a framework of remote diabetic monitoring system for ... - sdiwc

A FRAMEWORK OF REMOTE DIABETIC MONITORING SYSTEM FOR DEVELOPING COUNTRIES Media Anugerah Ayu and Barroon Isma’eel Ahmad Intelligent Environment Research Group Kulliyah of Information and Communication Technology (KICT) International Islamic University Malaysia (IIUM) P.O. Box 10, 50728 Kuala Lumpur, Malaysia. {media, barroonia} @ieee.org ABSTRACT Diabetes Mellitus or simply diabetes is a chronic metabolic disease that affects about 5% of the world population. The increasing rate of diabetes patients is a serious challenge that needs to be controlled worldwide. Management of diabetes involves monitoring blood sugar level to make sure it does not go beyond the normal range. Failure to monitor the level of glucose in diabetes patients can increase the risk of complications like hypertension, stroke, kidney disease, heart disease, skin, foot, and eye complications, etc. However, healthcare delivery cost can be reduced by using telemedicine applications that focus on monitoring patients from outside the clinics or hospitals. This paper proposes a framework of a low-cost telemedicine system based on GPRS, SMS and NFC technologies, for remote monitoring patients with diabetes. The solution presented in this paper is especially useful for developing countries, where Internet data connection may not be available everywhere, even though GSM network can be found in almost every place. Another advantage of this system is patients with basic phone (no Internet capability) can also benefit from it, by using SMS as an alternative means of sending data to healthcare centre. Finally, we envisage the decrease in the cost of monitoring diabetes patients when this system is developed and implemented.

KEYWORDS Remote Monitoring, Diabetes, GPRS, SMS, NFC, Telemedicine, Rete Algorithm, Free to End User.

1 INTRODUCTION The availability of different technologies in the field of computing plays an important role in developing applications that simplify the living standard of people. Things that in the past you have to travel

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very long distance before you obtain, can now be acquired while at home. This is made possible by using technologies like Internet, SMS, GPS, NFC, etc. to perform things like transaction, study, participate in meeting, and medical consultation. The integration of these technologies brings about the idea of monitoring patients from home without necessarily being present at a hospital. There is need for further research in order to derive the maximum benefit of patient remote monitoring. Arnrich et al. [1] pointed out that some of the benefit of providing healthcare to each and every one at anytime and anywhere include more patients being diagnosed, having access to patients long-term records, and managing health by patients; they suggested that areas like preventive care, continuous and reliable monitoring system need to be further researched. On the other hand, healthcare delivery is very poor in some countries especially developing countries, where about eighty percent of the world’s population lives. In these countries normally lack of finance, human resources, and appropriate infrastructure negatively affect healthcare delivery as well as research related to it [2]. In addition, Ibekwe [3] stressed that healthcare problems resulted from different factors such as economic; poor planning or poor implementation of health policies; problem of availability, accessibility, affordability, and sustainability of health facilities; and weak referral system. He suggests that, the use of communication equipment like mobile phones will facilitate referral system. Obviously, improving healthcare will enhance the life of people suffering from diseases like diabetes, whose associated long-term effect is a challenge globally.

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Diabetes is a chronic disorder of glucose metabolism with too much sugar in the blood which is related to deficiency of insulin, or insulin is produced but the body cells don’t respond to it appropriately. Some of the complications developed as a result of diabetes include stroke, kidney disease, nerve damage, hearing loss, hypertension, eye complication, foot complication, skin complication, etc. [4]. Diabetes is mainly categorised into two types: Type I or InsulinDependent Diabetes Mellitus (IDDM), which is caused by damage of insulin secreting cells in the pancreas normally begins before age 20. The insulin dependency means that insulin is required by individuals to live. Type II or Non-InsulinDependent Diabetes Mellitus (NIDDM), this is the very common type in which the diabetics have at least the required level of insulin in their blood but rather not responsive to the hormone, this happens later in life than type I. In 2006 United Nation’s General Assembly passed a resolution that considers diabetes as a chronic and costly disease with a lot of complications seen as a threat to the world. [5] According to WHO [6] about 346 million people have diabetes, and also in 2004 about 3.4 million people died as a result of cases related to diabetes. They also predict that the number will double by 2030. It is also reported by Debussche [7] that, more than three-quarters of the diabetes patients live in developing countries. Lowering blood sugar is the first step in treatment of diabetes; as such patients suffering from diabetes need to be monitored so that their blood glucose level will not go beyond the expected value. Having a remote monitoring system will ensure that patients live happily, despite the fact that they are infected with one or more disease. This paper proposes a system that we expect it to be a cheap solution, especially for people living in developing countries where provision of healthcare is below average, and getting Internet service there is a bit challenging. The main objective of this paper is to propose a lowcost patient remote monitoring system that people suffering from diabetes in developing countries can depend on. The system will allow doctors to monitor their patients without the need for patients to travel

