On-Demand at will.

If the physician needs more assistance, another expert can be invited in the virtual collaboration session. The system enables virtual teams to collaborate using a very flexible small group meeting component. It allows up to 5 members per virtual team to collaborate in a real time manner, good video quality in the video communication and speaker identification during the session. The shared space component enables the active physician to upload and share medical resources in the system, integrate special equipments using the media streaming or desktop sharing features and interact with the group using the own voice and annotation tools.

The collaborative environment is easy-to-use, user friendly and provides the end-users with a high degree of interactivity. The shared space component allows the physician to remotely access medical applications and equipments or handle the video captures from the S-VIDEO Output of the special equipments (echograph, laparoscope, etc) and interact with the attendees using the annotation tools (handwriting, draw lines, rectangles, circles, squares, text boxes, zoom in, zoom out, etc).

The transmission parameters in the real environment vary from case to case according to the bandwidth conditions and access terminals. For example, if the physicians use a reliable Internet connection about 1-1.5 Mbps, at least, the communication link is setup to support a video communication at a resolution about 320x240 pixels, frame rate=10 fps, key frame interval=30, (H.264 compression standard), audio link with a sample rate=22.1 kHz, 8 bits/sample and the device/desktop sharing at a resolution about 1024x768 pixels and the frame rate=5 fps. Another parameter is taken into account - response time. Usually its value is in the interval between 50 ms and 100 ms. If the Internet connection is not stable, the system will automatically adjust the transmission parameters: firstly the video link will be reduced (video transmission about 160x120 pixels, 5 fps) or even stopped because the audio and shared space are considered as priorities. If the network problems persist, the system will setup another transmission values for the shared space (resolution about 800x600 pixels and the frame rate=2-4 fps) but the virtual collaboration will not be affected and physicians will have the options to zoom in/out and share just the selected area if more details are necessary.

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The annotation tools can be also used for creating interactive educational materials for medical staff. The experienced physicians are able to create video-based multimedia presentations for the younger colleagues in order to describe complex cases they have been involved in or professors and head of departments are able to define tutoring and mentoring schedules in order to help the students and new colleagues to improve their skills. Figure 5 illustrates the manner of annotating medical information in order to prepare it as an educational resource.

Figure 5. Authoring tool.

In the same way, the specialists and professors when reviewing recorded complex surgery acts to also annotate the key frames/sequences for highlighting their importance and capturing attention of the young colleagues about special facts in the surgery act with text, handwriting, zooming and audio/video explanations.

CONCLUSIONS Current personal computers, workstations and servers are

designed to handle traditional forms of data. Their performance is optimized for a transaction-oriented type of workload. Those systems do not perform well for multimedia data, requiring fast data retrieval and guaranteed real-time capabilities. The I/O capacity is usually a severe bottleneck, so, it’s important to improve their capabilities by using advanced software components. Moreover, the medical act, in its origin, is a standalone process and it is not simple to make it distributed.

Often, the physicians need an opinion about a complex case but the phone calls are not enough for explaining the situation and the information are not shared between the physicians. The video communication link and the shared space allow the physicians to have an efficient discussion and make the decision in time. They just have to schedule a collaborative session, setup the web cam and headset and integrate the medical equipment needed. A high-resolution camera can also be integrated if the physician considers it as necessary for the remote examination.

The system is used for several types of investigations in the following areas: urology, gynecology and cardiology, in

the university hospitals and medical studios. The end-users integrated special medical equipments such as portable and fixed echographs, laparoscopes, portable and fixed ECG/EKG devices, etc. The integration is realized using the TV-Tuner or the device application the physician handles on the own machine and shares it with the expert(s) using the shared space capabilities.

Additional equipments are not expensive because we consider the physician already uses the medical devices. A web camera, TV tuner and headset, digital tablet / tablet PC and a high-resolution camera are all that is required. There are no expensive communication requirements. A reliable Internet connection will allow the access to the services and real-time interaction.

The professional network able to support ad-hoc hallway meetings held with physicians separated by large geographic distances should be considered as a first step in the globalization of the medical act and that is the first main advantage of the prototype. We can also add here the possibility to archive the communication sessions and review them each time when that thing is necessary. Another advantage is the flexibility – the prototype can be used for both medical act and career development processes. The cost effectiveness is a very important requirement governing the future of the interactive multimedia services. The telecommunications service providers increased the bandwidth of the Internet connection and the each physician can be active in such a system. The minimum bandwidth requirements for accessing the services are: real-time collaboration that includes equipment and desktop sharing=768 kbps; real-time collaboration with stored medical information sharing and video-based multimedia presentations (medical images/video sequences)=512 kbps.

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[3] C. Kazoun, and J. Lott, “Programming Flex 2.0”, O’Reilly Publishing House, 2007.

[4] S. Porumb, “Contributions to the implementation of collaborative work capabilities in E-Services platforms”, PhD Thesis, 2009.

[5] V. Chan, P. Ray, and N. Parameswaran, “A Multi-Agent Collaborative Framework for Mobile E-Health”, Proc. HICSS 2007: 40th Hawaii International Conference on System Sciences, 2007, pp. 134-143.

[6] O. Anya, H. Tawfik, A. Nagar, and S. Amin, “e-Workbench: A Case for Collaborative Decision Support in e-Health,” Proc. UKSim 2009: 11th International Conference on Computer Modelling and Simulation, 2009, pp. 634-639.

[7] T. Kuroda, A. Sakatoku, G. Kitagata, D. Chakraborty, and N. Shiratori, “Open 3D Space Construction Scheme for Symbiotic Collaborative Work” Proc. 28th International Conference on Distributed Systems Workshops, 2008, pp. 78 – 83.

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