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Czech Technical University in Prague Faculty of Electrical Engineering

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1. View Resource gt Attributes Admin lt lt extend gt gt lt lt extend gt gt Figure 4 4 Use Cases Resource Types management 20 Add Resource extend lt lt eytend gt gt Select i View oo E gt lt erne Remove Resource Bindina rc RSet lt lt extend gt gt METIDO Binding Binding ates User ape id den cente ner pL Add Resource Remove Bindin Resource 9 R Edit Import Export Resource Resource sten Figure 4 5 Use Cases Resources Management 4 3 System Architecture One of the main requirements of the system is to allow patients to send data to their physicians In order to realize this function we use a system architecture based on REST Representational State Transfer REST is a software architecture style for designing networked applications web services Rather than using complex mechanisms such as CORBA RPC or SOAP to connect between machines simple HTTP Hypertext Transfer Protocol is used to make calls between machines 18 Application Logic Figure 4 6 Global overview of the system 21 This architecture uses the client server model for communication This means that tasks or workloads are portioned between the provider of a resource and service called server and service requesters called clients Rest architecture is good a choice for us as it fits the low resources requirement for the following
2. MOD P lt lt indlude gt gt xexter ds E lt lt extend gt gt lt lt extend lt extend gt Figure 4 2 Use Cases Users management _ lt lt extend gt __ Select access extend nn me The admin can also manage Organizations as shown in figure 4 3 This includes adding a new Organization editing or removing existing ones In figure 4 4 we can see use cases for managing Resource Types and their attributes and bindings When installing the system the admin can create Resource Types and their attributes He can also define relationships between the created Resource Types by adding bindings Later he can define other Resource Types edit or remove existing ones It is also possible to add new bindings and new attributes and to edit or remove the existing bindings and attributes 19 After the meta data are created i e Resource Types Resource Type Bindings data records can be added Figure 4 5 shows use cases for manipulating Resources This includes adding new records resources editing and removing existing ones It is also possible to view Resource Bindings add new Bindings edit or remove the existing ones Admin E extend lt lt extend gt Figure 4 3 Use Cases Organizations management lt lt extend gt lt lt eyxtend gt T xextend lt lt include gt gt Resource Xm DD oo
3. 7 Nan E Johnson and Lois Critical Issues in Rural Health Introduction In Nina Glasgow Lois Wright Ames IA Blackwell Publishing 8 GONZALEZ ARMENGOL J J CARRICONDO F CARLOS MINGORANCE PABLO GIL LOYZAGA Telemedicine in emergency care methodological and practical considerations REVIEW ARTICLE 9 Becker s Hospital Review URL http www beckershospitalreview com healthcare information technology overcoming 4 challenges in implementing telemedicine healthcares next frontier html assessed 2015 10 Telehealth Resource Centers Telehealth Legal and Regulatory Module URL http www telehealthresourcecenter org legal regulatory assessed 2014 11 Lt Col Salil Garg and Wg Cdr Mudit Mathur Ethical and Legal Aspects of Telemedicine and Remote Consultation Express Healthcare 12 Firas Sarhan MSc PGDip BA Telemedicine in healthcare 2 the legal and ethical aspects of using new technology Nursing Times 2009 13 B M Dickens R J Cook Legal and ethical issues in telemedicine and robotics International Journal of Gynecology and Obstetrics 2006 94 73 78 14 S Kobayashi Open Sourse Software Development on Medical Domain Ehime University Japan 15 B Sainz de Abajo and Llamas B A Overview of the Most Important Open Source Software Analysis of the Benefits of OpenMRS OpenEMR and VistA University of Valladolid Spain 16 Linuxaria To
4. Testing 8 1 Testing the Dynamic Aspect of the System The objective of this testing is to test that the system is really dynamic and can be customized to fit the needs of different Organizations To do that 3 different Organizations have been created Bilongo Hospital Central Hospital Yaound and Veterinary Hospital For each Organization data has been added as follow First Organization for the testing Bilongo Hospital Organization the following Resource Types are created e Patient with attributes ID First Name Last Name Birth Date Birth Place ID Number Address Gender Age and Grade and binary attributes Pictures Documents Heart Rate e Visits with the following attributes ID Date Time Description Then a binding has been created between Patient and Visit where Patient has been set as the parent Resource Type Figure 8 1 shows the two Resource Types displayed by the system Bilongo Hospital Resource Types Show 10 v entries Search Patient Patient isi Visits Showing 1 to 2 of 2 entries Previous 1 Next Figure 8 1 Testing Resource Types for Bilongo Hospital Organization The following functionalities have been tested e Creating new records new patients and visits where created 56 e Viewing records the created patients visits could be viewed e Editing a record created patients visits were edited e Removing some created patients visits were removed e Bindings visits were assign
5. 1 Telemedicine can be beneficial to patients living in isolated communities and remote regions who can receive care from doctors or specialists far away without the patient having to travel to visit them 6 From this point of view we can say that telemedicine can be vital and save lives in critical care and emergency situations Objectives and Goals of this Thesis The aim of this thesis is to develop a method allowing the remote patient s data collection using store and forward telemedicine paradigms in low resource environments lack of diagnostic devices limited knowledge of patients regarding telemedicine unreliable telecommunication etc Our motivation is to analyze the major difficulties encountered by patients in regions with limited facilities in cardiology e g developing countries and their regional health professionals and to design a data collection system using low cost IT solutions The main result is a web based software system for patient data acquisition storage and retrieving for the purpose of establishing a diagnosis The work is broken down as follows e First we analyze requirements from the cultural legislative infrastructural and IT perspectives e Inthe second chapter we mention some existing solutions and approaches used to implement those solutions e The following chapters describe the design of our solution including its implementation e The last part of the work covers testing Chapter 2
6. 28 Joel Murphy Yury Gitman Pulse Sensor URL http pulsesensor com assessed 2012 29 Kana M A Generic Telemedicine Software Framework In review Int J Telemed Appl 30 w3Techs Usage of server side programming languages for websites URL http w3techs com technologies overview programming_language all 31 Blog Udemy PHP vs ASP NET Costs Scalability and Performance URL https blog udemy com php vs asp net assessed 2015 32 George j Mandellos George V Koutelakis Theodor C Panagiotakopoulos M N Koukias and D K Lymberopoulos Requirements and solutions for advanced Telemedicine applications Biomedical Engineering Carlos Alexandre Barros de Mello Ed ISBN 978 953 307 013 1 InTech 33 Cecily Morrison Adona Iosif Miklos Danka Report on existing open source electronic medical records Technical Report UCAM CL TR 768 ISSN 1476 2986 34 Arduino URL http www arduino cc assessed 2015 35 Michel Kana and Rosion Dzian Analysis of Requirements in Telemedicine Semestral Project 2013 66 Appendix A User Manual for Measuring and Sending Data to the Server To measure your heart rate you are supposed to have the Pulse Sensor the board and a A B USB cable As serial client we are using Tera Term but you may use another one the process is the same D Connect your Arduino or other board that you using to your PC using the A B USB cable
7. Requirements 2 1 Business Requirements in Telemedicine Telemedicine is a relatively young and evolving field Building a telemedicine application requires detailed domain analysis of users needs The requirements are various and differ from a country or a region to another That is one of the reasons why objectives technologies and even philosophies of each telemedicine system will usually differ from others However there are of course still common requirements that every telemedicine solution covers In order to have a clear understanding of specific user requirements in telemedicine in low resource environments we have made a small survey back in 2013 35 The aim of the survey was to find out what are the main difficulties encountered by users while using telemedicine We received 14 answers from people living in Cameroun Congo Czech Republic France and Switzerland Unfortunately many people did not answer us because they did not even know what telemedicine is But the few answers we received from different countries gave us an idea of how some people consider telemedicine Here is the summary Telemedicine software programs are not free or not available 5 455 Telemedicine software programs are difficult to understand 2 182 Telemedicine software programs don t offer the needed functionalities 2 18 2 Lack of infrastructure T 636 6 545 Problems with Internet connection Figure 2 1 e More than 18 of participan
8. e Lack of Knowledge and Trust Many health organizations lack knowledge about open source possibilities 17 Some are afraid of using an application that is free For them free means without values and will certainly not achieve their needs They perceive in it a lack of accountability regarding quality security and liability Hospitals and providers also have to solve the question of support while opting for open source solutions If the system gets down who will provide support Complex open source software requires qualified programmers familiar with it to provide continuous support e Difficulty Interfacing with Proprietary Products Another barrier to the use of open source is the difficulty to include and connect it with proprietary resources due to the GPL license This can occur for example with labs e prescription networks and decision support databases 17 This difficulty can be overcome if open source software uses a license that allows third parties to keep code proprietary The reason why we did not choose one of them to build our system is that we did not find one that fulfils all the requirements defined in section 2 2 According to the report mentioned in 33 PatientOS OpenVistA are complex and difficult to install and configure do not meet requirement N2 OpenEMR is not customizable and OpenMRS does not allow practitioner customization both do not match requirement N3 OpenDental is specific as it focused
9. on oo Fill Form and click Save v Y ee S cA LES ES p HERS Show Error ss EIL S Figure 5 9 Adding a Resource e View Resource Bindings The ResourcesController allows also viewing Resource Bindings This is done in its method viewBinding which accepts 3 parameters the id of the parent Resource Type the id of the Resource and the id of the child Resource Type If for example we have created Resource Types Patient and Diagnosis and defined a Binding between them then to view a given patient s diagnosis the following arguments must be provided o The id of the Resource Type here the Resource Type is Patient o The id of the patient whose diagnosis has to be displayed o The id of the child Resource Type here Diagnosis e Adding a Binding Record To add a Resource Binding for example to add patient s diagnosis we use the method addBinding of the ResourcesController Just like the viewBinding method the addBinding also accepts 3 parameters the id of the parent Resource Type the id of the Resource and the id of the child Resource Type In figure 5 10 we can see the sequence of interactions between ResourcesController and other objects when adding a new Resource Binding 4 sd Add Resource Binding ResourcesController ResourceAttributeType ResourceTypeBindingName i H H L Add New Resource Child i j k GetParentResourceTypeName i L Fill Form and click
10. sd Defaut Model View Controller sequence HTTP Requrest Request Data Return Data 1 Send Data Retriuved Fram Model Formated view mm m i HTTP Response H i LI i 1 i Se s sn al Figure 5 2 sequence diagram request cycle 5 2 6 Routing Routing is a feature that maps URLs to controller actions The application routing is handled by the CakePHP Dispatcher The Dispatcher allows specifying the name of the controller and the action to be performed by this controller directly in the URL The URL pattern format is http servername org controller action param 1 param2 param3 For example the URL resourcetypes view maps to the view action of the ResourceTypesController and resources add_binding maps to the add_binding action of the ResourcesController If no action is specified in the URL the index method is assumed 31 It is also possible to pass parameters to the actions using the URL A request for resourcetypes view 25 would be equivalent to calling view 25 on the ResourceTypesController for example 5 3 Data Structure Figure 5 3 shows the data model of the system taken from 29 As one can notice the data model does not map specific concepts like Patient or Physician Instead it contains the meta model This is because specific Resource Types will be created dynamicall
11. IBI 10 total total rate N 1 add the latest IBI to total 11 total N average the last 10 IBI values 12 BPM lt 60000 total 13 RETURN BPM These algorithms are directly implemented on the microcontroller using Arduino development environment IDE This IDE is free and easy to use The next chapter describes how to send the measured data but not only to the server 51 Chapter 7 Implementation of the Client for Sending Patient Data Because the server is using a standard protocol HTTP HTTPs and JSON format for the communication with client applications the client can be whatever that supports this protocol and format It can be a Web Desktop or Mobile application it can be implemented using PHP Java etc it can run on Windows UNIX or other Operating Systems Also because the server is programmed to support dynamic creation of resources there may be many clients each being specialized in sending specific resources to the server using the communication protocol described in chapter 4 All this means that the server is ready to communicate with different clients and this is what we wanted develop a central component server and allow different types of clients to communicate with it What this means for organizations that will use the system is that they have the possibility to develop different clients according to their needs to share data with the server The proposed architecture allows client applicat
12. Place the Pulse Sensor on your finger Open Tera Term and choose Serial O TCP IP Host myhost example com vi History Service C Telnet IUP uusii Le SSH SSH version SSH2 Other Protocol UNSPEC Serial Port COM5 USB Serial Port COM5 v Cancel Help Go to File and then choose Log and select a file where you would like to save you hear rate data At this point you should see the measured values in the scree When you think you are finish simply close the terminal data are saved in the file Go to the client application and choose Send Pulse Rate Send Pulse Rate e Send Document Sending Pulse Rate Data Filename Browse No file selected Submit 67 8 Click to Click to Browse and select your pulse rate file and click to submit Appendix B Survey In order to have an idea of user requirements we have realized a survey using Google Form The survey was realized in English and in French Answers given in French are described in chapter 2 Among the participants two were doctors All are men from Congo Cameroun France Czech Republic and Switzerland The questions and the result of the survey are summarized below Telemedicine in your country region 1 Is there Telemedicine use in your country Yes 1 8 3 No 0 0 Idontknow 0 0 2 How would you rate the use of Telemedicine t 0 Very good use of Telemedicine is necessary 68 1 83 Good use of Telemedicine is good but not
