AN EMBEDDED SYSTEM FOR THE REMOTE PATIENT MONITORING

MUKESH KUMAR KASHYAP (12EC62R17) Indian Institute of Technology, Kharagpur 721302

ABSTRACT - This paper presents the methodology for monitoring patients remotely using wireless
networks, such as GSM, WiFi, Zigbee, World Wide Web (WWW) and Bluetooth. Patient monitoring systems consist of equipment, devices and supplies that measure, display and record human physiological characteristics, including blood pressure, body temperature, heart activity, various bodily substances (e.g. cholesterol, glucose, etc.), pulse rate, respiration rate and other health-related criteria. The real-time patient monitoring consists of two services: Patient Locator Service (PLS) and Vital Sign Monitoring Service (VSMS). The PLS provides the information of patients currently being monitored. The VSMS allows the user to observe a stream of vital sign data of a specific patient such as ECG, respiration, temperature, SpO2, invasive blood pressure, non-invasive blood pressure, and others in real-time. The system architecture is described. Patient monitoring systems measure physiological characteristics either continuously or at regular intervals over time. An application of this method in Biomedical requires better accuracy, design security, productivity, speed and flexibility. These system will be useful for not only those rich people of the India who has enough money and resources to have treatment from the higher-tier hospitals, but also for those villagers, BPL communities which do not have direct and easy access of such high quality medical assistance.

1. Introduction
As one of the most rapidly developing countries in the world, India has a large number of people living below the poverty standards. These BPL communities have needs such as medical services, and education, and most of these communities do not have direct and easy access to the high-quality health care provided by the higher-tier hospitals. Currently in India, there are two existing ways through which patients (or people who need monitoring) can get help: visit higher-tier hospitals or wait for the medical specialists in their own villages or communities who visit them regularly. This results in two disadvantages. The former method is ineffective in terms of cost and time while the latter increases the potential for health risks. On the other hand, more than 1 million C/VDs, who mainly deal with the BPL population, are active all over the India. These doctors, who have been given a basic medical training by the Indian government, often offer people simple medical diagnosis and treatment. Due to their limited knowledge, they are not able to provide complete medical assistance to patients. One of the objective of this is to design an affordable patient monitoring system for community and Village doctors (C/VDs) that can gather real time bio-signals; store, display, and analyze data and communicate information between servers and terminals. The C/VDs can use the system for on-the spot diagnosis as well as remote specialist consultations in higher-tier hospitals for further medication. Also within a Hospital this system may be very useful in a way of flexibility of Doctors movements. Generally Patient monitoring systems are installed in a certain location like ICU (intensive care unit) or CCU (coronary care unit). Therefore, in order for a physician to access patient data, he or she must be in a place where the system is running. Also Wireless sensor technology makes possible to free patients from their equipment, allowing greater freedom and even making possible monitoring by their health provider while the patient is on the way.

2. Need of the Such System Implementations

By monitoring continuously, medical emergencies can be detected sooner and treatments can be applied earlier. For people who experience acute medical events outside a hospital, time is critical. For example, according to the American Heart Association, treatment of a patient experiencing ventricular fibrillation within the first 12 minutes of cardiac arrest gives a survival rate of 48%-75%. After 12 minutes have elapsed, the survival rate drops to 2%-4%.

In India in road accidents many people died because of late in treatment, those can be rescued by this system by using wireless sensor and quick data availability to the doctors. People suffering from chronic conditions can also benefit from continuous monitoring. For example, early detection of recurring problems can be managed by medication adjustment rather than hospital stays. Better management of chronic diseases can be of special benefit to the elderly by prolonging their independence and by allowing them to avoid infectious environments, such as hospitals and managed care facilities. Many times we found that a local hospital doctors suggest to shift the patients to big hospital due to their disability, and in such cases many times patients died on the way itself, which may be rescued by using such system to get quick assistance from the higher-tier hospitals. Heart Attacks and Heart failure disease may even lead to death within few minutes which may be saved by continuous ECG test and required treatment. The unusual electrical activity in the brain of the patient which can lead to a epilepsy, can be detected by sleep EEG measurement and assisted accordingly. High blood pressure (BP) and high sugar (glucose) can also cause great deficiencies in absence of instant treatment.

