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Hindawi Publishing CorporationJournal of Computer Networks and CommunicationsVolume 2013 Article ID 781620 12 pageshttpdxdoiorg1011552013781620

Research ArticleOperating Protocol and Networking Issues ofa Telemedicine Platform Integrating from Wireless HomeSensors to the Hospital Information System

Massimiliano Donati1 Tony Bacchillone1 Luca Fanucci1

Sergio Saponara1 and Filippo Costalli2

1 Department of Information Engineering University of Pisa and Consorzio Pisa Ricerche scarl 16 G Caruso Street 56122 Pisa Italy2 Caribel Programmazione Srl 1 G Malasoma Street 56121 Pisa Italy

Correspondence should be addressed to Massimiliano Donati mdonatiietunipiit

Received 29 July 2012 Accepted 8 February 2013

Academic Editor Bruno Neri

Copyright copy 2013 Massimiliano Donati et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Chronic heart failure (CHF) is among the major causes of hospitalization for elderly citizens Its considerable impact on patientquality of life the resources congestion and the related costs can be efficiently mitigated using remote wireless biosensors networksplaced at patient home able to communicate in secure way over the public Internet with the cardiology departmental HospitalInformation System (HIS) In this way physicians can monitor the situation of several patients at distance and quickly realize andact alterations in vital parameters In this scenario the HealthHome (HH) platform is conceivedThe pool of Bluetooth sensorsenables patients to daily collect vital signs at home in noninvasive fashion A home gateway receives and processes all signals beforesending them to a server node in charge of interfacing with the usual HISThe novel concept of operating protocol (OP) represents alist of actions remotely configurable that the domestic network has to follow (requiredmeasurements transmissions comparisonswith personalized thresholds etc) The first medical tests on 30 patients (1 month) allowed to verify the model both from thepatient and the medical perspective The main evaluation metrics were usability flexibility and reliability of the communicationfrom sensors to HIS

1 Introduction

Chronic heart failure represents one of the most relevantchronic diseases in all industrialized countries affectingapproximately 20million people in Europe and US [1ndash3]Thehospital admissions mainly concentrated in the older adultssegment range from a prevalence of 15 to 84 in 65ndash74years and 75 years or older groups respectively [2] Admis-sions to hospital with heart failure have significantly doubledin the last 20 years [1] Despite the advancements in medicaland pharmacological fields CHF continues to increase inboth prevalence and incidence with 4million new cases eachyear in Europe and US as result of the general ageing ofpopulation [4] To address the societal and economical issuesposed by the hospital admissions due to CHF [5] (2 of thetotal healthcare expenditure [6 7] with hospitalizations that

represent more than two-thirds of such expenditure [3]) theintroduction of cost-efficient healthcare servicestreatmentsis required in particular preventive strategies aiming at moreeffective outpatient follow-up management programs [8]

It is acknowledged that the current healthcare modelbased on periodic visits usually monthly leads to a high re-hospitalization rate (25 within 30 days and 45 within 6months [9]) failing to early detect the signs of destabilizationBesides the important problem of poor quality of life ofsurviving patients and their caregivers [10] this results inhigh congestion in specialized health facilities and posesfinancial problems to the National Health Systems There isin the literature some evidence that a multidisciplinary man-agement program [8 11] including a home-based follow-up strategy that is telemonitoring or structured telephonesupport can improve the outcomes of heart failure patients

2 Journal of Computer Networks and Communications

It provides a reduction in mortality hospital readmissionsand lengths of hospital stays and in general increases patientsatisfaction [12ndash14]

The current ICTs (Information and CommunicationTechnologies) enable to build effective telemonitoring sys-tems overcoming the limit of the actual models Biomedicalwireless sensors networks allow for a daily collection ofinteresting biological parameters at home The increasingcomputational power available in numbers of embeddeddevices permits more and more complex signal processingalgorithms while large amounts of data can be safely movedglobally via the Internet

The HeatlhHome (HH) project introduces a newflexible and high configurable platform for domestic vitalsigns acquisition and processing along with a managementscheme able to support in an integrated and coordinatedfashion the whole treatment of CHF patients since theirenrolment in the system Being directly integrated with theusual cardiology departmental HIS the HH platform aimsat connecting in-hospital care of the acute syndrome without-of-hospital followup by patientfamily caregiver Patientsrsquosigns symptoms and raised alarms can be received remotelyby the healthcare providers and aggravations can be quicklydetected and addressed More frequent (usually daily) assess-ment of clinical parameters than in conventional practice ispermitted [15]Thebenefits extend beyond the early detectionof clinical destabilization better and optimized scheduling ofspecialized resources and reduction of unnecessary travel tohospital

Hereafter Section 2 reviews the state of the artTheHHsystem architecture is introduced in Section 3 Sections 4 5and 6 describe respectively the sensing devices the homegateway and the collection server Communication detailsare explained in Section 7 Section 8 describes the testingvalidation phase Conclusions are drawn in Section 9

2 State of the Art Review forTelemedicine Systems

Considering the Ambient Assisted Living (AAL) roadmap[16] that draws the guidelines to develop efficient strategiesand systems to face the aging of population along with futurechallenges in telecare [17] and some recent studies on AALsolutions [18] especially for telemonitoring [19] the desirablefeatures of a monitoring platform for chronic disease are asfollows

(1) health monitoring service using wearableportablesensors for non-invasive measure of vital signs activ-ity level and symptoms signaling

(2) reasoning and data processing to detect emergencysituations or behaviors

(3) secure and reliable communication of data(4) interconnection between stationary home care and

acute medical treatment(5) integration with existing solutions and components(6) modular structure of the solution to ensure easy

maintenance and future extensions

(7) high degree of interoperability accomplished by theuse of well-known communication standards

(8) flexibility to face the wide range of patientsrsquo status andthe progress of chronic diseases

(9) interfaces and system requirements defined takinginto account the individuality of the end user group

Today there are many system of telemedicine [20ndash27]specific for CHF or suitable for this kind of disease togetherwith many dedicated prototypes and project trial [28ndash30]However at the state-of-the-art it is difficult to find a solutionthat completely agrees with all the previous requirementsSystems based on telephone calls or web-portal to reportsymptoms and outcomes of themeasures have to be discardedfor scalability and usability issues Considering instead sys-tems in which measures are performed by the patient andautomatically transmitted to remote nodemost of them use adedicated collection database failing the requirement point 4and partially the point 5 This way data collected at home arenot flowed into the existing HIS that in turn contains onlydata related to acute syndrome All solutions have a gatewaythat at least receives and forwards data coming from sensorsSometimes signal processing and reminders are providedThis device is often realized using a smartphone or tableta set-of-box or a PC However their mall screens and richapplication interfaces do not meet the requirements of olderusers (gt65 years and often with comorbidity and cognitiveor sensorial deficit) lowering the acceptanceusability of thesystem Finally all considered systems donot include a formalmethod to adapt and monitor the follow-up activities to beperformed at home by the patient The HH telecare plat-form described in detail in the following sections representsa complete and high configurable ICT solution for CHFremote management developed taking into consideration allthe guidelines discussed in the above points to overcome thelimits of the state of the art