13. e et pay e la consultation virtuelle Les personnes malades v s ou ag es peuvent tre li es avec leur m decin qui fait la supervision ou par ligne de telephone ou mieux par Internet Une connexion distance via une visioconf rence faisant intervenir les m decin d o qu il se trouve pour soigner les malades 11 Quel genre de donn es aimeriez vous partager Les textes 10 90 9 96 Les images 9 81 8 96 Les vid os 9 81 8 Les signaux cardiaques 8 72 7 96 qT 12 Avez vous des dispositifs m dicaux n cessaires pour collecter les donn es dans un environnement mobile Non 10 ww 1 Ou 1 8 3 Non 10 83 3 13 Si non quel type de dispositif pensez vous qu il serait bien d utiliser Question pour les professionnels de sant Le petit appareil de ECG ou q c similaire N tant pas du domaine m dical je suis incapable de vous donner les dispositifs m dicaux indispensables dans un environnement mobile 14 Pensez vous qu une telle solution serait avantageuse Pourkoi p6 2 5 Oui en cas de danger d infarctus ou de la faiblaisse ou une crise de diab te etc Je pense que oui oui L gislation 15 La t l m decine est elle l gale dans votre pays Non 3 Je ne sais pa 1 Oui 7 Oui 7 58 3 78 Non 3 25 Je ne sais pas 1 83 16 Quelle sont les d marches l gales faire afin de pouvoir tre en droit de faire usage de la t l m decine je
14. which is a popular choice of database for use in web applications As the HTTP Server we use Apache the world s most widely used web server software This combination of technologies Apache MySQL and PHP is sometimes called LAMP or WAMP depending on the operating system on which there are installed LAMP stands for Linux Apache MySQL and PHP Perl Python The W in WAMP means Windows 21 These technologies are selected to match our requirements low cost and low resource In 20 and 30 a list of server side programming languages is dressed The most used ones are PHP 8296 ASP NET and Java But ASP NET is platform dependent and requires Windows hosting which is most of the time more expensive then Linux hosting 30 Furthermore Scripting languages like PHP could be easier to learn for beginners then Java By choosing PHP we allow potential feature developers to be able to continue the development of the system The PHP programming language is usually used with Apache and MySQL These two technologies do not present any serious drawbacks for any of our requirements mentioned in chapter 2 5 1 1 The Used Framework In order to facilitate the development of the application we use a web application framework WAF called CakePHP an open source framework written in PHP CakePHP uses well known software engineering concepts and software design patterns such as Convention over configuration Model View Controller Active Rec
15. After sending pulse rate data to the server it is expected that the server will print it as a chart for a physician or a clinician to view it and evaluate the patient s health state Below is the description of this process Viewing Patient s Pulse Rate Each Resource Type Attribute defined in server has a sub attribute or characteristic called is chart whose value can be either O false default value or 1 true When its value is set to 1 the server will automatically provide a button View Chart to print it as a graph This is ensured by the server s Controller ResourcesController in the method viewBinary This method expects data containing in file to be in array with the following format series series2 series3 And each data series is consist of values of x axis and y axis Ix y Put it all together data will be in the following format x1 yl x2 y2 x3 y3 x4 y4 But sometimes the value of y is known or is constant and there is no need to specify it In this case the following format is also acceptable xl x2 x2 x3 x4 x4 When there are too many samples i e more then 500 data will be automatically divided into smaller arrays and will be displayed progressively The user can update a chart periodically to get a real time effect by using a timer to insert the new data in the plot and redraw it Time between updates is specified in milliseconds Heart rate samples measured by the Puls
16. For example First Name gt first name ID Number gt id number e Resource Type Binding Table Naming Resource Type Binding tables are used to map relationships between Resource Types They must be named after the model tables they will join arranged in alphabetical order medical problems patients rather than patients medical problems Here are some examples Table Name 1 Table Name 2 Binding Table Name patients medical_problems medical_problems_patients patients heart_rates heart_rates_patients organizations resource_types organizations_resource_types Table 14 example conventional binding table names These convention rules must be respected when creating a Resource Type and when trying to retrieve information stored in the dynamically created model All this is solved by the component ResourceNameSolverComponent which implements algorithms allowing determining the right model and table names according to the above defined rules This component implements a couple of methods among which we can mention e getResourceTableName accepting a Resource Type name as parameter this method returns the corresponding table name For example if the argument is Patient the method will output patients The output will be the same if the given Resource Type name is patient patients or Patients The input Medial Record will have as output medical records e getResourceModelName this method also accepts a Resource Type
17. Infection control system for developing countries Programming language Java License OpenMRS Public License Website http openmrs org Table 3 Technical overview of OpenMRS PatientOS PatientOS has been designed from the outset to be a HER It supports not only human hospitals but also veterinary care hospitals It is a distributed web based clinical system written in pure Java with toolset to customize Key Features e Scheduling e Orders e Meds e Pharmacy e Clinical documentation PatientOS Type Free healthcare information management system designed for hospitals and healthcare practitioners Programming language Java License GNU GPL Website http www patientos org Table 4 Technical overview of PatientOS GNUmed The GNUmed project builds free liberated open source Electronic Medical Record software in multiple languages to assist and improve longitudinal care specifically in ambulatory settings i e multi professional practices and clinics It is made available at no charge and is capable of running on GNU Linux Windows and Mac OS X It is developed by a handful of medical doctors and programmers from all over the world Key Features e Appointment handling e Document archive e Medication Handling e Vaccination Handling GNUmed Type EMR specifically in ambulatory settings Programming language Python License GPL Website http www gnumed org Table 5 Technica
18. Meta Type For example Resource Types Patient Physician and Nurse can be categorized as Human Hospital Device and Room are Material and finally Diagnosis and Medical Record are Abstract Human Material and Abstract are examples of Resource Meta Types e Resource Type Attribute Each Resource Type has some attributes For example if we create a Resource Type Patient then we can also create its attributes like Name Age Personal Number and so on In this model we refer to each of them as Resource Type Attribute e Resource Type Attribute Type Each Resource Type Attribute has some characteristics it can be mandatory or not it can be binary printable etc A Resource Type Attribute Type represents such characteristics e Resource Type Binding Two Resource Types may have a relationship between them i e a Patient can be related to a Doctor and vice versa a Patient might have a Diagnosis This relationship is called Resource Type Binding In this relationship one ResourceType is set as the parent of the other e Resource A Resource is a specific record or an instance of a Resource Type If we have a Resource of type Patient then we refer to a given patient 1 e Jean Paul as a Resource e Resource Attribute A Resource Attribute 1s an instance of a Resource Type Attribute e Resource Binding A Resource Binding is a specific record of a Resource Type Binding Assume we have created two Resource Types Patient and Diagnos
19. SmartCare Electronic health record system EHR Programming language License Website http smartcare org zm Table 7 Technical overview of SmartCare CottageMed Cottage Med is an electronic medical record software based on FileMaker It uses templates that interact with the FileMaker database management program The project was officially created in 1999 by the physician Stefan Topolski It is one of the first publicly distributed free EMR systems to be both open source and cross platform for PC Mac amp Linux in the world Key Features e CottageMed became Basic accounting functions Full and flexible access to all data fields e Powerful search functions on any and all fields e Report generation CottageMed Type Electronic health record system EHR Programming language License GPL v2 Website www cottagemed org Table 8 Technical overview of SmartCare ClearHealth ClearHealth is another web based open source practice management and electronic medical records system Available under the GNU General Public License it is been used by a number of large institutions including the Primary Care Coalition network out of Maryland USA 16 ClearHealth is developed in the PHP programming language and it is able to be run on most server configurations in Windows Linux or Mac OS and it uses Web Servers such as Apache and MySQL database Key Features e Scheduling e Patient registration e Electronic medical r
20. Units emergency and critical care robotic telemedicine users were asked to identify the factors that motivate and the barriers that impede the acceptance and maintenance of remote presence telemedicine One of the barriers revealed by the survey was the cultural barrier that occurs because of lack of desire or unwillingness of some physicians to adapt clinical paradigms for telemedicine applications 13 As revealed by our survey mentioned above this is most probably due to the complexity of telemedicine applications or to the fact that existing telemedicine applications do not always fit their needs Building a simple easy to use and flexible telemedicine application may motivate some physicians to start using it 2 1 4 Ethic and Legal Issues Despite of the increasing use of telemedicine there are still a lot of discussions about the ethical and legal issues surrounding it Using telemedicine implies many issues of concern regarding the legal and ethical aspects Among them we can mention the responsibilities and potential liabilities of the health physicians the obligation to maintain the confidentiality and privacy of patient records and the jurisdictional problems associated with cross border consultations Issues regarding privacy and confidentiality in the medical realm are not necessarily different in telemedicine As with conventional medicine a telemedicine clinician has the same duty to safeguard a patient s medical records and k
21. code between controllers or even projects Helpers Helpers are more like Components they are used to avoid code repetition The difference with the Components is that Helpers are used in the View Layer see figure 5 1 They contain presentational logic that is shared between many views 30 5 2 5 Request Cycle Figure 5 1 also describes cycle of user client requests and the way they are handled by the server application In this section we explain in more details how all this works The sequence of communication between the 3 main layers of the application can be viewed in figure 5 2 The request cycle starts when a user or a client requests a page or a resource in the application This request just like all requests is first of all handled by the application Dispatcher The Dispatcher is an object whose main functionality is to convert all requests into controller actions It uses the dispatched request to locate and load the correct controller This is actually the use of the Front Controller pattern which provides a centralized entry point for handling requests 20 When the controller received the request it may communicate with the Model Layer to retrieve modify or save data in case of need After that the controller will proceed to delegate to the correct view object the task of generating output resulting from the data provided by the model Finally when this output is generated it is immediately rendered to the user
22. create the needed Resource Types Let us remember that a Resource Type is a meta object used internally by the system to encapsulate specific objects such as Patient Physician Device Diagnosis Document etc So by creating a Resource Type we mean creating a specific instance of the Resource Type object This is done by providing the following attributes e The id of the Organization to which the new Resource Type will belong It is possible to specify more Organizations has a Resource Type can be bind to more than one Organization e The Resource Type Name for example Patient This name must be unique in the system because two Resource Types cannot have the same name within the system e The Resource Type Description 37 e The Resource Type Attributes and their characteristics such as Name Age etc When all the needed information is specified the request for creating the new Resource Type is sent to the ResourceTypesController who is responsible for creating Resource Types The following actions are then performed by the ResourceTypesController Some checks are performed to make sure that the specified data are valid A new database table is created The name of the table matches the one of the Resource Type and the table columns correspond to the given Resource Type Attributes A new record new row is inserted into the database table resource types The record contains the Resource Type name and description This table ke
23. crois que pour ce qui est des NTIC il faut passer par ARPCE au congo bien s r je pense Je ne sais pas Pas tr s inform sur le sujet Je pense de mon exp rience que c est ne pas le demarche l gale mais plut t le demarche dans le domaine de la m dicine priv c est dire c est conomie En France il faudrait une loi vot e par le parlement assembl e nationale et le s nat Mais cel n arrivera pas la seule possibilit d utilisation de la t l m decine peut se faire entre professionnels de sant c est tout notamment pour changer des documents radios et autres 17 Existe t il une plateforme l gale permettant les diagnostics les consultations et les prescriptions distance Oui 2 16 7 Non 5 41 7 Jenesaispas 4 33 3 18 Que dit la l gislation locale sur la s curit des donn es des patients Qu elles doivent tre prot g es Souvent il y a un conflit d int ret en Suisse les assurances maladadie offrent des service de t l m decine par t l phone mais ils doivent traiter les donn es avec confidentialit ce qui n est pas tj respect L tat tch que a la legislation d UE qui tient sur la s curit des donn es des patients Pas tr s inform sur le sujet Quelles fonctionnalit s aimeriez vous avoir dans le cadre de l utilisation de la t l m decine 79 19 Veuillez choisir les fonctionnalit s que vous jugez utiles dans une plateforme t l m decine La connexion d
24. given Resource Type Example data firstName John lastName Doe firstName Annabel lastName Gates firstName Peter lastName Steven l It is also possible to combine both binary and text data within one request The format is shown in the following example data file attributeCode DOC filename a conrete file name size file size content file content base64 encode firstName John lastName Doe firstName Annabel lastName Gates 24 firstName Peter lastName Steven As one can notice the file field is inside the data field and not the contrary This must be respected otherwise the request will be invalid A complete valid request body may look like this resourceID 12345 data file attributeCode heartrate filename my heart rate txt size 58096 content 23s84weeej4smndjd09ems jdaszzzzxxxxpoe9982njd sdsdsdksdj8uuennenn7ee7766636636hgbnssnndddndnddgbddny 9983ndjdndndndn dnkjshdkjsdhsjkdhjkdhjksdhjksdhkjshdkjn psdnd ddddsdsdsdsdsdsd9e8snsd jsdjsddddddddddddddddddddddddddjjnndedjdjdjdjd firstName John lastName Doe firstName Annabel lastName Gates firstName Peter lastName Steven Making the HTTP Response The server responds to each client request using standard HTTP response The response contains standard status
25. heart pulse in Arduino 82
