Diabetes and hypertension have become increasingly. Remote Health Monitoring Using Mobile Phones and Web Services ORIGINAL RESEARCH

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1 ORIGINAL RESEARCH Remote Health Monitoring Using Mobile Phones and Web Services Sparsh Agarwal, B.Eng. (Hons) and Chiew Tong Lau, B.Eng. (Hons), M.A.Sc., Ph.D. School of Computer Engineering, Nanyang Technological University, Singapore, Singapore. Abstract Diabetes and hypertension have become very common perhaps because of increasingly busy lifestyles, unhealthy eating habits, and a highly competitive workplace. The rapid advancement of mobile communication technologies offers innumerable opportunities for the development of software and hardware applications for remote monitoring of such chronic diseases. This study describes a remote health-monitoring service that provides an end-to-end solution, that is, (1) it collects blood pressure readings from the patient through a mobile phone; (2) it provides these data to doctors through a Web interface; and (3) it enables doctors to manage the chronic condition by providing feedback to the patients remotely. This article also aims at understanding the requirements and expectations of doctors and hospitals from such a remote health-monitoring service. Key words: healthcare, telemedicine, remote health monitoring, blood pressure, integrated healthcare, mobile phone healthcare Introduction Diabetes and hypertension have become increasingly prevalent perhaps because of extremely busy lifestyles, unhealthy eating habits, and a highly competitive workplace. In Singapore (with total population of around 4 millions), over 360,000 Singaporeans have diabetes and over 900,000 suffer from hypertension. 1 These diseases are called silent killers because they lack clear symptoms and patients are often caught completely unaware until it is too late. Hence, regular monitoring of one s health condition is very important. However, appropriate management for some patients calls for regular and frequent monitoring rather than a medical check-up or a monthly visit to the general physician. They need to take their health readings perhaps three to five times a day or even more frequently. These data should be available to the patient s doctors in a timely manner to enable time-sensitive management of chronic diseases. The rapid advancement of mobile communication technologies offers innumerable opportunities for developing convenient healthmonitoring solutions at incrementally lower cost over time. Such mobile communications are very pertinent in developing regions where healthcare remains inaccessible to a vast majority, but have high mobile penetration rates. This article aims at describing one such project that provides an end-to-end solution for remote monitoring of blood pressure (BP). This article also demonstrates the utility of mobile phones in remote monitoring of chronic health conditions such as diabetes and hypertension. The application developed as part of this project enables remote monitoring of only BP, but can be easily extended to monitor other health conditions. The application provides a complete end-to-end remote healthmonitoring solution: (1) it collects BP readings from the patient using a mobile phone; (2) it stores the data on an online server; and (3) it enables doctors to manage the chronic condition by providing feedback to the patients remotely. Inadequate understanding of the requirement of doctors from such a service has limited wide-scale adoption. This article also aims at providing an insight into the expectations of doctors from such a service. For this purpose, this article presents findings from a survey of 100 specialist cardiologists attending the 2009 annual conference of the Association of Physicians of India. Past Efforts Remote monitoring of health parameters essentially involves two phases collection of data from the patient and transmission of these data to a remote location. There have been several attempts in the DOI: =tmj ª MARY ANN LIEBERT, INC.. VOL. 16 NO. 5. JUNE 2010 TELEMEDICINE and e-health 603

