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AN INTELLIGENT DIABETES MOBILE CARE SYSTEM WITH ALERT MECHANISM REN-GUEY LEE1, CHUN-CHIEH HSIAO2, KUEI-CHIEN CHEN1, MING-HSIO LIU1 1
Department of Electronic Engineering, National Taipei University of Technology, Taipei, Taiwan 2 Department of Computer and Information Network Engineering, Lunghwa University of Science and Technology, Taoyuang, Taiwan
ABSTRACT Diabetes mellitus is a kind of chronic disease which can be effectively prevented and controlled only if the blood glucose level of the patient is constantly monitored, and the health education and professional medicine care is fully supported. In this paper a role-based intelligent diabetes mobile care system with alert mechanism in full diabetic care environment is proposed and implemented. The roles in our system include patients, physicians, nurses, and home care assistants. Each of the roles uses a mobile device such as a PDA with GSM module or a mobile phone to communicate with the server so that he or she can go around without restrictions. Our system provides alert management by using an automatic urgency strategy to assure the information correctness and notification completeness so as to improve the quality of diabetes care. The reliability test and performance test have also shown that our system can provide fast and reliable assistance to the diabetes patients. With the help of our system, it is possible to set up a whole intelligent diabetes care chain in the care center. Biomed Eng Appl Basis Comm, 2005(August); 17: 186-192. Keywords: Telecare, Mobile Communication Devices, Alert, Role-based, Urgency, Web services
the patients. To effectively prevent and control diabetes which is such a complicated chronic disease, good blood glucose monitoring and control, and the support of health education and professional medical care is urgently needed [1-2]. The traditional care for non-hospitalized diabetic patients has disadvantages such as the complete data of blood glucose is frequently in lack, and the information interchange between physicians and patients is usually inefficient. However with the telecare systems which utilize information and communication technology, proper medical care for the remote patients can be provided [3-5]. It is especially important for those chronic diabetes patients who need not to be hospitalized while need to be monitored over a long period of time. Along with the advances in communication technology, mobile communication devices can now
1. INTRODUCTION According to the statistics, the diabetes mellitus, or diabetes, has become the fifth among the top ten causes of death in Taiwan. Diabetes not only can cause death, but also can cause various acute and chronic complications such as hypoglycemia, infections, and major pathological changes in nerve, retina, and kidney systems. It has caused the uprising of expense of medical treatment and the decreasing quality of life of Received: Feb. 7, 2005; Accepted: June 28, 2005 Correspondence: Chun-Chieh Hsiao Department of Computer and Information Network Engineering, Lunghwa University of Science and Technology, Taoyuang, Taiwan E-mail:
[email protected]
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provide efficient and convenient services such as remote information interchange and resource access through mobile devices so that the users can work ubiquitously [6]. This paper integrates wireless network technology for mobile communication and implements an intelligent diabetes care system with tele-alert mechanism through Internet and GSM networks. It is role-based and can actively send various alert messages to remind users according to different diabetes care scenarios to achieve the objective of intelligent diabetes care and management. This paper is organized as follows. Section 2 gives the system architecture and methodology of our proposed system. System design and implementation principles are given in Section 3. Finally, the discussion and conclusion is given in Section 4.
2.1 Patient does not upload blood glucose data on schedule so care center sends alert notification. For instance, one patient is of the insulin-reliant diabetes so he needs to have injection with proper amount of insulin everyday to retain his life. He once had to take a four-hour bus to attend a meeting in a branch company far away. On the bus he fell asleep and did not upload the blood glucose data on schedule. The care center immediately sends an alert message to wake him up. If the patient still did not reply to the alert and upload the blood glucose data, the care center will raise the urgency level from urgent to critical . The care center will not only resend alert message to the patient's mobile care device but also automatically notify the other care assistants or organization to assist and prevent the patient from going into a coma due to hypoglycemia. Only when the patient or the care assistant receives the alert message, do the blood glucose test, and upload the data to the care center will the system lower the urgency level. The corresponding care system message passing procedure is as shown in Figure 3. The details are given as follows. (1) The patient does not upload blood glucose data on schedule. (2) The care center automatically sends an urgent alert to notify the patient. (3) The patient does not receive the alert and reply to it for some reasons.