26. midpoint of ADC range But if there is more light the signal goes up With less light the opposite appends Light from the green LED that is reflected back to the sensor changes during each pulse 28 6 3 The Signal Processing Algorithm Even though the signal coming from the Pulse Sensor is amplified we have still to clean it from external noise in order to get a cleaner signal To do that we use the algorithm described below Before viewing this algorithm let us first see how the heart rate waveform looks like This is shown in figure 6 4 When the heart pumps blood through the body there is a pulse wave that travels along all arteries to the very extremities of capillary tissue where the sensor is attached This produces a rapid upward rise in signal value peak 28 48 UI d VU Figure 6 4 Example of a PPG waveform What we want to do is to find successive moments of instantaneous heart beat and measure the time between called the Inter Beat Interval IBI Having the IBI we can then compute another important parameter called BPM beats per minutes This can be done by following the predictable shape and pattern of the PPG wave There exists many methods allowing finding the instantaneous moment of heart beat Some choose the upward rise event the peak others say it is better when the signal gets to 2596 of the amplitude and finally certain researchers think is 5096 of the amplitude 28 We have tried all these m
27. nt out de bes ne ets 18 4 3 S ystemoNTOBIee Ute spe s a e Wd Eee ades Pr Ne ee tnt nd 21 Moris The SERVER as ne totas iain uti alas dabas cies ne pl 22 ac T 22 433 Deseripiomolte HTTPONPTI nmani tears was ees de dp dee ue 23 5 Implementation of the Server cese e eee e ee ee ee ee sete sesto sete ao setae s sean e eene setas ee eaas sees 28 Sok sed Dechnolb8le Sce co RS a uer course eas Sede ed 28 Sill The Used Prame work usine ne nee ai e Te t bei de 28 5 2 Structure OF thie Application oe edi tn o ed oed iode beds aspe ius 20 PN o IUD dca RC E 30 pud TheView aye c osos osdio seo a seeds ra i iua Io fca red 30 moo ThedControlle E ayy Si aaa RE dit ie ie te 30 2 244 Components and Helpers oct tite Sneton Eu oce Ete Roo eoe triste edd 30 D Request Cy ele Se pesca eet aae ee intus e qe uitis fe pd 31 5 2 0 ROUNE Soto edat es at atras ed ET 31 5 Data sStr ct re rete tte erede erede E T oov E ine etes ees 32 34 JImplementa on Details Essen Paene duds fame cipe ed 33 AU INEMECC AEucnmM ne E 33 5 4 3 Implementation of the Dynamic Model ss 37 53 SECU i n a E E O R nina 43 6 Implementation of a Method for Patient Data Acquisition 45 6 1 Overview of Physiological D ls coacti pecie te eite Yee epe d oeba resp otedeg iun 45 62 Hardwate PIOIODIDO uo SS bao ei ree i sae 46 6 3 The Signal Processing Algorithm visiciisccsssceecsanscetdsetpsenccssvaseeee roe
28. objects to create a new Resource Type The ResourceTypesController communicates with the ResourceType and OrganizationResourceType models to create and save Resource Types OrganizationResourceType ViewlresourceTypes ResourceTypesController 1 I 1 I User Add New Resource Type iGet Form NEIN l Fill Form and click Save lt lt create gt gt if Created lt lt create gt gt 1 1 1 1 2h r Redirett to Print All View 1 1 Print All Resource Tyges LE l eS else Show Error MI 1 i I i 1 i i I i 1 I i I 1 I 1 Lu j Jj 23 Figure 5 8 Adding a new Resource Type Adding Bindings After Resource Types are created the admin may wish to define a relationship between two Resource Types This relationship is what we call Resource Type Binding The creation of Resource Type Bindings is also handled by the ResourceTypesController In order to define a Resource Type Binding the following must be specified e The names of the two Resource Types between which the Binding has to be created e One of the two Resource Types has to be set has the parent of the other To create the Binding then the ResourceTypesController performs the following e Make sure that this Binding does not exist in the system already e Create a new database table for this Binding The name of the new table matches the name of the two
29. really necessary 0 O Bad use of Telemedicine is not good 0 0 3 What are the main difficulties you encounter while using Telemedicine Telemedicine software programs are not free or not available 1 100 Telemedicine software programs are difficult to understand 1 100 Telemedicine software programs don t offer the needed functionalities 1 100 Lack of infrastructure 1 100 Problems with Internet connection 1 100 Ostatni 0 0 4 Can you tell which is roughly the percentage of people who use Telemedicine in your region country Less then 10 1 83 More then 10 0 0 Between 10 and 50 0 0 More then 50 0 0 I don t know 0 0 Ostatni 0 0 5 Is there use of Telemedicine in form of free software 69 Yes 0 don t know 0 Yes 0 0 No 1 8396 Idontknow 0 0 6 If so can you tell us what is are the open source program s used for this purpose 7 What are the benefits Connecting patients and doctors 1 100 Making remote diagnosis 1 100 Sharing data 1 100 Ostatni 0 0 8 how to improve it what would be good to do Use of Telemedicine 9 Are you interested in connecting with your doctor patients remotely Yes 1 No 0 Yes 1 83 70 No 0 0 10 How do you imagine such a scenario 11 Which kind of data would you share Text 1 100 Images 1 100 videos 1 100 ECG signals 1 100 Ostatni 0 0 12 Do you have medical devices for data collection in a mobile envi
30. requirements After defining the requirements we proposed a solution that will meet these requirements The proposed solution consisted in a client server web application allowing patients to send data to their doctors or clinicians The server part of the system is designed to be a dynamic system allowing different organizations to customize it to their needs Building such a system was not easy It was time demanding and required deep analysis The results The following was accomplished within this work e A prototype server application was implemented with basic functionalities including the ability to dynamically create and manage resources create and manage users receive data from different client applications store retrieve and display the received data The server can receive different types of data including physiological data such as heart rate or ECG signals e A client application has been created to allow sending data to the server e A prototype low cost hardware solution was implemented to measure patient heart rate using a pulse sensor and a microcontroller The measured samples can be saved into a file and sent to the server using the client application Further work Even though the implemented system fits the requirements many features remain to be implemented in order for the system to be more robust For example different algorithms can be implemented for processing patient s physiological data Different sheet
31. secteur d utilisation Dans mon Pays la t l med cine ne se fait pas il n y a pas m me un projet dans ce genre L usage de la t l m decine 9 Pensez vous qu il soit utile de permettre la connexion distance entre les patients et les m decins 76 Oui 11 91 7 96 Non 0 0 96 10 Comment imaginez vous ce sc nario Permetre une connection amelior a internet et un acces pour tous Creer des formations pour des specialists En Suisse les pharmacies ont tabli un syst me de t l m decine qui permet au patients qui n arrivent pas obtenir un rendez vous chez leur m decin de famille et qui n estiment pas n cessaire d aller aux urgences de se mettre en communication avec un m decin en ligne en pr sence d un pharmacien L utilit de ce syst me est mis en question parce qu on soupconne les pharmaciens de vouloir vendre avant tout des m dicaments 1l faut d j commencer par mettre en place les structures necessaires pour permettre sa pratique ensuite s assurer que la connexion internet soit de bonne qualit capacit la encore c est un probl me suite au fait que beaucoup ingnore encore bien l utilisation des outils informatiques et autres Dans les zones rurales pour des RDV de routine par exemple pour des personnes g es ne necessitant pas la pr sence du m decin ou tr s loign Cela peut aussi tre le cas pour le suivi de la m dication Par email interpos peut tre mais comment serait factur
32. software such as OpenEMR When receiving data from the clients the server does not provide a possibility to append data to previously added data This feature could be added as well In chapter 5 we mentioned naming conventions when it comes to naming the dynamically created Resource Types Our solution works only for English names It would be great to add UTFS support and the use of ID instead of resource name for unique identification And finally a glossary is missing in this work Some terms used here may be new for some readers 64 Literature 1 ATA Web site URL http www americantelemed org assessed 2012 2 WHO Telemedicine opportunities and developments in Member States report on the second global survey on eHealth Cataloguing in Publication Data 2009 3 Telemedicine com URL http www telemedicine com assessed 2015 4 WHO A health telematics policy in support of WHO s Health For All strategy for global health development report of the WHO group consultation on health telematics 11 16 December Geneva 1997 Geneva World Health Organization 1998 5 Bayliss E Steiner J F Fernald Descriptions of barriers to self care by persons with comorbid chronic diseases Ann Fam Med 1 1 D H Crane L A amp Main D S 2003 6 Berman Matthew Fenaughty Andrea Health Economics Health Economics Wiley 14 6 559 573 doi 10 1002 hec 952 PMID 15497196 June 2005
33. to the above mentioned methods telemedicine also uses client server applications to deliver advanced diagnostic methods and telemedical devices to support in home care To help understand the use of telemedicine the American Telemedicine Association has dressed a list of examples of services provided and mechanisms used to provide those services in telemedicine This includes remote patient monitoring primary care and specialist referral services and consumer medical health information Telemedicine can also be used to provide medical education 1 Of course these are only examples of the use of telemedicine many other services and uses may be involved in telemedicine These examples however give us an idea of what telemedicine means in practice We can summarize the use and importance of telemedicine by the following 1 Its main goal is to improve patient s clinical health status 2 Itis used to overcome distance barriers by providing services at distance and connecting patients to health staff located in different physical locations 3 To fulfill its goals telemedicine uses various types of telecommunication and information technologies 4 Among the main benefits of telemedicine we can mention cost efficiencies It has been proven that telemedicine significantly reduces the cost of healthcare as it reduces travel times and fewer or shorter hospital stays It also increases efficiency through better management of chronic diseases
34. Czech Technical University in Prague Faculty of Electrical Engineering Master s thesis Telecardiology Data Collection in Low Resource Environments Rosion Versace DZIAN Prague May 2015 Acknowledgement I would like to thank my supervisor Ing Michel Kana Ph D for dedicating a lot of his time and patience in order to help me write this thesis His advice allowed me to improve the quality of the work I would also like to thank my co supervisor Ing Michal St panovsky whose practical advice helped me a lot Declaration I declare that I worked out the presented thesis independently and I quoted all used sources of information in accord with Methodical instructions about ethical principles for writing academic thesis Abstrakt C lem t to pr ce je vytvorit webovou platformu pro ukl d n fyziologickych dat pouzitim telemedic ny v prost ed ch s n zk mi zdroji Pr ce zahrnuje anal zu po adavk pacient a l ka v takov ch prost ed ch Prvn st pr ce se zab v po adavky v oblasti telemedic ny v etn existuj c ch Open Source e en Druh st popisuje navrhnut e en a jeho implementaci Abstract The aim of this thesis is to develop a web based platform for patient physiological data acquisition and storage using store and forward and interactive telemedicine paradigms in low resource environments The work includes the analysis of difficulties encountered by patients and their health pr
35. Name as parameter an returns the corresponding model name For the input Medical Record or medical record the method will produce MedicalRecord e getResourceBindingTableName This method accepts two parameters the parent Resource Type name and the child Resource Type name and returns the corresponding binding table for the two Resource Types Note these conventions assume that used names would be in English 5 5 Security The server ensures data security in different levels Authentication Each user interacting with the system remotely via a client or not must login by providing valid password and login The user password is encrypted bcrypt a key derivation function that a salt per user to protect against rainbow table attacks Authorization 43 The authorization can be specified for each Resource Type and also for each attribute of a Resource Type For each Resource Type Resource Type Attribute the following access rights can be defined View defines access for viewing a Resource Type Resource Type Attribute Insert access for adding new records Update access for updating Delete access for deleting Encrypt access for encrypting Import access for uploading data Export access for exporting data This offers security and respects at the same time our requirement N3 defined in chapter 2 about flexibility Indeed instead of deciding who has access to what the system organizations define their own access r
36. Resource Types To generate the right table name respecting the naming convention the ResourceTypesController calls the ResourceNameSolverComponent which applies the naming convention 39 A new row is inserted into the table resource types resource types The record contains the id of the parent Resource Type and the id of the child Resource Type This helps keep track of the Resource Type Bindings Managing Resources Resource Type objects are not directly known by the system they are not part of classes modeled in the system because they are created dynamically Here we explain how the system manages them This includes creating new instances of these dynamically created Resource Types which means adding new records in the new generated tables This is possible thanks to the meta tables They store information about the dynamically created tables That is why before or after creating a new Resource Type we store information about it into the meta table resource types In the same way we also save Resource Type Attributes Resource Type Bindings into meta tables Viewing the created Resource Types All dynamically created Resource Types are immediately visible via the view method of the ResourceTypesController controller class This method accepts one parameter the id of the Organization So by typing resourcetypes view some existing organization id the user can view the list of all created Resource Types of the give
37. Save SS i et Show Error Jj 4 Figure 5 10 Adding a Resource Binding Naming Conventions From the above section we have learned that to be able to retrieve data in the dynamically created tables the application used the information stored in the meta tables That means that the application first gets the Resource Name from a meta table which allows it then to query on the dynamically created table using that name For all this to work properly it is necessary to respect certain conventions when it comes to naming such tables This is very crucial as the application relies on the correct table names to be able to work with it To achieve this a couple of rules are necessary In this section we define those rules and explain how they are implemented e Model Naming As already stated model class names are singular and CamelCased The model name is important as it corresponds to a database table This correspondence is made possible by using the model class name e Resource Type Table Naming Table names corresponding to models are plural and underscored Examples of conventional model and corresponding table names are shown in the following table Model Name Table Name Patient patients MedicalProblem medical_problems HeartRate heart_rates Table 13 example conventional model and table names 42 Table field names are also singular The table fields with two or more words are underscored
38. URI The URI notation is usually in the format containing a relative path related to some base address The base address depends on the final placement deployment of the application It will be the root or other specific address of the server on which the application will be deployed That is why we do not consider it here All requests will use the following format service action resource_type e Service this is the name of the service provided by server i e data upload For illustration purposes we implemented one service called restDataTransmitter e Action this tells the server which action or operation to perform in order to serve the client s request 3 actions operations are currently supported o add resource used for creating a new Resource o add binding used to create a Resource Binding o add binary used to send a file If the specified Action is not supported by the server the server returns the status code 501 in its response Note Implemented see table 11 26 e Resource type this is the name of the Resource Type related to the client s request It can be patient diagnosis heart rate It must match the exact name of an existing Resource Type on the server otherwise the server will return the 404 status code Not Found see table 11 To determine the exact name of Resource Type we use a naming convention Resource Type names used in the request are singular and CamelCased Examples of the correct Resour