3 HH Telecare System andNetworking Overview

The requirements of the system come from a close collab-oration among important healthcare providers (HospitalesVirgen del Rocio Spain DomKoperHospital in Slovenia andthe research clinical center Fondazione Gabriele Monasterioin Italy) and technical entities within the HH consortiumThis multidisciplinary approach leads to develop a platformable to meet medical expectation patientrsquos features (elderlywith numerous comorbidity and cognitive deficit) and theprogressive nature of the disease

The key points of the proposed architecture are twoFirstly the concept of follow-up operating protocol (OP) asembed formal description of the medical prescription anddefinition of the behavior of the home system Secondary thenative integration with the HIS which is already present inmost cardiology departments Other interesting features arethe reduced impact on the patient due to the limited effortrequired to follow the assigned therapy and the low overheadintroducedwith respect to the regular activity ofmedical staff

Journal of Computer Networks and Communications 3

Sensors

HTTPS

HH serverHH gateway

Figure 1 HH system architecture

Data rate

Presence onthe market

Distance

Excessive

Powerconsumption

Line-of-sightrequired

Ok Ok Ok

OkOkOk

OkOkOk

Ok Ok Ok

YesNo No No

Ko

Ko

Ko

Figure 2 Comparison among wireless technologies for sensornetwork communication

From the architectural point of view the global systemfollows the clientserver paradigm (see Figure 1) At patientrsquoshome a set of wireless biosensors allows to measure the mainvital signs while the home gateway centralizes all computa-tion and communication resources masking the complexityof the sensors network to the server The latter installedat health service facilities accepts and processes data fromseveral gatewaysmaking them available in theHIS and finallyallows the management of all patients since their enrolmentThis hierarchical structure improves the scalability and theupgrading of the system

Biomedical sensors that form the network are equippedwith wireless connectivity in order to submit acquired datato the home gateway In that sense Bluetooth 20 technologyrepresents the better tradeoff among available bandwidth(430Kbps against sim18 Kbps required by the ECG-SpO2device) security and reliability of the connection (SAFERencryption algorithm) cost and power consumption of thenode link distance Comparison among Bluetooth and therest of possible communication technologies is shown inFigure 2

The home gateway behaves as a server in the wirelesssensors network located at the patientrsquos home It receives datafrom sensors over point-to-point connections managing intime-division way the communication resource Specific sig-nal processing algorithms executed on incoming values allowto timely detect alterations in punctual values and trends

over short and medium periods The final step consists offorwarding elaborated data to the hospital server to be furtheranalyzed and stored into the ElectronicHealthRecord (EHR)

To accomplish the transmission task multiple availabletechnologies ensure a good adaptability of the system inoverall operating areas As outcome of the survey illustratedin Figure 3 the home gateway exploits both ADSL (viaEthernet or WiFi) and mobile broadband connectivity TheGSM global coverage of 99 gives a very high degree ofconnectivity dealing also with digital divide issues becausein the worst case the GPRS upload data rate of 20Kbps issufficient to transmit data in few minutes Furthermore thegateway leverages the GSM capability to send SMSs to thephysician patientrsquos relatives and caregivers in case of alarmsituations

Because of the personal nature of the data in transit theprivacy is a primary goal to achieve avoiding that eavesdrop-pers could understand the content of the communicationsDifferent protocols ensure simultaneously authenticationintegrity and confidentiality IPSec SSLTSL HTTPS sym-metric protocols The chosen HTTPS relies on SSL connec-tion and allows to exchange HTTP messages over a securechannels It comes natively with all operating systems anddoes not require any further configuration other than the SSLcertificate installation

Finally HH involves international and well-known for-mats for data representation to definitively improve the inter-operability of the system and the integration with existingHIS The ANSI HL7-RIM Clinical Document Architecture(CDA) v2 [31ndash33] and XML codify respectively the post-processed vital signals and the current OP

4 Wireless Sensors

The sensing elements of the domestic network are wirelessbiomedical devices selected with the rationale to minimizethe impact on the patient in order to be easily usedautonomously by the patient at home According to the analy-sis carried out by the physicians the sensors in the HH sys-tem are wearableportable noninvasivity wireless [34] andbattery powered Additionally to meet the peculiar patientfeatures the measurement experience consists of wear-ingusing the sensors only for the duration of the acquisition


Coverage

Data rate

Contract∙ Pay-per-use

∙ Rural simOk ∙ Rural simOk ∙ Rural Ko

Ko

Ok Ok Ok Ok

∙ Fixed fee ∙ Fixed fee∙ Pay-per-use

∙ SMS Pay-per-use∙ SMS Pay-per-use∙ Data Pay-per-use

and fixed fee∙ Data Pay-per-use

and fixed fee

∙ Urban Ok ∙ Urban Ok ∙ Urban Ok∙ Sub-urban Ok ∙ Sub-urban Ok ∙ Sub-urban simKo

Figure 3 Comparison among communication technologies for home gateway

without any long-term installation of electrodes or otherreading terminals Low quality signals arising from sensorsmispositioning are detected and requested again Indeedsignal quality is not excessively dependent on transducerpositioning (eg 3-lead ECG instead of a more complex 12-lead ECG is adopted as in [35])

The significant vital parameters to monitor in aCHF patient (ECG SpO2 weight blood pressure chestimpedance respiration and posture) have been clusteredinto two possible configurations basic and advanced Basicpartitioning implements the minimum set of requirementsto achieve a complete telecare system while the advancedversion integrates additional features to widen the kind ofCHF patients to be enrolled into the service and to cope withother chronic diseases (ie chronic obstructive pulmonarydisease diabetes) Table 1 shows the features of the sensorsand the composition of the basic and advanced version ofthe system

The basic version of the HH monitoring system usedfor the demonstration phase envisages the use of threesensing devices (see Figure 4)

(i) The commercial UA-767BT arm cuff device for bloodpressure readings by AampD Medical The sensibil-ity range and the accuracy are 20ndash280mmHg andplusmn3mmHg respectively It outputs packets with 8 bitvalues of systolic and diastolic pressure and heart rate

(ii) The commercial UA-321PBT digital scale by the samemanufacturer for body mass measurements It hasa maximum capacity of 200Kg and an accuracy ofplusmn01 Kg The value of the current body mass can becalculated from the 5 bytes data packets