2 AGARWAL AND LAU past at making effective remote health-monitoring solutions. The collection and transmission of data in many of these solutions differ widely. One such product that enables remote blood sugar monitoring is Glucoþ by HealthPia, United States. 2 Glucoþ is a glucometer add-on that can be attached to appropriate mobile phones (Fig. 1). The same company also manufactures the GlucoPhone a mobile phone with an integrated glucometer. Both these products demonstrate the use of mobile phones in remote management of diabetes. Data collected through the mobile phones are stored in an online database that can be accessed by patients. However, there is no current service that links these data to the doctors. Other solutions that provide doctors with an ability to remotely monitor their patients have also been developed. For instance, Walker and his team from the University of Texas propose the use of Wireless Sensor Networks as opposed to Bluetooth or Wi-Fi for the transmission of vital health data (such as BP) from a patient to a remote monitoring computer. 3 Their interest in Wireless Sensor Networks is due to the cost-effectiveness, compact nature, and energy efficiency of wireless sensor nodes. In contrast, several solutions for remote monitoring of health using existing third-generation wireless networks on cell phones have also been proposed. For instance, Hiroki and his team from the University of Tokushima, Japan, have developed a system for telemedicine using a third-generation mobile phone. Their system aims at increasing the amount of information that can be provided to doctors. The system comprises of a Central Station Monitor that gathers vital patient data from bedside monitors installed in hospitals. These data are captured by the hospital s servers and can be accessed by any Java-enabled mobile phones, carried by the doctors. 4 Fig. 1. Glucoþ, a glucometer add-on for mobile phones. Recently, in March 2009, during the launch of the Apple ª iphone 3.0 Operating System, LifeScan ª, a Johnson & Johnson Company, showcased a demonstration of a blood sugar management application to be launched sometime soon. This application lets users transfer their blood sugar readings from their existing One-Touch Ò blood sugar monitors to the iphone through Bluetooth or through the serial communication interface. The application also allows the users to send their readings and a message about how they are feeling to caregivers such as their parents, children, or physician. 5 Another mock-up of a BP storage application was shown at the same event to display the potential of iphone applications as health-monitoring solutions. Another major application of remote telemedicine is providing healthcare in inaccessible rural areas. Of the world s population, 80% 90% live in the range of a cell-phone tower. Unfortunately, quality healthcare remains inaccessible to a vast majority. MOCA, a project of the Massachusetts Institute of Technology NextLab, uses Google Android-based mobile phones to remotely monitor patients in rural areas for diagnosis by medical experts located anywhere in the world. 6 The above examples are a very small subset of the vast number of technical solutions to remote telemedicine. With the rapid advancement in mobile communications technology, smarter and more powerful smartphones (such as the iphone and the Android-based smart phones) along with a decrease in associated costs will see a greater adoption of such services in the future. However, technological solutions that are unable to integrate the ever increasing demands of hospitals and medical practitioners from remote telemedicine would not attract large-scale adoption. Survey of Health Practitioners To gauge the requirements and expectations of doctors from a remote health-monitoring system, a survey involving specialist healthcare professionals was carried out. This survey was conducted amongst 100 specialist cardiologists attending the 2009 annual conference of the Association of Physicians of India. The survey results indicate that most of the doctors believe that a remote health-monitoring solution is beneficial and would improve the quality of healthcare. Figure 2 indicates which kind of health parameters the doctors would like to monitor. Some of the parameters suggested in the Others section were (1) drugs taken for specific medical conditions, (2) ECG, (3) oxygen saturation, and (4) cardiac arrhythmias. Most doctors (92%) believed that such a remote monitoring service would reduce the number of patient visits to hospital. The doctors 604 TELEMEDICINE and e-health JUNE 2010

3 REMOTE HEALTH MONITORING Others Heart Rate Weight Glucose BP 12% 62% 50% 92% 94% Fig. 2. Health parameters that doctors want to monitor. were also asked whether they considered such a service as a threat to hospital revenues (Fig. 3). Most doctors believed that innovative business models around remote monitoring services could be developed and hence this would not be a hindrance in the adoption of such a service. Several attempts at remote monitoring of health have been attempted in the past; however, there is no major commercial solution widely available. When posed the question of hindrances for doctors as well as patients in the adoption of such a service, several reasons were cited. Figure 4 illustrates the rating (on a scale of 1 5) doctors gave to different reasons that are a hindrance for remote health monitoring, from the point of view of a doctor. It can be concluded from Figure 4 that doctors considered the cost of setup as well as reliability of the system as strong deterrents. However, it must be noted that all of the above were considered a relatively strong (scale 3) hindering factor in the adoption of such a service. As part of this study, the authors also approached the Head of Technology at a leading Singapore hospital. In his view, for a system to be successfully adopted by large hospitals, it has to be customized for both the doctors as well as patients because their requirements are quite different. He also pointed out that over one-third (or 33%) of patients can be treated without visiting the hospital this technology, which can truly cater to the needs of both patients and doctors, would be a great step forward in providing integrated healthcare. These findings, coupled with the long waiting times for getting appointments at leading hospitals, strongly support the need for a convenient and practical remote monitoring solution. Methodology The application developed in this study has three main components a Web service which collects health data and relays feedback, a mobile client for the patients and a Website client for the doctors to monitor and manage their patients health. All the components in this project were designed using Java 2 Micro Edition (J2ME) for the mobile client, Java API for XML Web Services (JAX-WS) and Java Server Pages (JSP) for the Website client. The entire system was tested using a Nokia E71 mobile phone and the Web service and Website client running on an Apache Tomcat Server. Figure 5 illustrates the architecture of the system. The mobile client provides the interface through which patients can provide their health data (in this case, BP), which is then stored for remote monitoring on a Web server. The mobile client also provides the patient with the ability to view a graph showing recent BP trends and a log of the recent BP entries. The mobile client has been developed using J2ME. This enables portability of the mobile client across multiple Java-enabled mobile phones, enabling this project to reach a vast audience. One major objective of a complete end-to-end remote healthmonitoring system would be if health-monitoring devices (such as a BP monitor) could directly communicate with the mobile phone running the health-monitoring mobile client (shown in white in Fig. 5). However, in the absence of such a hardware device, the patient has to manually enter the BP readings into the mobile client. 100% 80% 60% 40% 5 (Strong Deterrent) % 18% 39% Yes (This would be a deterrent) Yes (But new business models solve the issue) 20% 0% 2 1 (Weak Deterrent) No Fig. 3. Consideration of remote health monitoring as a threat to hospitals. Fig. 4. Reasons hindering adoption of technology. ª MARY ANN LIEBERT, INC.. VOL. 16 NO. 5. JUNE 2010 TELEMEDICINE and e-health 605