39. actions between an actor user or admin and the system The first diagram figure 4 1 shows all basic actions that can be performed by the system user An ordinary user can login into the system view its profile change its password and update its personal data if he is allowed to do so personal data exeend extend i Mp n lt lt extend gt gt Exe xextendes D lt enbn gt Cone om Data lt lt extend gt ae Manage M Resources panum 7 sxextend gt gt password View Resource m y View Organizations Manage Resource Types Manage Organizations Figure 4 1 Use Cases Basic actions performed by system user 18 Admin An ordinary user can eventually view Organizations and Resource Types and possibly manage some Resources on which he has access rights The admin user inherits all actions of the ordinary user meaning that he is able to perform all use cases an ordinary user can perform In addition to this admin can also manage users Organizations and Resource Types The diagram in figure 4 2 illustrates use cases for managing users As shown in the diagram the admin can not only manage users add edit and remove but he can also manage groups and access rights Thus he can grant access rights to specific users or to a group or users lt lt extend gt gt lt lt extend gt lt lt extend gt a lt lt extend gt Admin geen lt lt
40. ader and the body is made of e Resource id id of the resource for which data are being sent If data to be sent is for example patient s documents pictures or heart rate the resource id will be the patient id e Data data to be sent to the server The admin has to specify which users are allowed to upload data for chosen Resource Types There are two kinds of data that can be sent o Binary data file this is used when data to be sent are saved in a file It is possible to send more files at once Each file to be sent has the following attributes 23 AttributeCode this refers to a specific Attribute of a Resource Type For example the Resource Type Patient may have an attribute called Documents So when sending a patient s document the client must specify Documents as the value of the attributeCode field Filename the name of the file that is being sent Size the size of the file Content the file content This content must be encoded into a text using Base64 method Here is an example of what it looks like files file attributeCode DOC filename a conrete file name size file size content file content base64 encoded file attributeCode PICTURE filename another file name size another file size content another file content base64 encoded o Text data the set of attribute value pairs where attributes are the Resource Type Attributes of a
41. artRate or Picture Once data are specified the client proceeds by preparing the request to be sent to the server The request will have the format described in chapter 4 and will look like data resourceType Patient resourceID 12344 file attributeCode Picture filename picture1 txt type text size 58096 content 23s84weeej4smndjd09ems jdaszzzzxxxxpoe9982njd Osdsdsdksdj8uuennenn7ee7766636636hgbnssnndddndnddgbddny0e9983nd jdndndndn dnkjshdkjsdhsjkdhjkdhjksdhjksdhkjshdkjn psdnd ddddsdsdsdsdsdsd9e8snsd jsdjsddddddddddddddddddddddddddjjnndedjdjdjdjd l Concretely the client will extract information concerning the file name type and size transform the file content into a text using 64base transformation and finally encode all this into JSON format That will form the body of the request 53 In the header the client must also specify the user credentials login and password for the authentication That is all data can be now sent to the server The next step is to handle server s response 7 3 Sending Patient Pulse Rate The process for sending patient s heart rate is exactly the same as described in the previous section The appendix A contains a User Manual describing how to measure pulse rate and save the measured samples into a file Because patient s heart rate data is saved into a file sending it to the server is the same as sending any other file to the server
42. atient 1 83 other 0 0 73 24 Your name 25 Your email address La t l m decine dans votre pays r gion 1 La t l m decine est elle utilis e dans votre pays Oui 3 25 Non 5 41 7 Je ne sais pas 3 25 2 Que pensez vous de l utilisation de la t l m decine La t l m deci 4 La t l m deci 0 La t l m deci 7 La t l m decine est n cessaire 7 58 3 La t l m decine est utile mais ce n est vraiment pas une n cessit 4 33 3 La t l m decine n est vraiment pas utile 0 0 3 Quelles sont les principales difficult s que vous rencontrez lors de l utilisation de la t l m decine Il n y a pas de logiciel de t l m decine qui soit libre ou gratuit 5 45 5 96 74 Les logiciels de t l m decine existants sont difficiles comprendre 2 Les logiciels de t l m decine existants n offrent pas les fonctionnalit s 2 n cessaires Le manque d infrastructure 7 Des probl me li s la connexion Internet 6 18 2 18 2 63 6 54 5 9b 4 Pouvez vous dire quel est peu pr s le pourcentage de personnes qui utilisent la t l m decine dans votre pays r gion Je ne sais pa 5 Entre 10 et 5 0 Plus de 50 0 Plus de 10 1 Moins de 10 5 Moins de 1096 5 41 7 Plus de 10 1 83 Entre 10et 5076 0 0 Plus de 5096 0 0 Je ne sais pas 5 41 7 5 La t l m decine est elle utilis e sous forme de logiciel libre dans vot
43. ce Type naming in requests are o Patient o PatientDiagnosis and o PatientHeartRate e The asterisk means that the request may have some parameters The parameters are specified in the following format parameter1 value1 In the case of more parameters the format will be parameter 1 value1 parameter2 value2 parameter3 value3 The following table gives examples of valid Request URI Request URI Description restDataTransmitter add_binding Add a new Resource of type restDataTransmitter add_binary Used to send some binary data restDataTransmitter add_resource Used for example by a doctor to remotely add a new patient to the system Table 12 examples of requests URI 21 Chapter 5 Implementation of the Server This chapter describes the implementation of the proposed solution in details focusing on the server side of the system First we introduce technologies used for the implementation of the server application and then we describe the application structure and the data model used in the server part of the application Some implementation details are also discussed in this chapter 5 1 Used Technologies The server application is completely programmed in the PHP script language PHP is a server side scripting language primarily designed for web development but can be used as general purpose programming language as well For the database we use the relational database management system called MySQL
44. cess role id Figure 5 3 Data model Below is the description of some of these meta tables e resource types will contain information about Resource Types e organizations resource types association table that will store the relationship Organizations and Resource Types 32 e resource types resource types association table that will store the Resource Type Bindings e resource type attributes will contain store Resource Type Attributes e resource type attribute types will store Resource Type Attributes characteristics Besides these tables there are also other tables that will contain Organizations Users User Groups and Access Roles and Rights User access rights are defined in different levels users can have access on Resource Types and or on their Attributes and on Organizations The same applies for user groups 5 4 Implementation Details 5 4 1 Class Diagram Model Classes 29 The model classes form the business layer in the application They represent data and are used to manage almost everything regarding data This includes processing validating associating or other tasks related to handling data Each model class corresponds to a database table A model can be associated with other models as we can see it in figure 5 4 For example the model class ResourceType is associated with the model class ResourceMetaT ype AppModel N Lo xS ResourceBinaryData getOrganizationResourceTypes
45. changePassword add edit view delete view delete addAccessRight viewAccessRights editAccessRight Component Classes Component classes are functions that are shared between controllers They are best used for code that is used in many but not necessarily all controllers In the application we implement for now two components as show in figure 5 6 the ResourceNameSolverComponent and the AuthorizedComponent The first one is used to manage the naming convention Given a Resource Type name this component is able to render the exact name of the database table of this Resource Type and also the model class representing this Resource Type It does so by applying the naming convention rules see the section Naming Conventions for more details The AuthorizedComponent is used to ensure the application authorization Concretely it is used to determine if the identified authenticated user is allowed to access the resources they are requesting In addition to these two components the application also uses the components provided by the framework such as Pagination Sessions Authentication Security and Request Handling ResourceName SolverComponent AuthorizeComponent getResourceTableName isAuthorizedResourceType getResourceModelName isAuthorizedResourceTypeAttribute Figure 5 6 Component classes Helper Classes Helpers are the component like classes for the presentation layer
46. code and possibly data required by the client The following table contains all status codes that can be sent by the server Note that these are some of the standard HTTP status codes 20 HTTP response Description 200 OK 201 Created Request to create a new resource is successful 204 No Content The server fulfilled the request but does not need to return a response body Successful request 25 HTTP response Description The request could not be processed because it contains missing or invalid information For example the bad JSON format file sent is too big 400 Bad Request 401 Unauthorized The credentials provided with this request are missing or invalid 403 Forbidden The server recognized the given credentials but the user does not have proper access rights to perform this request 404 Not Found URI provided in a request does not exist 405 Method Not Allowed The HTTP method specified in the request is not supported for this URI The server encountered an unexpected problem which prevented it from fulfilling the request 500 Internal Server Error The server does not currently support the functionality required to fulfill the request 501 Not Implemented Table 11 status codes sent by the server The Resource Identification Each resource is uniquely identified by a so called Request URI Uniform Resource Identifier
47. d it can easily be used in the presence of a firewall 18 4 3 1 The Server The server is the main application responsible for managing clients requests and serving them The server application is also used for managing Resource Types Resources Organizations and users It is the central part of the system administered by an organization hospital clinic or another health organization 4 3 2 Clients The client side of the system will be mainly used but not only by patients to send their data to the server There may be many clients each being specialized for a given Resource Type For example if the Resource Type is Patient then a client can simply generate a form for filling Patient attributes such as Name Age ID number etc But if the Resource Type is heart rate data measured by a sensor and saved into a file then a client may be specialized for reading such file and generating attribute value sets that will be sent to the server Another client can send patient s medical data 22 4 3 3 Description of the HTTP API As already mentioned both client and server use HTTP HTTPs for communication Because clients will be sending data to the server the HTTP POST and PUT methods are used as their allow posting data to the server The GET method can also be used to send data to the server but is less secure compared to POST because data sent is part of the URL 20 Thus we choose the POST method to fit the security requirement W
48. dBinding viewAII viewBinding viewBinaryData containAttribute selectResourceAttributes getResourceBinaryData ResourceTypesController beforeFilter index view add edit remove viewBindings addBinding editBinding AppController isAuthorized beforeFilter MetaDataController beforeFilter index viewResouceMetaTypes addResourceMetaType EditResourceMetaType viewResouceTypeAttributes addResourceTypeAttribute EditResourceTypeAttribute CakePHPController viewResouceTypeResourceTypeBindingGroups addResouceTypeResourceTypeBindingGroup EditResouceTypeResourceTypeBindingGroup viewOrganizationResourceTypeBindingGroups addOrganizationResourceTypeBindingGroup viewOrganizationResourceTypeBindingGroup ResourceMetaTypesController beforeFilter index RestDataTransmitter Controller beforeFilter handleClientResquest add resource add binding add binary sayeFiles AccessRolesController index beforeFilter add edit OrganizationsController index menu Figure 5 5 Controller classes 35 UserGroupsController beforeFilter index add edit addAccessRight ViewAccessRights editAccessRight PagesController display UsersController beforeFilter index login logout
49. e them All tested functionalities worked successfully 8 2 Testing Heart Rate Measurement The hardware prototype was tested by four users independently Each of them has measured its heart rate and sent it successfully to the server using the implemented client application The experiments have been made in three different scenarios 1 We tried to measure with the sensor not attached in the body at all the result is shown in figure 8 7 8 7 Example of measured signal when the sensor is not attached on body 2 The sensor attached on ear lobe 8 8 Sensor attached on ear lobe 3 The sensor placed on finger 61 8 9 Sensor placed on finger Conclusion When attached on finger the sensor measured real hear rate 62 Chapter 9 Conclusion The aim of this thesis was to develop a web based system allowing the patient data acquisition storage and retrieving in low resource environments Before designing and implementing the system we have first analyzed the requirements in telemedicine especially in low cost environments This analysis consisted in communicating directly with potential users patients and heath care specialists from different countries This was done by means of a survey and also by personal contact with some doctors We have also explored the literature to get more information about the requirements All this analysis including the study of existing open source solutions allowed us to define our system
50. e Sensor as described in previous chapter are saved in a file in the above format i e x1 sample x2 sample x3 sample x4 y4 sample where sample is either the Inter Beats Intervals IBI or Beats Per Minutes BPM and x timestamp 54 7 4 Handling Server s Response After sending data to the server the client expects the server to send some feedback The server s response in this case contains essentially a status code such as described in table 11 One of the client s tasks is to receive and interpret the server status code The following rules apply when it comes to interpreting status codes e If the code is in the range of 200 299 this means that everything is OK especially when the status code value is 200 The client then lets the user know by printing a OK message OK Data successfully sent e If the code is in the range of 400 499 there is an error in client s side forbidden user not authenticated not allowed bad request etc The client prints an error message Oops The server could not process your request It seems like there is something in your request that the server does not like Here is what he said bad request e When the code is between 500 and 599 this means that an error occurred in server s side In this case the client also prints an error message Oops It seems like the server encountered a serious problem while processing your request Please try it again later 55 Chapter 8