(iii) The ECG-SpO2 sensing module for acquiring syn-chronized 3-lead ECG SpO2 and plethysmographictraces developed ad hoc in the HH project anddetailed by the authors in [36] Conditioned anddigitalized (at 500 sampless) ECG waveforms of twostandard limb leads level of oxygen saturation inthe blood digitalized (at 100 sampless) plethysmo-graphic waveform are sent in real time during theacquisition

The latter device is assembled on a single 90 times 14mmprinted circuit board hosting the CARDIC integrated circuit

Table 1 Home gateway sensor resources

Parameters Sampling Basic Advanced3 lead ECG 500 Sslead (12 bitS)

SpO2 3 Ss (10 bitS)

Blood pressure 1 Stype (32 bit int)

Weight 1 S (32 bit float)

Chest imp 25 Ss (10 bitS)

Respiration 25 Ss (10 bitS)

Posture 3 axes times 1 Ssaxis (8 bitS)

[36] to read 12 bit resolution ECG leads the ChipOx OEMby Envitec which provides SpO2 readings and a digitalizedplethysmographic waveform (measurement range from 45to 100 with an accuracy of 15ndash2 for oxygen saturationand measurement range 0ndash255 LSB with an accuracy of6 ppmLSB for plethysmography) the Bluetooth 20 chipOEMSPA312i by Connect Blue and the MSP430F2418 Ultra-Low Power Mixed Signal Controller for mixing raw databefore passing them to the Bluetooth interface IntegratingECG and SpO2 functionalities in a novel single sensorreduces the number of devices in the final system and alsoenables for advanced analysis (eg the Pulse Transit Timeestimation) using synchronization between SpO2 and ECGtraces The sensor naturally allows to deal with a singleparameter at a time

All sensing devices send only raw data exploiting theonboard Bluetooth 20 Class I transceiver and data signalprocessing is completely demanded to the home gatewayThey use the Service Discovery Protocol (SDP) and the SerialPort Profile (SPP) services to wirelessly communicate withthe gateway which acts as access point PIN-based peeringprocedure is required once at configuration time whileduring the permanence at patientrsquos home the wireless sensorsnetwork not require further configurations (device searchesPIN validations etc) Indeed each sensor acts as initiatorof connections towards the home gateway when activatedThis means that a measure acquisition simply consists ofturning on the sensing device and waiting until the end of themeasurement process without any preventive interactionsintroducing also benefits in battery saving Only one activeconnection at a time can be managed by the implementedhome gateway while simultaneous connection attempts lead


Figure 4 Wireless sensors for the basic version of the HH system

to discard attempts other than the first This is not a reallimitation since measurements have to be done one by oneby the user

5 Home Gateway and Operating Protocol

51 Home Gateway HWSW Platform The home gatewayis the elaboration and communication node of the wirelesssensors networkCentralizing and automating the acquisitionand transmission of vital signs it minimizes patient effortsThe gateway accepts incoming connections over the Blue-tooth channel and handles all sensor-dependent communi-cation protocols to receive data packets from the biomedicalsensors and to extract their content Its primary task isthe data processing for early detection of critical alterationsand the secure forwarding of the computation results (iefiltered data alarms etc) to the remote server system tobe further analyzed and finally flowed into the cardiologydepartmental HIS The system provides a permanent storageof pending datawaiting for transmission so that power supplyfailures do not result in data loss (16MB for 1 week completeacquisitions) With respect to the remote server the gatewaymasks the complexity and the heterogeneity of the sensorsnetwork behind it

The gateway follows the OP and guides step by stepthe patient in performing the activities as scheduled by thephysician leveraging its powerful graphical user interfaceIn addition to the planned measures the system can receiveothers spontaneously performed by the patient In this caseit asks to select the reason of the measurement from a liststill ensuring the analysis process Finally it is possible tosubmit alarms manually from a selectable list (ie dyspnoeapalpitation breathlessness etc)

To achieve a fully compliance of requirements taking intoaccount flexibility robustness and user-friendliness and atthe same time reducing costs and project risks several hard-ware solutions have been considered Full custom platformpresents some advantages but long developmenttesting timeMoreover the number of devices for early demonstration isvery low resulting in a high cost per unit Mobile phone hastoo small display and keys limited memory space and comeswith only mobile broadband connectivity In smartphonepotentially the allocation of memory and the computationalresources meet the demands However it is not the bet-ter solution due to the size of display and also becausebeing born to telephony running applications are placedon holddelayed status in case of incoming call Bluetoothaccess points are typically used to realize Bluetooth networkin proximity marketing Some of them allow customizingits functionality thanks to a Linux software platform andspecific SDKs These products are upgradeable with a seriesof interfaces with USB connection such as GSMUMTS orWifimodulesThe degree of customization reachable withoutincurring the cost of SDK inferred by tests is not adequatefor the project needs

A netbook represents the best tradeoff among all metricsDesigned for wireless services it typically includes most ofthe needed resources Bluetooth Wifi modem 9-10 inchesscreen speakers low-power times86mdashcompatible processorstorage space Allmissing interfaces or future extensions canbe added by USB connector The only drawback is the key-board whose keys are too small and too many with respectto the request So in replacement of the native keyboard acustomonewas developed for the selected netbook (SamsungN150) including only the required buttons Yes No Alarmsending and UpDown scroll buttons (see Figure 5)


Intel ATOM N450 166GHz

Memory RAM 1GB DDR2

Hard Disk Sata250GB

Ethernet 10100LAN

Bluetooth 20GSMGPRSEDGEand UMTSHSPA

Bulit-in audio

Ad hoc 5 keys keypad

Display 10 1998400998400

Wireless 80211 bgn

(a)

LCD

Keypad

Bluetoothinterface

Massstorage

Processing unit

Powersupply

RAM

LANWifi

RF interface(GSMEDGEUMTSHSPA)

Sensors

Optional AProuter ADSL

(b)

Figure 5 Home gateway architecture and hardware resources

The operating system chosen for the gateway is based onLinux kernel 2627 or higher customizedwith the addition ofa lightweight window manager and deprived of unnecessaryservices applications and kernel modules The HH soft-ware runs directly when netbook is switched on It is imple-mented in C language using respectively libbluetoothlibSSL libXML libgtk to support Bluetooth managementsecurity XML parsing and graphical development

The software architecture is represented in Figure 6 usingan UML diagram

(i) the sensor server manages incoming connectionsover Bluetooth interface to receive raw data fromsensors

(ii) the network communicator manages the availablechannels to forward both collected information to theserver and alert SMS to caregiversphysicians

(iii) the clock and the scheduler ensure scheduling andreminder of all the therapeutic activities

(iv) the graphical user interface handles both events throwduring interaction with the keypad and the visualiza-tion of messages in the application window

The main concerns of the system were implementedin separated threads to ensure a high modularity and themaximum flexibility when combining them in any arbitraryoperating protocol This modular architecture ensures easymaintenance and upgrades including future extensions withnew sensors or the introduction of new communicationstandards