3. System Overview
Our medical monitoring system is designed to support a single subject (single patient) and consists of five main components: sensors, sensor proxies, a real-time streaming database with long-term storage capabilities, and communication facilities. The sensors sample physiological data from a subject and send it to a sensor proxy. Note that sampling in bursts at regular intervals is sufficient to capture the details of many important physiological signals. Sensor proxies act as device drivers and translate the raw data from the sensors into streams of time stamped data with meta-data describing their contents. The streams are fed into a streaming database, where real-time classification and detection take place. Applications can access both new and old data via the streaming database. In addition, applications can subscribe to alerts that the streaming database may generate. Our sensors are body-worn and wirelessly transmit their data to a sensor proxy implemented on a portable device with a wireless network connection. The portable feeds streams to a distributed streaming database, where computation is performed. If a network partition occurs, local devices can perform limited versions of the computations. Since the sensors are body-worn, portability is a key issue for our system. Therefore, wires and heavy batteries are undesirable. Low latency is also important because some medical emergencies need to be detected quickly.

Fig 1: The architecture of the System

To remove or minimize cables requires a robust wireless link with low-power capabilities. Although many wireless standards can be used, there are important considerations such as range, throughput, security, ease of implementation and cost. An overview of popular wireless technologies for cable replacement is summarized in Table 1. Table 1: Wireless technology comparison for medical cable replacement Technology 900MHz Pros Unlicensed band Long range Large installed base of equipment Programmable for worldwide band usage Low-power for intermittent data Short packets are more robust Large installed base of equipment Optimized for ad-hoc networking Cons Unnecessary range increases security concern Different frequencies for U.S. (915 MHz) and EU (868 MHz) Long-packets are less robust High current draw Protocol stack required on host Network coordinator required Seven device limit per piconet Instantaneous power similar toZigbee

WiFi

Zigbee Bluetooth

3.1 The Sensor Unit To allow the flexibility of Patients locations and to make the possibility of treating patients on the way, different wireless type of sensors are utilized. Out of these several wireless techniques tabulated in table1, Bluetooth is quickly becoming the preferred technology for wireless patient monitoring. It has sufficient range too much range can cause security and power concernsbalanced throughput for stationary and battery-operated devices, encryption capabilities, reasonable cost due to installed base and ease of use. Several types of wireless sensors are explained in below Glucose meter Pulse oximeter Blood analyzer

Fig 2: Sensor and Base station

3.1.1 Blood Pressure The noninvasive measurement of arterial blood pressure is performed by inflating a cuff around an arm or finger. As pressure is released, the arterial pulsation returns, with the first pressure reading known as the systolic. The pressure in the cuff continues to decrease until pulsations are no longer detected, with the last reading known as the diastolic. Typically, conversion of pulses from the physical to the electrical domain is accomplished with either a pressure sensor or a piezoelectric strip. Wireless Improvement: Retrofitting existing equipment can be as simple as attaching a module to the RS-232 port, if it exists or by connecting a module to the UART lines of the embedded microcontroller. By slightly modifying the embedded software, it is possible to use DUN to send results to a clinic. For a continuously monitoring system, a piezoelectric sensor is required. 3.1.2 Glucose/Sugar The density of glucose is usually measured either optically or electrically. In the case of an optical measurement, a sample is placed on a material that reacts with the glucose in the sample while an emitter and photodetector are used to measure the reflectance. For the majority of products on the market today, glucose measurement is accomplished by measuring the current that passes through the sample, which is related to the glucose content. A test strip with the patients blood sample is excited with a voltage source, as shown in Figure 3. The sample conducts current as a proportion of glucose. This minute current is converted and amplified by the trans-impedance converters before sampling by the analog- to-digital converter (ADC) after selection through the analog MUX. The microcontroller filters the readings and then uses a look-up table to convert the reading into standard units. The same microcontroller can be connected to a LMX9820ASM module via the UART ports to enable wireless connections.