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from their home to the clinic. Another benefit is a doctor can monitor many patients within a time frame that is never possible physically. Additionally, since most of our hospitals are still operating manually; this will encourage the hospitals to adopt the computerized or automated system, which can later be used to connect all the healthcare centres in a region or country. 2 RELATED WORK Literature shows that several patients monitoring systems have been developed. The differences between these systems usually are in terms of technologies used, type of application, disease monitored, etc. For instance, Xiaohong et al. [8] proposed remote medical monitoring systems using sensor and GPRS, the sensor collect the physiological data then send to medical centre via intelligent terminal using GPRS, the medical centre later process the data. The system has three components: 1. physiological data acquisition module 2. intelligent terminal control module and 3. monitoring centre module. When sensors collect the data, the intelligent terminal processes and monitors the data then transmit it to monitoring centre. The terminal’s collection part uses SCM (Simple Chip Microcomputer) to collect and analyze physiological signal. The monitoring centre has monitoring station that receives and processes physiological data then store in a database, and information management system which include Electronic Medical Record (EMR), electronic map database for displaying user’s location, alarm system, data analysis system and system database. The drawback for the system is the use of GPRS as the only medium for sending data to monitoring centre; in addition, sensors and other devices used in the terminal control module increase the cost of monitoring. A secure based mobile healthcare system was put forward by Harish et al. [9], which include authentication and access control. They laid emphasis on the security aspect. From the database

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the data is encrypted using elliptic curve algorithm which will be decrypted in the mobile phone. Username and password are required to access the database using the application on the mobile phone; the authentication level determines which part of the application each user can access. The paper Mobile Application for Diabetes Control in Qatar discusses about mobile application developed to help diabetes patient in Qatar to manage their disease using glucose monitoring and diet management [10]. Glucose monitoring in this case involve recording the relevant data and sending it to the healthcare centre by the patients; while for diet management, ontology concept is used to represent Qatari food items and their nutritional value, then the patients will be advised about the appropriate food. The system has three components: patient module, which can be used for recording blood glucose level, food consultation, recording food intake, view statistics for glucose data; server module with database where patients information is stored, food ontology reasoning is also done at this module; and physician module, which is an interface to the server module. Ongenae et al. [11] developed an ambient-intelligent patient room. In their system, each patient and nurse has a badge with call button that anytime from anywhere can call each other. There are various devices and sensors in the environment that sense the surroundings and get information related to it. The head nurse can use desktop application to enter and edit information pertaining to department, patient, and caregivers with their roles. Ontology concept was used for interpreting the data for the environment, and also models information like staff, patients, tasks, call, devices, sensors, etc. Three different calls can be made using the system, a call initiated by patients pushing a button; an assistance call by caregivers pushing a button or pressing an icon on the mobile application; and a context call generated automatically by the system if there is problem from the sensor measured data like rise in temperature. An algorithm is used when the system receives a call to find the right person to handles that request. The staff will receives the call on their smartphone by indicating the patient, number of times the call was made, patient location, type of

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call, time of call, etc. However, the caregiver can redirect the call, or can contact the patient by pressing an icon to know the reason and importance of the call; in each case when the caregiver react to the call they can indicate that they are going to handle it, so that the call from other related caregivers will disappear. Although the patients can move freely within the room, but still they have to be in the environment before they can be monitored; this can be seen as the weakness of the system. MobiHealth is a project that was proposed by Konstantas et al. [12], which is based on development of generic Body Area Network (BAN) for health monitoring. They defined BAN as a collection of communication devices which are worn on the body. A BAN is called health BAN if the devices of it measure physiological signals or perform some functionality related to health. The idea of this project is to have a platform called Open which will allow integration of devices from different companies. MobiHealth is based on GPRS and UMTS technology which are not functional in most parts of developing countries. CodeBlue is a wireless sensor network research project for medical care and disaster response. The project provides communication between wireless medical sensors, PDAs, PCs and some other devices that will help in monitoring patients. GPS is also integrated into the system for tracking the actual location of patients as well as doctors [13]. WAITER is a wearable personal healthcare and emergency aid system that continuously monitors body status and automatically sends an alert for medical aid in case of emergency. The system uses the heartbeat, motion and body temperature sensors for collecting user’s signals and sends it to a mobile phone for processing and storage. Bluetooth ear-set is the only device that will be attached to the user's body. Reports about the user and alerts are periodically sent to the healthcare centre for further necessary action [14]. UbiMon is a project that deals with developing a system for monitoring patients for detection and prevention of severe abnormalities. Body-area and wireless communication technologies were used to interconnect the six components involved; these are:

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sensors, remote sensing units, local processing units, central server, patient database, and workstations [15]. One of the limitations of UbiMon is the issue of body sensor network being dependent on wireless technology, which can be affected by factors like noise. Kumar [16] developed a disease management system designed to motivate adherence to an intensive monitoring regimen in patients with Type I Diabetes Mellitus (T1DM), DibetNet as the system is called was tested and analyzed. DiabetNet is an interactive, networked and predictive game which can be played within a community developed in this system. The game can only be played after a patient checks at least three glucose measurement for the day, and enters three records of carbohydrate consumption. The patient views his/her earlier data (glucose, carbohydrate and insulin) upon entering the record as prerequisite and is challenged to predict the upcoming glucose measurements, and then measure actual glucose level. The patient gets points depending on the difference between the estimated and measured result, also points are earned by entering data and qualifying to play the game. Measurement of Blood Glucose by NFC is an article that presents a work on system of measuring blood glucose, where by the blood glucose sensor is attached to NFC-enabled device or smartphone. The NFC-interface supplies the sensor with power supply. The measured data will be transferred to various data storages like telemonitoring centre via smartphone. Some of the advantages of NFCenabled blood-glucose measurement as discussed include possibility of reducing the size of the meter to the size of a credit card; ability to store measurement data on a smartphone, NFC datatransfer or in any accessible data storage; using smartphone display to show the measurement result, graphs or instructions; eliminate the requirement for additional battery as a source of power needed for the measurement; benefiting from the automatic pairing capability of NFC for connection between smartphone and the meter [17].

Technical Research Centre Finland; applications in various areas were developed under this project such as mobile payment and ticketing, smart poster, attendance system for schools, home use, household access control and security, blood glucose meter, etc. Smart NFC interface platform is a small multipurpose device with inbuilt 8-bit microcontroller, rechargeable battery, RS-232 serial port, wired and wireless communications like NFC, IrDA, and Bluetooth. NFC enabled blood glucose meter is one of the applications of smart NFC interface which consists of, a commercial blood glucose meter merged with smart NFC interface, NFC phone with a java based software application installed, and the backend system. The backend system receives data from the meter by touching it with NFC phone after taking the measurement, after which the healthcare personnel can have access to the data sent, and send message to the patient if the need arise. The mode of communication between the NFC phone and smart NFC interface is peer-to-peer, while the interface receives data from glucose meter through a wired Universal Asynchronous Receiver Transceiver (UART). Since JSR 257 Java API does not support launching an application based on peerto-peer mode, an NFC tag is included to enable starting the software application on the phone by touching the tag [18]. It is clear from the preceding works that, most of the applications developed used Internet as the only mode of communication, which is hard to get in some places. Wearable devices were developed in some systems using sensors, while some create NFC enabled glucose meters; these seem to be a problem that may result to an increase in monitoring expenses. Consequently, a cost-effective remote monitoring system is proposed in this paper that will use SMS as an alternative to Internet for communication, common measuring devices, and NFC for authorization. In addition, Free to End Use (FTEU) text messaging plan will be subscribed so that the patients can send SMS to the system at no cost.

SmartTouch is a project that focuses on NFC technology which was coordinated by VTT

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3 SYSTEM ARCHITECTURE The increasing number of diabetes patient at an alarming rate is really a concern globally; this implies that there is a serious need for a way to manage these large numbers of patients. Part of the solution is developing a low-cost remote monitoring system, since most of the patients live in rural areas where access to healthcare facilities is very difficult besides being economically challenging. The proposed system consists of three main modules as depicted in Figure 1; the modules are patient, doctor, and hospital modules. The communication modes between these modules are Internet and SMS; the Internet service may be GPRS or WI-FI.