52 Operating Protocol The newly developed OP conceptconsists of a set of actions like taking measurements orreplying to simple questions that the patient must followduring the monitoring period as well as it completely definesthe behavior of the home gateway in terms of types andfrequencies of measurements transmission policy selectablesymptoms comparison thresholds and phone numbers foreach alarm The OP is tailored by the physician at thebeginning of the monitoring period and it can be remotelyupdated in progress according to the patient conditions Infact at the end of any data transmission if necessary theserver is able to update the current operating protocol bysending the new one to the interested gateway The OPupdate and the consequently reconfiguration of the gatewayis totally transparent to the user Usual values for measuring


HH gateway software

Shared variables among threads

GUI thread

System clock thread

Activity scheduler thread

(lowast) ldquousesrdquo dependences with all threads was omitted to simplify the notation

(lowast)

Network communication thread

Activity reminder thread

Sensor server thread

FileSystem storage fileldquofilerdquo

ldquousesrdquo

ldquousesrdquo

ldquosendrdquo

ldquoexecutablerdquo





ldquoexecutablerdquoldquosendrdquo

Figure 6 Components diagram of the gateway application software

Table 2 The operating protocol

Data Schedule Alarm level3 lead ECG 1-2day (5min) 50 ltHR lt 100 bpmSpO2 1-2day (5min) gt90

Blood pressure 2-3day 85 lt sys lt 160mmHg50 lt dia lt 100mmHg

Weight 1-2day Gain lt 1 kgdayGain lt 3 kgweek

Chest imp 1day (5min) Fluctuation lt 30Respiration 1day (5min) 12 lt 119877 lt 25 bpmPosture Continuous No activityfallTherapy reminder 1-2day 3 faults in a week

frequencies and ranges for alarms detection are shown inTable 2 but clinicians can configure each parameter

53 Data Processing and Alarm Management Sensor datasignal processing implemented in the home gateway is incharge of detecting alterations in vital signs potentially dan-gerous for the patient In this way the physicians are timelyalerted if anything out of the ordinary is found and they havein the HIS all patientsrsquo data to plan the following actionsData processing involves three main steps preprocessinganalysis and cry wolf avoidance The preprocessing consistsof the filtering of raw data provided by the sensors removalof noise and main interference and the extraction of derivedinformation The analysis step compares the outcome of

the preprocessing with the thresholds defined in the OPthat establish the admissibility range for punctual valuesor trends over a medium period The last step is useful toreduce the number of false positive alarms for example dueto temporary stress or sensors misuse In the presence ofabnormal values the same measurement is shortly deferredand only if the condition is confirmed the gateway raisesthe alarm contacting caregiver or health professionals viaSMS The required arithmetic precision is compliant withreal-time implementation on 32-bit single-core processor andthe RAM memory available in the netbook All involvedalgorithms have a linear complexity with the number ofconsidered samples of the signal both in terms of memoryand computational cycles

The electrocardiographic signal is treated to extractmaxi-mumminimum and average heart rate over the track as wellas to detect the presence of atrial fibrillation The referencepoint within the ECG signal is the QRS complex threedeflections that occur periodically and in rapid successionwhere the R point represents the main upward ones Aderivative-based algorithm [37] and a rule-based system [38]for the QRS complex detection are applied The source signalis filtered in order to keep just the central frequencies (8 to30Hz) where the QRS complex information lays Afterwardsthe signal is differentiated squared and averaged Comparingthe averaged signal against a threshold creates a set ofwindows that allow to recognize the R peaks in the filteredsignal (maximum positive within the window) The R peakhas still passed through a rule-based system that evaluateswhether the detected QRS is a valid QRS complex or not


28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)

Figure 7 (a) Raw ECG signal corrupted by powerline noise (b)filtered ECG signal and valid R peaks detected by the processingalgorithm (c) envelope signal of the valid R peaks

based on the distance in time between consecutive peaks Toimprove the legibility of the track for furthermedical review a50Hznotch filter is applied to the signal to remove power-linenoise Figures 7(a) and 7(b) show the raw and filtered signalThere is also a cubic spline data interpolation algorithm thatextracts the envelope of the R peaks as an indirect indicationof the respiratory activity Figure 7(c) shows the envelopesignal of the peaks The analysis of the intervals betweenconsecutive R peaks using a 30 secondswindow shifted alongthe time axis by 5 seconds length steps [39] allows to calculatethe heart rate

Concerning SpO2 signal analysis relevant values aremaximum minimum and also the average level of oxygensaturation over the track extracted by a digital low-pass FIRfilterThenormal range in healthy people is from94 to 100while oxygenation can quickly lower in CHF patients hencea frequent monitoring is necessary to detect these changes

Concerning blood pressure signal processing systolicand diastolic values are analyzed (see Figure 8) to find outunder or over threshold situations and the general trends ofboth parameters are verified looking for suspicious variabilitythat are typical manifestation of cardiac instability

As far as weight this parameter is easy to measure andelaborate as well as very effective in the CHF management It

Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul

Figure 8 Example of blood pressure analysis of HH

Please measure your ECG and SpO2

Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg

Figure 9 Example of the graphical user interface requesting ameasurement

allows to detect fluid retention in the patient The system isable to find out increases of 1 Kg in a day or 3Kg in a weekthat are considered potentially critical situations in CHF

54 User Interface The user interface has an essential rolein this application having to guide the patient in followingthe scheduled measurements or drugs assumptions Thedeveloped home gateway provides an intuitive user interfaceable to display guide images reminder messages and soundswhen a planned activity time is reached Figure 9 showsthe appearance of the graphical interface Patients can readthe last measured values of weight blood pressure heartrate and oxygen saturation At the top of Figure 9 thereminder textbox indicates the requested activity along withthe graphical helper that shows the correct actions to be doneas gif animation The other textboxes report the status of therelated sensor included battery charge Green yellow andred textboxes background colors are used for informationwarning and error messages respectively In idle state thetime of the next activity is visualized The custom keypadallows to navigate and confirm symptoms in case of manualalarm or extra measure and to answer questions about pillstherapy

The gateway provides also the possibility to store in a localdatabase all collected vital signs occupying less than 1GBfor one year observation This functionality allows to selectand visualize ECG tracks R-Wave envelops SpO2 tracks and


Ack

Automaticnotification

XML OP

HL7 CDA document

Gateway Software platform

HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document

Gateway Software platform Department HIS

HL7 CDA document

Departmental HIS

Figure 10Methods of integration between theHH software platform (server side) and the departmental HISThe communication betweenthe HH home gateway and the server software platform is the same in both cases

plethysmographic waves or trend graphs for weight bloodpressure heart rate and SpO2 This is particular useful whenmedical staff is present at patientrsquos home and needs to consultthe measurements repository on-site