Fig 3: Glucose meter block diagram Wireless Improvement: Monitoring is an important concern to the 18 million individuals with diabetes. The majority of devices on the market today already have two-wire serial ports that can be used with PC or PDA software. Conversion to wireless can be accomplished simply by connecting a Bluetooth module to the manufacturers nine-pin serial connector. An embedded solution is easily realized by connecting a Bluetooth module on the circuit board to the two-wire interface. There is no software impact to the glucose monitor because the PC or PDA application can access the same data through the virtual serial drivers, provided by the Bluetooth stack and profiles, as if they were connected with a serial cable. 3.1.3 Sleep EEG (Sleep Electroencephalography) Monitoring brain activity requires handling signals in the range of 0.5 V to 100 V at frequencies that are typically less than 20 Hz. There is a challenge since it is essential to suppress the 50/60 Hz induced line noise and also to provide galvanic isolation. Wired connections are usually very long and can be restrictive when performing sleep studies.

Wireless Improvement: A more convenient method to record EEG is to place the sensing and digitizing electronics into a waist size device and equip it with a low-power, short-range wireless solution. By using a medical-grade computer or PDA, it also becomes possible to leverage existing equipment and thereby lower cost. 3.1.4 Arterial blood gas (SPO2) By passing two different wavelengths of light into the human body, it is possible to measure the absorption of oxygen in the blood. ECG and pulse oximetry devices can benefit by adding a Bluetooth audio gateway, enabling the practitioner to listen to audio cues while allowing the patient to remain in a more natural, relaxed state. The patients pulse and oxygen saturation is computed through the absorption of visible (red) and near-infrared light. The corresponding intensity of each is measured by the phototransistor, sampled by the ADC and then filtered and finally scaled by the microcontroller, as shown in Figure 4. The microcontroller on the UART can be attached to an LMX9820ASM module to enable Bluetooth functions such as serial cable replacement or even dial-up networking.

Fig 4: Pulse oximeter block diagram Wireless improvement: Since pulse oximeters have now been reduced to roughly the same size as a typical finger sensor, they are already portable, making them suitable for sports and fitness monitoring. Instead of driving a display, the power budget can instead be allocated to an embedded Bluetooth module. This becomes especially compelling when considering the size, power consumption and cost of flash memory used for recording trends. 3.1.5 Heart rate ECG (Eletrocardiography) There are a number of locations to measure a patients pulse that range from the chest, to the arm, wrist or even a finger. An electrocardiogram measures the electrical response of the heart allowing it to show great detail. Since signal levels are no more than 5 mV in amplitude with a 3 dB bandwidth of 0.05 Hz to 100 Hz, a gain of 46 dB to 60 dB (voltage gain: 200x to 1000x) is required, along with a common mode rejection ratio (CMRR) greater than 60 dB to overcome interference. Wireless improvement: The true potential for a wireless ECG is realized when the sensing and processing electronics are reduced to a portable pack, allowing cables to be significantly shorter and the patient to be ambulatory. Adding Bluetooth in this case involves connecting to the processors UART to enable the upload of recorded data or to stream readings in real-time to a standard PDA, laptop or workstation. So overall a sensor system may be considered as simple as Blood analyzer as shown below in figure 5 or even complex.

Fig 5: Blood analyzerBluetooth connects to RS-232 or directly to the CPU.