51. e by clinicians OpenVistA provides clinical administrative financial and infrastructural functions It has been adopted for use by several other health institutions in US as well as hospitals in other countries e g Egypt Germany and Mexico However the technology used by Vista is not based on modern computer language or platform 14 Key features e Clinical documentation e Health Information Management System HIMS e Patent registration e Scheduling e Notification and reminders OpenVistA Type Electronic health record for all clinical field based on veteran s hospital information system Programming language MUMPS Delphy Kylix Public domain GPL http www medsphere com open vista Table 2 Technical overview of OpenVistA OpenMRS OpenMRS is a collaborative open source electronic medical record system entirely programmed in Java OpenMRS is also a community of people working to apply health information technologies to solve problems primarily in resource poor environments It has been supported by the Google Summer of Code from 2007 14 Key features e Tools for data export and reporting e Support for HIV AIDS Drug resistant TB primary care and oncology e Supports open standards for medical data exchange including HL7 LOINC and IXF e Form based tools such as the Form Entry module and XForms module e Bidirectional synchronization with systems such as MoTeCH and TRACnet OpenMRS Type
52. e reset values 22 IF N delay2 THEN 23 Reset all parameters to their default values 24 END IF After reading the signal from the sensor line 1 we compute time since the last valid beat and try to make some controls and make sure that the signal is really a heartbeat In lines 5 and 8 we keep track of the highest and lowest values of the PPG wave Peak and Trough in order to get the accurate amplitude which we compute in line 18 To avoid noise there is a time period of 3 5 IBI that must pass before we compute the Trough line 4 In line 10 we can see that there is another time period that must pass before we look 50 for a valid heartbeat in order to avoid high frequency This time period can be for example 250 milliseconds which is equivalent to a maximum of 240 BPM After that delay if the s a heart beat Boolean parameter was set to false then we know that we have a heartbeat We can then compute the BPM and send the signal via the serial port Note that the function implementing this algorithm must be called every 2 milliseconds as described in the previous section The BPM is derived every beat from an average of the previous 10 IBI times We compute it by using the following algorithm Algorithm 2 ComputeBPM IBI 1 Is a heart beat true 2 lastTime time 3 total 0 4 N 10 5 FOR alli 0 N 2DO 6 rate i rate i 1 ds total total rate i 8 END FOR 9 rate N 1
53. e use POST for inserting new data and PUT in case we want to update existing data This is according the HTTP recommendations 20 This section describes the API or application programming interface used for the communication between the clients and the server Concretely it deals with the design of the model of resources to be shared between clients and server This includes the identification of the resources the format used to represent those resources and the attribution of URL for getting them Data Representation We use the format called JSON to represent data JSON stands for JavaScript Object Notation and it is an open standard format that uses human readable text to transmit data objects consisting of attribute value pairs It is completely language independent and easy for machines to parse and generate 19 JSON is built on two structures e Acollection of name value pairs e Anordered list of values Note that this is not the internal data representation in server s nor in client s side This is used only for the communication The server has its own data structure described in chapter 5 which is unknown to the client Each client may also have its own internal data representation and the server will not care of what it can be Making a HTTP Request The client application addresses the server using standard HTTP request Each request sent by a client contains the authentication information login and username in the he
54. eant Uo aea ener eate 48 7 Implementation of the Client for Sending Patient Data ses 52 T Loginto the Applicat OM oio ere Mist toe aspe eU mile QOL and 52 7 2 Collecting and Sending Data to the Server 53 T3 Sending Patient Pulse Raten soos pra etna EE E EE RR 54 7 4 Handling Server s Response oe nentes Heo SU as ke Ur IU sues tees aves tid arva pede 55 D PSN ainsi uet opea T ATIT Dai UR UE sisi 56 8 1 Testing the Dynamic Aspect of the SysteM essseesssessseessecssoossoossssssssessseessoossoossssssssesssose 56 5 2 Testing Heart Rate Measurement 25365 se oe Po S eso p cons ee ipso S NEU EUM eek RVp e Se pb CER ER RE UNE ENSE CUR 61 9 CONCIUSION m cr 63 Literati C ecc 65 Appendix A User Manual for Measuring and Sending Data to the Server 67 Appendix B SUEYGV eoi ers tn eire tode shore pp EE ns den ee ni nent etes 68 Appendix C Contents of the attached CD eee eee eee eee ee esee ee seen seen staat aae 82 Chapter 1 Introduction TELEMEDICINE is the use of telecommunication and information technologies to improve patient s clinical health status 1 The aim is to improve a patient s health by allowing two way interactive communication between the patient and the physician or practitioner at the distant site The term telemedicine was first used in the 1970s and literally means healing at a distance 2 There is no definitive definition o
55. ecords e Electronic and paper billing e SQL reporting e Support for manipulation of with data in HL7 and Continuity of Care Record CCR formats mO 2 ClearHealth Type Practice management and electronic medical records system Programming language PHP License GPL Website clear health com Table 9 Technical overview of ClearHealth OpenDental The last electronic medical records application we would like to mention is OpenDental It has the specification of being focused on dental care providers Previously known as Free Dental OpenDental is owned and sponsored by Open Dental Software Inc which is incorporated in the State of Oregon in the United States of America It is written in the C programming language compatible with Microsoft NET Framework Key Features e Online patient forms e 3D movable teeth e Text messaging e Mobile Web application e Kiosk e Signature pads e Multipage scanning OpenDental Stable release Programming language C License GPL Website www opendental com Table 10 Technical overview of OpenDental 3 2 Discussion about Existing Open Source Solutions In the previous section we presented some existing Open Source solutions in telemedicine It is obvious that Open Source Systems have a great potential in offering low cost and relatively quality electronic health records systems This is a great alternative to proprietary solutions for developing countries with limited
56. ecurity systems etc e Telecommunication equipment and systems In telemedicine the equipment used for both the patient and the specialist varies depending on concrete requirements These include telephone terminals personal computers PDAs video stations computer peripheral equipment such as digital cameras document scanners high resolution screens etc e Communication network Communication network allows the transmission of information to a referral center In 9 Dr Andrew Watson recommends strong platforms for managing people locations and devices to address infrastructure issues In developing countries the choice of adequate technologies can be very difficult In addition to the distance barrier patients in rural areas must also deal with issues related to the lack of technologies In many developing countries people have still to deal with issues such as lack of electricity poor or lack of Internet connection While designing a telemedicine system therefore it is important to consider the availability of local infrastructures and select the adequate technologies adapted to those infrastructures to fit the local needs A telemedicine system should propose a way to transmit data even in the context of poor or lack of Internet connection For this purpose alternatives should be used such as mobile phones 2 1 3 Requirements regarding Cultural Barriers In the study Barriers to Telemedicine Survey of Current Users in Acute Care
57. ed to patients All tested system functions worked as expected The following figures show the screenshots realized while testing Bilongo Hospital Resources of Type Patient Visit Picture Documents Heart Rate Show 10 v entries Search Ali Bakari 1986 01 28 Douala 452315 Douala Male 29 MUDr Ben Khan 1981 01 14 Yaounde 758451 Yaounde Male 34 Ing Denis Green 1968 08 09 Douala 555412 Douala Male 47 Bc Eric Essindi 1985 02 28 Kribi 758451 Kribi Male 30 Figure 8 2 Created patients in Bilongo Hospital testing Organization Visit Adding New Resource of Type Visit for Patient Date June v 12 M 2015 Time 11 L 0 X am v Description Figure 8 3 Adding a visit for a given patient Second Organization 57 For the first Organization Central Hospital Yaound we have created the following Resource Types e Patient with the same attributes described previously e Diagnosis with the following attributes ID Name Code and Type e Physicians with the following attributes ID First Name Last Name Central Hospital Yaounde Resource Types Show 10 v entries Search Diagnosis Diagnosis Patient Patient Physician Physician Visit Visits Showing 1 to 4 of 4 entries Previous 1 Next Figure 8 3 Resource Types created for the Central Hospital Yaound Organization Then a binding has been created between Patient and Diagnosis and between Physician and Patient The following functionalities have bee
58. eep their treatments confidential Transmission and storage of electronic files images audios videos etc needs to be done with the same caution and care as applicable to paper documents 10 To cope with these issues a telemedicine system must provide as much security as possible Users must be sure while using the system that their data are securely protected against unauthorized users To ensure maximum security the system must use secure networks while transmitting data stored data must be encrypted appropriate authentication and authorization must be provided 2 1 5 Financial Problems Another barrier to telemedicine is reimbursement Medicare services lack reimbursement terms This is due to the fact that there are no clear standards for payment or reimbursement for telemedicine in many countries 9 In developing countries there is significant limited competition for telecommunication services which keeps the communication cost high 32 In addition the equipment designed for telemedicine including hardware and software is also relatively expensive and therefore not accessible for many Due to these financial problems the resources used by a telemedicine application must be low cost meaning that the selected resources to be used must be as cheap as possible This includes software and hardware 2 2 Functional and Non functional Requirements Based on the above analyze of business requirements we define the following
59. egarding requirements for a telemedicine solution in low resource environments 2 1 1 Requirements regarding distance barriers As mentioned in the introduction distance barrier is one of the basic problems faced by people living in rural and sometimes in completely isolated regions Indeed rural residents must travel longer distance than people who live in cities to get to hospitals The challenge is made even more complicated by the largely absent public transportation systems 7 Because ambulances and other emergency vehicles must travel so far rural residents with emergencies receive medical attention more slowly than their urban counterparts Most of the time people who live in rural communities are more poor that those living in cities so paying for the transport to get to the hospital or to a health center may complicate life to many people For example a patient with chronic disease will have to spend a lot of money in order to receive appropriate heath care A telemedicine system should help overcome these issues by allowing access to specialists regardless of location This can be done by using live video conferences or medical image or video sharing communication portals A telemedicine application should allow for reliable transmission of vital signs This enables patient assessment by specialists in the specific pathology and immediate reception of appropriate treatment guidelines until the patient s arrival at hospital 8 Allowing r
60. el class may need specific queries that are not available in the inherited methods In this case we can define a method that will perform the needed queries This is the case for the model class Resource Besides the inherited methods it implements its own methods getResourceBindings saveResourceBinding getResourceBinaryData getBinaryDataByID The application model class AppModel is used as the intermediate class between all model classes and the CakePHP internal model For now it is empty But the idea of having the AppModel is to have a possibility to define functionality that should be made available to all models within the application Controller Classes Controller classes are kind of middle man between the Model and View layers After routing has been applied the Dispatcher chooses the correct controller to process user s or client s request Controllers provide a number of methods that handle requests These are called actions Each public method in a controller is an action and is accessible from a URL An action is responsible for interpreting the request and creating the response Figure 5 5 shows all the controllers of the server application As we can see controllers don t talk to each other They even ignore the existence of each other This does not apply for the AppController this class is the parent class to all the application s controllers meaning that all application controllers extend the AppControll
61. emote communication between patients and physicians or nurses can not only help in solving emergency and overcome the distance barrier but it also helps saving money that would be spent for travelling purposes Many studies have been conducted to show telemedicine significantly reduces unnecessary transport of patients or medical staff For example one study in Peru in the province of Alto Amazonas shows an important reduction in emergency transport which confirmed that the system was efficient and also demonstrated that the additional costs of maintaining the system were lower than the direct costs of the health system 8 2 1 2 Technology requirements The success of telemedicine systems depends primarily on the various medical devices used to collect patient information and the telecommunication infrastructure used to share data with physicians or other medical staff Basically we have the following categories 8 e Terminal devices to capture patient biomedical signals This includes Electrocardiography ECG or EKG and sensor based devices such as glucose sensors mobility and or position sensors for the elderly or people with reduced mobility temperature measurement devices etc e Services components and applications for healthcare management These may be software applications that enable service coordination appointments agenda setting patient identification patient file management medical records system messaging data s
62. eps track of all Resource Types New records are inserted into the database table organizations resource types to specify to which Organizations the new Resource Type belongs New rows are inserted into database table resource type attribute types to record the new Resource Type Attributes and their characteristics A new model class is generated in the Model layer defined in a new generated file The name of this class corresponds to the name of the Resource Type The created model class is empty meaning that it contains no logic but just the class definition which looks like php This file was generated automatically aa This class represents the Resource of Type SRESOURCE TYPE NAME x author System class SRESOURCE TYPE NAME extends AppModel no code is needed here The new created class does not need to implement any logic because it extends the AppModel which in turns extends the CakePHP core Model As already explained this inheritance allows new created model class to be endowed with all the functionality it needs to manage data in the database that means create save and delete data etc 38 That is all The new Resource Type is created and ready to be used No controller class is needed because there is one controller that helps manage all the dynamically created Resource Types the ResourcesController see the third step Figure 5 8 shows the sequence of communication between different