6 Remote Server Module

The HH server platform is a web-based application thatreceives data from gateways providing a detailed process ofanalysis based on expert systems and finally the update of thepatient record in the departmental HIS No summarizationfunction is provided but it deals with all the received unag-gregated data Moreover the HH server platform exportsinterfaces that allow the clinicians to interact with the systemretrieve information and manage all patients

The format of data shared between the HH server andthe HIS is the ANSI HL7-RIM CDA v2 the same templateadopted for the communications gateway-server BesidesHL7 CDA v2 is also possible to use other XML formats

Transmissions leverage the web services architecture andMLLP (Minimum Low Level Protocol) is applicable

Two possible ways of integration with existing HIS areavailable (see Figure 10) in order to improve the interoper-ability of the system In the first mode called synchronousrequest (SR) all data are stored locally in the HH serverplatform and vital signs are provided on-demand as resultof query messages submitted from the HIS Queries addressa dedicated service endpoint and use XML to specify thesearching parameters the patient identification the vitalsigns and the time interval In the SR mode a specificinterface to build the queries has to be added to the HISThe second mode the automatic notification (AN) methodrequires that the HIS interested in receiving the clinicalinformation coming from the gateways exposes a dedicatedwebservice reachable by the HH software platform Whennew data are received and stored in the HH server theyare immediately flowed to the registered HIS enabling anautomatic update of the EHR


Figure 11 Appearance of the physician frontend

From the functional point of view the software platformis composed of two main parts the core and the frontend

The frontend represents the human machine interfacefor the physicians (see Figure 11) Its main functions arerelated to the patient management since their enrolmentwhen the physician inserts the patient data and configureshis OP To be noted that user interfaces at both homegateway and server sides have been realized in differentlanguages (English Italian Slovenian Spanish) to allow theinstallation of the system in the National Health Systems ofthe different project partners At any time the physician isable to look through the patient clinical folder comparingthe patient health status in different periods by means ofmeasurement trends The system is able to highlight thealarms encountered during the monitoring If necessary thephysician can modify the OP at any time this producesan automatic and transparent update of the gateway Thefrontend is based on the rich client technology which allowsdefining a simple user interface with high performance fromthe user interactivity point of viewThe architecture is able tocompletely decouple application logic from data displayingin order to make the interface fast flexible and usable bythe user Conceptually the browser provides the features ofa desktop application accessible from the Internet withoutinstalling any add-onThe visual components written in JavaScript are downloaded at runtime and run locally into thebrowser

The core part is based on the Spring Framework [40]which accepts patient measurements collected and sent bythe gateways through a dedicated webservice endpoint Allreceived messages are formally verified and the containedobservations are stored in the local database The core is alsoin charge of managing the integration with the HIS bothserving the incoming queries in SR mode or forwarding vitalsigns to HIS in ANmode Additionally the core is responsiblefor data retrieval when requested by the frontend Databetween the core and the frontend is exchanged through JavaScript Object Notation Finally the core exposes an additionalservice useful when a gateway has to be customized for newusers

7 Gateway-Server Networking

WAN (Wide Area Network) technologies ADSL or mobilebroadband are used to communicate with the collection

server As data exchanged between gateway and serverinvolves the public Internet the use of HTTPS protocol fitscompletely the requirements of confidentiality authenticityand integrity for the data traffic The protocol also meetsperfectly the web service paradigm the request messagecontains all pending results and events within its body codedaccording to the HL7-RIM CDA v2 while the responseincludes the XML description of the current OP allowingremote updates after each transmission

The header of the CDA document contains informationabout the patient used to address its EHR and the recipienthospital Result and Vital Signs sections contain numericand waveform observation blocks one for each measureTheInterpretationCode tag is used to mark normal or abnormalvalues Symptoms are hosted as event observations in thePurpose section Medical equipment section describes thesensing devices used All observations use SNOME CT [41]or LOINC [42] codes

Transmission occurs according to the OP at the end ofan activity or on time-base (ie daily or weekly) and alwaysafter an alarm either manually signaled or automaticallydetected

Communication occurs also when the gateway has to beconfigured for a new patient A dedicated interface allowsto completely configure the home gateway or to modify thecurrent patientrsquos information status server IP addresses andports names of the collection and configuration serviceand regionalization The gateway contacts the configurationendpoint indicating the patientrsquos ID The server replies withall the information of the given patient and the personal OPNow the configuration is complete the reachability of theendpoints is tested and the monitoring can start Using thisprocedure patient information and operating protocol aredefined only once at server-side reducing the possibility ofmistakes

8 HH Telecare System Testing

One of the key issues for the adoption of new telemedicinesystems is an exhaustive mixed HWSW test [43 44] TheHH system follows a very structured and incrementaltesting procedure concluded with the final technical val-idation and demonstration phase Unit test of hardwarecomponents and operational correctness of software andfirmware applications using conventional procedures werethe first steps The following integration test verified the end-to-end communication in the system and the overall system-level interactions of the different HW and SW parts To thisaim some ad hoc prepared scenarios and the involvementof healthy users were used The last important phase beforethe final technical demonstration was the alpha-testing twopatients minimally aware of ICT and younger than the CHFaverage age (1month)The first impressions of physicians andpatients coming from these tests made possible to tune thefinal version of the system

The technical validation of the HH platform involved30 patients with CHF disease in New York Heart Association(NYHA) classes III and IV with an average age of 62 years


hospitalized for acute heart failure in the previous 6 monthsand consenting to take part in the study Acute coronarysyndromewithin 3months before the enrolment was the onlyexclusion criteria The size of the set of CHF affected patientsis similar to those of other works published in the literatureabout ICT systems for CHF monitoring [45] The minimumperiod of monitoring was one month

The metrics established for the evaluation of the systembelong to two main categories objective and subjective Thefirst ones are related to items unequivocally measurablethe latter depend on the personal experience during thedemonstration and the feeling with the system A specifictesting protocol and a questionnaire to collect patientscaregivers and physicians feedbacks were used to validatethe system A group of selected cardiologist checked outthe information arrival in HIS evaluating the quality andcoherence of data collected and the relevance of the alarmsThe ergonomic of patientrsquos interface was evaluated as a keypoint of system functionalities as well as the general end-userusability On the other hand the robustness and reliabilityof data transmission and the effectiveness from the medicalpoint of view were evaluated

The results show a very limited number of activity misses(lt3) mostly in the first days of monitoring Moreoverthe number of false positive alarms is less than 5 Noconnectivity and transmission problems occurred includingdata or sensors network configuration lostThanks to the highquality of acquired signals and alarms detection capabilitythe physicians reported a valid impression of the system tocontrol at distance the evolution of the followed patients Allphysicians involved in the demonstration are definitively infavor of the adoption of the HH system 89 of the patientsreport a very high satisfaction level motivating their choicewith the friendliness of the solution and the easiness to followthe therapy