Figure 1. Proposed System Architecture

3.1 Patient Module The patient module includes the devices for measuring physiological data and an interface where the patients can access the server if they have an Internet service. The devices include medical related devices like: glucometer for measuring the blood glucose level, thermometer for measuring temperature, and weight scale; mobile phone which can be basic (for sending only SMS) or NFC enabled (for accessing the server side application through Internet); NFC tag that keeps the patients basic information including the login credentials, this tag will serve as the patient’s card when visiting hospital for consultancy or for authenticating the patient before getting access to the web based application.

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3.2 Doctor Module This module has only two elements mobile phone and PC. The PC is optional if the mobile phone is like smartphone; this is because the doctor can use the smartphone to interface with the system but because normally limited functionalities are provided by mobile version of web based applications, so it’s better to use both mobile phone and a PC. The mobile phone is necessary unless the doctor also can use a tablet with SIM card slot, since the doctor may send or receive SMS from or to the patient. 3.3 Hospital Module Hospital module is the nerve centre of the system; the core feature is a server that keeps the record of all the patients, doctors, and information about hospitals in form of EMR. The EMR with decision making capability controls the whole system; MySQL database will be used to store the aforementioned information. Part of this module is a computer attached with NFC reader & writer that will be used by the hospital administrative staff to manage patients’ record. Additionally, the module has two important components for better decision making, they are knowledge base and inference engine. The knowledge base is where the diabetes knowledge will be stored in form of rules, each rule represent a particular knowledge. The rules are of the form: IF condition (s) THEN action (s). For instance IF BMI >= 27 THEN alert (you need to control your weight). The inference engine looks for rules with conditions that will result to true based on the given fact (data from the user) and fire such rule. In a simple implementation of rule based systems each rule is compared against every given fact. This procedure is called pattern matching which takes place continuously until the end of the whole process. The list of facts may be modified by adding new fact or removing an old fact, this may result to satisfying conditions that were previously unsatisfied. In this case all the facts will also be compared against all the rules in each cycle. Since the pattern matching is a continuous process, for large number of facts and rules the process performs slowly. Therefore, the performance can be improved

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by implementing the system using different approach like Rete algorithm. Rete algorithm is a pattern matching algorithm for matching facts against the rules in a rule based systems. The algorithm reduces the number of comparison by retaining list of rules matched by the current fact, thus avoid re-evaluating the rules unless the facts are modified [19]. In general, when patients visit hospital for the first time they will be registered in the system; and NFC tag will be issued to them containing their basic information and login credentials. The information required from the patients is their bio data with mobile phone number as compulsory field, after they are consulted their medical history is added to their profile. The doctor’s recommendation will decide the next action; i.e. the patient need to be taking drugs, on exercise, on diet, measuring blood glucose level, etc. the interval for each of the above action will be registered against the patient and send it to his/her mobile phone. The only action that needs the patient to send a result to the server is taking glucose level, each time patients takes the reading they will enter it in their mobile phone and send it to the hospital. When the server receives the data from the patient, it will compare it with the most current if it exist, then send a feedback to the patient on whether there is progress or not. Based on the patients’ action entry they will be reminded if it’s time for taking medicine or glucose reading, if the server does not receive patients result after like 10 minutes of the stipulated time, then a reminder will be sent to the patient, this will be repeated three times after which nil or any proper message will be stored against the entry. Similarly, patients can send message if they are feeling unusual, so that the doctor can suggest something to them. Also, if there is a need for emergency the system will decide and send it to the doctor for validation, when the message is verified by the doctor it will be forwarded to the patient. The NFC tag will serve as patients’ card that will be used anytime the patients visit hospital to access their record, or anytime they want to access the application through Internet. Without this tag the patients can still access the application but can only view their report.

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Patients, doctors, and hospital management staff are going to be the users of the system apart from administrator, their access to the application will be controlled such that they can only view and manage what is defined for them. Some of the roles defined for these users are presented in Table 1. The central point where all the three users of the system communicate is the web server that hosts the EMR, the decision making part of EMR will use the patients data to know if there is any sign of abnormality. Decision made by the system like prescription is only suggestion, because before patients know about it an alert must be sent to the doctors in order to login to the system, view and validate the suggestion. If the doctor found the suggestion made by the system to be correct, then it will be sent to the patient, this will avoid being treated by the system erroneously, which will also prove the correctness, accuracy and effectiveness of the system. The doctors can also at anytime suggest to the patients the medicine, diet, exercise, etc., or send them a referral message. When a patient is referred to another hospital a brief history about the patient will be sent to his mobile phone to show to the new doctor, but if the hospital has Internet facility they can get the patient medical history. Table 1. Users and their Roles