2. SYSTEM ARCHITECTURE AND METHODOLOGY Due to the ubiquity of Internet, it is easy to browse, access, manage and share data with web-based information system, either through area Intranet or international Internet. In this paper, a three-tier clientserver architecture as shown in Figure 1 is used to construct an intelligent diabetes mobile care system with alert mechanisms. The front end of our system includes the mobile devices or desktop PCs for each role and the back end includes the server in the care center and the database. The internal system function block diagram of the server in the care center is as shown in Figure 2. The mobile devices or desktop PCs of the front end provides the transmission and reception of data including the acquisition and upload of physiological parameters of the patients, the sending of alerts, the access of health education resource, and the consultation of care providers. The server in the care center provides the service of monitoring of various physiological parameters, execution of alert messages, procedure management, and web access. With such architecture, every user in the diabetes care system can easily and adequately play his or her role. The database is the depository for various kinds of data resources. Our system can provide various intelligent care services of which two scenarios are given here to demonstrate their functions. The first scenario is that the patient does not upload the data of blood glucose on schedule and the care center sends the alert notification to the patient while the second scenario is that the care center sends the alert to notify the patient should go back to the hospital for subsequent consultation. The care process in our system is depicted as follows.
Fig 1. Three-tier client-server system architecture.
Fig 2. System function block diagram.
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This paper is based on Kafeza, et al. [7-8] to implement an alert management model as shown in Figure 5 for effective and convenient operation of alert messages. The care center alert management model is mainly consisted of two parts. The first part is the alert creating module responsible for setting up adequate alerts. The second part is the execution module which contains three submodules: role matching module, alert monitor module, and priority urgency module. The complete alert execution flowchart is as shown in Figure 6. The execution module will check whether the alert to be sent has a target such as a patient, a physician, or a care assistant. If there is no target, then the role matching module will try to find one. The alert is then sent to the target. After the alert is sent, the alert monitor module will monitor the response of the target to figure out whether the target has received and replied the alert. If the care center does not receive the reply from target, the priority urgency module will raise the urgency level, update the targets for the alert, and resend the alert [9]. The urgency in priority urgency module is divided into three levels: normal, urgent and critical. The alert will be sent to different and appropriate roles according to the level of urgency. The urgency function U(t) is defined as follows:
(4) The care center raises the urgency level of the alert and resends the alert to notify proper roles. (5) The notified roles wake the patient up to deal with the hypoglycemia condition.
2.2 The care center notifies the patient to go back to the hospital for subsequent consultation. When it is about time for the patient to go back to the hospital for subsequent consultation, the care center will automatically send an alert to the patient to notify him of the fact. After the patient receives the alert, he can use the available mobile care devices to connect to the hospital's online registration system to register. He can then go to the hospital according to the reservation time. On the way to the hospital, he can make use of electronic map function in the mobile care device to show the geographical information of the current position, to provide suggestion of MRT and bus routes, and to provide traffic condition so as to assist the patient to arrive on time. Soon after he arrives, it is turn for him to see the doctor for consultations. Since there is automatic number calling function in our intelligent care system, the care center will send an alert to his mobile care device to notify him to enter the consultation room. The care system alert passing procedure in this care scenario is as shown in Figure 4. The details are given as follows. (1) The care center sends alert for subsequent consultation. (2) The patient uses the online registration system to register. (3) The patient refers to the related information of the traffic. (4) The care center sends an alert to notify the patient that his number is called. (5) The patient enters the consultation room for consultation.
T, dt1, and dt2 stand for the default deadline, urgent deadline, and critical deadline respectively. If there is no response from target after default deadline T, the priority urgency module will raise the urgency level from normal to urgent and resend the alert. There are different strategies for different urgency levels.
Fig 4. Message passing procedures when patient should be back to hospital for subsequent consultation.
Fig 3. Message passing procedure when blood glucose data is not uploaded on schedule.
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An example for default strategy table is as shown in Table I. According to the table, if the urgency level is normal , an alert will be sent to the target by Email. If the urgency level is urgent , an alert will be sent to patient with short message. If the urgency level is critical , an alert will be sent to care assistants via mobile phone short message.