The complete success of the HH technology test undermedical control led to plan a clinical validation (withOPEXCAPEX economical analysis) including 500 patientsin the Italian Regional Tuscany Health System

9 Conclusions

The technologies currently available allow for the provi-sioning of effective out-of-hospital telemonitoring strategiesfor chronic diseases instead of the actual in-hospital-basedfollow-up procedure based on periodic visits In this scenariothe HH system proposes an innovative home care modelfor the CHF patients based on a Bluetooth wireless sensorsnetwork equipped with software tools and communicationtechnologies for remote acquisition analysis and securetransmission of the main vital signs The final aim is todesign an integrated platform to support the whole processof the patient treatment connecting in-hospital care without-of-hospital followup The system was developed aroundan OP with a per-patient granularity allowing to generatea really meaningful database for every patient The use ofinternational standards for data exchange and the well-knowcommunication protocols improves the interoperability

favoring the future integration of the platformwith other HISor sensors

All metrics about usability reliability and robustness ofthe platform evaluated during the first technology assessmentin a real medical scenario with tens of patients affected byCHF disease NYHA classes III and IV prove the effectivenessof the HH telemonitoring system from both the patientsand the caregiversrsquo point of view

Acknowledgment

This work was supported by the Ambient Assisted LivingProgramme

References

[1] ldquoSHAPE survey results to the general publicrdquo in Proceedingsof the Annual Congress of the European Society of CardiologyVienna Austria September 2003

[2] F Zannad N Agrinier and F Alla ldquoHeart failure burden andtherapyrdquo Europace vol 11 no 5 pp 1ndash9 2009

[3] V L Roger A S GoDM Lloyd-Jones et al ldquoHeart disease andstroke statistics-2011 update a report from the American HeartAssociationrdquo Circulation vol 123 pp 18ndash209 2011

[4] World Population Ageing 2009 Department of Economic andSocial Affairs of the United Nations 2010

[5] F Alla F Zannad and G Filippatos ldquoEpidemiology of acuteheart failure syndromesrdquo Heart Failure Reviews vol 12 no 2pp 91ndash95 2007

[6] C Berry D R Murdoch and J J V McMurray ldquoEconomics ofchronic heart failurerdquo European Journal of Heart Failure vol 3no 3 pp 283ndash291 2001

[7] A Bundkirchen and R H G Schwinger ldquoEpidemiology andeconomic burden of chronic heart failurerdquo European HeartJournal Supplements vol 6 pp 57ndash60 2004

[8] S Stewart ldquoFinancial aspects of heart failure programs of carerdquoEuropean Journal of Heart Failure vol 7 no 3 pp 423ndash4282005

[9] J S Ross J Chen Z Lin et al ldquoRecent national trends in read-mission rates after heart failure hospitalizationrdquo CirculationHeart Failure vol 3 no 1 pp 97ndash103 2010

[10] S Stewart K MacIntyre D J Hole S Capewell and J JMcMurray ldquoMore lsquomalignantrsquo than cancer Five-year survivalfollowing a first admission for heart failurerdquo European Journalof Heart Failure vol 3 no 3 pp 315ndash322 2001

[11] F A McAlister S Stewart S Ferrua and J J J V McMurrayldquoMultidisciplinary strategies for the management of heart fail-ure patients at high risk for admission a systematic review ofrandomized trialsrdquo Journal of the American College of Cardiol-ogy vol 44 no 4 pp 810ndash819 2004

[12] E Seto ldquoCost comparison between telemonitoring and usualcare of heart failure a systematic reviewrdquo Telemedicine and E-Health vol 14 no 7 pp 679ndash686 2008

[13] CKlersy ADe Silvestri GGabutti F Regoli andAAuricchioldquoAmeta-analysis of remotemonitoring of heart failure patientsrdquoJournal of the American College of Cardiology vol 54 no 18 pp1683ndash1694 2009

[14] S C Inglis R A Clark F A McAlister et al ldquoStructuredtelephone support or telemonitoring programmes for patientswith chronic heart failurerdquo Cochrane Database of SystematicReviews vol 4 no 8 Article ID CD007228 2010


[15] J P Riley and M R Cowie ldquoTelemonitoring in heart failurerdquoHeart and Education in Heart vol 95 no 23 pp 1964ndash19682009

[16] G van den Broek F Cavallo and C Wehrmann ldquoAmbientAssisted LivingRoadmaprdquoMarch 2010 httpwwwaalianceeu

[17] S J Devaraj and K Ezra ldquoCurrent trends and future challengesin wireless telemedicine systemrdquo in Proceedings of the 3rdInternational Conference on Electronics Computer Technology(ICECT rsquo11) vol 4 pp 417ndash421 April 2011

[18] C Fabbricatore M Zucker S Ziganki and A P KarduckldquoTowards an unified architecture for smart home and ambientassisted living solutions a focus on elderly peoplerdquo in Pro-ceedings of the 5th IEEE International Conference on DigitalEcosystems and Technologies Conference (DEST rsquo11) pp 305ndash311June 2011

[19] A J JaraM A Zamora andA F G Skarmeta ldquoAn architecturefor ambient assisted living and health environmentsrdquo in Dis-tributed Computing Artificial Intelligence Bioinformatics SoftComputing and Ambient Assisted Living vol 5518 of LectureNotes in Computer Science pp 882ndash889 2009

[20] J H Shin B Lee and K Suk Park ldquoDetection of abnormalliving patterns for elderly living alone using support vector datadescriptionrdquo IEEE Transactions on Information Technology inBiomedicine vol 15 no 3 pp 438ndash448 2011

[21] Aerotel Medical System httpwwwaerotelcom[22] Advanced Digital Technologies httpwwwaditechsrlcom[23] Parsys telemedicine httpwwwparsyssantecom[24] Tunstall httpwwwtunstallit[25] Telcomed httpwwwtelcomedie[26] Insight Telehealth System httpwwwitsmyhealthyheartcom[27] K Kang K J Park J J Song CH Yoon and L Sha ldquoAmedical-

grade wireless architecture for remote electrocardiographyrdquoIEEE Transactions on Information Technology in Biomedicinevol 15 no 2 pp 260ndash267 2011

[28] A Gund I Ekman K Lindecrantz B A Sjogvist E LStaaf and N Thorneskold ldquoDesign evaluation of a home-based telecare system for Chronic heart failure patientsrdquo inProceedings of the Annual International Conference of the IEEEEngineering in Medicine and Biology Society pp 5851ndash58542008