3.2 The Server Unit The server unit consists of data processing software, a database, and a Web site. The data processing software is developed based on the platform of C++, which can input data from sensor unit or output data to expert system either automatically or on demand. One SQL 2000 database is created for storing data from the various monitored patients and guarantees the data integrity. The Web site, which was developed using ASP and PJAVA applet, displays all the necessary patient information including biodata (name, age, sex) and waveforms (ECG,EEG etc). The Web site can be accessed by the Expert system anywhere round the globe through WWW using any IE Explore viewer running on Microsoft Windows or Windows CE systems with a Java virtual machine (JVM). 3.3 Expert & Medical Assistant Unit The connection between the MA unit and the server unit is based on browser/server architecture because many MA units would work in parallel. A WinCE.net-based tablet PC is chosen in this design as the MA unit hardware (size: 224 182 28 mm3; weight: 760 g) due to sufficient screen size for displaying data waveforms and the sufficient memory to install a CE database. A demo is designed using embedded visual C++ for storing data from the server. A user-friendly interface was designed by specially considering the level of computer knowledge and convenience of C/VDs.

Fig 6: A sample view of Patient Locator Service (PLS)

Fig 7: A sample view of Vital Sign Monitoring Service (VSMS) 4. System requirements Some technical improvements are necessary before a product is made, to have accurate remote monitoring according to the design specifications, system should include the following 1) Vital signs such as ECG, respiration, temperature, SpO2, invasive blood pressure, and non-invasive blood pressure should be continuously monitored in real-time. 2) Alarms from the results of data processing such as high heart rate and the operating conditions of the bedside monitor such as ECG lead faults should be promptly informed. 3) On the waveform display area in a Web browser, parameters such as chart speed and sensitivity can be selected. 4) Remote control operations such as ECG lead selection and start of noninvasive blood pressure measurement can be performed from a Web browser. 5) Trend of heart rate, temperature, blood pressure, respiration rate, etc. should be provided. 6) Basic patient information such as name, age, sex, weight, etc. should be provided. 7) User-friendly interface for data communication: The current design is based on bluetooth, which cant meet all needs for different implementations. Some research will focus on interface development such as transmitting data through ADSL, TV cable, or phone cable. 8) Medical information management: Another improvement point of the design is an expert system to manage the medical information. More attention will be added to the basic electric health records system such as computer aided diagnosis and data standards for security. 9) Medical information security: The protection of personal medical data is always considered as the first priority although most of the people didnt care about it. It should have an electronic health record (EHR) software based on the Health Information System. The Health Level 7 (HL7) standard is currently under development to improve the current system. 10) Since the sensors are body-worn, portability is a key issue for our system. Therefore, wires and heavy batteries are undesirable. Low latency is also important because some medical emergencies need to be detected quickly.

5. Conclusions A wireless monitoring system for C/VDs has been designed, same system can be useful to allowing flexibilities to doctors as well as patients. Biodata was gathered by the sensor unit and transmitted to the server through a medical hub. The data was then stored in the server and displayed in the MA system. C/VDs could analyze the data with available functions and could make the preliminary diagnosis while requesting assistance for remote consulting with specialists located in higher-tier hospitals. This design may be robust, affordable, and ideal in terms of meeting the health care needs of Indias BPL population. 6. Alternative approaches and Future Prospects Since this system only realized the detecting and transmission of heart rate, respiration rate, EEG and body temperature, and the detection accuracy is not enough. The next step focuses on how to improve the detection accuracy, how to realize more reliable transmission of data, and extend more sensor module, so as to conduct further research on the monitoring of more psychological parameters. At the same time, due to the limitation of the master chip, the power dissipation of routers and terminal device is not low enough. More work should be done concerning this aspect to further reduce the power dissipation and lower the cost. To have consideration of all these we can use FPGA system in place of microcontroller. Also one further limitation of our system is this is completely for single object, so further step may be taken along this way, to enhance the system for multi object purposes. In this regard we can have several set of Sensors and by using the different identification for each, by observing the different addresses. One sample screen view can be something like as shown in figure 8.

Fig 8: Multi patients Monitoring System sample Another chance of improvement will be for medical information security. The protection of personal medical data is always considered as the first priority although most of the people didnt care about it. An electronic health record (EHR) software based on the Health Information System can be implemented. The Health Level 7 (HL7) standard is currently under development to improve the current system. Also we need to try to reduce the cost and latency of the system so that it will be easy affordable to BPL community doctors and will produce accurate and quick results.