63. er class AppController itself extends the controller class included in the CakePHP core library As in the case of models the inheritance of the CakePHP core controller allows the application controllers to use CakePHP functions available in the core controller This prevents us from writing some boilerplate code we would otherwise need to write As already stated controller classes do not communicate between them but each controller can use its corresponding model When the model name matches that of the controller this 34 model is automatically made available for access and the controller can directly use it For example the controller ResourceTypesController will automatically initialize the ResourceType model But the controller can also load other models and use any component class see the next section In the class diagram of figure 5 5 one can notice that most of the controllers have a method called beforeFilter This is one of the callback functions provided by the CakePHP core controller used to insert logic around the request life cycle This function is executed before every action in the controller We use it especially to control the user access So before processing the user request we first control in this method if he has access to the resource is requiring or not ResourcesController beforeFilter index View add edit remove export import encrypt Ad
64. erent business cases Each organization has its own needs The system should allow different organizations to adapt it to their needs e N4 The system must provide a high level of security Because the system will work with patient s data it must provide different security methods to protect it including encryption secure transmission authorization and authentication e N5 The implemented solution should be low cost The system will primarily be used in low resource environments e g developing countries it should use the cheapest possible resources That means that technologies and resources used to build the system must be adaptable in low resource environments Chapter 3 Existing Solutions in Patient Management and Data Acquisition With the advent of the Internet many patients are eager to get information about their health instantly As its name says Electronic Health Record EHR refers to a systematic collection of electronic health information about an individual patient or population 15 Sometimes the term Electronic Medical Record EMR is also used to refer to EHR In many countries the use of EHR is getting more and more popular That is why many governments make considerable efforts to improve efficiency in medical services using EHR systems However even though EHR systems have proven their efficiency many healthcare organizations have yet to implement them This is mainly due to financial reasons medical software
65. ethods and found out that better results were in our case observed while measuring the IBI by timing between moments when the signal crosses 5096 of the wave amplitude The algorithm looks like this 28 Algorithm 1 Process the Heart Rate Analog Signal Signal Read Analog Signal from Sensor 2 time lt time 2 time between two signals 2 ms 3 interval time lastTime time since the last beat to avoid noise 4 IF Signal Trough AND interval gt IBI 5 3 AND if Signal Trough THEN avoid noise 5 Trough lt Signal remember the lowest point in pulse wave 6 ENDIF 49 7 IF Signal gt T AND Signal gt Peak THEN 8 Peak Signal remember the peak 9 ENDIF here we assume the signal is good 10 IF interval gt delay AND Signal gt T AND Is a heart beat false AND interval gt 3 5 of IBI THEN 11 IBI time lastTime Inter Beat Interval the time between beats 12 BPM ComputeBPM IBI Beat Per Minute this is our famous heart rate 13 SendDataToSerial Signal IBI BPM send the signal via serial communication 14 END IF after the heartbeat values go down 15 IF Signal lt T and Is a heart beat true THEN 16 Is a heart beat false 17 amplitude Peak Trough 18 T amplitude 2 Trough set T at 50 of the amplitude We can try also 25 19 Peak T 20 Trough T 21 END IF if after certain delay there is no heartbeat w
66. f telemedicine but we can retain the one adopted by the World Health Organization The delivery of health care services where distance is a critical factor by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis treatment and prevention of disease and injuries research and evaluation and for the continuing education of health care providers all in the interests of advancing the health of individuals and their communities 4 From the above definition one can notice that emphasis is placed on the distance meaning that telemedicine is mainly used to eliminate distance barriers and improve access to medical services that would often not be consistently available in distant rural communities The given definition also highlights that telemedicine is an open and constantly evolving science because it incorporates new advancements in technology and tends to respond and adapt to the changing health needs and contexts of societies and cultures Actually telemedicine involves a growing variety of applications and services using two way video email smart phones wireless tools and other forms of telecommunication technologies These technologies allow communication between a patient and a physician or other medical staff with both convenience and fidelity as well as the transmission of medical imaging and health information data from one site to another In addition
67. financial resources Advantages of Open Source Among the benefits of Open Source we can mention the following 17 e Open Collaboration U One of the most significant advantages of the use of Open Source is the fact that it involves an open collaboration and transparency Many people come with new ideas and share them with others Most of the time they do not hesitate to criticize and improve other s work Instead of being hidden problems are exposed early open to see and fix Being open the code is free to be evaluated by a large community which accelerates the innovation allows testing to be done by a broad audience Moreover there are no timetables or deadlines and release does not occur until the product is refined e Modularity Another great advantage of open source applications is the fact of being most of time modular Modularity allows software to be easily extended and to collaborate with other systems e Interoperability and standards The open source programming model has being shown to facilitate development of interoperability and standards 17 In open source model developers usually use existing project as a reference and build upon it This makes standardization quickly achieved Drawbacks of Open Source From the above we can clearly say that Open Source has many attractions However it also has some barriers that must be considered Let us mention some of them e Lack of Non Programmer Configurabil
68. functional and non functional requirements for our system 2 2 1 Functional Requirements e RI The system must allow remote communication between patients and their health professional in order to eliminate distance barriers between them R2 The system should be flexible enough to allow managing different types of objects It should be possible to manage not only people users but also other objects such as devices documents etc R3 The system must allow patient to send different kinds of data R4 The solution should include a method for patient cardiac data acquisition The patient will have a possibility to measure view and send heart rate signals to his doctor via the application R5 Allowed users can log in into the system and view resources they are authorized to view This means that the system must provide authentication and authorization Different access rights will be defined for different users R6 All patient data will be saved into a secured database 2 2 2 Non functional Requirements e NI The system should allow the use of mobile phones to transmit data This will allow users with poor Internet connection to use the system with their mobiles phones e N2 The system should be easy to manipulate As the system will be used by people who do not necessarily have good experience in the use of IT systems it is required that the system will be user friendly and easy to manage e N3 The system should be adaptable to diff
69. he system at all but only patients and physicians As we can see in the scenarios above each organization has its own needs Our ambition therefore is to build a system that will be flexible enough to respond to all these needs The key for the success of such a system is a clever generic or meta data model instead of defining model specific classes such as Patient Physician Nurse Device etc we simply define a generic class called Resource Type This meta class will then encapsulate specific classes such as Patient or Physician When installing the system the organization will not only be able to define its specific Resource Types but also set relationships between them A system having such characteristics will match requirements R2 R3 N2 and N3 defined in section 2 2 4 1 Definitions e Resource Type A Resource Type is a meta class used internally by the system to encapsulate specific classes Because the model is generic we do not directly define specific resources like Patient or Physician because we do not now in advance if organizations will incorporate them into their model or not But we assume that organizations may wish to have such resources and therefore we prepare a place for them and give them a generic name Resource Type Thus a Resource Type can be whatever Patient Physician Device Diagnosis Document etc e Resource Meta Type 16 Resource Types are grouped in different categories called Resource
70. icate the user but let the server do the authentication This is because the client does not have any database to compare user credentials Hence when the user log in the client application simply remembers saves into Session the user s password and login and will use them later when contacting the server to send data for state less communication 52 7 2 Collecting and Sending Data to the Server As already mentioned this client is designed to send binary data files to the server To do so the client proposes a form to load the file to be sent to the server When sending data the following must be provided by the user via the form e The name of the Resource Type i e Patient Diagnosis This must match the name of an existing Resource Type in server s side e The Resource ID In case of Resource Type Patient for example this will be the patient s id e The Resource Type Attribute name This also must match the name of an existing Resource Type Attribute name in server e Load the file containing data to be sent All this depends on Resource Types that have been created in server If for example the server has a Resource of type Patient with attributes Document HeartRate and Picture and all have a characteristic of been binary the user can send patient s document heart rate or picture The parameters will be in this case e Resource Type name Patient e Resource Type id 12344 e Resource Type Attribute name Document or He
71. ion of the tissue and provide information on the cardiovascular system in particular the pulse rate 25 A photoplethysmographic waveform is made of two components as shown in figure 6 1 the Direct Current DC component corresponding to the detected transmitted or reflected optical signal from tissue and venous blood and the Alternating Current AC component that shows the changes in blood volume that occurs between the systolic and diastolic phases of the cardiac cycle 27 Light source Other tissues Venous blood Non pulsatile component of artery blood Pulsatile component of artery blood Systolic Diastolic Time phase phase AC Pulsatile part DC Steady part PPG waveform Time Figure 6 1 Variation in light attenuation by tissue taken from 27 6 2 Hardware Prototype In order to monitor patient s heart rate we use the PPG Photoplethysmography method instead of ECG because it is cheaper and simpler than ECG 26 As figure 6 2 shows the hardware prototype we propose will allow a patient to measure its heart rate using the Pulse Sensor which is connected to the Arduino board connected itself to the computer via USB AB connector The following components are used e A pulse sensor called Pulse Sensor Amped e Arduino Duemilanove board with the microcontroller ATmega328 e Anda USB A B cable for serial communication 46 Figure 6 2 Components used for the hardware prototype This
72. ion to be divers and simple Any application supporting HTTP control can communicate with the server by using the IP defined in chapter 4 It can be for example a simple web form installed in patient s PC or mobile phone or another telemedicine application such as OpenEMR That said in this work we implement a PHP web based client to allow users to send binary data to the server The objective of this client is double test the server functionalities to make sure it does well its work and serve as a prototype that will help in the implementation of other clients The client is also implemented using the CakePHP framework The principles of the implementation are therefore the same as in the case of sever see chapter 5 That is why we will not repeat these implementation details here Instead we will focus on how the client works and how users can collect and send their data to the server The client is simple and does not have any data structure It does not communicate to any database It implements the following functionalities allowing users to log in collecting user data using a web form sending data to the server handling server s response This chapter describes all these functionalities in detail 7 1 Login to the Application To be able to send data to the server the user must be authenticated Before the client application shows the form for the user to input its data it first tells the user to login However it does not authent
73. is and defined a Binding between them Then for a given patient i e Jean Paul we call its diagnosis i e diagnosis number 1234 Resource Binding In other words the diagnosis number 1234 is a binding of the Resource Jean Paul of type Patient e Organization An Organization is an entity such as an institution It can be a hospital clinic health care center etc In this model it is possible to define more Organizations in the system Organizations are grouped in a hierarchic structure meaning that an Organization can have one or 17 more children and one parent One and only one Organization is set as the root The root Organization does not have any parent Resource Types are contained in different Organizations Each Organization therefore has a list of Resource Types contained within it e User A system User is an actor who interacts with the system We distinguish two types of users o Ordinary User a normal user with limited access to the system o Admin a more privileged user who can perform more actions than the ordinary user see the next part The admin can grant access rights to each user allowing performing or not some specific actions in the system e User Group Users are categorized into groups called User Group Each user belongs to at least one group Access rights are also defined for each group 4 2 Use Cases This section describes the system Use Cases i e the list of actions defining inter
74. is expensive and many care providers such as doctors hospitals dentists independent clinics and so on have been under a lot of pressure to maintain or reduce run costs while at the same time continuing to provide the quality patient care and customer service expected of the medical care industry 14 In order to reduce the high costs of implementing IT systems in health care many organizations opt for the use of Open Source Software OSS As the open source community continues to grow the number of open source medical applications also grows with it In this chapter we discuss some of the most used OSS in telemedicine and their characteristics 3 1 Existing Open Source Solutions OpenEMR OpenEMR is one of the most popular Free and Open Source electronic health records and medical practice management applications It is ONC certified and supported by a strong community of volunteers and professionals Key Features e Multilanguage Support e Electronic Billing e Document management e Integrated practice management OpenEMR Type Medical practice management software Electronic Medical Records Programming language PHP GNU General Public License www open emr org Table 1 Technical overview of OpenEMR OpenVistA OpenVistA is a fully integrated clinical solution with all necessary functions to run hospitals and their clinics It was designed to improve the care and patient safety for veterans and to be rapidly adoptabl