[29] C Masella P Zanaboni G Borghi A Castelli M Marzegalliand C Tridico ldquoIntroduction of a telemonitoring service forpatients affected by Chronic heart failurerdquo in Proceedings ofthe 11th IEEE International Conference on E-Health NetworkingApplications and Services (Healthcom rsquo09) pp 138ndash145 Decem-ber 2009

[30] E Villalba D Salvi M Ottaviano I Peinado M T Arredondoand A Akay ldquoWearable and mobile system to manage remotelyheart failurerdquo IEEE Transactions on Information Technology inBiomedicine vol 13 no 6 pp 990ndash996 2009

[31] R H Dolin L Alschuler S Boyer et al ldquoHL7 clinical docu-ment architecture release 2rdquo Journal of the American MedicalInformatics Association vol 13 no 1 pp 30ndash39 2006

[32] Implementation Guide for CDA Release 20 Personal Health-care Monitoring Report (PHMR) httpwwwhl7org

[33] M Yuksel and A Dogac ldquoInteroperability of medical deviceinformation and the clinical applications an HL7 RMIM basedon the ISOIEEE 11073 DIMrdquo IEEE Transactions on InformationTechnology in Biomedicine vol 15 no 4 pp 557ndash566 2011

[34] B Shrestha E Hossain and S Camorlinga ldquoIEEE 802154MAC with GTS transmission for heterogeneous devices with

application to wheelchair body-area sensor networksrdquo IEEETransactions on Information Technology in Biomedicine vol 15no 5 pp 767ndash777 2011

[35] R Trobec and I Tomasic ldquoSynthesis of the 12-lead elec-trocardiogram from differential leadsrdquo IEEE Transactions onInformation Technology in Biomedicine vol 15 no 4 pp 615ndash621 2011

[36] L Fanucci S Saponara T Bacchillone et al ldquoSensing devicesand sensor signal processing for remote monitoring of vitalsigns in CHF patientsrdquo IEEE Transactions on Instrumentationand Measurement vol 62 no 3 pp 553ndash569 2013

[37] J Pan and W J Tompkins ldquoA real-time QRS detection algo-rithmrdquo IEEE Transactions on Biomedical Engineering vol 32no 3 pp 230ndash236 1985

[38] N M Arzeno Z D Deng and C S Poon ldquoAnalysis of first-derivative based QRS detection algorithmsrdquo IEEE Transactionson Biomedical Engineering vol 55 no 2 pp 478ndash484 2008

[39] I Sanchez-Tato J C Senciales J Salinas et al ldquoHealth homea telecare system for patients with chronic heart failurerdquo in Pro-ceedings of the 5th International Conference on Broadband andBiomedical Communications (IB2Com rsquo10) pp 1ndash5 December2010

[40] Spring development framework for JavaEE httpwwwspringsourceorg

[41] Systemized Nomenclature of MedicinemdashClinical Termshttpwwwnlmnihgov

[42] Logical Observation Names and Identifier httploincorg[43] B-K Miller and W MacCaull ldquoToward Web-based Careflow

management systemsrdquo Journal of Emerging Technologies in WebIntelligence vol 1 no 2 pp 137ndash145 2009

[44] B Chen L A Clarke G S Avrunin L J Osterweil E A Hen-neman and P L Henneman ldquoAnalyzing medical processesrdquoin Proceedings of the 30th International Conference on SoftwareEngineering (ICSE rsquo08) pp 623ndash632 2008

[45] L Pecchia P Melillo M Sansone and M Bracale ldquoDiscrim-ination power of short-term heart rate variability measures forCHF assessmentrdquo IEEE Transactions on Information Technologyin Biomedicine vol 15 no 1 pp 40ndash46 2011

International Journal of

AerospaceEngineeringHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

RoboticsJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


Active and Passive Electronic Components

Control Scienceand Engineering

Journal of



RotatingMachinery


Hindawi Publishing Corporation httpwwwhindawicom

Journal ofEngineeringVolume 2014

Submit your manuscripts athttpwwwhindawicom

VLSI Design



Shock and Vibration


Civil EngineeringAdvances in

Acoustics and VibrationAdvances in



Electrical and Computer Engineering

Journal of

Advances inOptoElectronics


Volume 2014

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

SensorsJournal of


Modelling amp Simulation in EngineeringHindawi Publishing Corporation httpwwwhindawicom Volume 2014


Chemical EngineeringInternational Journal of Antennas and

Propagation




Navigation and Observation



DistributedSensor Networks



It provides a reduction in mortality hospital readmissionsand lengths of hospital stays and in general increases patientsatisfaction [12ndash14]

The current ICTs (Information and CommunicationTechnologies) enable to build effective telemonitoring sys-tems overcoming the limit of the actual models Biomedicalwireless sensors networks allow for a daily collection ofinteresting biological parameters at home The increasingcomputational power available in numbers of embeddeddevices permits more and more complex signal processingalgorithms while large amounts of data can be safely movedglobally via the Internet

The HeatlhHome (HH) project introduces a newflexible and high configurable platform for domestic vitalsigns acquisition and processing along with a managementscheme able to support in an integrated and coordinatedfashion the whole treatment of CHF patients since theirenrolment in the system Being directly integrated with theusual cardiology departmental HIS the HH platform aimsat connecting in-hospital care of the acute syndrome without-of-hospital followup by patientfamily caregiver Patientsrsquosigns symptoms and raised alarms can be received remotelyby the healthcare providers and aggravations can be quicklydetected and addressed More frequent (usually daily) assess-ment of clinical parameters than in conventional practice ispermitted [15]Thebenefits extend beyond the early detectionof clinical destabilization better and optimized scheduling ofspecialized resources and reduction of unnecessary travel tohospital

Hereafter Section 2 reviews the state of the artTheHHsystem architecture is introduced in Section 3 Sections 4 5and 6 describe respectively the sensing devices the homegateway and the collection server Communication detailsare explained in Section 7 Section 8 describes the testingvalidation phase Conclusions are drawn in Section 9

2 State of the Art Review forTelemedicine Systems

Considering the Ambient Assisted Living (AAL) roadmap[16] that draws the guidelines to develop efficient strategiesand systems to face the aging of population along with futurechallenges in telecare [17] and some recent studies on AALsolutions [18] especially for telemonitoring [19] the desirablefeatures of a monitoring platform for chronic disease are asfollows

(1) health monitoring service using wearableportablesensors for non-invasive measure of vital signs activ-ity level and symptoms signaling

(2) reasoning and data processing to detect emergencysituations or behaviors

(3) secure and reliable communication of data(4) interconnection between stationary home care and

acute medical treatment(5) integration with existing solutions and components(6) modular structure of the solution to ensure easy

maintenance and future extensions

(7) high degree of interoperability accomplished by theuse of well-known communication standards

(8) flexibility to face the wide range of patientsrsquo status andthe progress of chronic diseases

(9) interfaces and system requirements defined takinginto account the individuality of the end user group