TABLE
3. SYSTEM DESIGN AND IMPLEMENTATION
XML alert messages for cross-platform and service functions. In our system, users can send and receive various alerts via web browsers. For the system design, the PDA end for alert reception is designed as shown in Figure 8. In the figure, it shows the display for a received and yet to be replied alert and the alert record for the past received and replied alerts [10]. J2ME is used to the write the application programs for the mobile device, mobile phone end. The appearance of our design is as shown in Figure 9. The care management system main menu includes four main functions: (1) Biosignal Upload: can upload realtime physiological data such as blood glucose, blood pressure and ECG data; (2) Alert List: can receive and reply alerts; (3) Internet: can connect to Internet to make online registration, and access to health education resource and consultation from care providers; (4) History Record: users can access their data of blood glucose, blood pressure, and ECG data in the past. While for the alert passing and physiological parameters upload, the short message service (SMS) and multimedia message service (MMS) are used. The medical care provider can receive real-time patient information and acquire the case history and related information of the patient from database by using multimedia message. Different roles will receive and process different alerts. The medical care providers such as physicians or nurses will receive the notification of job dispatch from care center. The physicians or nurses can then decide for himself or herself to choose the proper or higher urgency-level jobs to service. If the patient simultaneously receives two alerts, and one is online register for next subsequent consultation and the other is your number is called in hospital pharmacy , the patient can choose to take the medication first for better efficiency. The web server module in care center can provide the manager with real-time monitoring and management of all the alerts in the system by using web browser in the remote site. The appearance of the alerts monitoring web page is as shown in Figure 10. It can show the information of the alerts such as ID number, time, content, and sender. The alerts with or without reply can be further processed. The performance evaluation includes the short
The role-relationship diagram for analysis of roles of diabetes care according to the two care scenarios described in Section II is as shown in Figure 7. In the scenario, the roles include patients, physicians, care assistants, care center and database. The relationship between patients and physicians is consultation. The relationship between patients and care center is alert, blood glucose upload and information acquirement. The relationship between care center and database is the data access. The relationship between physicians and care center is alert. The relationship between care assistant and care center is alert. To integrate mobile communication devices to realize our intelligent diabetes care system by using alert mechanisms according to the relationship between each role, web services technology is used to compose
Fig 5. Care center alert management model.
Fig 6. Alert execution flowchart.
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. Urgency level strategy table
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receiving time of the short message. The configuration used for this test is as shown in Figure 11. Test result: Chunghwa Telecom SIM card and KG Telecom SIM card have been used for the test and the results are as shown in Table II and Table III. The test results show that the signal intensity is between 19-22 dB (data read by using AT command built in mobile phone) and both telcom companies can send the messages back within 7 seconds.
message stability test between different mobile phone companies and different base stations, and the stress test to management platform by using multiple roles [11]. The value shown in the following is the average value for 20 short message tests.
3.1 Same base station transmission stability test
short message
The so called same base station test is performed by letting a mobile phone send a short message to itself and measure the time between the sending time and
3.2 Same telcom company's SIM cards, different base stations short message transmission stability test The so called different base stations are located at different geographical locations. In this test one mobile phone module is placed in Taoyuang in Taiwan and the other mobile phone module is placed in Hsinchu. The PC in one location sends short message via local GSM module to the remote GSM module. The remote GSM module then immediately sends the same short message back to the local GSM module. After that, the PC can calculate the run-trip time for the transmitted message. Twenty run-trip tests have been performed and the test platform is as shown in Figure 12.
Fig 7. Role-relationship diagram for diabetes care.
Fig 10. Appearance of alerts monitoring via Web server for care center. Fig 8. Appearance of alert reception interface for simulator of PDA end.
Fig 11. Configuration for same base station-short message stability test platform. In (1) the GSM module sends a short message to the base station. In (2) the base station sends an acknowledgement to GSM module. In (3) the base station sends the short message to its destination which is the source itself.
Fig 9. Appearance of care management system for simulator of mobile phone end.
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3.3 Test for different telecom companies and different base stations The test methodology is the same as shown in Figure 12 with the only exception of changing the remote SIM card to Chunghwa SIM card. The test results are as shown in Table V. According to the results, the run-trip transmission time of all the 20 short messages sent between KG Telcom and Chunghwa Telcom SIM cards is within 19 seconds.
3.4 System performance evaluation In the reliability test, 20 urgent alert short messages, either sent consecutively or nonconsecutively, can be 100% received and processed by the system. It thus proves the reliability of our system. In the system performance test, the average time needed for a whole procedure which includes sending an alert message to care center, information processing in the care center platform, and sending a short message to a care assistant is 20 seconds. The sending of an alert message takes 8 seconds. The processing in the care center platform takes 4 seconds. The sending
Fig 12. Configuration of test platform for same telcom company with different base stations short message stability test. In (1) the local GSM module sends a short message to the local base station. In (2) the local base station sends an acknowledgement to local GSM module. In (3) the remote base station sends the short message to the remote GSM module. In (4) the remote GSM module sends a short message to the remote base station. In (5) the remote base station sends an acknowledgement to remote GSM module. In (6) the local base station sends the short message to the local GSM module
TABLE . Test results for same telecom company with different base stations
TABLE . Chungwa telecom same base station test results in seconds
TABLE . KG Telecom same base station test results in seconds TABLE .Test results for different company with different base stations
Table IV shows the test results for same telecom companies with different base stations. KG Telecom SIM cards are used to perform the test. It can be seen from the results that 20 short messages can be transmitted in round trip within 14 seconds. The processing time of the remote processor is included in the test results.