75. ist client data between page requests o The Request Handler to manage HTTP and HTTPs requests 5 2 Structure of the Application Because the server application is developed using the CakePHP framework it has the same structure like all CakePHP based applications In this section we describe this architecture based on the information provided CakePHP documentation in 21 View Helpers Controller Components Dispatcher m a Model Figure 5 1 The Server Architecture Figure 5 1 shows the architecture of the server application The application is divided into 3 main layers The Model View and Controller layers In terms of Object oriented programming theses layers are nothing but packages containing classes 29 5 2 1 The Model Layer The Model Layer is the central component of MVC that implements the business logic and rules of the application It captures the behavior of the application in terms of its problem domain and it is independent of the user interface The Model directly manages data That means that it is responsible for retrieving data and converting it into meaningful concepts for the application This includes processing validating associating or other tasks related to handling data 5 2 2 The View Layer The View Layer is responsible for rendering a presentation of modeled data It uses the information it has available to gene
76. istance entre patients et m decins Les outils permettant le partage des donn es telles que des images du texte des signaux ECG L valuation des tests cardiaques autonomes La mise en ligne des signaux ECG Les r seaux sociaux ou autres outils de conversation La gestion des patients La planification des visites avec les patients La gestion des dossiers m dicaux lectroniques Les prescriptions en ligne Le support de plusieurs langues 80 90 54 45 45 90 Renseignements sur vous 20 Votre nationalit Congolaise congolaise CONGO FRANCE Tch que Camerounaise Francaise Suisse Congo 21 Dans quel pays ou r gion vivez vous actuellement France FRANCE R Tcheque Europe CANNES France afrique centrale congo R publique Tch que Tch quie Prague Suisse 22 Quel est votre pays d origine France CONGO congo R publique du congo Tch quie Prague Cameroun 81 Suisse Congo 23 Vous vous exprimez ici en tant que M decin 1 83 Patient 2 16 7 Autre 8 66 7 Appendix C Contents of the attached CD A CD with source codes and other materials is attached to the thesis The content of the CD is organized in following directories e Text contains electronic version of the thesis text e Code server the implementation of the server e Code client the implementation of the client e Code Arduino the implementation of the
77. ity Open source software depends mainly on volunteers and is usually proposed as is This may be a problem for organizations that require EMR to be configurable to some degree 17 This requirement is legitimate as clinics and hospitals or other health organizations have different workflow and unique local environments and needs This configuration has to be often done by a non technologist clinician who understands this complex workflow Many open source applications in EMR that are mentioned in this chapter are ultimately configurable but most of them are complex and require a higher level of technical expertise If we consider for example OpenEMR for a non programmer user who would like to start using it it may be a big challenge to even get started The application includes many modules that make it too complex for a beginner Some of the modules may not be needed and it may be very difficult to get rid of them and keep just the needed ones e Perceived Lack of Security As already mentioned clinical information systems require a high level of security in order to maintain patient privacy Some people are skeptical about security of open source software due to the openness of its code 14 Of course this perception may be wrong Open source software can theoretically 14 be made more secure than proprietary software because it can receive input from many developers which allows the immediate identification of security risks
78. l overview of GNUmed FreeMED FreeMED is an open source electronic medical record system based on LAMP Linux Apache MySQL and PHP The project was initiated by Jeffrey Buchbinder in the United States in 1999 Since then it has become an international growing up project with thousands of downloads and several translations FreeMED is currently hosted by a non profit corporation called FreeMED Software Foundation The corporation also provides commercial support for FreeMED FreeMED Type Electronic medical records system for general practitioner clinics Programming language PHP License GPL Website http freemedsoftware org Table 6 Technical overview of FreeMED SmartCare SmartCare is an internationally distributed electronic medical records tool that was developed by the government of Zambia in collaboration with the Centers for Disease Control and Prevention CDC and many other implementing partners The application is currently widely used in Zambia Ethiopia and South Africa It was designed in order to support clinics that need to interface internationally but also have co existing paper based systems It is also built around the assumption that many of the clinics may not have ubiquitous access to telecom systems or even reliable electrical power 16 Key Features e Distributed database system e Smart Card used to store health information e Touchscreen allowing the clinician to view and record patient data
79. n Organization if he has access rights What this method does is simply query on the table resource types where all Resource Types are stored using of course an appropriate model to talk to the database Viewing Records of a Resource Type Viewing records from the dynamically created table is ensured by the controller ResourcesController via its method viewAll The viewAIl method accepts the Resource Type ID as parameter First it gets the Resource Type Name then it tries to load the corresponding model of this Resource Type which is then used to query on the table corresponding to the Resource Type i e on the generated table Adding a Record into a Dynamically Created Table Adding records or Resources into a generated table is also done using the ResourcesController and follows the same logic The edit also follows the same strategy To add a record the method add of the ResourcesController is called This method also accepts the Resource Type ID as parameter in order to be able to determine the right Resource Type table into which the new record has to be inserted Figure 5 9 shows the message sequence chart between different objects while adding a new or editing an existing Resource 40 sd Add Resource Edit is the same M es ae i l 1 i 1 User GetResourceTypeName i LoadResourceType ResourceTypeName I i I 1 1 I I i i i GetResourceTypeAttributes i i 1 1
80. n tested e Creating new records new patients and physicians where created e Viewing records the created patients physicians could be viewed e Editing a record created patients physicians were edited e Removing some created patients physicians were removed from the e Bindings patients were assigned to physicians and diagnoses were assigned to patients figures 8 4 and 8 5 58 Central Hospital Yaounde Alexander Galiente Patient Patient Records assigned to Physician id First Name Last Name Birth Date Birth Place ID Number Address Gender Age Grade 1 Jean Mbida 1985 03 10 Yaounde 123654 Yaounde Male 30 Ing 2 Ali Bakari 1986 01 28 Douala 452315 Douala Male 29 MUDr Figure 8 4 Patients assigned to a Physician Central Hospital Yaounde Jean Mbida 1985 03 10 Yaounde 123654 Yaounde Male 30 Ing Diagnosis Visit Picture Documents Heart Rate Diagnosis Records assigned to Patient New id Name Code Type 1 Diabetes A CX5423 DISEASE 2 Arrhythmia HD3009 DISEASE Figure 8 4 Diagnoses assigned to a patient Third Organization For the Veterinary Hospital the following Resource Types were created e Veterinarian with the following attributes ID First Name and Last Name e Animal ID Name Birth Date Race Gender Then a binding has been created between Veterinarian and Animal where Veterinarian has been set as the parent Resource Type In figure 8 5 we ca view the result 59 Veterinary Hospital Resource Ty
81. of the application They contain presentational logic that is shared between many views Figure 5 7 shows the application Helper sub layer Just like models extend AppModel and controllers extend AppController all helpers extend a special class AppHelper which in turn extends the CakePHP Helper class The application implements just one helper class called TreeHelper This helper is used to display Organizations in hierarchic order i e in a tree like structure 36 PN AppHelper TreeHelper GENERE n Figure 5 7 Helper classes 5 4 2 Implementation of the Dynamic Model As stated in chapter 4 of this document the system we are building is supposed to be generic That is the reason why in all class diagrams and in the database model described in the previous sections there is no specific concepts or objects such as Patient Physician Nurse Diagnosis etc All these are supposed to be created dynamically by the system owner Organization That means that the system is a kind of a global meta model and organizations have to create their own instance of the system to fit their needs In other words how can a system admin create an instance of the system In this section we explain how all this can be done We will describe the way Resource Types can be created and how the system allows managing the dynamically created Resource Types The process follows the following steps Creating Resource Types First the admin has to
82. ofessionals in developing countries The first part of the thesis deals with the analysis of requirements in telemedicine in low resource environments and the study of the existing Open Source software The second part describes the proposed solution and its design including the implementation of the system Contents 1 Introductio Port 1 Z Requirements edo peii TAA EO EEI E EET 3 2 1 Business Requirements in Telemedicine eret teintes tene eet Ue 1 tne ee Ren 3 2 1 1 Requirements regarding distance barriers eeseseeseeseeeseesrssresstseresresseesresressessresees 4 2 1 2 Technology requirements cr OESTE UNSER ARES HER eiis 5 2 1 3 Requirements regarding Cultural Barriers cette teret etae tenete tuos 5 2X14 Cie And Legal 185088 oy sane GG pn cp eae o e a a eae 6 2 1 5 Financial Pr bl ms es einen ie ga ae ea eel Opa de ea ce ee 6 2 2 Functional and Non functional Requirements 6 2 21 Functional Requirements dete dei pado ae aesti ed up QU QUOI Ra i EIAS 6 2 2 2 gt JNornstunctional Requirements oot ceo oett hie bn ele lie een mine 7 3 Existing Solutions in Patient Management and Data Acquisition es 8 3 1 Existing Open Source Solutions oneri etapa ea eere ee en detre 8 3 2 Discussion about Existing Open Source Solutions 13 gittis e c 16 41 Definitions e J M 16 AD Use C ases ster adele etle etse ane en des
83. oles according to their needs Secure data transport When communicating with the clients the server used HTTPS protocol which uses SSL to encrypt data Data are encrypted All patients data are encrypted and saved into database Saving data into database allow effective access control on them 44 Chapter 6 Implementation of a Method for Patient Data Acquisition In this chapter we discuss the implementation of a low cost method for patient physiological data acquisition Our focus is to provide patients with a system allowing them to measure their heart rate and to be able to send it to their help professionals We start the description of the implementation by first providing an overview of physiological signals and different methods used to measure heart rate 6 1 Overview of Physiological Data Human body is constantly communicating information about a person s health state This information is defined by variety of physiological parameters such as heart rate blood pressure oxygen saturation levels blood glucose nerve conduction brain activity and so forth 23 24 Many instruments have been developed to capture those physiological parameters such as sensors placed on the body or implanted These measurements provide useful information upon which clinicians can make decisions However not all physiological parameters are informative and can be used to evaluate patient s health state Moreover the measurement of
84. on dental care providers For this reason it does not fit N3 requirement After personally trying the other OSS we can also affirm that they do not fit all our requirements especially N3 requirement defined in the above chapter Proprietary solutions were not considered as they mostly do not meet the low costs requirements 15 Chapter 4 Solution Design This chapter introduces the design of the solution we propose in this work Low resource environments constraint for our solution requires the system to be easy to use flexible and configurable Such a system will not require unnecessary resources because organizations will configure and adapt it to their needs according to the available resources For example knowing that their Internet connection is not good they may wish to share only data that can be sent through the available bandwidth For the system to be flexible and configurable we propose to build a generic model The Proposed Concept was taken from 29 and is described as follows The idea behind the generic model is to propose a meta model and allow each organization that will use the system to build its own specific model using our meta model Meaning that instead of hard coding a specific concept we let the organization define its own While an organization may wish to manage only patients physicians nurses and devices another one would maybe want to manage patient visits as well Another will not have nurses in t
85. ord Association Data Mapping and Front Controller 20 21 Among all the features that come with CakePHP the following are very significant 21 e MVC architecture CakePHP follows the MVC Model view controller software design pattern which allows strict separation of the application into three main parts called Model View 28 and Controller more about it in the next section This concept turns the application into a maintainable modular package and allows new features to be added without breaking the old ones Developers and designers can work simultaneously including the ability to rapidly prototype e Security CakePHP comes with built in tools for input validation CSRF protection Form tampering protection SQL injection prevention and XSS prevention helping the programmer keep the application safe and secure The security component of Cake also allows the use of SSL Secure Sockets Layer e Localization The internationalization and localization features provided by Cake make it easy for the application to be quickly translated in multiple languages e Documentation CakePHP is one of the most documented frameworks All features including the API are well documented with examples allowing new developers to quickly get started with the framework e Many useful components CakePHP provides many other components such as o Authentication for identifying authenticating and authorizing users O Session provides a way to pers
86. p Open Source Medical Billing and EMR Software URL http linuxaria com recensioni top open source medical billing and emr software 17 Robin Mickelson MS Open Source Software amp the Electronic Health Record RN Informatics Nurse Specialist Methodist Hospital of Souther California 65 18 Elkstein Rest Tutorial URL http rest elkstein org assessed 2015 19 JSON URL http json org 20 W3 org HTTP Specifications 21 Wikipedia Representational state transfer URL http en wikipedia org wiki Representational state transfer access May 2015 22 CakePHP URL http cakephp org assessed 2015 23 A Dosinas M Vaitk nas J Daunoras Measurement of Human Physiological Parameters in the Systems of Active Clothing and Wearable Technologies MEDICINE TECHNOLOGY ISSN 1392 1215 24 Engineering in Medicine amp Biology Society Biomedical Signal Processing URL http www embs org assessed 2015 25 Dr Dallas Price How to read an Electrocardiogram ECG Part One Basic principles of the ECG The normal ECG The South Sudan Medical Journal 26 Jana O enaSkova A HW SW Prototype for Cardiovascular Biofeedback Using OOPic Microcontroller and Matlab Simulink Bachelor Thesis Kladno 2011 27 Toshiyo Tamura Yuka Maeda Masaki Sekine and Masaki Yoshida Wearable Photoplethysmographic Sensors Past and Present Electronics ISSN 2079 9292 2014