Today there are many system of telemedicine [20ndash27]specific for CHF or suitable for this kind of disease togetherwith many dedicated prototypes and project trial [28ndash30]However at the state-of-the-art it is difficult to find a solutionthat completely agrees with all the previous requirementsSystems based on telephone calls or web-portal to reportsymptoms and outcomes of themeasures have to be discardedfor scalability and usability issues Considering instead sys-tems in which measures are performed by the patient andautomatically transmitted to remote nodemost of them use adedicated collection database failing the requirement point 4and partially the point 5 This way data collected at home arenot flowed into the existing HIS that in turn contains onlydata related to acute syndrome All solutions have a gatewaythat at least receives and forwards data coming from sensorsSometimes signal processing and reminders are providedThis device is often realized using a smartphone or tableta set-of-box or a PC However their mall screens and richapplication interfaces do not meet the requirements of olderusers (gt65 years and often with comorbidity and cognitiveor sensorial deficit) lowering the acceptanceusability of thesystem Finally all considered systems donot include a formalmethod to adapt and monitor the follow-up activities to beperformed at home by the patient The HH telecare plat-form described in detail in the following sections representsa complete and high configurable ICT solution for CHFremote management developed taking into consideration allthe guidelines discussed in the above points to overcome thelimits of the state of the art

3 HH Telecare System andNetworking Overview

The requirements of the system come from a close collab-oration among important healthcare providers (HospitalesVirgen del Rocio Spain DomKoperHospital in Slovenia andthe research clinical center Fondazione Gabriele Monasterioin Italy) and technical entities within the HH consortiumThis multidisciplinary approach leads to develop a platformable to meet medical expectation patientrsquos features (elderlywith numerous comorbidity and cognitive deficit) and theprogressive nature of the disease

The key points of the proposed architecture are twoFirstly the concept of follow-up operating protocol (OP) asembed formal description of the medical prescription anddefinition of the behavior of the home system Secondary thenative integration with the HIS which is already present inmost cardiology departments Other interesting features arethe reduced impact on the patient due to the limited effortrequired to follow the assigned therapy and the low overheadintroducedwith respect to the regular activity ofmedical staff


Sensors

HTTPS

HH serverHH gateway


Data rate


Distance

Excessive

Powerconsumption


Ok Ok Ok

OkOkOk

OkOkOk

Ok Ok Ok

YesNo No No

Ko

Ko

Ko









4 Wireless Sensors



Coverage

Data rate



Ko

Ok Ok Ok Ok




and fixed fee












SpO2 3 Ss (10 bitS)


















Memory RAM 1GB DDR2

Hard Disk Sata250GB

Ethernet 10100LAN


Bulit-in audio


Display 10 1998400998400

Wireless 80211 bgn

(a)

LCD

Keypad

Bluetoothinterface

Massstorage

Processing unit

Powersupply

RAM

LANWifi


Sensors


(b)











HH gateway software


GUI thread

System clock thread



(lowast)





ldquousesrdquo

ldquousesrdquo

ldquosendrdquo


















28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation










Sensors

HTTPS

HH serverHH gateway


Data rate


Distance

Excessive

Powerconsumption


Ok Ok Ok

OkOkOk

OkOkOk

Ok Ok Ok

YesNo No No

Ko

Ko

Ko









4 Wireless Sensors



Coverage

Data rate



Ko

Ok Ok Ok Ok




and fixed fee












SpO2 3 Ss (10 bitS)


















Memory RAM 1GB DDR2

Hard Disk Sata250GB

Ethernet 10100LAN


Bulit-in audio


Display 10 1998400998400

Wireless 80211 bgn

(a)

LCD

Keypad

Bluetoothinterface

Massstorage

Processing unit

Powersupply

RAM

LANWifi


Sensors


(b)











HH gateway software


GUI thread

System clock thread



(lowast)





ldquousesrdquo

ldquousesrdquo

ldquosendrdquo


















28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation










Coverage

Data rate



Ko

Ok Ok Ok Ok




and fixed fee












SpO2 3 Ss (10 bitS)


















Memory RAM 1GB DDR2

Hard Disk Sata250GB

Ethernet 10100LAN


Bulit-in audio


Display 10 1998400998400

Wireless 80211 bgn

(a)

LCD

Keypad

Bluetoothinterface

Massstorage

Processing unit

Powersupply

RAM

LANWifi


Sensors


(b)











HH gateway software


GUI thread

System clock thread



(lowast)





ldquousesrdquo

ldquousesrdquo

ldquosendrdquo


















28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation



















Memory RAM 1GB DDR2

Hard Disk Sata250GB

Ethernet 10100LAN


Bulit-in audio


Display 10 1998400998400

Wireless 80211 bgn

(a)

LCD

Keypad

Bluetoothinterface

Massstorage

Processing unit

Powersupply

RAM

LANWifi


Sensors


(b)











HH gateway software


GUI thread

System clock thread



(lowast)





ldquousesrdquo

ldquousesrdquo

ldquosendrdquo


















28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation











Memory RAM 1GB DDR2

Hard Disk Sata250GB

Ethernet 10100LAN


Bulit-in audio


Display 10 1998400998400

Wireless 80211 bgn

(a)

LCD

Keypad

Bluetoothinterface

Massstorage

Processing unit

Powersupply

RAM

LANWifi


Sensors


(b)











HH gateway software


GUI thread

System clock thread



(lowast)





ldquousesrdquo

ldquousesrdquo

ldquosendrdquo


















28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation










HH gateway software


GUI thread

System clock thread



(lowast)





ldquousesrdquo

ldquousesrdquo

ldquosendrdquo


















28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation










28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Raw ECG

Seconds

(a)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

ECG

(mv)

Filtered ECGR peaks

R

Q S

Seconds

(b)

28 30 32 34 36 38 40 42 44minus1

minus05

0

05

R peaks envelope

R en

velo

pe

Seconds

(c)






Over threshold

Under threshold

150

125

100

75

50

25

30

Jul

1A

ug3

Aug

24

Jul

26

Jul

5A

ug7

Aug9

Aug

11

Aug

13

Aug

15

Aug

17

Aug

19

Aug

21

Aug

SysDia

22

Jul

28

Jul



Heart rate 99

SpO2 99

SYS 58118 DIA

Weight

Waiting for ECG

Waiting for SpO2

773 kg






Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation










Ack


XML OP

HL7 CDA document


HL7 CDA result

XML query

XML OP

Synchronousrequest

HL7 CDA document


HL7 CDA document

Departmental HIS



























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation




























9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation














9 Conclusions




Acknowledgment


References













































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation







































RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation











RoboticsJournal of





Journal of



RotatingMachinery





VLSI Design



Shock and Vibration







Journal of



Volume 2014


SensorsJournal of





Propagation









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