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plants - an experimental field trial. IEEE Trans. on Information Technology in Biomedicine, 2000; 2: 37-44. 4. Anliker U and Ward JA: AMON: a wearable multiparameter medical monitoring and alert system. IEEE Transactions on Information Technology in Biomedicine, 2004; 4: 415-427. 5. Boric-Lubeke O and Lubecke VM: Wireless house calls: using communications technology for health care and monitoring. IEEE Microwave Magazine, 2002; 3: 43 - 48. 6. Shabot MM, LoBue M, and Chen J: Wireless clinical alerts for critical medication, laboratory and physiologic data. Proceedings of the 33rd Annual Hawaii International Conference on System Sciences, Jan. 2000; 4-7. 7. Kafeza E, et al.: Alerts in Mobile Healthcare Application: Requirements and Pilot Study. IEEE Transactions on Information Technology in Biomedicine, 2004; 2: 173-181. 8. Dickson KW, Kwok BWC, et al.: Alerts for Healthcare Process and Data Integration. Proceedings of the 37 th Hawaii international Conference on System Sciences, 2004. 9. Chiu DKW, Kwok BWC, Wong RLS, Cheung SC and Kafeza E: Alert-driven e-service management. Proceedings of the 37th Annual Hawaii International Conference on System Sciences, Jan. 2004; 68-77. 10. Choi J, Chun J, et al.: MobileNurse: hand-held information system for point of nursing care. Computer Methods and Programs in Biomedicine, 2004; 245-254. 11. Xiao Y, Seagull, FJ, Nieves-Khouw F, Barczak N, and Perkins S: Organizational-historical analysis of the failure to respond to alarm problems. IEEE Transactions on Systems, Man and Cybernetics, Part A, 2004; 6: 772-778. 12. Li M, et al.: 3G network oriented mobile agents for intelligent diabetes management: A conceptual model. Proceedings of the 4th International IEEE EMBS Special Topic Conference on Information Technology Applications in Biomedicine, April 2003; 24-26. 13. Wang M, Lau C, Matsen FA, and Kim Y: Personal health information management system and its application in referral management. IEEE Transactions on Information Technology in Biomedicine, 2004; 3: 287-297.
of message to the care assistant takes 8 seconds. It thus proves the ability of our system to provide prompt assistance to the diabetes patients.
4. DISCUSSION AND CONCLUSION Because the medical resource is very precious, the hospitalized all-day-long care is usually applied to patients who need urgent medical treatment. Chronic patients with diabetes are thus often taken care of at home. However the care at home either by care assistant or by the patient himself or herself is normally not professional. In this paper, information technology and medical resource is integrated to provide professional care to diabetes patients at any time and at any place. As for the care providers, since they usually have to execute different types of jobs at different locations, adequate mobile communication devices are also provided to assist them to complete their jobs. Alert messages are applied in the role-based point of view to implement a mobile care system to fulfill the functions for message passing between each role device. It allows each role or care center to actively send alerts by using different messages to notify different roles at different locations to realize the circulation among different platforms such as desktop PCs, PDAs, and mobile phones [12]. By applying the automatic alert urgency strategy to send the alert to the proper persons located at the right place at the right time, the accuracy of information and the completeness of the notification can be assured so that the quality of diabetes care can be improved [13]. In the reliability test and performance test for the transmission and processing of the alert messages, it can be further inferred that our system can reliably and promptly provide assistance for the diabetes patients. Together with the alerts monitoring and management schemes in the care center, patients with diabetes can obtain complete care from a whole intelligent care chain.
REFERENCES 1. Bellazzi R, Larizza C, et al.: A telemedicine support for diabetes management: the T-IDDM project. Computer Methods Programs Biomedicine, 2002; 2: 147-161. 2. Gomez EJ, Hernando ME, et al.: Telemedicine as a tool for intensive management of diabetes: the DIABTel experience. Computer Methods Programs Biomedicine, 2002; 2: 163-177. 3. Lee RG, Chen HS, Lin CC, Chang KC, and Chen JH: Home telecare system using cable television
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