Users Administrator Doctor

Patient

Hospital Administartive Staf

Roles Manage users Assign patient to himself, view own patients report, send alert, administer drug, referral, confirm diagnosis Input data, view doctor assign to him, view own report, edit some fields like mobile number Add/edit patients’ and doctors details, referral, send message to patient, send message to doctor

Let us consider a case of a patient living in a rural community, what is required from this patient is to have a mobile phone with physiological data

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measuring devices. The patients will measure their blood glucose level, height and weight in some cases then enter the values into their mobile phone; and send it to the clinic through SMS. The patient can as well use mobile phone to access the online application and input the values directly. As soon as the data reach the server a feedback will be sent back to the patient. The patient can access the application in order to view detailed analysis of his/her medical history, if they are not interested they can only rely on the feedback and alert that will be sent to them periodically. The doctor can send query as an SMS to know some information about his/her patients, but the details can only be known if the doctor access the application via Internet. Some of the things that the doctor can get from his mobile phone include: scheduled patients to visit clinic on a particular date, patients address and mobile phone numbers, etc. The doctor can ask patients their location from his/her mobile phone, in order to know the nearest hospital in case there is a need for an emergency. The previous paragraph show that the key components for the decision making were discussed, and RETE algorithm was chosen for improving decision making performance. It is clear that the use of this system will reduce the number of hospital visits since the patients can send their data remotely. In addition, a feature of the system, which is the use of SMS in sending the patient data as an alternative to Internet, which may not be obtainable in various areas in addition to being price, make this system can be seen as a low cost system. Furthermore, the patients can as well send their data to hospitals free of charge by employing Free to End User (FTEU) messaging service 4 CONCLUSION Remote monitoring is an interesting and useful area that needs a lot of research in order to come up with a solution that benefits humanity. In this work, we proposed an inexpensive solution to monitor diabetes patients remotely, which will hopefully improve the standard of living for those suffering from the disease. We chose the approach of not creating new devices or incorporating sensors into

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existing devices because of two reasons: increasing the monitoring expenses while we are looking for economical solution, and the patients mobility being affected because most of these devices need to be connected to the patient, with our proposed solution patients can move freely to anywhere and still use the system without inconveniences. 5 REFERENCES Arnrich, B., Mayora, O., Bardram, J., Troster, G.: Pervasive Healthcare Paving the Way for a Pervasive, User-Centered and Preventive Healthcare Model. dms.ife.ee.ethz.ch/index.php/attachments/single/677 2. Nuffield Council on Bioethics. The Ethics of Research Related to Healthcare in Developing Countries. http://www.nuffieldbioethics.org/research-developingcountries 3. Ibekwe, P. C.: Healthcare Problems in Developing Countries. Medical Practice and Reviews 1, 9-11 (2010). 4. American Diabetes Association, Living with Diabetes. http://www.diabetes.org/living-with-diabetes/ 5. Horwitz, D. L.: Diabetes: Global Perspective. Johnson & Johnson Diabetes Institute. http://ocdiabetesconference.org/wpcontent/uploads/2010/01/Diabetes%20%20Global%20Perspective.ppt 6. World Health Organization, Diabetes. http://www.who.int/mediacentre/factsheets/fs312/en/ 7. Debussche, X., Balcou-Debussche, M., Besançon, S., Traore, S. A.: Challenges to Diabetes Self-management in Developing Countries. http://www.idf.org/sites/default/files/attachments/2009_D SM_Debussche%20et%20al.pdf 8. Xiaohang, W., Li, L.: The Design of Remote Medical Monitoring System Based on Sensors and GPRS. In 2009 International Forum on Information Technology and Applications, pp.516-519 (2009). http://ieeexplore.ieee.org/xpl/articleDetails.jsp?arnumber= 5232174 9. Harish, U., Ganesan, R.: Design and Development of Secured M-Healthcare System. In Proc. 2012 IEEEInternational Conference on Advances in Engineering, Science and Management, pp.470-473 (2012). http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber =6215890 10. Alhazbi, S., Alkhateeb, M., Abdi, A., Janahi, A., Daradkeh, G.: Mobile Application for Diabetes Control in Qatar. In 8th International Conference on Computing Technology and Information Management (ICCM), vol. 2, pp.763-766 (2012). http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber =6268603 1.

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