87. pes Show 10 v entries Search Animal Animals View View Veterinarian Veterinarian view Showing 1 to 2 of 2 entries Previous 1 Next Figure 8 5 Testing Resource Types for the Veterinary Hospital Organization The following functionalities have been tested e Creating new records new animal patients and veterinarians where created e Viewing records the created animal patient veterinarians could be viewed e Editing a record created animal patients veterinarians were edited e Removing some created animal patients veterinarians were removed from the e Bindings animal patients were assigned to veterinarian figure 8 6 Jean Paul Bakida Animal Animal Records assigned to Veterinarian New id Name Birth Date Race Gender 554e73671d013 Jack 2008 01 19 Catahoula Leopard Dog M 554e740bbdf71 Johny 2012 11 02 Dog Chesapeake Bay Retrieve E Figure 8 6 Resources of type Animal assigned to a Veterinary Results Three different business cases were created with different needs The first case can be adapted to a physician or doctor who would like to manage its patients and their visits The second case can be used by a clinic for example having more physicians patients with patients having their diagnoses saved in the system Finally the last case illustrates that the system can be used also as a Veterinary center 60 Different Resource Types with different attributes where created and the system was manag
88. pes res type id res type attribute id res type linked attribute id res type attribute type local res bin data filename Tes bin data mimetype res bin data size res bin data content resource types res meta type id res type name res type description res type icon res type user map res type qr search res type device input res type table name res type attribute type mandatory res type attribute type printable res type attribute type is binary res type attribute type is chart access roles resource type attributes res type attribute type id res type attribute access role view res type attribute access role insert res type attribute access role update res type attribute access role delete res type attribute access role commit res type attribute access role rollback res type attribute access role encrypt res type attribute access role import res type attribute access role export access roles resource types res type id res type access role view res type access role insert res type access role update res type access role delete res type access role commit res type access role rollback res type access role encrypt res type access role import res type access role export resource type attributes user access rights user id res type attribute access role id resource types user access rights user id res type access role id group access rights resouce types og user group id res type ac
89. pm getResourceTypesBindings Resource ResourceTypeAttribute ER ResourceTypeAttribute getResourceBindings saveResourceBinding beforeSave getResourceBinaryData getBinaryDataBylD AccessRoleResourceType ResourceTypeAttributeType i o AccessRoleResourceTypeAttribute getOrganizationResources getAllResourceTypedAttributes AccessRoleResourceTypeAttribute ResourceTypeAttributeUserAccessRight Figure 5 4 Model classes 33 From figure 5 4 we can notice that all model classes extend the application model AppModel which in turn extends CakePHP s internal model class The CakePHP internal model comes with methods for e retrieving data from the database such as find findById findAIIBy e saving or updating data into the database such as create save saveField saveMany saveAssociated saveAll updateAll Q e and for deleting data from database such as delete and deleteAll Thanks to inheritance all these methods are available for all model classes By extending the CakePHP model class therefore each model class is endowed with all the functionality it needs to create queries and to save and delete data This helps keep the model classes clean and avoids writing multiple queries to communicate with the database That is the reasons why the majority of the application model classes are empty contain simply the declaration but have no methods However in some cases a mod
90. rate an output representation to the user The View is completely separated from the Model Layer and it is not limited to HTML or text representation of the data It can be used to deliver data in different formats such as XML PDF videos music etc 5 2 3 The Controller Layer The aim of the Controller layer is to handle user s requests It collaborates with the Model and the View layers to render a response to the client user The Controller layer is nicely described in 21 A controller can be seen as a manager that ensures that all resources needed for completing a task are delegated to the correct workers It waits for petitions from clients checks their validity according to authentication or authorization rules delegates data fetching or processing to the model selects the type of presentational data that the clients are accepting and finally delegates the rendering process to the View layer Controller classes contain public methods called actions 5 2 4 Components and Helpers As one can notice in figure 5 1 besides the 3 main layers we have just described there are also two sub layers that are part of the application structure Components and Helpers Components Components are packages of logic that are shared between controllers Instead of having the same functionality repeated in two or more controllers we put it in special packages called Components Components keep controller code clean and allow the reuse of the same
91. re pays r gion Je ne sais pa 3 gt Oui 0 Non 1 75 Oui 0 0 Non 1 83 Jenesaispas 3 25 6 Si oui quels sont les logiciels utilis s en passant je souhaite ajout que les NTIC vienne de voir le jour en afrique plus pr sicement au congo par exemple certaine structure medical manque encore des outils telque un simple ordinateur aller comprendre l innovation c est bien mais pr parer les gens avant celle ci c est mieux c est ce qui manque en afrique plus pr cisement au congo 7 Quels sont les avantages li s ces logiciels La connexion distance entre patients et docteurs 6 66 7 96 La possibilit d tablir un diagnostic en ligne 4 444 Le partage des donn es m dicales 4 444 Autres 4 444 8 Y at il des am liorations que l on peut faire sur ces logiciel d apr s vous Je pense seulement des fonctions li es avec le coeur On peux aussi penser d epilepsie diab te dialyse etc Certaines de tes questions s adressent plut t a des professionnels de sant Il est difficile d y r pondre pourquoi n aurais tu pas fait 2 questionnaires 1 pour les patients et un autre pour le corps m dical Une info importante pour toi il y a quelques jours la justice frangaise a autoris les pharmaciens vendre certains m dicaments 500 je crois par Internet Il faudrait que tu consultes la presse frangaise pour avoir plus de pr cisions oui beaucoup m me mais tout dependras du
92. reasons e The client and the server are completely separated each of them may be replaced and developed independently 20 21 The only thing that connects them is the interface existing between them This leads to separation of concerns SoC Clients are not concerned with data storage This allows the client code to be more portable and simpler 21 Meaning that the client can be easily installed in patient s post without the need of installing a database server The client can be simply a web form installed in patient s PC or mobile phone for example 21 e The protocol is stateless each request is an independent transaction that is unrelated to any previous request so that the communication consists of independent pairs of request and response That means that no client context is stored on the server between requests Operations are self contained and each request carries with it all the information state that the server needs in order to complete it Thus the server is not required to retain session information or status about each client 20 The server code is therefore simpler and more scalable e The service is platform independent e The service is language independent clients can be written in other languages than the server e The architecture is standards based as we use HTTP for communication This architecture fulfills also our security requirement because it allows the use of security standards like HTTPs an
93. ronment Yes 1 8 3 No 0 0 Idontknow 0 0 13 If not which kind of device could you imagine to require 14 Do you see any benefits in such a solution Legistation 15 Is Telemedicine legal in your country 71 Yes 1 c No 0 VI don t know 0 Yes 1 83 No 0 0 Idontknow 0 0 16 Which certifications are required by the local government in order to use a health care software 17 Is there a legal framework for remote consultancy diagnosis and prescriptions c Yes 0 Ostatn 0 Yes 0 0 No 1 83 Ostatni 0 0 18 What does the local legislative say about patient data security Which features would you welcome in Telemedicine use 19 Select features you would like to have in Telemedicine sofware Remote connection between patients and doctors 1 100 Tools allowing sharing data such as images text ECG signals 1 100 72 Evaluation of autonomic cardiac tests 1 100 Upload of the ECG signals 1 100 Social networking or other conversation tools 1 100 Patient management 0 096 Patient Scheduling 0 0 Electronic Medical Records 0 0 Online prescriptions 0 0 Multilanguage Support 0 0 Can you tell us something about yourself 20 What is your nationality Cameroonian 21 In which City region do you live Prague 22 What is your country of origin Czech Republic 23 You are expressing yourself here as c a doctor 0 a patient 1 other 0 a doctor 0 0 ap
94. s and charts can be proposed for viewing resource data It would also be interesting to reconsider the data model In our solution we are using a relational database But other databases can be considered such as NoSQL databases which are built to allow the insertion of data without a predefined schema 63 Another point that can be worked out as well is the implementation of a robust method for ensuring data integrity Such method will allow the server to make sure that the data transmitted were not modified This can be done using for example an advanced encrypting algorithm that would be implemented both in clients and server s side This work did not include a comparative study of existing Open Source Software OSS and proprietary software in telemedicine Even though we mentioned the existing OSS we did not compare them between them End costs analysis for each OSS is missing as well how product A is compared to B We did not conduct a comparative study of PHP frameworks for the implementation of the system We used CakePHP but another framework could maybe meet better our requirements defined in chapter 2 In this work we did not mention the standard HL7 format which is widely used for data communication in medicine HL7 messages could be sent and decoded using JSON format used for communication between clients and server It would be also interesting to create in the server an interface for communication with RTG MRI devices and other
95. solution is low cost and does not require many components The Pulse Sensor costs 24 99 the Arduino board around 21 16 and the USB A B cable around 4 The board can operate on an external supply of 6 to 20 volts but the recommended range is 7 to 12 volts 34 The Pulse Sensor has a 24 flat color coded ribbon cable with 3 male header connectors 73V to 5V GND and Signal The connection to the Arduino board is done as figure 6 3 The Signal wire is connected to the Arduino AO analog pin The 5V wire is connected to Arduino 5V pin The GND is connected to Arduino GND pin 47 Patient Pulse Sensor GND Arduino Serial Communication Figure 6 3 Measuring patient s heart rate When all these connections are done the microcontroller starts immediately sampling The samples are sent to the PC via serial communication and can be viewed or saved into a file using a serial port terminal COM such as RealTerm or Tera Term Data saved in a file can then be sent to the server using the client application this process is described in the next chapter The sampling frequency is set to 500 Hz which gives us a high enough resolution to get reliable signal28 The pulse sensor we use is a photoplethysmograph and produces an analog fluctuation in voltage It amplifies the raw signal and normalizes the pulse wave around V 2 512V When the amount of light on the sensor remains constant the signal value will remain at 512V
96. some of them may require special conditions and expensive medical equipment and materials 23 It has been suggested that assessing the cardiovascular and respiratory systems by measuring heart rate respiration rate temperature and blood pressure provide significant insight in patient health state 23 The so called vital signs are useful in detecting or monitoring medical problems Let us see in more detail the methods used for measuring human heart rate Heart Rate Monitoring Methods To monitor heart rate two primary technologies are available to device manufacturers ECG Electrocardiography and PPG Photoplethysmography ECG or Electrocardiography is a representation of the electrical activity of the heart over a period of time using electrodes placed on a patient s body Just like other muscles cardiac muscle contracts in response to electrical depolarization of the muscle cells The sum of this electrical activity when amplified and recorded is what we call ECG 25 PPG or Photoplethysmography is a light based technology to sense the rate of blood flow as controlled by the heart s pumping action The technology consists of a light source and a detector with red and light emitting diodes LEDs commonly used as the light source 45 The PPG sensor monitors changes in the light intensity via reflection from or transmission through the tissue The changes in light intensity are associated with small variations in blood perfus
97. ts thought that existing free telemedicine software programs are difficult to understand so they would prefer a very easy to use system and 18 2 shared the opinion that existing solutions do not offer the needed functionalities e Some mentioned the lack of infrastructure In Congo for example certain medical centers do not even have a computer e Problems with Internet connection were also mentioned e Some questioned people recommended to first provide education in order for users to familiarize to telemedicine and its use The entire survey can be found in the appendix B We had also an opportunity to discuss personally with two doctors Both insisted on the security of the system to protect patient s data According to one of them clear rules regarding communication and confidentiality must be defined Patients can be sceptic while using such systems They may require some proof or confirmation that the system is really secure The second doctor mentioned that a telemedicine system should allow not only patient to physician remote communication but also physician to physician remote communication This can allow for example physicians in developing countries to consult their counterparts in other countries This can lead to better results while making diagnosis Again confidentiality rules must be clearly established In addition to this we also made researches on the existing literature Below are the results of our researches r
98. y as already explained organizations resource types org id res type id org res type binding id y 6 organizations org_parent_id org_name org description org address org logo server id access roles organizations org id org access role view org access role insert Org access role update Org access role delete Org access role commit Org access role rollback org access role encrypt Org access role import Org access role export V group access riphts resource type attributes user group id res type attribut access role id 7 user_group_id org_access_role_id ORGANIZATION RESOURCE BINDINGS org res type binding name org res type binding description resource type attributes res meta type id res type attribute name res type attribute code res type attribute description res type attribute type res type attribute type constraints y group_id name password email picture admin linked_res_type_id linked_res_id user_groups fuser orup name user_group_description organizations_user_access_rights resource_types_resource_types res type parent id res type id res type binding id res type resources tabla resource type bindings res type binding name res type binding description resource binary data resource njeta types res meta type parent id res meta tjpe name res meta type description resource type attribute ty

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