4 AGARWAL AND LAU Fig. 5. Architecture of the system. The Web service acts as a communication medium between the patient s mobile client, the online databases (storing the medical data), and the Web site client providing access to doctors to remotely monitor their patients. Using the Web services architecture provides interoperability between different programming languages, hence allowing the extension of this project to other non Java-based mobile phone clients. Finally, the Web site client provides a platform for doctors to monitor their patients health. The Web site also provides an interface for a user to access his health records in a greater detail than on the mobile client. This client is one of the most important features of this project because it links the doctor s with their patients a feature that has not been seen in most remote health-monitoring solutions available today. The Web site client has been divided into two portals: (1) Doctor Portal and (2) Patient Portal. Upon authentication, a user is automatically redirected to his portal depending on his status within the system. This logical separation of the portals allows for further customisation of the Web site to accurately reflect the different needs of doctors and patients from a remote health-monitoring service. The data obtained from the patients in this system are currently available to doctors through the Web site interface. However, the Web service could be integrated with existing hospital infrastructure to provide these data to doctors on their existing applications, making it even more convenient for them to use. Benefits Considering the increase in health disorders such as diabetes and hypertension, remote monitoring at the point of care could provide clear benefits. Such a service would improve the quality of healthcare by allowing doctors to make more informed choices. Moreover, such a service would reduce the number of visits required to the hospital, enabling doctors to focus their attention on patients who really need to be examined in a hospital. The mobile client provides a platform that could be integrated with point-of-care diagnostic medical devices in the future. The devices could directly provide the mobile client with the health readings of the patient via Bluetooth or other wireless methods. This would remove the need for the patient to manually enter the health reading, thereby providing an end-to-end automatic remote health-monitoring system. The Web site client provides a single portal with a summary view of all the patients, enabling quick and easy monitoring. This helps the doctor save time and direct his efforts to improved healthcare. The client also provides automatic alerts when BP goes above a certain threshold. This enables the doctor to send timely recommendations to the patient vital for quality healthcare. Independent research indicates that remote monitoring of BP is accurate and helps patients gain control over their BP. When used regularly, this can improve control and help reduce health problems associated with high BP (a condition known as hypertension). 7 Though this project focussed only on remote monitoring of BP, it could easily be extended to monitor other chronic diseases because the underlying architecture would remain the same. Besides aiding in managing health disorders, such a service also provides an infrastructure that enables diagnosis in inaccessible remote areas, for the elderly as well as for emergency healthcare during disaster recovery. By utilizing mobile phones for remote telemedicine, accurate diagnosis can be provided to anyone, anywhere in the world. Conclusions The study demonstrates the power of mobile communications technology to aid doctors and patients and to improve the quality of healthcare. However, many past attempts at such technology have not been widely adopted because they did not accurately reflect the different needs of both doctors and patients from such a service. Further research into the requirements of doctors, patients, as well as hospitals would enable this technology to be practically realized and open room for further innovation in remote telemedicine. 606 TELEMEDICINE and e-health JUNE 2010

5 REMOTE HEALTH MONITORING Acknowledgments The authors thank Dr. Seema Agarwal and Mr. Gurmeet Arora for their help to conduct a survey amongst leading cardiologists in India. Disclosure Statement No competing financial interests exist. REFERENCES 1. Ministry of Health. National Health Survey Available at (last accessed November 1, 2009). 2. HealthPia. Glucot, remote blood sugar monitoring. Available at ¼ products_glucoplus.cfm (last accessed September 25, 2009). 3. Walker W, Polk T, Hande A, Bhatia D. Remote blood pressure monitoring using a wireless sensor network. Dallas: Department of Electrical Engineering, University of Texas, Kogure Y, Matsuoka H, Akutagawa M, Shimada Y, Kinouchi Y. The applications of remote patient monitoring system using a Java-enabled 3G mobile phone. Berlin: Springer, iapphealth. Diabetes and the iphone Lifescan app for diabetes management. Available at (last accessed September 24, 2009). 6. MOCA. Care anywhere Wireless healthcare, MIT MOCA Project. Available at (last accessed October 20, 2009). 7. Artinian NT, Washington OG, Klymko KW, Marbury CM, Miller WM, Powell JL. What you need to know about home blood pressure telemonitoring: But may not know to ask. Home Healthc Nurse 2004;22: Address correspondence to: Sparsh Agarwal, B.Eng. (Hons) Smriti Nursing Home Link Road Saharanpur (UP) India sparshpolly@gmail.com Received: November 15, 2009 Revised: January 11, 2010 Accepted: January 11, 2010 ª MARY ANN LIEBERT, INC.. VOL. 16 NO. 5. JUNE 2010 TELEMEDICINE and e-health 607